Responding to the Overturning of Roe v. Wade: 6 Immediate Actions for Primary Care Internists

Following the landmark US Supreme Court case overruling Roe vs. Wade on June 24, 2022, access to abortion services has drastically decreased or disappeared in many US states. Internists generally do not provide abortion services and make up only around 1% of abortion providers in the USA¹; however, internists can help to support the response to this ruling by increasing delivery of comprehensive contraceptive care. Contraceptive care is within the scope of primary care physicians, yet only 51% of family medicine physicians and 20% of internal medicine physicians prescribe the pill, patch, or ring². According to a nationally representative survey, 1 of 3 women who had tried to obtain a prescription for a hormonal contraceptive reported difficulties accessing or refilling a prescription³. As with any shortage in medical services or disruption in access to care, this Supreme Court ruling will require a comprehensive and coordinated response from governments, health systems, and other organized bodies. In the short term, though, individual internists who provide primary care can help prevent unplanned pregnancies and reduce additional stress on the system by optimizing delivery of contraceptive care. Immediate action strategies include the following:

1. Add contraception to your health maintenance template

Contraception is a crucial component of preventive health for all pre-menopausal patients. During contraceptive counseling, clinicians can use shared decision-making to find the contraceptive method that is best for the patient at the present time, as well as counsel the patient regarding contraceptive failure risks⁴. Tools such as the US MEC website and app (www.cdc.gov/reproductivehealth/contraception/mmwr/mec/summary.html) can aid clinicians in advising patients with underlying medical conditions during their selection of a contraceptive method, and the US SPR guidelines (https://www.cdc.gov/reproductivehealth/contraception/mmwr/spr/summary.html) outline recommendations for the initiation and use of specific contraceptive methods, including any indicated testing prior to use⁵. Contraception can be discussed with people of any gender and while respectfully acknowledging the sexual preferences of the patient, therefore asking about contraception should be the default in health maintenance care for all pre-menopausal patients.

• 2.Optimize contraceptive prescriptions to reduce contraceptive failure

Notably, approximately half of the unintended pregnancies in the USA result from contraceptive failures⁶. For patients who endorse that they are already using contraception, clinicians can assess whether there is a risk of treatment failure, advise on proper use, and discuss adherence tools, such as the use of alarms or app-based reminders. Combined hormonal contraceptive prescriptions can be provided for one year in 3-month increments where allowed by insurance. Clinicians should also be familiar with the various options for emergency contraception, including levonorgestrel, combined oral contraceptive pills, ulipristal acetate, or copper-bearing intrauterine devices (IUDs), including evidence suggesting that obesity reduces effectiveness of levonorgestrel and possibly ulipristal for emergency contraception⁵.

• 3.Identify yourself as a contraception provider

Patients are finding their primary care physicians through the internet, and many medical practices have public webpages listing clinicians with their areas of expertise. Internists can take this opportunity to create or update a list of contraceptive services they provide, being as specific as possible. Adding keywords like “sexual health”, “contraception”, “birth control”, or “IUDs” can help make physicians findable by patients seeking services. Physicians without a website can consider creating a personal networking page and listing contraception as a provided service and keyword. Having an accurate and updated representation of contraceptive services provided can remove one barrier for patients, allowing them to more easily find a physician who can provide the contraceptive medication or device they seek.

• 4.Provide virtual care for contraceptive counseling

A commonly cited barrier to accessing contraceptive care is difficulty obtaining or getting to an appointment³. Contraceptive counseling can be provided easily over a virtual encounter⁷. Hormonal contraception does not require a pelvic exam prior to initiation³ and can be prescribed through virtual care after a thorough screening for medical contraindications⁷, including a requirement for blood pressure measurement prior to initiating combined hormonal contraception⁵. Even if a long-acting reversible contraceptive that must be placed in person is ultimately recommended, providing the initial consultation remotely can reduce the number of in-person visits a patient must undergo. Clinicians who engage in virtual care and video visits can have this service prominently displayed on their webpage and check in with scheduling staff to ensure streamlined access.

• 5.Sign up for long-acting reversible contraceptive training

Internal medicine physicians do not consistently offer long-acting reversible contraceptive services. Of internal medicine physicians who billed for providing in-person contraception, only 2.6% of these physicians provided IUDs and only 1.8% provided the implant². The contraceptive failure rate is almost 20 times higher among people using the pill, patch, or ring than in those using a long-acting reversible contraceptive method (4.55 per 100 participant-years vs. 0.27 per 100 participant-years)⁶. These contraception options are safe and provide highly effective contraception for years. Clinicians who can make room in their practice for administration of long-acting reversible contraception should pursue training now.

• 6.Keep pregnancy on your differential

Regardless of the legal options in each state, early diagnosis of pregnancy is important for the patient’s ability to plan and pursue medical care. Internists should keep pregnancy high on the differential for relevant chief complaints and offer pregnancy testing where appropriate.

CONCLUSION

Internists who provide primary care services can assist in the response to the overturning of Roe v. Wade by improving patient access and expanding contraceptive services provided, specifically by pursuing training in long-acting reversible contraception methods.

Declarations

Conflict of Interest

The author declares that she does not have a conflict of interest.