To be healthy, support their families, and be productive members of their communities, women must have access to comprehensive reproductive health services including treatment of miscarriage and ectopic pregnancy and access to abortion, sterilization, and other contraceptive methods. However, in the United States, hospitals and legislative bodies are erecting barriers and limiting access to these basic health care services. These barriers are caused by factors such as hospital mergers (specifically those that are religiously affiliated); federal, state, and local legislation; hospital policies; and business-related decisions are threatening reproductive health care. Such barriers, of which women are often not even aware, put women at real risk of harm. This commentary provides clinical examples of these harms and recommends ways that obstetrician-gynecologists can get involved to publicize the consequences of these barriers and, hopefully, prevent them from occurring or break them down to promote women’s health.
The Scope of the problem
Receiving reproductive health care is becoming increasingly difficult for women in the United States. The most well-publicized restrictions are on access to abortion and contraception, but as we highlight in the following text, the access issues are much broader, placing women at risk of harm and eroding the quality of the doctor-patient relationship. This Viewpoint provides clinical examples of these harms and recommended actions obstetrician-gynecologists can take to address the existing obstacles and prevent new threats women’s health.
The barriers to reproductive health care have arisen for many reasons. First, many publicly funded hospitals are consolidating or closing, whereas religiously affiliated health systems are expanding, such that they accounted for more than 1 in 9 hospital admissions in the United States in 2011. For example, in Washington state, almost 40% of hospital beds are in religiously affiliated hospitals. These hospitals often consider the life of the fetus to be equal to that of the mother and thus restrict physicians’ abilities to provide life-saving management of miscarriages or ectopic pregnancies.
Second, health care institutions limit the scope of reproductive health care because of hospital policies, financial pressures, and a desire to limit negative press. In some cases, large hospital systems dictate the types of reproductive health services that private practice clinicians with admitting privileges at their hospitals can provide while providing inpatient care. In addition, large hospital systems increasingly own physician practices, and those same limits are being forced into ambulatory office settings.
Finally, legislative decisions lead hospitals to limit reproductive health care services. For example, in 2011, the Virginia Board of Health demanded that clinics providing abortions adhere to the same architectural requirements as newly constructed hospitals. This demand was later overturned because it became clear that these limitations compromised, rather than promoted, women’s health and were not based in necessity.
Recently the US Supreme Court struck down similar requirements for abortion clinics in Texas to meet ambulatory surgical center regulations because such regulations do not improve the safety of the procedure or promote women’s health but do pose an undue burden to women’s ability to access basic health care services. Although we celebrate these small victories, we are mindful of the many challenges women still face in obtaining reproductive health care.
Clinical examples
The first step in solving a problem is identifying it. Thus, in this report we present several examples of ways in which restrictions on reproductive health care are putting women at risk of harm.
Miscarriage
Although most miscarriages occur in the first trimester and are uncomplicated, sometimes an early pregnancy loss requires urgent intervention. Premature rupture of membranes and other second-trimester pregnancy complications often require induction of labor or uterine evacuation to remove the previable fetus. Delays in treatment put women at risk of hemorrhage, infection, psychological trauma, and death. However, some institutions forbid an evacuation if the fetus has cardiac activity, and others require evidence of infection before clinicians are allowed to intervene. Additionally, confusion about when or if exceptions are allowed can delay care.
Ectopic pregnancy
In nearly all ectopic pregnancies, the fetus will not survive. If not surgically removed or treated medically in a timely fashion, ectopic pregnancy can cause hemorrhage, impair the woman’s future fertility, and even result in maternal death. Despite these consequences, some hospital policies prevent practitioners from intervening before tubal rupture if the fetus has cardiac activity. Such unnecessary delays in care have grave medical, legal, and ethical implications.
Induced abortion
The American College of Obstetricians and Gynecologists (the College) has recognized abortion care as basic health care for women, and the College encourages hospitals and women’s health care providers to support abortion care as essential medical care for women and to eliminate barriers to the provision of such care. All pregnancies carry risks of maternal morbidity and mortality, especially in the second and third trimesters, such as postpartum hemorrhage and cesarean delivery–related morbidities. Although millions of women each year are willing to take these risks to have a baby, women with unwanted pregnancies should have access to the safer option, abortion, if that is their choice. Additionally, when women with desired pregnancies are diagnosed with maternal or fetal complications, they may choose abortion as the best treatment option for their clinical situation.
Clinical examples
The first step in solving a problem is identifying it. Thus, in this report we present several examples of ways in which restrictions on reproductive health care are putting women at risk of harm.
Miscarriage
Although most miscarriages occur in the first trimester and are uncomplicated, sometimes an early pregnancy loss requires urgent intervention. Premature rupture of membranes and other second-trimester pregnancy complications often require induction of labor or uterine evacuation to remove the previable fetus. Delays in treatment put women at risk of hemorrhage, infection, psychological trauma, and death. However, some institutions forbid an evacuation if the fetus has cardiac activity, and others require evidence of infection before clinicians are allowed to intervene. Additionally, confusion about when or if exceptions are allowed can delay care.
Ectopic pregnancy
In nearly all ectopic pregnancies, the fetus will not survive. If not surgically removed or treated medically in a timely fashion, ectopic pregnancy can cause hemorrhage, impair the woman’s future fertility, and even result in maternal death. Despite these consequences, some hospital policies prevent practitioners from intervening before tubal rupture if the fetus has cardiac activity. Such unnecessary delays in care have grave medical, legal, and ethical implications.
Induced abortion
The American College of Obstetricians and Gynecologists (the College) has recognized abortion care as basic health care for women, and the College encourages hospitals and women’s health care providers to support abortion care as essential medical care for women and to eliminate barriers to the provision of such care. All pregnancies carry risks of maternal morbidity and mortality, especially in the second and third trimesters, such as postpartum hemorrhage and cesarean delivery–related morbidities. Although millions of women each year are willing to take these risks to have a baby, women with unwanted pregnancies should have access to the safer option, abortion, if that is their choice. Additionally, when women with desired pregnancies are diagnosed with maternal or fetal complications, they may choose abortion as the best treatment option for their clinical situation.
Prenatal diagnosis
Offering prenatal diagnostic screening to all pregnant women has become common practice in the United States over the last decade. When hopeful parents-to-be learn that their fetus has a severe anomaly, they may choose to have an abortion. Because of this, or perhaps to limit up-front costs, many health care institutions limit the standard screening tests that physicians can offer to pregnant patients.
Contraception and sterilization
Nearly half of all pregnancies in the United States are unintended, and approximately 40% of those are terminated. To decrease unintended and unwanted pregnancies, women should have unimpeded access to all US Food and Drug Administration–approved contraceptive methods and sterilization procedures. However, many religiously affiliated hospitals and faith-based health insurance plans limit the contraceptive options of the women they serve, thereby infringing on patient autonomy and compromising health care quality.
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