By Melinda Young
Ahead of potential rollbacks in access to abortion care and contraception care through the next administration’s policies, there are some actions the reproductive health community can take now. These include strategies that would be helpful to patients regardless of what happens next on the national stage.
These actions include the following:
Discuss reproductive life planning: “Everybody should be bringing up reproductive life planning with every patient they have — all doctors,” 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.
“Even if it’s not a focus of your visit, it impacts your care,” she says. For example, an internist who is seeing a reproductive-age patient with diabetes could ask about the patient’s reproductive life plan. If the woman wants to get pregnant in the near future, it is a good time to discuss ways to ensure the pregnancy is healthy and safe. If the patient says she has no plans to get pregnant, then it is an opportunity to discuss contraception, she explains.
Specialists can discuss reproductive health planning and refer patients to OB/GYNs as needed. “Every provider should bring it up in the conversation,” Cwiak adds.
The Centers for Disease Control and Prevention (CDC) has a reproductive life plan assessment that was published in 2017.1 The CDC recommends that all people be encouraged to have a reproductive life plan and that healthcare providers assess women’s reproductive life plans at every patient encounter, including primary care and preventive clinic visits.1
At visits that involve reproductive life planning, clinicians can ask these questions:
- Do you have any children?
- Do you want to have (more) children?
- How many (more) children would you like to have and when?
“The reproductive life plan is a set of personal goals and plans for having or not having children,” says Mimi Zieman, MD, an Atlanta author of Managing Contraception.
“It can help people avoid unwanted pregnancies and have the number of children they want; all men and women should have a reproductive life plan,” Zieman adds.
Improve contraception and abortion access now: OB/GYNs and reproductive health clinicians need to use telemedicine to meet with patients whenever an in-person visit is challenging for the person. They also can provide contraceptive counseling and access to people who live in OB/GYN/maternity deserts.
“We can use telemedicine and electronic health records, where we can send electronic refills, and we can use patient-centered questionnaires,” Cwiak says. “You can use this to deliver healthcare and information about which kind of methods they’re looking for, and you can provide many options without patients having to come in for a visit.”
Clinicians do not need to see patients in person or do a physical exam for many forms of contraception. “We can re-evaluate the things we do and the processes we have in our clinic,” Cwiak says. “Look to the new documents from the CDC, the selective practice recommendations, and see where we can cut some of the barriers we’re forcing people to do, like doing refills without seeing someone in person.”
Providers also can make certain their patients are aware of the over-the-counter contraceptive pill and the different forms of emergency contraception, she adds. OB/GYNs could prioritize in-person patient visits for long-acting reversible contraception (LARC) in January and February 2025, in anticipation of people losing insurance funding for these methods. If they stock up on LARC, they also could provide same-day intrauterine device (IUD) and implant procedures.
Another option that OB/GYNs need to be aware of and open to is sterilization — permanent contraception. These methods became more popular after the Dobbs decision, and increasing numbers of younger people have opted to not have children or not have any more children.
“Given severe limitations in reproductive health access between birth control and abortion, it’s up to clinicians to support patients’ choices that may include having a permanent contraceptive procedure at a young age,” Zieman says. “It’s up to clinicians to be aware of their own biases and not let that interfere with patients’ self-determination,” she adds. “They need to think about why they are not providing that option.”
Preventing pregnancy in the Dobbs era is a matter of life and death for some women, and physicians should honor their patients’ choices.” While the media recently focused on the spread in the United States of the Korean 4B movement, which advocates for women to say “no” to dating men, marrying men, having children with men, and having sex with men, there is a broader societal trend to permanent contraception that is not as political in nature as is 4B. (See the article on “Tubal Sterilizations Increased Post-Dobbs, Remain Higher in Abortion-Ban States,” in the November 2024 issue of Contraceptive Technology Update.)
“There’s an increase in the sociologic shift of many more young people saying they will never have children,” Zieman says. “More people are not necessarily wanting to get married and not necessarily wanting to have children, and that goes back to the reproductive life plan.”
For those who are uncertain about whether they will want children in the future, it is important to maintain contraceptive options so they can select a method that works best for their lifestyle and plans. Abortion access also is crucial. Online pharmacy dispensing also can help with maintaining access — at least for now — to abortion medication.
“Any provider can be trained to prescribe medication abortion and become certified,” says Ushma Upadhyay, PhD, MPH, a professor at the University of California — San Francisco. “They can write a prescription through an online pharmacy,” she adds. “Many patients would prefer medication abortion from their primary care provider rather than going to a clinic.”
There already is evidence of better integration of abortion care in primary care, she notes. “I am co-chair of WeCount, a national effort to monitor the impact of the Dobbs decision, and it’s a census where every abortion provider who is offering abortion care reports the number of abortions they do each month, and they’re compensated for their time,” Upadhyay explains. “We have many clinics like small OB/GYN practices or family medicine providers that are reporting a handful a month, but across the country, they add up.” This destigmatizes abortion care, treating it like any other form of healthcare and could be available to any patient who needs it, she adds.
The change to telehealth for abortion care occurred because of the availability of online pharmacy dispensing, which had been a major hurdle for physicians. It was difficult to stock medications in their offices and hard to plan for requests of the pills. Plus, recent studies show that an ultrasound is not necessary for provision of abortion care. “Now, they can write a prescription and send it to an online pharmacy, and the patient gets it in two days,” Upadhyay says. “It makes it a lot easier.”
If the Comstock Act is enforced, then family practices still could provide care, but it would need to be in person, she adds.
Keep contraception affordable: “Consider long-term methods now while the Affordable Care Act is still in existence because that’s supposed to cover full contraceptives with no copay,” Zieman suggests.
Already, an estimated one out of four women with insurance do not have their contraception adequately covered, she adds.
“You can also send out an email to your patients to tell them about potential changes in contraception coverage or access and how they should consider a visit to ensure they have enough supplies or to change to a longer-term method,” Zieman says. “This is such a dystopia — it shouldn’t be this way.”
The other reason to stock up contraceptives now is because of anticipated tariffs that could raise the costs of purchasing some healthcare supplies, she notes. “We need, as providers, to look outside of ourselves and start working with insurance companies to make sure they get the message that this is healthcare and is vital to everyone,” Cwiak says. “We can have broader conversations about the cost of these methods and the coverage.”
Maintaining access likely will be challenging under a Trump administration. Last time, hundreds of thousands of women lost access to their family planning center when the Title X gag rule was put in place. This time, Trump has talked about undoing the Affordable Care Act, at least in part. It is possible he will take away the contraceptive coverage mandate.
“Just because the mandate goes away does not mean there is no ethical obligation for the insurance company to provide healthcare,” Cwiak says. “The mandate is the floor: You have to do this to have a semblance of values.” If the mandate disappears, the healthcare industry still has some ethical obligations to ensure patients receive needed care regardless of their ability to pay out of pocket. “We need to remind insurance companies why they are here,” Cwiak says.
“Have a conversation with employers,” she adds. “For instance, if you work for a large company, then you need to give feedback to your company about what you and your fellow employees need and what you demand is covered by your insurance plan. That’s another reason why unions are so important.”
Melinda Young has been a healthcare and medical writer for 30 years. She currently writes about contraceptive technology.
Reference
- Robbins CL, Gavin L, Carter MW, Moskowsky SB. The link between reproductive life plan assessment and provision of preconception care at publicly funded health centers. Perspect Sex Reprod Health. 2017;49:167-172.
