Call to Action Reproductive Rights Advocacy: Not Just for the Family Planning Community

Abstract

Women and families benefit from access to the full spectrum of reproductive care, including family planning services. We commend our family planning colleagues on their tireless dedication to preserve the rights of women through advocacy. While several of our perinatology peers have also set an example by dedication to these issues, advocacy for patient access to reproductive care options has not been a focus of the larger perinatology community. The time has come for individual perinatologists, as well as the overall perinatology community, to join them and do the work needed to preserve access to safe care, including contraception and abortion services. In this call to action, we detail several ways that individuals and the community can become more involved in working for reproductive rights.

The Problem:

It is imperative that patients and families have access to the full spectrum of reproductive care options, including contraception and pregnancy termination. These choices are particularly salient when pregnancy complications arise, so perinatologists work with many patients who benefit from access to these services. Recent developments in American politics and public discourse seek to limit a woman’s autonomy regarding decisions surrounding pregnancy and therefore threaten our patients’ health. Some of our fellow perinatologists have set an example by acting as vocal advocates to preserve patient access to appropriate care but advocacy for these issues has not been a focus of the perinatology community.

A Solution:

The time has come for our community to be more vocal in advocating for our patients to have access to the full spectrum of reproductive care options.

Every perinatalogist has taken care of women who dream of taking home a healthy newborn, but who suffer dangerous obstetric or grave fetal complications.. One of our recent cases comes to mind – that of a young nullipara with life-threatening hypertension, pulmonary edema, and fetal growth restriction at 21 weeks due to preeclampsia. We surmise that the reader is now imagining a handful of his or her own such cases. We have all borne witness as these patients and families struggle to process a diagnosis that shatters their hopes for a healthy pregnancy and child. It is imperative that these women have the opportunity to make decisions about pregnancy that protect their health and fit with their goals and values. Reproductive health and women’s rights receive significant media coverage in the U.S. Physicians and reproductive rights advocates play a major role in educating the public about reproductive health access, including full access to contraception and abortion. Our family planning colleagues have aptly been the standard-bearers of this movement, but they should not have to march alone.

As perinatologists, we fear that the reproductive rights and safety of our patients are in danger. The time has come for our community to be more vocal on questions of reproductive options, an example that has been set by select individuals in the community. Although we do not exempt the general ob/gyn community or the medical community at large from advocating for patient choice nor do we ignore the contributions of these groups, the current piece is targeted to our perinatology community. A recent article in this journal addressed ways in which the larger obstetrics and gynecology community may contribute to the advancement of reproductive rights.¹ Perinatologists in particular share many of the same patients and collaborate frequently with family planning specialists. We have a unique patient population and therefore a unique perspective to bring to the discussion. In high-resource countries, the majority of pregnancy terminations after 20 weeks gestation are for maternal or fetal indications that fall within our primary scope of practice.² Optimal interpregnancy interval and pregnancy planning, especially in women with complex medical conditions, improve pregnancy outcomes^3,4 and obviously require access to contraception.⁵ Furthermore, perinatologists frequently interact with patients during the post-partum period, a time that provides multiple opportunities to offer contraceptive counseling and initiation.⁵ This article will discuss how perinatologists can be more active in ensuring that our patients have access to the appropriate range of reproductive choices and are able to make decisions that best reflect their values and beliefs, and optimize their personal and family health.

Legislative and Judicial Advocacy

First, we call on perinatologists to actively work against restrictive legislation limiting women’s reproductive options. One example of restrictive federal legislation, the Hyde Amendment, which prohibits federal funding for pregnancy termination (except in rape/incest/danger to mother’s life), has been reaffirmed by Congress every year since 1976. Thus, military personnel, government employees, and women who are insured via Medicaid in states that provide no financial support must pay out-of-pocket to terminate a pregnancy complicated by a lethal fetal anomaly.

At the state level, there are many laws restricting reproductive access. Last year, Utah became one of the first states to pass a “fetal pain” bill, in direct conflict with the ACOG position statement and the best medical evidence.^7,8 Nine states have proposed so called “heart beat bills” which would ban abortions after detection of fetal cardiac activity. Ohio recently joined several other states and passed a restrictive ban on pregnancy termination after 20 weeks post-fertilization.⁹

Many states have mandatory “waiting periods,” medically incorrect counseling requirements, and other medically unnecessary and inhumane measures such as requirements for women to listen or see the fetal heart which are, by design, harmful to women.¹⁰ Those of us who live in states where reproductive rights are being insidiously dismantled must be especially vigilant, appropriately outspoken, and remain active in local medical-political processes.

Perinatologists can influence the legislative process in a number of ways. Most simply, writing or calling your representatives at the state and federal level to express views about pending legislation or judicial nominees can be influential, especially if done consistently and with sound medical logic. Along with their fellow obstetrician-gynecologists, perinatologists can make themselves available when local agencies, such as television news sources, seek opinions on reproductive health matters. A proactive approach of contacting legislators and offering our expertise about reproductive matters is generally preferable to reactive responses. Even a letter or an email may be influential, especially if several physicians are willing to sign a single statement. Contact information for national lawmakers is available at www.senate.gov and www.house.gov. For local and state legislators, most states have a governmental website but search sites such as www.openstates.org can also be helpful in finding this information.

For those interested in a higher level of involvement, contacting and working with groups such as your state medical association, Planned Parenthood, Physicians for Reproductive Health, and others can provide additional opportunities, including testifying on proposed bills, fundraising to support legal fees for combatting restrictive legislation, providing expert testimony in court cases, or even helping to draft legislation.

Advocacy on the local or hospital level can also be influential. By partnering with hospital administration and the state health-department, we can influence policies that have real and immediate effects on patients. Examples include expanding patient-friendly options for documentation of pregnancy terminations (e.g. some patients with lethal fetal anomalies will request some type of birth or death certificate and some patients prefer not to have such documentation), providing supportive staff and resources for patients undergoing pregnancy termination, confirming that hospital protocols conform to best-practice guidelines, ensuring that patients have access to post-partum contraception options, and many other seemingly small changes that can make a big difference to patients.

Public dialogue

Second, we must work together to change the public narrative surrounding pregnancy termination. For example, misinformation about “late-term” abortion creates images that are appalling to the medically naïve, provides fuel to those that seek further restrictions on crucial reproductive health services, and contributes to the climate of violence against providers and clinics.¹¹

The truth is that innumerable obstetric or fetal complications that can arise, and for some of these pregnancy termination is unequivocally the best medical course. Given this reality, rigid rules restricting termination of pregnancy created by politically motivated agencies can be dangerous for the pregnant woman and her family, both medically and emotionally.

As perinatologists, we are charged with the opportunity and responsibility of screening for fetal anomies. We know all too well the myriad of complex ways in which fetal development goes awry. We have all cared for women with pregnancies complicated by grave fetal anomalies. We have all borne witness as a woman processes the worst news she can imagine - her baby is “not normal.” In an ideal situation, we are then able to give her all of her options and help her access the care that is right for her and her family.

The stories that we as perinatologists can tell make for powerful and justifiably influential dialogue. We task our fellow perinatologists with humanizing the women we care for to politicians, voters, and even other activists. As with legislation, there are different ways to be involved in this process. Simply speaking up among family and friends to correct misconceptions around abortion is powerful. Social and traditional media are important platforms for disseminating this message too. We have the opportunity and responsibility to be the voice for our patients when they have none.

Medical education

Finally, those of us fortunate enough to work with trainees can use the education process to expose students, residents, and fellows to the full spectrum of reproductive options. In particular, we have a special opportunity to promote among our trainees an empathetic understanding of these complex patients. These trainees will enter multiple different specialties and will hopefully carry with them a different perspective of this crucial issue. Practices that do not work with trainees may wish to provide education of referring physicians and the local medical community. We urge you to ask yourself, “Is my institution doing enough to humanize women dealing with complex pregnancies and change the hearts and minds of our next generation of physicians?”

Different approaches to education on the topic of reproductive options have been described and the optimal approach likely depends on the institution and educator. Some institutions have all students rotate through the family planning clinic as part of the clerkship. Others use simulation, standardized patients, and/or values clarification to address some of these topics. Several websites exist with supportive material including, but not limited to: medical students for choice (https://www.msfc.org/medical-students/) and Curricula Organizer for Reproductive Health Education (http://core.arhp.org). As medical schools vary in their approach to these topics,¹² we recommend coordinated efforts with clerkship directors, family planning specialists, and other stakeholders.

Call to action

We call upon perinatologists to advance women’s health beyond our direct care of women and their pregnancies. We must advocate for our patients. It is time that we join our family planning and general OB/GYN colleagues in fighting for reproductive health and rights. Our patients deserve it. ACOG supports us in this endeavor, recommending the elimination of the Hyde amendment and the repeal of legislation that creates barriers to abortion access.¹³ The American Medical Association encourages physicians to “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being”.¹⁴

Consider joining or donating to an organization that formally advocates for reproductive rights. Speak with your local and state legislators. Get involved in national and regional leadership organization such as Society of Maternal Fetal Medicine, ACOG committee and/or ACOG district leadership. Write letters. Educate the public. The voice of a physician matters. As perinatologists, we can highlight the way these laws directly affect our ability to provide the best care for our patients. With practice, and with the support of advocacy and professional organizations, you can learn how to be a stronger advocate and navigate the legislative system. Our unique perspective as physicians has never been more important.

Fellow perinatologists, these are our patients whose care is being threatened. We are in a unique position to understand the difficult decisions that women make about their pregnancies and the ways in which limiting their choices will profoundly and negatively affect them. Right now, perhaps more than ever, women and their stories are being misused as political fodder in the battle to demolish reproductive rights. Join us in our efforts to protect and promote the best care for women.

Condensation:

Perinatologists should join our Family Planning colleagues in advocating for the reproductive rights of our patients, including access to contraception and pregnancy termination.