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Reproductive healthcare during a pandemic: a New York state of mind

      Abstract

      The purpose of this Commentary is to assess whether the designation by New York State Department of Health of ‘sexual and reproductive health services as essential’ is consonant with the seemingly divergent objectives of providing patient-centred care and advancing national public health objectives in the resource-constrained setting of a global pandemic.

      Keywords

      On 7 April 2020, from its position at the epicentre of the COVID-19 epidemic, the New York State Department of Health, acting on Executive Order 202.10 of Governor Andrew M. Cuomo, courageously recognized
      Health Advisory
      Sexual and Reproductive Health Services During the COVID-19 Public Health Emergency.
      . The types of sexual and reproductive health services deemed essential included contraception, fertility treatments, gynaecological surgeries, abortion services, obstetric care, treatment of sexually transmitted diseases, and gynaecological and breast care. In addition, the New York Department of Health took care to emphasize that the ‘ultimate decision on when such services must occur is between a patient and clinical provider’. It is the purpose of this article to assess whether the designation of ‘sexual and reproductive health services as essential’ is consonant with the seemingly divergent objectives of providing patient-centred care and advancing national public health objectives in the resource-constrained setting of a global pandemic.
      The remarkable position taken by New York State must be viewed in the context of the response to the COVID-19 pandemic, which has illuminated multiple deficiencies in the US healthcare system. The rapid shift from patient-centred care to a national public health campaign has presented complex ethical dilemmas and challenged the very core of the moral values of clinicians (

      Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2 (COVID-19). The Hastings Center. available athttps://www.thehastingscenter.org/wp-content/uploads/HastingsCenterCovidFramework2020.pdf; Accessed April 10, 2020

      ). Frontline healthcare professionals have simultaneously faced physical danger due to scarcity of personal protective equipment, and deteriorating economic conditions due to strain placed by the pandemic on the entire US healthcare system. To date, the Centers for Disease Control and Prevention (CDC) have reported over 9000 infections among US healthcare workers; tragically, many have lost their lives in their line of duty. In this challenging environment, regulatory agencies including the CDC and many state Departments of Health have called for the suspension of ‘elective’ and ‘non-essential’ medical services. In a number of states, including Texas and Ohio, reproductive healthcare, including abortion services, have been all but suspended under such decrees (
      • Bayefsky M.J.
      • Bartz D.
      • Watson K.L.
      Abortion during the Covid-19 Pandemic - Ensuring Access to an Essential Health Service.
      ). As such, these drastic steps risk rolling back much of the progress that has been achieved in reproductive medicine and in reproductive rights over the past generation. Viewed in this context, the policy directive issued by New York State stands out as exceptional. Even in its darkest hour, the state of New York elected to declare reproductive health services as ‘essential’.
      The rationales advanced for the discontinuation of reproductive healthcare services emphasized the importance of preventing the diversion of critical resources from hospitals and of minimizing the contagion through social distancing. Both arguments, however, are misguided. After all, most reproductive healthcare encounters take place in an ambulatory setting and thus do not divert significant critical resources away from the care of COVID-19 patients in hospital settings. Moreover, the postponement of reproductive care is likely to prove counterproductive by potentially exacerbating both the acuity and severity of extant and evolving reproductive conditions. Women faced with abnormal uterine bleeding, endometriosis and ectopic gestation can be successfully managed in an ambulatory setting rather than in emergency and hospital operating rooms. Delayed access to contraception and abortion services is particularly troubling since unintended pregnancies result in termination at later stages when the risks of complications are substantially higher (
      • Bayefsky M.J.
      • Bartz D.
      • Watson K.L.
      Abortion during the Covid-19 Pandemic - Ensuring Access to an Essential Health Service.
      ). Alternatively, women who are denied abortion services and instead continue their undesired pregnancies will require significant ongoing healthcare resources, especially obstetric and neonatal care. The most vulnerable women, who already face disparities in the access to healthcare, will likely be disproportionately affected by delayed access to care. Finally, ambulatory practices have rapidly implemented steps to mitigate the risk of contagion by offering telemedicine for non-urgent consultations, enhanced hygiene protocols, infection screening prior to clinical encounters, and social distancing of patients and staff in public areas. Collectively, these efforts minimize the risk of infection for patients and clinical staff, without interrupting critical patient care in an ambulatory setting.
      Several professional associations have gone on record to articulate official positions consonant with the position promulgated by New York State. In its official statement,

      The American Academy of Family Physicians Support of Continued Access to Reproductive Health Services During the COVID-19 Pandemic. Available athttps://www.aafp.org/dam/AAFP/documents/advocacy/prevention/women/ST-RHHealthDuringCOVID-040220.pdf. Accessed April 12, 2020

      (AAFP) notes that ‘we must remain patient-centric and recognize that delaying care has immediate impacts on the health of the woman ... physicians … should be trusted to make decisions in the best interest of their patients’. Similarly, the

      COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology; American College of Obstetricians and Gynecologists. available athttps://www.acog.org/clinical-information/physician-faqs/covid19-faqs-for-ob-gyns-gynecology; Accessed April 17, 2020

      (ACOG) has recommended that gynaecological patients be triaged based on the urgency of the condition while ‘ensuring that patients who are pregnant or considering becoming pregnant have the patient-centered, safe care they need’. ACOG has also voiced unequivocal support for continued access to ‘essential’ and ‘time-sensitive’ abortion services, and emphasized that ‘the consequences of being unable to obtain an abortion profoundly affects a person's life, health, and well-being.’ Finally, not only has ACOG demonstrated its continued support for women's reproductive rights and access to care, but it has also gone on to offer detailed guidance to providers with an eye toward attenuating the risk of infection within their practices.
      While early in the pandemic both American and European reproductive medical societies took a cautious approach and advised the postponement of most non-urgent infertility treatments, as more data about the virus emerged these organizations’ position has shifted. In a recent the American Society for Reproductive Medicine (ASRM), the International Federation of Fertility Societies (IFFS) and the European Society for Human Reproduction and Embryology (ESHRE) concluded that ‘Reproduction is an essential human right that exists regardless of race, gender, sexual orientation or country of origin’ and that ‘Reproductive care is essential.’
      The Affordable Care Act (ACA) has notably improved access to reproductive healthcare in the realm of family planning and pregnancy termination (
      • Daw J.R.
      • Sommers B.D.
      The Affordable Care Act and Access to Care for Reproductive-Aged and Pregnant Women in the United States, 2010–2016.
      ). However, comprehensive support for specialized reproductive services such as infertility care was not included in the ACA. In its progressive quest to address unmet reproductive needs, New York State has taken to address this void as well by passing Insurance Laws §§ 3221(k)(6)(C) and 4303(s)(3), aimed at expanding access to infertility treatments. These laws, along with Executive Order 202.10, place New York State at the forefront of the nascent national efforts to assure comprehensive maternal and reproductive healthcare for all.
      The

      Universal Declaration of Human Rights, United Nations; available athttps://www.un.org/en/universal-declaration-human-rights/index.html; Accessed April 10, 2020

      stands firm behind the ‘right to marry and to found a family’. The suspension of time-sensitive reproductive healthcare, even in the midst of a pandemic, is not only counterproductive, but may also undermine what has been deemed a fundamental human right. Reproductive health decisions fall under the premise of shared decision-making, a key component of patient-centred healthcare. Providing patients with informed consent about the benefits versus risks of proceeding with essential reproductive services ensures that physicians are practising with beneficence while allowing patient autonomy to frame the final decision. Front-line physicians are best positioned to triage patients based on the acuity of the circumstance and to provide indicated urgent care. Empowering front-line physicians to determine the best course of action is not only beneficial for individual patients, but also, in the context of essential reproductive healthcare, consistent with advancing public health. An alteration in this course of action may result in a recession of women's rights that could take decades to reverse. The healthcare system must thus rely on its dedicated front-line healthcare professionals to continue providing patient-centered care while acting in the best interest of the public. These front-line providers deserve the full trust and support of the nation, its states and its professional organizations. Once the current crisis abates, one would hope that the healthcare community and the regulatory bodies thereof will follow New York's lead, thereby uniting around the simple truth that reproductive healthcare is essential, and that decisions concerning its exercise are best left to the patient and her provider.

      References

        • Bayefsky M.J.
        • Bartz D.
        • Watson K.L.
        Abortion during the Covid-19 Pandemic - Ensuring Access to an Essential Health Service.
        N. Engl. J. Med. 2020; 382 (May 7): e47https://doi.org/10.1056/NEJMp2008006
      1. COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology; American College of Obstetricians and Gynecologists. available athttps://www.acog.org/clinical-information/physician-faqs/covid19-faqs-for-ob-gyns-gynecology; Accessed April 17, 2020

      2. COVID-19 and Human Reproduction Joint Statement: ASRM/ESHRE/IFFS. available athttps://www.asrm.org/covid-19-and-human-reproduction-joint-statement-asrm-eshre-iffs?utm_source=Informz&utm_medium=email&utm_campaign=EmailBlast&_zs=VAqBd1&_zl=QPuo6. Accessed June 4, 2020

        • Daw J.R.
        • Sommers B.D.
        The Affordable Care Act and Access to Care for Reproductive-Aged and Pregnant Women in the United States, 2010–2016.
        Am. J. Public Health. 2019; 109 (Apr): 565-571https://doi.org/10.2105/AJPH.2018.304928
      3. Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2 (COVID-19). The Hastings Center. available athttps://www.thehastingscenter.org/wp-content/uploads/HastingsCenterCovidFramework2020.pdf; Accessed April 10, 2020

        • Health Advisory
        Sexual and Reproductive Health Services During the COVID-19 Public Health Emergency.
        New York State Department of Health, 2020 (available at) (Accessed April 10)
      4. The American Academy of Family Physicians Support of Continued Access to Reproductive Health Services During the COVID-19 Pandemic. Available athttps://www.aafp.org/dam/AAFP/documents/advocacy/prevention/women/ST-RHHealthDuringCOVID-040220.pdf. Accessed April 12, 2020

      5. Universal Declaration of Human Rights, United Nations; available athttps://www.un.org/en/universal-declaration-human-rights/index.html; Accessed April 10, 2020