A blueprint for a new model of sexual and reproductive health care in subspecialty medicine

Abstract

The United States has the highest rate of maternal mortality of any developed country in the world. 1 This excess mortality burden is related, in part, to the rising prevalence of pregnant people with chronic diseases, such as systemic lupus erythematosus, pulmonary hypertension, asthma, cystic fibrosis, diabetes, hypertension, epilepsy, chronic kidney disease, and inflammatory bowel disease. [2][3][4][5][6] Patients with chronic diseases are significantly more likely to experience adverse pregnancy and perinatal outcomes than healthy people. [7][8][9] In addition, people of color, people who are poor, or who are otherwise socially marginalized, experience the worst pregnancy outcomes as a result of the complex intersections between chronic disease and social determinants of health, structural and medical racism, and inadequate access to quality health care. 10,11 Medicine subspecialists are often consulted to provide expert clinical care to people whose chronic diseases are particularly severe, complicated, or rare. 12 Subspecialists are responsible for helping to manage the pregnancies of some of the most complex and severely ill patients-the very patients who are at greatest risk of death during pregnancy. Subspecialists who are armed with salient knowledge and experience may be better able to prepare patients for a healthy pregnancy; counsel patients with accurate and up-to-date information; address issues that might complicate a pregnancy, such as the use of teratogenic medications; advise patients about the safety of their contraception options; identify "red flags" that might suggest worsening disease severity of life-threatening sequelae during pregnancy (e.g., preeclampsia); and make referrals for abortion care when needed and if available. Such competencies may be lifesaving. However, at present, subspecialty medical practice may paradoxically potentiate adverse reproductive outcomes. 10 Subspecialists across the internal medicine disciplines of rheumatology, pulmonary and critical care medicine, gastroenterology/transplant hepatology, cardiology, nephrology, endocrinology, infectious disease, and hematology-oncology, indicate that they do not have the basic knowledge, skills, or resources to manage disease-related aspects of sexual and reproductive health (SRH). [13][14][15][16][17][18][19][20][21][22] Our collective of multidisciplinary subspecialty clinicians and health services researchers has described some of the common challenges that subspecialists feel undermine their provision of SRH

Barriers and enabling factors to reproductive healthcare utilization for women in the sex trade: a qualitative study

“…General guidelines. First, interventions should be based on woman-centered and trauma-informed approaches as well as principles of reproductive justice, which emphasize women's preferences and life circumstances as a foundation for equitable RHC delivery [32]. Second, RHC utilization by women in the sex trade should be regarded as a "window of opportunity" to identify psychosocial needs surrounding violence, addictions, mental health, etc.…”

Continuing to chart the course toward improved reproductive care for women with chronic conditions

“…Birru Talabi et al continue this conversation with a focus on subspecialty medicine, offering a beautifully constructed set of strategies for improving care for women with chronic conditions. 9 Their work underscores the Roadmap's focus on the importance of pre/interprofessional building trust. 11 The authors' work focuses on building patientprovider communication and enhancing women with a physical disability's capacity to make fully informed decisions about childbearing through the design and testing of a pregnancy decision-making tool.…”

“…Birru Talabi et al continue this conversation with a focus on subspecialty medicine, offering a beautifully constructed set of strategies for improving care for women with chronic conditions. 9 Their work underscores the Roadmap's focus on the importance of pre/interprofessional training and collaboration as well as building relational care and bidirectional education for women with chronic conditions. The work of these two author teams reflects and in part responds to challenges described by Black and NA women in the paper by Verbiest et al in the December issue.…”