Transcript Access Issues in Reproductive Health

Meg O’Reilly MD MPH
Objectives
 Review a range of reasons an individual might have
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difficulties obtaining a full range of reproductive
health care services
Identify “at risk” populations who may have more
challenges in obtaining care or services
Discuss cases which will serve as examples of
diminished health care access
Develop a framework to think about access issues
during the remainder of the course
Consider biases involved in providing reproductive
care to women
Impediments to Access
 Legal
 Religious
 Rural
 Military
 Lesbian/Bisexual/Transgender
 Poverty
 Cultural
 Age
Resources
 www.acog.org
 www.guttmacher.org
 Making the Grade on Women’s Health: A National and
State-By-State Report Card
 Special Issues in Women’s Health, ACOG
 Ethics in Obstetrics and Gynecology, ACOG
 Social Workers and Case Workers at your institution
Case 1--Rural
 23 yo G5P3023 who desires contraception. There is only
one pharmacy located in her rural town and no other
pharmacy within 2 hours.
 Her provider writes her a prescription for OCPs. The
only pharmacy in town will not fill the prescription due
to the pharmacist’s opinions regarding contraception.
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Is this “legal”? What are a pharmacist’s responsibilities regarding
provision of medications he might be ethically opposed to? What are the
patient’s options in this case?
Case 1--Rural
 23 yo G5P3023 who desires contraception. There is only
one pharmacy located in her rural town and no other
pharmacy within 2 hours.
 Her MD gives her a prescription for “Plan B”
(progesterone only emergency contraception) to use as a
backup for condoms.
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Is “Plan B” different than regular OCPs? Does the use of “Plan B” induce
an abortion? Should a pharmacist have a right to decline a doctor/patient
plan for contraception?
Case 2--Legal
 21 yo who presents to her health clinic with an
unplanned and undesired pregnancy
 Her health clinic is a FQHC, the only clinic within 3
hours of her home
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What is an FQHC? What are the rules regarding provision of abortion
services (or counseling) in clinics who receive funding from federal
sources? Does access to medical care always mean access to
comprehensive care?
Case 2--Legal
 21 yo who presents to her health clinic with an
unplanned and undesired pregnancy
 Her doctor is a Family Medicine practitioner who does
not have training in medical or surgical abortion care
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Who can legally provide medical or surgical abortions? Does this have to
be an OB/GYN? What percentage of counties in the United States have
abortion providers?
Case 2--Legal
 21 yo who presents to her health clinic with an
unplanned and undesired pregnancy
 Her doctor is a member of the state’s Right to Life
organization and does not believe in counseling all
options
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What do you think are the physician’s responsibilities to this patient? Do
physicians have to provide comprehensive counseling of all options even if
these are counter to strongly held personal beliefs? What is the “law”.
What ethical principles are involved?
Case 3--Religious
 46 yo who presents to the ED with acute onset of LLQ pain and
bleeding. Her pregnancy test is positive. Her hospital is
religiously affiliated and has a policy which forbids termination
of pregnancy and sterilization procedures.
 Her ultrasound reveals a threatened miscarriage. This is an
undesired pregnancy and she wishes to proceed with D and C for
treatment and concurrent sterilization with tubal ligation.
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What is an elective abortion? Is this an elective abortion? Should the patient be
able to decide on her ultimate treatment plan? Does a hospital have the
responsibility to provide comprehensive treatment options? Should this patient be
able to use her anesthesia for a tubal ligation procedure if she were bleeding
heavily enough to “need” a D and C? Under what circumstances can this patient be
discharged to go to another hospital to get care?
Case 3--Religious
 46 yo who presents to the ED with acute onset of LLQ pain
and bleeding. Her pregnancy test is positive. Her hospital is
religiously affiliated and has a policy which forbids
termination of pregnancy and sterilization procedures.
 Her ultrasound reveals a left tubal (ectopic) pregnancy with
fetal cardiac activity. She wishes to avoid surgery and be
treated with methotrexate.
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What are her options for treatment? Would use of methotrexate (or
surgery) constitute a termination of pregnancy? Does this pregnancy
pose a potential risk to the patient? Should she be able to receive
treatment for this condition at any hospital?
Case 4--Infertility
 35 yo G0 who has a 10 year history of infertility with her
current partner. She now has insurance with limited
coverage for infertility services.
 She makes an appointment for evaluation and is told that she
has bilateral tubal obstruction. At the visit, she finds that she
will have to pay out of pocket for all of her treatment options.
The couple cannot afford the costs of in vitro fertilization.
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Should infertility services be covered by insurance? By Medicaid? Is
infertility a “disease”. Do some states mandate coverage for infertility
treatment? What might be some ramifications of mandated coverage?
Case 4--Infertility
 35 yo G0 who has a 10 year history of infertility with her
current partner. She now has insurance with limited
coverage for infertility services.
 The patient and her partner are women in a long term
relationship. The clinic is in a conservative community where
the REI physician has chosen not to treat same sex couples.
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Should infertility services be available for all patients regardless of sexual
orientation or other personal characteristics? Does this physician have
the right to determine who should “parent”? Does this physician get to
decide who he is willing to treat?
Case 5--Military
 25 yo female serving in Iraq goes to her military
physician
 with an undesired pregnancy and requests pregnancy
termination
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What are the options the military doctor can counsel this patient about?
What services can be offered to the patient? What are her options?
Case 5--Military
 36 yo female Army officer who presents to her military
physician to discuss her amniocentesis results after
abnormal ultrasound findings
 This is a highly desired pregnancy with a diagnosis of
Trisomy 18
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Given that she receives her healthcare in the military, what are her
options?
Do you know the usual outcome of Trisomy 18? Would you feel differently
about this case if the diagnosis were Trisomy 21?
Case 6—L/B/T
 38 yo G1P0, 26 weeks pregnant, presents to the ED
with loss of consciousness and concern for stroke. Her
partner follows the ambulance and requests to join her
for her evaluation and serve as her primary medical
decision maker.
 Her partner is her husband of 2 years
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Will her husband automatically be able to make medical decisions for his
wife? Would it be different if he were her unmarried partner?
Case 6—L/B/T
 38 yo G1P0, 26 weeks pregnant, presents to the ED
with loss of consciousness and concern for stroke. Her
partner follows the ambulance and requests to join her
for her evaluation and serve as her primary medical
decision maker.
 Her partner is female and they have been together for 12
years
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Will her partner be able to assist this patient with her health care
decisions? What documents might help make this a possibility?
Case 7--Poverty
 32 yo G2P1011 who presents with heavy vaginal bleeding,
severe anemia and a finding of uterine fibroids. She has
contraindications to medical management and she and her
doctor decide on surgical management.
 She is a single parent who works as a waitress. She earns just
over 200% of the federal poverty level, does not qualify for
Medicaid, and has no insurance available through her work.
She cannot afford the cost of the surgery.

Is health care a right? Think about this case in the context of the current
health care debate. Who pays for her care if she needs emergency
surgery?
Case 7--Poverty
 32 yo G2P1011 who presents with heavy vaginal bleeding,
severe anemia and a finding of uterine fibroids. She has
contraindications to medical management and she and her
doctor decide on surgical management.
 She is a Guatemalan citizen, undocumented, who works as
a waitress. She cannot afford the cost of the surgery.
 What is the difference to access of care for this patient and the prior patient?
Do you think this patient has the “right” to receive medical care in the US?
Final…and ongoing…questions
 Who is at risk for having inadequate access to a full
range of reproductive health options?
 What are some common reasons that there is limited
access to comprehensive care?
 Is it okay to have limitations to options? Do limited
resources mean that we are required to ration? Will
access always be a problem?
 How should we as a nation (or state, hospital, clinic,
individual health practitioner) decide which services
are most important to make available?