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Friday Nov 17, 2017

In Defense of Reproductive Health Care

My patient, Joe, had tried diligently to bring down his blood sugar with diet and exercise. His A1c was still too high, and we needed to start pharmacologic treatment. A highly effective medication, metformin, was easily available to Joe at our pharmacy and covered by his insurance.

[Package of oral contraceptive pills]

Another patient, Lisa, had struggled with ovarian cysts for years. She had experienced painful cyst ruptures and debilitating bloating. Lisa was not able to use a highly effective medication for ovarian cysts, TriNessa, to treat her condition because she couldn't afford to pay for it out of pocket. Her insurance didn't cover it because her employer had filed for a religious exemption to avoid paying for contraception coverage.

Why wasn't Lisa's medication for ovarian cysts covered while Joe's diabetes medication was?

Starting Jan. 1, employers can refuse to provide insurance coverage for contraception(www.hhs.gov) based on religious or moral objections. Lost in the partisan arguments about birth control is the fact that contraception is a safe, effective treatment for many medical conditions. Contraceptive medications treat endometriosis, dysmenorrhea, menorrhagia, fibroids, ovarian cysts, dysfunctional uterine bleeding and the secondary anemia that can result, among other conditions.

In addition, contraception helps many patients plan their pregnancies and family size.(rooseveltinstitute.org) It helps them space healthy pregnancies, allowing them to continue to provide optimal care to their children and families.

Only 11 states have higher infant mortality numbers than Ohio, where I live and practice. Cuyahoga County, home to three large hospital systems, has the second-highest rate in the state.(www.odh.ohio.gov) The infant mortality rate for black infants in the county is more than twice that of white infants. One critical recommendation to reduce infant mortality is allowing an interval of at least 18 months between pregnancies. This requires affordable, accessible and highly effective contraception.

The Patient Protection and Affordable Care Act (ACA) allowed more than 55 million people to access birth control by requiring that all insurance plans cover the benefit without cost-sharing such as copayments and deductibles. The Trump administration's move to reverse that policy means that hundreds of thousands of patients may lose that benefit. Since many women are unable to afford contraception without insurance coverage, this policy would disproportionately reduce reproductive autonomy for poor and low-income women.

Furthermore, research has shown access to contraception is associated with higher completion rates of education and ability to maintain employment.(www.contraceptionjournal.org) Removing that access from poor and low-income women perpetuates the cycle of poverty.

Long-acting reversible contraception, or LARC, is the most effective reversible form of pregnancy prevention for sexually active individuals. IUDs and implants, like other contraception, can be used to treat many medical conditions in addition to being highly effective at preventing unplanned pregnancy. LARC removes the possibility of human error, because these devices are placed in the arm or uterus and can stay in place for several years.

The efficacy of natural family planning methods, on the other hand, varies widely by study. According to HHS, one in four women will become pregnant(www.hhs.gov) while using natural family planning to prevent pregnancy.

When contraception fails to prevent unwanted pregnancy or is not accessible, patients must choose between staying pregnant or ending the pregnancy. This year, we have seen repeated threats to patient access for both choices -- continued pregnancy and abortion -- through higher costs and increased restrictions.

Repealing or replacing the ACA would make things even more difficult for women. The American Health Care Act (AHCA) and the Better Care Reconciliation Act (BCRA) would have permitted states to use a waiver process to alter or otherwise change the essential health benefits package, which includes maternity care. This, in turn, would have allowed states to drop maternity coverage as an essential health benefit. Although plans would still be required to offer maternity coverage as a policy rider, this obviously would increase costs to the patient.

The AHCA and the BCRA also would have defunded Planned Parenthood(www.businessinsider.com) for one year. That's significant because each year, 2 million Americans receive their health care -- including cervical and breast cancer screening, sexually transmitted infection screening, and contraception -- from Planned Parenthood.

We must do more for our patients. We must do more for women. Contraception is health care. Maternity care is health care. Abortion is health care.

And it's important to note that these are not only women's issues. Allowing women reproductive autonomy is an issue of public health; it benefits partners, families and children. Reproductive autonomy allows women to keep their jobs, complete their education and care for their loved ones. The financial well-being of women has ripple effects on the financial well-being of whole communities -- communities we live in alongside our patients.

When women can control if and when they have children, as well as how many children they have, we all benefit. When that autonomy is taken away, we all suffer.

Natalie Hinchcliffe, D.O., loves teaching residents, advocating for her patients and addressing stigmas in medicine. She is passionate about providing care for lesbian, gay, bisexual, transgender and queer patients; HIV primary care; and reproductive health and family planning services where access to such care is limited. She practices in Ohio.  

Posted at 02:15PM Nov 17, 2017 by Natalie Hinchcliffe, D.O.

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