Melissa Kottke, MD, MPH, MBA

The 1973 Supreme Court of the United States (SCOTUS) decision in Roe v Wade was a landmark ruling,¹ establishing that the United States Constitution provides a fundamental “right to privacy,” protecting pregnant people’s freedom to access all available reproductive health care options. Recognizing that the right to abortion was not absolute, the majority of justices supported a trimester system. In the first trimester, decisions about abortion care are fully controlled by patients and clinicians, and no government could place restrictions on access to abortion. In the second trimester, SCOTUS ruled that states may choose to regulate abortion to protect maternal health. (As an example of such state restrictions, in Massachusetts, for many years, but no longer, the state required that abortions occur in a hospital when the patient was between 18 and 24 weeks’ gestation in order to facilitate comprehensive emergency care for complications.) Beginning in the third trimester, a point at which a fetus could be viable, the Court ruled that a government could prohibit abortion except when an abortion was necessary to protect the life or health of the pregnant person. In 1992, the SCOTUS decision in Planned Parenthood v Casey² rejected the trimester system, reaffirming the right to an abortion before fetal viability, and adopting a new standard that states may not create an undue burden on a person seeking an abortion before fetal viability. SCOTUS ruled that an undue burden exists if the purpose of a regulation is to place substantial obstacles in the path of a person seeking an abortion.

If, as anticipated, the 2022 SCOTUS decision in Dobbs v Jackson Women’s Health Organization³ overturns the precedents set in Roe v Wade and Planned Parenthood v Casey, decisions on abortion law will be relegated to elected legislators and state courts.⁴ It is expected that at least 26 state legislatures and governors will enact stringent new restrictions on access to abortion. This cataclysmic reversal of judicial opinion creates a historic challenge to obstetrician-gynecologists and their patients and could threaten access to other vital reproductive services beyond abortion, like contraception. We will be fighting, state by state, for people’s right to access all available reproductive health procedures. This will also significantly affect the ability for providers in women’s reproductive health to obtain appropriate and necessary education and training in a critical skills. If access to safe abortion is restricted, we fear patients may be forced to consider unsafe abortion, raising the specter of a return to the 1960s, when an epidemic of unsafe abortion caused countless injuries and deaths.^5,6

How do we best prepare for these challenges?

• We will need to be flexible and continually evolve our clinical practices to be adherent with state and local legislation and regulation.
• To reduce unintended pregnancies, we need to strengthen our efforts to ensure that every patient has ready access to all available contraceptive options with no out-of-pocket cost.
• When a contraceptive is desired, we will focus on educating people about effectiveness, and offering them highly reliable contraception, such as the implant or intrauterine devices.
• We need to ensure timely access to abortion if state-based laws permit abortion before 6 or 7 weeks’ gestation. Providing medication abortion without an in-person visit using a telehealth option would be one option to expand rapid access to early first trimester abortion.
• Clinicians in states with access to abortion services will need to collaborate with colleagues in states with restrictions on abortion services to improve patient access across state borders.

On a national level, advancing our effective advocacy in Congress may lead to national legislation passed and signed by the President. This could supersede most state laws prohibiting access to comprehensive women’s reproductive health and create a unified, national approach to abortion care, allowing for the appropriate training of all obstetrician-gynecologists. We will also need to develop teams in every state capable of advocating for laws that ensure access to all reproductive health care options. The American College of Obstetricians and Gynecologists has leaders trained and tasked with legislative advocacy in every state.⁷ This network will be a foundation upon which to build additional advocacy efforts.

As women’s health care professionals, our responsibility to our patients, is to work to ensure universal access to safe and effective comprehensive reproductive options, and to ensure that our workforce is prepared to meet the needs of our patients by defending the patient-clinician relationship. Abortion care saves lives of pregnant patients and reduces maternal morbidity.⁸ Access to safe abortion care as part of comprehensive reproductive services is an important component of health care. ●

The 1973 Supreme Court of the United States (SCOTUS) decision in Roe v Wade was a landmark ruling,¹ establishing that the United States Constitution provides a fundamental “right to privacy,” protecting pregnant people’s freedom to access all available reproductive health care options. Recognizing that the right to abortion was not absolute, the majority of justices supported a trimester system. In the first trimester, decisions about abortion care are fully controlled by patients and clinicians, and no government could place restrictions on access to abortion. In the second trimester, SCOTUS ruled that states may choose to regulate abortion to protect maternal health. (As an example of such state restrictions, in Massachusetts, for many years, but no longer, the state required that abortions occur in a hospital when the patient was between 18 and 24 weeks’ gestation in order to facilitate comprehensive emergency care for complications.) Beginning in the third trimester, a point at which a fetus could be viable, the Court ruled that a government could prohibit abortion except when an abortion was necessary to protect the life or health of the pregnant person. In 1992, the SCOTUS decision in Planned Parenthood v Casey² rejected the trimester system, reaffirming the right to an abortion before fetal viability, and adopting a new standard that states may not create an undue burden on a person seeking an abortion before fetal viability. SCOTUS ruled that an undue burden exists if the purpose of a regulation is to place substantial obstacles in the path of a person seeking an abortion.

If, as anticipated, the 2022 SCOTUS decision in Dobbs v Jackson Women’s Health Organization³ overturns the precedents set in Roe v Wade and Planned Parenthood v Casey, decisions on abortion law will be relegated to elected legislators and state courts.⁴ It is expected that at least 26 state legislatures and governors will enact stringent new restrictions on access to abortion. This cataclysmic reversal of judicial opinion creates a historic challenge to obstetrician-gynecologists and their patients and could threaten access to other vital reproductive services beyond abortion, like contraception. We will be fighting, state by state, for people’s right to access all available reproductive health procedures. This will also significantly affect the ability for providers in women’s reproductive health to obtain appropriate and necessary education and training in a critical skills. If access to safe abortion is restricted, we fear patients may be forced to consider unsafe abortion, raising the specter of a return to the 1960s, when an epidemic of unsafe abortion caused countless injuries and deaths.^5,6

How do we best prepare for these challenges?

• We will need to be flexible and continually evolve our clinical practices to be adherent with state and local legislation and regulation.
• To reduce unintended pregnancies, we need to strengthen our efforts to ensure that every patient has ready access to all available contraceptive options with no out-of-pocket cost.
• When a contraceptive is desired, we will focus on educating people about effectiveness, and offering them highly reliable contraception, such as the implant or intrauterine devices.
• We need to ensure timely access to abortion if state-based laws permit abortion before 6 or 7 weeks’ gestation. Providing medication abortion without an in-person visit using a telehealth option would be one option to expand rapid access to early first trimester abortion.
• Clinicians in states with access to abortion services will need to collaborate with colleagues in states with restrictions on abortion services to improve patient access across state borders.

On a national level, advancing our effective advocacy in Congress may lead to national legislation passed and signed by the President. This could supersede most state laws prohibiting access to comprehensive women’s reproductive health and create a unified, national approach to abortion care, allowing for the appropriate training of all obstetrician-gynecologists. We will also need to develop teams in every state capable of advocating for laws that ensure access to all reproductive health care options. The American College of Obstetricians and Gynecologists has leaders trained and tasked with legislative advocacy in every state.⁷ This network will be a foundation upon which to build additional advocacy efforts.

As women’s health care professionals, our responsibility to our patients, is to work to ensure universal access to safe and effective comprehensive reproductive options, and to ensure that our workforce is prepared to meet the needs of our patients by defending the patient-clinician relationship. Abortion care saves lives of pregnant patients and reduces maternal morbidity.⁸ Access to safe abortion care as part of comprehensive reproductive services is an important component of health care. ●

The 1973 Supreme Court of the United States (SCOTUS) decision in Roe v Wade was a landmark ruling,¹ establishing that the United States Constitution provides a fundamental “right to privacy,” protecting pregnant people’s freedom to access all available reproductive health care options. Recognizing that the right to abortion was not absolute, the majority of justices supported a trimester system. In the first trimester, decisions about abortion care are fully controlled by patients and clinicians, and no government could place restrictions on access to abortion. In the second trimester, SCOTUS ruled that states may choose to regulate abortion to protect maternal health. (As an example of such state restrictions, in Massachusetts, for many years, but no longer, the state required that abortions occur in a hospital when the patient was between 18 and 24 weeks’ gestation in order to facilitate comprehensive emergency care for complications.) Beginning in the third trimester, a point at which a fetus could be viable, the Court ruled that a government could prohibit abortion except when an abortion was necessary to protect the life or health of the pregnant person. In 1992, the SCOTUS decision in Planned Parenthood v Casey² rejected the trimester system, reaffirming the right to an abortion before fetal viability, and adopting a new standard that states may not create an undue burden on a person seeking an abortion before fetal viability. SCOTUS ruled that an undue burden exists if the purpose of a regulation is to place substantial obstacles in the path of a person seeking an abortion.

If, as anticipated, the 2022 SCOTUS decision in Dobbs v Jackson Women’s Health Organization³ overturns the precedents set in Roe v Wade and Planned Parenthood v Casey, decisions on abortion law will be relegated to elected legislators and state courts.⁴ It is expected that at least 26 state legislatures and governors will enact stringent new restrictions on access to abortion. This cataclysmic reversal of judicial opinion creates a historic challenge to obstetrician-gynecologists and their patients and could threaten access to other vital reproductive services beyond abortion, like contraception. We will be fighting, state by state, for people’s right to access all available reproductive health procedures. This will also significantly affect the ability for providers in women’s reproductive health to obtain appropriate and necessary education and training in a critical skills. If access to safe abortion is restricted, we fear patients may be forced to consider unsafe abortion, raising the specter of a return to the 1960s, when an epidemic of unsafe abortion caused countless injuries and deaths.^5,6

How do we best prepare for these challenges?

• We will need to be flexible and continually evolve our clinical practices to be adherent with state and local legislation and regulation.
• To reduce unintended pregnancies, we need to strengthen our efforts to ensure that every patient has ready access to all available contraceptive options with no out-of-pocket cost.
• When a contraceptive is desired, we will focus on educating people about effectiveness, and offering them highly reliable contraception, such as the implant or intrauterine devices.
• We need to ensure timely access to abortion if state-based laws permit abortion before 6 or 7 weeks’ gestation. Providing medication abortion without an in-person visit using a telehealth option would be one option to expand rapid access to early first trimester abortion.
• Clinicians in states with access to abortion services will need to collaborate with colleagues in states with restrictions on abortion services to improve patient access across state borders.

On a national level, advancing our effective advocacy in Congress may lead to national legislation passed and signed by the President. This could supersede most state laws prohibiting access to comprehensive women’s reproductive health and create a unified, national approach to abortion care, allowing for the appropriate training of all obstetrician-gynecologists. We will also need to develop teams in every state capable of advocating for laws that ensure access to all reproductive health care options. The American College of Obstetricians and Gynecologists has leaders trained and tasked with legislative advocacy in every state.⁷ This network will be a foundation upon which to build additional advocacy efforts.

As women’s health care professionals, our responsibility to our patients, is to work to ensure universal access to safe and effective comprehensive reproductive options, and to ensure that our workforce is prepared to meet the needs of our patients by defending the patient-clinician relationship. Abortion care saves lives of pregnant patients and reduces maternal morbidity.⁸ Access to safe abortion care as part of comprehensive reproductive services is an important component of health care. ●

In February of 2016, the World Health Organization declared Zika a Public Health Emergency of International Concern and the Centers for Disease and Prevention elevated its Zika Emergency Operation Center activation to Level 1, its highest level. The Zika epidemic is unique in many ways, particularly in that women and reproductive health care are at the center of the epidemic.

Most people who are infected with Zika are asymptomatic; those who do have symptoms generally have a mild, self-limited infection. However, a pregnant woman can pass the infection to her fetus, which can lead to severe outcomes. As ob.gyns., we are called upon to guide pregnant women who have been exposed or infected regarding testing, diagnosis, options counseling, surveillance, and management. Additionally, we can help pregnant women prevent Zika infection. Discuss avoiding travel for her and her partner(s) to areas with Zika. Encourage strategies for mosquito bite prevention if traveling to endemic areas and at home. Recommend abstaining from sex or using a condom for those who have partners who have recently traveled to areas with Zika transmission.

With that said, most of our patients are not pregnant. Many are capable of pregnancy and potentially at risk for unintended pregnancy since almost half of pregnancies in the United States are unintended (N Engl J Med. 2016 Mar 3;374[9]:843-52). Contraception for women who are not desiring pregnancy may help prevent unintended pregnancy, but also may help prevent the serious effects that can be seen with mother-to-fetus transmission of Zika. We can play a critical role in this important prevention message for nonpregnant women.

We do not know how long the Zika virus will continue to spread nor do we know whether we will have local transmission in the continental U.S. But we do know that travel is common and sexual transmission is possible. As such, all women need to be educated about the Zika virus. All women should be aware of the risks it poses for their reproductive health and be given an opportunity to discuss what that might mean to each of them. Whether a woman is planning a pregnancy, trying to avoid one, or is unsure of what she wants, having a conversation with her ob.gyn. may help her feel informed and supported in making the best decision for her right now. This may be particularly true of her plans for pregnancy timing and the use of contraception and condoms.

Beyond travel screening and mosquito bite prevention strategies, there are several key messages that we are uniquely poised to relay about Zika prevention. First, women who have been exposed to Zika should delay trying to conceive for 8 weeks. The recommendation for male partners to delay conception ranges from 8 weeks to 6 months depending upon local transmission and presence of symptoms. For those who are not trying to become pregnant or who want to delay pregnancy because of Zika concerns or exposures, we should offer the full range of contraceptive options and work with each patient to optimize her contraceptive selection, based on her individual preferences, goals, and needs. Finally, women should be counseled to avoid transmission from sex by choosing to not have sex or by using a condom with each act of sex with a partner who may have been exposed to Zika.

Our understanding of Zika infection is rapidly evolving. It will be particularly important for us to stay current on this issue. Providers can access up-to-date information about Zika, provider updates, patient information, posters and other information about the emergency response from the CDC’s website at www.cdc.gov/zika/index.html.

There are several tools available for guidance in these conversations. On July 1, 2016, the Office of Population Affairs released a toolkit for Providing Family Planning Care for Non-Pregnant Women and Men of Reproductive Age in the Context of Zika. It is available online at: www.hhs.gov/opa/news#toolkit.

The CDC also offers comprehensive guidance on providing contraception. Providers can access the Medical Eligibility Criteria for Contraceptive Use, the Selected Practice Recommendations for Contraceptive Use, and Providing Quality Family Planning Services, all of which are available on the CDC website.

Dr. Kottke is an associate professor in the department of gynecology and obstetrics at Emory University in Atlanta, Georgia. She is the director of the Jane Fonda Center at Emory, which is involved in research and program development focused on adolescent sexual and reproductive health. She also serves as the medical consultant for the state of Georgia’s Family Planning Program. Dr. Kottke reported that she is a Nexplanon (Merck) trainer, is a consultant to CSL Behring, and serves on the advisory board for Evofem.

In February of 2016, the World Health Organization declared Zika a Public Health Emergency of International Concern and the Centers for Disease and Prevention elevated its Zika Emergency Operation Center activation to Level 1, its highest level. The Zika epidemic is unique in many ways, particularly in that women and reproductive health care are at the center of the epidemic.

Most people who are infected with Zika are asymptomatic; those who do have symptoms generally have a mild, self-limited infection. However, a pregnant woman can pass the infection to her fetus, which can lead to severe outcomes. As ob.gyns., we are called upon to guide pregnant women who have been exposed or infected regarding testing, diagnosis, options counseling, surveillance, and management. Additionally, we can help pregnant women prevent Zika infection. Discuss avoiding travel for her and her partner(s) to areas with Zika. Encourage strategies for mosquito bite prevention if traveling to endemic areas and at home. Recommend abstaining from sex or using a condom for those who have partners who have recently traveled to areas with Zika transmission.

With that said, most of our patients are not pregnant. Many are capable of pregnancy and potentially at risk for unintended pregnancy since almost half of pregnancies in the United States are unintended (N Engl J Med. 2016 Mar 3;374[9]:843-52). Contraception for women who are not desiring pregnancy may help prevent unintended pregnancy, but also may help prevent the serious effects that can be seen with mother-to-fetus transmission of Zika. We can play a critical role in this important prevention message for nonpregnant women.

We do not know how long the Zika virus will continue to spread nor do we know whether we will have local transmission in the continental U.S. But we do know that travel is common and sexual transmission is possible. As such, all women need to be educated about the Zika virus. All women should be aware of the risks it poses for their reproductive health and be given an opportunity to discuss what that might mean to each of them. Whether a woman is planning a pregnancy, trying to avoid one, or is unsure of what she wants, having a conversation with her ob.gyn. may help her feel informed and supported in making the best decision for her right now. This may be particularly true of her plans for pregnancy timing and the use of contraception and condoms.

Beyond travel screening and mosquito bite prevention strategies, there are several key messages that we are uniquely poised to relay about Zika prevention. First, women who have been exposed to Zika should delay trying to conceive for 8 weeks. The recommendation for male partners to delay conception ranges from 8 weeks to 6 months depending upon local transmission and presence of symptoms. For those who are not trying to become pregnant or who want to delay pregnancy because of Zika concerns or exposures, we should offer the full range of contraceptive options and work with each patient to optimize her contraceptive selection, based on her individual preferences, goals, and needs. Finally, women should be counseled to avoid transmission from sex by choosing to not have sex or by using a condom with each act of sex with a partner who may have been exposed to Zika.

Our understanding of Zika infection is rapidly evolving. It will be particularly important for us to stay current on this issue. Providers can access up-to-date information about Zika, provider updates, patient information, posters and other information about the emergency response from the CDC’s website at www.cdc.gov/zika/index.html.

There are several tools available for guidance in these conversations. On July 1, 2016, the Office of Population Affairs released a toolkit for Providing Family Planning Care for Non-Pregnant Women and Men of Reproductive Age in the Context of Zika. It is available online at: www.hhs.gov/opa/news#toolkit.

The CDC also offers comprehensive guidance on providing contraception. Providers can access the Medical Eligibility Criteria for Contraceptive Use, the Selected Practice Recommendations for Contraceptive Use, and Providing Quality Family Planning Services, all of which are available on the CDC website.

Dr. Kottke is an associate professor in the department of gynecology and obstetrics at Emory University in Atlanta, Georgia. She is the director of the Jane Fonda Center at Emory, which is involved in research and program development focused on adolescent sexual and reproductive health. She also serves as the medical consultant for the state of Georgia’s Family Planning Program. Dr. Kottke reported that she is a Nexplanon (Merck) trainer, is a consultant to CSL Behring, and serves on the advisory board for Evofem.

In February of 2016, the World Health Organization declared Zika a Public Health Emergency of International Concern and the Centers for Disease and Prevention elevated its Zika Emergency Operation Center activation to Level 1, its highest level. The Zika epidemic is unique in many ways, particularly in that women and reproductive health care are at the center of the epidemic.

Most people who are infected with Zika are asymptomatic; those who do have symptoms generally have a mild, self-limited infection. However, a pregnant woman can pass the infection to her fetus, which can lead to severe outcomes. As ob.gyns., we are called upon to guide pregnant women who have been exposed or infected regarding testing, diagnosis, options counseling, surveillance, and management. Additionally, we can help pregnant women prevent Zika infection. Discuss avoiding travel for her and her partner(s) to areas with Zika. Encourage strategies for mosquito bite prevention if traveling to endemic areas and at home. Recommend abstaining from sex or using a condom for those who have partners who have recently traveled to areas with Zika transmission.

With that said, most of our patients are not pregnant. Many are capable of pregnancy and potentially at risk for unintended pregnancy since almost half of pregnancies in the United States are unintended (N Engl J Med. 2016 Mar 3;374[9]:843-52). Contraception for women who are not desiring pregnancy may help prevent unintended pregnancy, but also may help prevent the serious effects that can be seen with mother-to-fetus transmission of Zika. We can play a critical role in this important prevention message for nonpregnant women.

We do not know how long the Zika virus will continue to spread nor do we know whether we will have local transmission in the continental U.S. But we do know that travel is common and sexual transmission is possible. As such, all women need to be educated about the Zika virus. All women should be aware of the risks it poses for their reproductive health and be given an opportunity to discuss what that might mean to each of them. Whether a woman is planning a pregnancy, trying to avoid one, or is unsure of what she wants, having a conversation with her ob.gyn. may help her feel informed and supported in making the best decision for her right now. This may be particularly true of her plans for pregnancy timing and the use of contraception and condoms.

Beyond travel screening and mosquito bite prevention strategies, there are several key messages that we are uniquely poised to relay about Zika prevention. First, women who have been exposed to Zika should delay trying to conceive for 8 weeks. The recommendation for male partners to delay conception ranges from 8 weeks to 6 months depending upon local transmission and presence of symptoms. For those who are not trying to become pregnant or who want to delay pregnancy because of Zika concerns or exposures, we should offer the full range of contraceptive options and work with each patient to optimize her contraceptive selection, based on her individual preferences, goals, and needs. Finally, women should be counseled to avoid transmission from sex by choosing to not have sex or by using a condom with each act of sex with a partner who may have been exposed to Zika.

Our understanding of Zika infection is rapidly evolving. It will be particularly important for us to stay current on this issue. Providers can access up-to-date information about Zika, provider updates, patient information, posters and other information about the emergency response from the CDC’s website at www.cdc.gov/zika/index.html.

There are several tools available for guidance in these conversations. On July 1, 2016, the Office of Population Affairs released a toolkit for Providing Family Planning Care for Non-Pregnant Women and Men of Reproductive Age in the Context of Zika. It is available online at: www.hhs.gov/opa/news#toolkit.

The CDC also offers comprehensive guidance on providing contraception. Providers can access the Medical Eligibility Criteria for Contraceptive Use, the Selected Practice Recommendations for Contraceptive Use, and Providing Quality Family Planning Services, all of which are available on the CDC website.

Dr. Kottke is an associate professor in the department of gynecology and obstetrics at Emory University in Atlanta, Georgia. She is the director of the Jane Fonda Center at Emory, which is involved in research and program development focused on adolescent sexual and reproductive health. She also serves as the medical consultant for the state of Georgia’s Family Planning Program. Dr. Kottke reported that she is a Nexplanon (Merck) trainer, is a consultant to CSL Behring, and serves on the advisory board for Evofem.