Optimizing Access to Preventive Reproductive Health Care: Meeting Patients Where They Are At

“How can someone show up two hours late for an appointment? Should I still see this patient?” I (J. C.) vividly remember asking this of my continuity clinic preceptor early in my intern year about a patient presenting for her annual gynecological visit. My preceptor was an experienced and skilled obstetrician-gynecologist who had worked in this public hospital on the West Side of Chicago, Illinois, for many years. “Julie,” she said, “just think about all that it took for her to get here. She likely had to take a bus, a train, and then a bus again. Think of all the ways that could have gone wrong. All to get here today. This may be her only interaction with a provider for a while and an important opportunity to address her reproductive health needs. We have to meet her where she’s at.” Of the many lessons I learned in four years of obstetrics-gynecology residency, this was one of my most salient learning points, and I was grateful to have received it early in my career. Her comments helped me snap out of my naiveté and appreciate my position of privilege compared with many of the patients I have the good fortune to care for.

PREVENTIVE REPRODUCTIVE HEALTH CARE BARRIERS

Today, we hear ourselves repeating this wise attending’s words while working in our hospital’s family planning clinic in response to a question we sometimes hear from learners: “Why do you think she waited so long to have her abortion?” Patients seeking abortion care and those pursuing preventive reproductive health care describe many of the same psychosocial, interpersonal, and structural barriers to obtaining care.^1,2 Notable psychosocial challenges to obtaining care include medical mistrust and not prioritizing one’s personal health amid competing demands; interpersonal barriers include parenting and caregiving for adult family members; and structural barriers include instability around insurance, transportation, and childcare.¹ Although many barriers to seeking abortion and preventive reproductive health care coincide, those seeking abortion care face additional challenges, including stigma and antiabortion legal restrictions.

Delays in accessing reproductive health care can have significant and devastating effects. The Turnaway Study was a landmark five-year longitudinal study that followed individuals who presented for abortion just before or after the gestational age limits at 30 abortion clinics across the United States.² Participants who presented after the clinics’ gestational age limits and were unable to obtain a desired abortion were more likely to experience economic hardship and report being in fair or poor health years later, compared with those who presented in time to obtain their desired abortion.^2,3 Furthermore, what is often called the “well-woman visit,” which we refer to as the “preventive reproductive health visit” in recognition that not all individuals assigned female at birth identify as women, is an important opportunity to provide health screening, counseling, immunizations, contraception, and preconception care to help address individual and population-level reproductive health disparities.¹

INNOVATIVE APPROACHES TO OVERCOMING BARRIERS

Given the myriad interacting barriers individuals face in obtaining reproductive health care, innovative strategies to engage people in reproductive health care must prioritize meeting people where they are, figuratively and sometimes literally, to help them overcome their own context-specific barriers. One important component in these strategies is identifying and leveraging clinical opportunities for those who face substantial challenges when they interface with the health care system. A prime example of such a clinical opportunity is pregnancy because the vast majority of pregnant women seek medical care at some point in their pregnancy. Yee et al.⁴ identified prenatal visits and postpartum hospitalizations as encounters to implement a program to help low-income, largely minority women overcome barriers to engaging in follow-up postpartum care. These encounters were used as opportunities to address preventive health needs such as contraception, maternal health, mood, and transitions in care.⁴ The abortion visit also has been identified as a clinical point of contact with a substantial number of individuals who may lack a regular health care provider with whom to obtain routine preventive reproductive health care. Two studies found that people presenting for induced abortion had a lower prevalence of having a regular provider compared with the general reproductive-aged population.^5,6 Other pregnancy-related encounters, such as emergency department visits for management of miscarriage or ectopic pregnancy, represent additional opportunities to connect with individuals who are otherwise disconnected from preventive reproductive health care.

In addition to identifying clinical opportunities to reach individuals who do not routinely engage in preventive reproductive health care, approaches are needed to improve access to and use of care. Patient navigation is a model historically used to link individuals from low-resource settings to cancer screening and follow-up care. Patient navigators are lay health workers without formal medical training who come from a local community and serve as a bridge between members of that community and health care services. More recently, patient navigation has been used in obstetric and abortion settings to support low-income and minority individuals in their pursuit of preventive reproductive health care.^4,7 Yee et al.⁴ adapted the patient navigation model to the postpartum context, working with a patient navigator experienced in facilitating cancer screenings and treatments to translate these skills to assist patients in the postpartum period. To help patients overcome barriers to obtaining postpartum care, this patient navigator scheduled appointments, sent appointment reminders, provided psychosocial support, facilitated logistical and social work needs, and helped identify primary care medical homes for patients beyond the postpartum period. An evaluation of this postpartum patient navigation program found that patients in the program were significantly more likely to obtain care in the postpartum period compared with those who had not participated in the program.⁴ A similar model of patient navigation has been described linking individuals seeking abortion care to preventive reproductive and contraceptive care after the abortion visit.⁷

Beyond helping individuals overcome barriers to accessing preventive reproductive health care, innovative strategies have been developed to bring preventive reproductive health care to the individual. Haider et al.⁸ recognized that attendance was low at postpartum visits during which contraceptive counseling often occurs, but attendance by postpartum patients at well-baby visits was high. Accordingly, they implemented a program offering colocation of contraceptive services to mothers presenting for their young infants’ well-baby visits. Although uptake of a colocated visit was slightly less than 20%, study participants viewed this concept positively, and those who attended a colocated visit were more likely to be using highly effective contraception at five months compared with control participants.⁸ Optimizing system-level interventions, such as offering colocated services, is one promising strategy to improving access to care. In addition, even though telemedicine is not entirely novel, recent practice changes in response to the coronavirus disease 2019 pandemic have brought this modality of care to the forefront. The expansion of telemedicine during the current pandemic has allowed many to access preventive reproductive health care, including contraceptive counseling, reproductive life planning, and pregnancy options counseling, in the convenience and privacy of their own phones.

Although these myriad opportunities and evidence-based interventions help individuals overcome barriers to engaging in preventive reproductive health care, limitations and persistent challenges must be acknowledged and addressed. Importantly, preventive reproductive health care offers many potential health benefits but remains a downstream intervention that cannot fully mitigate long-standing, underlying structural and environmental factors that negatively affect individuals’ reproductive health and contribute to population-level reproductive health disparities. For example, innovative telemedicine interventions cannot reach those who are unable to afford regular phone service or who live in geographic areas that lack efficient high-speed Internet. Ultimately, state and federal policies and public health efforts must address these underlying structural barriers. Professional organizations must advocate for these essential changes, and health care professionals and researchers should continue to innovate solutions that address unmet reproductive health care needs.