The Executive Suite: Recent abortion legislation is an opportunity to focus on patient relations, reproductive health education

Legislative proposals restricting abortion access have dominated the headlines this year. From a near outright abortion ban in Alabama that seeks to levy 99-year jail sentences against participating physicians to "heartbeat" bills that have been introduced in more than a dozen states, abortion and reproductive rights have been at the center of a constitutional firestorm.

The American Medical Association (AMA) has recently intervened by filing a lawsuit that challenges two North Dakota laws, alleging they are politically motivated and force physicians to "provide patients with false, misleading, non-medical information about reproductive health." The laws require physicians to inform patients that abortions performed via the administration of medications are reversible — a claim for which there is no scientific backing — and that abortion terminates "the life of a whole, separate, unique, living human being," which crosses into forbidden ideological territory.

While most of these proposals will endure months, if not years, of litigation and appeals before they can fully impact patients, they represent an opportunity for primary care physicians (PCPs), regardless of geographic location and opinions on abortion, to transform a deeply polarizing issue into a commitment to provide extensive, evidence-based reproductive health education to patients — a move that preserves patient autonomy and reduces the likelihood patients will ever face a difficult abortion decision or fall prey to reckless misinformation campaigns.

With nearly half of all pregnancies unintended, according to research by Guttmacher Institute, the scope of reproductive rights and access to associated services like abortion and birth control remain prominent public health issues. A renewed and focused push for earlier, targeted interventions as well as wide accessibility to family planning and sexual well-being tools, resources and education could potentially shift the entire dynamic of care.

Here's how PCPs can adopt a comprehensive, nonjudgmental and patient-centered approach to sexual health, conception and even abortion — independent of political influences.

The gamut of primary care

As cradle-to-grave caregivers, PCPs are arguably the most influential healthcare provider over the course of patients’ lifespan. This ongoing relationship is ideal for identifying the wide-ranging reproductive care needs of patients, with pregnancy prevention accounting for only a portion of those services.

Read the AAFP policy on reproductive decisions:
"The American Academy of Family Physicians (AAFP) encourages all family physicians to provide patient education on contraceptive options at every available opportunity to avoid unintended pregnancies. In the event of an unintended pregnancy, family physicians should educate patients about all options. If a patient desires termination of their pregnancy or adoption, family physicians should provide resources to facilitate those services. If a family physician's moral or ethical beliefs conflict with the ability to provide the requested resources or education, the family physician should ask a colleague to provide this information in a timely fashion rather than omit it. Additionally, the AAFP encourages family physicians to stay informed of all state and federal laws as they apply to reproductive health."

"In order to truly provide comprehensive care, primary care physicians must recognize the importance of meeting patients' sexual and reproductive health needs across the reproductive life course, from sex education to family planning to infertility to menopause," says Christine Dehlendorf, MD, MAS, a board-certified family medicine physician, member of the Society of Family Planning (SFP), and director of the Person-Centered Reproductive Health Program (PCRHP) at the University of California, San Francisco. "While some of these services may be provided by obstetrician/gynecologist colleagues, it is still the responsibility of the primary care physician to make sure that these needs are being met holistically."

To that point, many family physicians are already operating within their full scope of practice by prescribing birth control, providing family planning support, performing pelvic exams and vasectomies and screening for and treating sexually transmitted infections (STIs). This follows the guidelines from the American Academy of Family Physicians (AAFP), which encourage a well-rounded approach to patient education, encompassing everything from contraception and abstinence to sterilization, counseling and emergency contraception care.

Despite such efforts, PCPs may still underestimate the need for clear and targeted conversations with their patients about reproduction.

"I'll be honest. I don't always think about [family planning and reproductive health] as a discrete entity," says Jennifer Caudle, DO, a board-certified osteopathic family medicine physician in Sewell, N.J., and associate professor in the department of family medicine at Rowan University-School of Osteopathic Medicine. "[Reproductive health] is an important life stage for our patients, [so we need to] make sure that we're [having] this conversation, providing options and supporting them through their journey — not ignoring the issue or failing to bring it up. [This] is a good reminder for us to be engaged and do more [for our patients]."

Engage patients early and often

Did you know? The CDC offers a preconception checklist for patients called Steps to a Healthier Me and Baby-to-Be. Consider using it as a patient handout to keep the conversation going.

By and large, females of reproductive age have typically been the core focus of pregnancy risk screenings and reproductive health initiatives. "Primary care physicians have been encouraged to ask any reproductive aged woman they see: Do you plan to get pregnant in the coming year?" says Ingrid Skop, MD, an OB/GYN in San Antonio and chairman-elect of the American Association of Pro-Life Obstetricians & Gynecologists (AAPLOG). While these efforts shouldn't be abandoned, this type of narrow approach may only address one subset of patients, leaving others without access to critical services and counseling.

One often underserved demographic is male patients. "I think it would be useful for PCPs to ask a variation of the pregnancy question to men: Are you in a relationship? Do you and your partner desire pregnancy this year? Are you using effective contraception? Are you having sexual intercourse outside of a relationship?" Skop says. Discussing the risks associated with sexual activity such as unintended partner pregnancy and STIs can be empowering. "As a society, we need to help men feel included and engaged, [especially] in the event a woman becomes pregnant."

Engage patients early and often

Experts say that early intervention starting in adolescence and continuing through adulthood can be key to establishing more favorable outcomes, particularly when physicians find ways to check in with patients frequently. "These conversations take less time than we think because our patients know a lot already," says Glenna Martin, MD, a board-certified family medicine physician in Seattle, Wash., and fellow with Physicians for Reproductive Health (PRH). "Primary care providers are creative problem-solvers, so whether [it's] adding a question on the intake form, putting more posters in your office to remind you and patients to talk about reproductive health or a flag in the EHR, everyone can find the solution that works best for them."

Starting this dialogue early with adolescents and young adults can drastically decrease unintended pregnancy rates, as demonstrated by the success of the Colorado Planning Initiative. The initiative, launched in 2009, made low- and no-cost long-acting reversible contraceptives (LARCs) along with additional educational and health services available to low-income women throughout the state via Title X family planning clinics. By 2014, both birth and abortion rates declined by nearly 50 percent for participants aged 15-19 and 20 percent among those aged 20-24.

While such a program may be difficult to mimic in day-to-day primary care practice, annual well child visits offer built-in face-to-face encounters ideal for the provision of sexual health and contraceptive education. The American Academy of Pediatrics (AAP) suggests using motivational interviewing to help young patients talk through their feelings on sexuality, brainstorm solutions that suit their lifestyle and deepen engagement and trust along the way. For those patients who do not wish to practice abstinence, the AAP recommends using LARCS as the first-line contraceptive choice.

The level of parental involvement during these encounters varies. "It's very, very individual [and] goes both ways," Caudle says. "Often, I'll ask the parents to step out, so I can have a private conversation with the child." Other times, parents are the ones inquiring about contraceptives on the child's behalf.

Since birth control does not provide adequate protection against sexually transmitted infections, reiterating condom usage and benefits as part of any contraceptive conversations is warranted as well. Regardless, physicians must carefully navigate these situations and follow their state's confidentiality laws to ensure the preservation of minor patients' privacy.

Beyond the female framework
Did you know? The CDC offers a preconception checklist for patients called Steps to a Healthier Me and Baby-to-Be. Consider using it as a patient handout to keep the conversation going.

By and large, females of reproductive age have typically been the core focus of pregnancy risk screenings and reproductive health initiatives. "Primary care physicians have been encouraged to ask any reproductive aged woman they see: Do you plan to get pregnant in the coming year?" says Ingrid Skop, MD, an OB/GYN in San Antonio and chairman-elect of the American Association of Pro-Life Obstetricians & Gynecologists (AAPLOG). While these efforts shouldn't be abandoned, this type of narrow approach may only address one subset of patients, leaving others without access to critical services and counseling.

One often underserved demographic is male patients. "I think it would be useful for PCPs to ask a variation of the pregnancy question to men: Are you in a relationship? Do you and your partner desire pregnancy this year? Are you using effective contraception? Are you having sexual intercourse outside of a relationship?" Skop says. Discussing the risks associated with sexual activity such as unintended partner pregnancy and STIs can be empowering. "As a society, we need to help men feel included and engaged, [especially] in the event a woman becomes pregnant."

A September 2016 position paper by the AAFP expa nded previous practice guidelines and preconception interventions for men with a goal "to ensure positive outcomes of their reproductive and sexual behaviors while minimizing negative consequences of unhealthy lifestyle choices." Male counseling and care should cover contraceptive methods, fertility issues and overall wellness. It should also offer guidance on how to support partners during pregnancy and postpartum recovery as well as the impact smoking and STIs may have on a partner's health.

Read ACOG's Committee Opinion on pre-pregnancy counseling in its entirety or in PDF form.

An even more expansive approach, one that requires a shift in clinical theory and practice, is to address the specific reproductive health of all patients, regardless of gender and orientation. To encourage this transition, the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) jointly released their first Committee Opinionon pre-pregnancy counseling in January 2019. The recommendation states, in part, that "all those planning to initiate a pregnancy should be counseled, including heterosexual, lesbian, gay, bisexual, transgender, queer, intersex, asexual and gender nonconforming individuals." While these guidelines are intended to be used primarily by OB/GYNs, PCPs who are prepared to address these matters will only further strengthen patient relations, outcomes and satisfaction.

Offer options, not judgments

If patients or couples would like to conceive in the next year, physicians should shift their focus to counseling patients about preconceptual health, such as maintaining a healthy body mass index and the cessation of alcohol, tobacco, cannabis and illicit drug use. Verifying immunization status, ensuring current medications are compatible with pregnancy and managing chronic conditions like diabetes and hypertension is also imperative.

When conception is not desired, then screening for pregnancy risk and reviewing current contraceptive methods is warranted. The AAFP recommends physicians have detailed discussions with patients about all available contraceptive options, where and how to obtain them, as well as the associated failure rates and reliability of each.

"I am a stickler for discussing the abysmal failure rates of most contraceptives," Skop says. Unlike LARCs, most contraceptive methods require daily user action such as taking a pill, so disclosure of both the perfect and real-world use failure rates allows patients to make more informed decisions.

When a pregnancy occurs, whether intended or not, physicians should discuss next steps with patients and help them develop a realistic plan going forward, independent of their personal feelings about those choices. "Pregnancy options counseling means providing nondirective, evidence-based information to newly diagnosed pregnant patients about all of their options for continuing or terminating the pregnancy and [making] referrals as necessary," Martin says. "This is an integral part of the public health prevention framework for addressing unintended pregnancy and is considered a clinical best practice."

As with many other aspects of primary care, this ultimately boils down to equipping patients with the facts and encouraging them to take control of their health, lives and futures. "Beyond preventing unintended pregnancies, [primary care] physicians can help empower patients," Martin says. Through reproductive care services, STI screenings and preconception and pregnancy counseling, patients are more aware of available options.

Dehlendorf agrees. "Our role as providers of family planning services should be to assess patient needs and support them to make a decision that reflects these needs, without judgment or stigma," Dehlendorf says. "In this way, we can advance our patients' reproductive health and work to ensure their reproductive autonomy."