Abortion and Family Planning During COVID: An Interview with Dr. Amber Truehart
Dr. Kate Anderson (PGY-2 @ UChicago EM) sits down with Dr. Amber Truehart (Assistant Professor @ UChicago OB/Gyn) to discuss disparities around abortion & family planning health services during Covid-19.
Edited by Dr. Quincy Moore (Assistant Professor @ UChicago EM)
What is your specific area of interest relating to reproductive health care?
I am fellowship trained in family planning (contraception, abortion) and have specialized training in pediatric and adolescent gynecology.
How has COVID-19 affected access to abortion care, contraception, and sexual health services?
Abortion is always under fire. Government officials in the states of Texas, Ohio, Alabama, and Oklahoma have tried to ban most abortions — that is, those that are not required to preserve the life or health of the mother — on the basis that they do not consider them urgent or medically necessary during this pandemic.
At our [University of Chicago], we never stopped providing abortion services. Abortion was deemed essential health care and clinics remained open. Contraception counseling and provision also continued, though in a somewhat different format. Counseling was done, for the most part, via telehealth. Short-acting methods such as the pill, patch, or ring, could be prescribed easily after counseling. If a patient was interested in injectable methods such as Depo-Provera, we were using a subcutaneous form that could be self-injected by the patient or family member. If a patient was interested in Long-Acting Reversible Contraception (LARC) devices such as an IUD or implant, we were working with the patient to get an in-person appointment that worked for them. If this patient had medical comorbidities that made it more dangerous for them to attend a hospital visit, we offered bridging methods of contraception in the meantime. If a woman already has a LARC device and reports it is “time for it to come out,” we [recommend] extended use of LARC devices, [which studies support for] many years longer than the FDA approved duration. For example, the Mirena IUD is FDA approved for 5 years but evidence shows it is effective for up to 7 years. We can delay a patient needing to come in for removal if they are overall happy with the method.
In your experience, how has COVID-19 affected patients’ interest in or ability to seek reproductive and sexual health services?
I think the interest has been the same. Women with unplanned pregnancies seeking abortion or women interested in starting contraception continue to have this interest. I think the ability to seek care has been hindered by limited appointments, changes in child care (kids not going to school during the day), and exacerbation of other barriers that have always been present for some patients, such as transportation. We have sought to be as flexible as possible in appointment times, seeing late or unconfirmed patients and rescheduling when necessary. We have worked with other organizations to have a small pot of money to help patients pay for transportation to their clinic appointment or pay for parking if they drive themselves.
I also think that as women may be concerned about losing their jobs and thus health insurance, going forward the interest in well woman exams and contraception could increase.
How has COVID-19 affected the way physicians should be thinking about access to reproductive health care?
I think as providers we should take full advantage of any patient encounter we have. If a patient has a telehealth visit with me regarding vaginal discharge or pelvic pain I also want to make sure I discuss pregnancy intention, contraception, and preventions of STIs. I may be their only touch point with the medical system for a while and want to make sure I at least opened that line of conversation. For ED providers, they have a patient physically present. They can offer some basic STI screening and counseling (this does not have to take a long time), and if it is a medically complicated patient I would urge them to contact GYN directly about setting up a telehealth appointment/further discussion of options if the patient is interested.
Are there unique questions that we should consider when making decisions about referral and follow up planning for patients with COVID-19 who are interested in terminating a pregnancy or accessing contraceptive services?
If you are caring for a patient with Illinois Medicaid who is interested in abortion services making sure they know that, since 2018, abortion is a covered benefit. This information can take one barrier away for patients. Offer them referral information to multiple sites of care (Planned Parenthood, FPA and Ryan Center) so that they can [have] options. Sometimes abortion can be booking out 2-4 weeks. If the patient is medically high-risk or in the second trimester, consider reaching out to the family planning service to help coordinate a sooner appointment.
What can emergency medicine providers do to help ensure women seeking reproductive and sexual health services get the resources and access to care they need?
If a patient is already in your ED seeking care, this is the perfect opportunity to provide some of the basic counseling around STIs and contraception/pregnancy prevention. ED providers can offer STI testing and pregnancy testing. They can screen for pregnancy risk and intention. At the least (depending on comfort level), they can counsel and prescribe emergency contraception.
What do you think are the most important research questions that need to be answered with regard to reproductive health services, particularly abortion care access, and COVID-19?
Data collection and Addressing Health Equity - Support for and participation in registries and data collection efforts to facilitate collection and analysis of comprehensive and accurate data is imperative to understand the full impact of the pandemic. These data will help us understand the full extent of these inequities and to guide equitable allocation of health care resources.
Research around telehealth and abortion. This mostly applies to medical abortion. [We could consider] changes in follow-up from in-person visits to monitoring via telephone and taking a home pregnancy test in a specified time from initial procedure. Is this system effective and are patient’s satisfied?
Are there any new policy measures, be they local or national, related to reproductive health services and COVID-19 that you are excited about? That you are apprehensive about?
The American College of Obstetricians and Gynecologists (ACOG) petitioned a federal court to require the U.S. Food and Drug Administration (FDA) to suspend a harmful restriction on mifepristone (medication used in management of early pregnancy loss and induced abortion). The requirements disproportionately affect patients from underserved communities who are burdened by the need to travel, arrange childcare, and present to their chosen clinician in person for the dispensing of the medication. More on ACOG’s petition can be found here. This perspective piece, published in the New England Journal of Medicine, also contains information regarding the regulation of mifepristone by the FDA.
Also urging payers to make expanded COVID-19 telehealth policies permanent. I think [expanded telehealth services during COVID-19] have increased access for many patients and needs to continue to be an option going forward. To read more on ACOG’s position on expanded telehealth services, click here.
[I am apprehensive] about any of the state laws that limit abortion access (making abortion not essential health care). This article contains information regarding policies issued by various states limiting access to abortion care during the COVID19 pandemic.
Are there any resources that you would recommend if people are interested in learning more about this topic?
Ideas regarding steps state policy makers can take to protect access to reproductive care during the pandemic can be found on the Guttmacher Institute.