Potential Challenges Ahead for Reproductive Healthcare

By Melinda Young

---

As the incoming Trump administration’s cabinet selections come into focus, the reproductive justice and health community has a glimpse of what is going to happen after Donald Trump takes office. It is a troubling picture of potential changes that could be dramatic and painful.

One of the main challenges for reproductive healthcare providers is unpredictability. No one knows what kind of change will occur or when. “Trump and his administration and appointees are capable of doing anything, and our attempts to predict that and control that are limited,” says Mimi Zieman, MD, an Atlanta author of Managing Contraception.

“It’s hard to know what a national [abortion] ban would look like,” says Nancy Berglas, DrPH, a public health scientist at Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology & Reproductive Sciences at the University of California, San Francisco in Oakland, CA.

Berglas’ recent research shows that abortion bans and restrictions in states have a tremendous effect on the services available to those who need them. “There are huge disparities geographically at this point, and we can see that at this two-year change [after Dobbs],” Berglas says. “You don’t want to underestimate the shock to the system that legal bans have, and we’ve seen how the healthcare system and providers are doing their best to support those in need, along with all the support systems that help people travel.”

If access to abortion faces drastic national barriers or if some contraception is removed from the market, it is hard to say what providers can do to offset those obstacles. “We can’t predict what he will do, so it’s hard to take the right course of actions or to plan for it,” Zieman says.

For example, should family planning clinics stock up now on abortion medication, intrauterine devices (IUDs), and emergency contraception in case Trump’s next attorney general enforces the Comstock Act of 1873 on day 1? The Comstock Act likely would ban the shipment of all abortion medication and probably some contraceptives, as well.

But what if clinics spent their tight resources on stocking mifepristone, IUDs, and emergency contraception, only to find out that Trump’s way of banning abortion medication and some contraception is through having a new director of the Food and Drug Administration (FDA) revoke their approval? “We don’t want clinics to barely have enough to cover costs, spending thousands of dollars on medication that might be prohibited on day 1,” Zieman says.

There are signs that some states will stock up on medication abortion pills and emergency contraception in anticipation of a national ban. Oregon was the first state to announce this plan after the presidential election.^1,2 Oregon Gov. Tina Kotek announced on Nov. 18, 2024, that her state was stocking abortion medication with an expiration date of September 2028. Her announcement said the plan was in response to the 2024 presidential election and that the Oregon Health Authority and Oregon Health & Science University had an agreement to continue distributing the state’s emergency mifepristone supply in the future. Kotek signed the Access to Reproductive Health care law, House Bill 2002, in the summer of 2024.^1,2

In most states, it will be up to individual providers and clinics to maintain access to abortion medication, if they can, and to contraceptives. Family planning clinics and the reproductive healthcare community will do what they always do and find a way to serve their patients. “If they can’t provide contraception, they’ll do the preventive healthcare they can do,” says Carrie Cwiak, MD, MPH, an author of the book Contraceptive Technology and a professor in the Department of Gynecology and Obstetrics at Emory University School of Medicine in Atlanta. “So, I don’t think it’s going to be helpful to do a lot of speculation about what will happen to this program or that,” Cwiak adds. “Speculation will let people stew in their worry.”

One change that appears very likely is the return of the Title X gag rule. Trump’s first term forced many Title X clinics to withdraw from the program because they could not adhere to the draconian rule that forbids them from giving patients information about abortion care or having property connected to an abortion clinic. This was before the U.S. Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization in June 2022. Enacting this change now could end contraceptive access and financial assistance for hundreds of thousands of patients, including those who most need this help. “Nonprofits are going to have to step up with funding for low-income patients in a big way because we can’t count on government assistance,” Zieman says.

“There are a few different avenues where a Trump administration could really curtail abortion access further,” says Ushma Upadhyay, PhD, MPH, a professor at the University of California — San Francisco.

“The numbers of abortions have increased since Dobbs, primarily due to telehealth abortions that have made abortions more available in states where abortion is legal and — also — in states where there are abortion bans,” Upadhyay explains. “I think that is going to be the next target of the new administration.”

For instance, the administration’s new head of the FDA could return mifepristone to its in-person dispensing requirement. If this happens, providers could use telehealth to prescribe misoprostol alone, although it has the downside of prolonged side effects. “Providers are not used to providing misoprostol, so it takes time for providers to get up to speed,” Upadhyay notes.

But if the administration starts enforcing the 19th century Comstock Act, misoprostol also would be unavailable — at least by telehealth. Since the Comstock Act, written as an anti-vice law that bans mailing obscene materials and abortion items, was never repealed by Congress, the administration would not have to make any legal changes to start enforcing it. That enforcement — banning the mailing of all abortion materials and medications — could occur on day 1.

The Biden administration’s Department of Justice determined the Comstock Act only applies when the sender intends for the material or drug to be used for an illegal abortion and that there are legal uses of the drugs in every state, so senders’ intent cannot be interpreted.³

New research also shows that states with abortion bans often have many hurdles to contraception that primarily affect people with fewer healthcare options and resources. For example, a study about barriers to contraception in Mississippi found that two out of five pregnancy-capable adults in Mississippi are not using their preferred contraceptive method and that structural barriers are very common.⁴

Mississippi has a limited number of policies that support contraceptive access, and the state did not expand Medicaid, which would have provided more people with contraceptive coverage, says Kari White, PhD, MPH, executive and scientific director at Resound Research for Reproductive Health, Tides Center, an independent nonprofit in Austin, TX.

“Only recently has the state extended postpartum coverage for Medicaid to 12 months, and before that we saw insurance churn and people losing access to contraceptive care as a result,” White says. “The state has historically underfunded safety nets, like health clinics where Title X family planning services were provided.”

The incoming administration also could signal that it will not enforce the Emergency Medical Treatment and Labor Act (EMTALA) when it applies to pregnant women. Biden’s administration took Idaho to court over EMTALA, and the U.S. Supreme Court punted on deciding whether a pregnant person’s health was important enough to supersede a state’s ban on all abortions — even when the pregnancy is not viable and the woman may suffer grave physical harm. “This would lead to increased morbidity and mortality, potentially,” Upadhyay says.

Before the Biden administration leaves in January 2025, it is time for productive healthcare providers to answer a call to action, Cwiak says. “No matter what is coming, we know there will be restrictions, and those restrictions will run the gamut and not just impact abortion,” she says. “It’s IVF [in vitro fertilization] and contraception, anything that can impact healthcare that predominantly affects people of reproductive age with a uterus.” It is time to be proactive: “All of us, OB/GYNs, no matter what your job is in this sphere, you have a job to do, and your job is to be proactive and not reactive,” Cwiak says.

“The way to be proactive is to ramp up our efforts to have a conversation about healthcare because, specifically with contraception, we’re talking about healthcare,” she adds. “We know there is a maternal mortality rate that is higher than if you’re just a reproductive-age person walking around. Pregnancy is relatively safe and usually a happy time if you want to be pregnant.”

But for those who do not want a pregnancy because of their health or socioeconomic reasons and who want to engage in sexual activity without undue risk to their bodies, they need to use contraception, which is why it is healthcare, Cwiak explains. “All of us need to be talking amongst our colleagues and neighbors, anyone in our circle — family and friends — about why it’s very important to protect access to healthcare, and we specifically mean contraception because that’s the one under the most threat right now,” she adds. “We shouldn’t waver from our message that our ability to access healthcare as Americans is under threat.”

Physicians and other reproductive health clinicians also could be more active on social media in the spaces where young women obtain contraception information. “With social media, there’s been an expansion of misinformation about hormonal methods, and it’s very worrisome,” Upadhyay says. “Maybe we need more providers on social media, contributing evidence-based information on TikTok and Instagram.” Providers also could join the new social media site BlueSky, which works like Twitter/X, but makes it easier for users to block hateful comments.

Change in contraception and abortion access should be expected. Had Kamala Harris won the election, abortion access would have stayed in the status quo until she could get Congress to pass bills to repeal the Comstock Act and also to expand access nationwide. With Trump as the president, the status quo likely will end. His cabinet selections for the FDA, the Centers for Medicare and Medicaid Services (CMS), and the U.S. Department of Health and Human Services all suggest major changes in the funding of women’s healthcare and access to reproductive healthcare.

“Based on their previous public statements, I don’t put anything past these people admitted to office,” Upadhyay says. “They do a lot of grandstanding and acts to keep themselves in the public eye.” For example, if confirmed to head CMS, Mehmet Oz, MD, could end the contraception mandate in the Affordable Care Act. “There could be many small administrative changes that could be made, and they could have large impacts,” Upadhyay says.

The incoming administration’s focus on migrant communities also could have a big effect on communities’ reproductive healthcare. Women who lack legal documentation could lose all access to contraception as they are detained or in hiding to avoid detention and expulsion. “Maybe we should prioritize our immigrant communities for reproductive health,” Upadhyay says. “It’s important that providers continue providing high-quality care to as many people as possible.”

Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.

References

1. Central Oregon Daily News Staff. Oregon secures new supply of abortion pill mifepristone after elections. Central Oregon Daily News. Nov. 18, 2024. https://www.centraloregondaily.com/news/regional/oregon-secures-mifepristone-supply-2028/article_b5868d06-a5da-11ef-b0ee-57528233fdfc.html
2. 2024 election statement by Oregon Gov. Tina Kotek. Nov. 18, 2024. https://app.frame.io/reviews/0b92f16f-c389-4808-ab83-792cb712f253/01f6d854-2a08-4b8e-a1a8-30d6213848c6
3. Felix M, Sobel L, Salganicoff A. The Comstock Act: Implications for abortion care nationwide. KFF. April 15, 2024. https://www.kff.org/womens-health-policy/issue-brief/the-comstock-act-implications-for-abortion-care-nationwide/
4. Nagle A, Lerma K, Sierra G, White K. Barriers to preferred contraception use in Mississippi. J Women’s Health (Larchmt) 2024; Sep 4. doi: 10.1089/jwh.2024.0127. [Online ahead of print].