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Urgent Call to Action: Engaging Hospitalists in Family Planning

T here are no training requirements in family planning for most hospitalists, possibly due to having timelimited relationships with patients and rare involvement in longitudinal care. Hospitalists frequently take care of patients of childbearing age, and this has never been more the case than now because of the concurrent epidemics of COVID-19, substance use disorders, and obesity and their resultant complications among younger persons. We argue that hospitalists should be addressing contraceptive needs among inpatients despite possible challenges. Current deliberations by the U.S. Supreme Court about abortion rights give new urgency to considering women's contraceptive needs in all interactions with the health care system. Accessing safe abortion is already difficult for millions of persons in this country, and it is expected to get much worse now that Roe v. Wade is overturned. This is expected to disproportionately affect low-income persons and people of color. As hospitalists, we have an opportunity to mitigate the damage this would cause by facilitating desired contraception. Nearly half of all pregnancies in the United States are unintended (1), and unintended pregnancy is associated with worse outcomes—not to mention profound changes in people's lives. Access to contraception decreases rates of unintended pregnancy and abortion (2). However, not everyone has access to contraception because of financial barriers, widespread misperceptions about family planning, regulatory and geographic barriers, and availability of prescribing clinicians (3). Many experience these barriers, and consequently there is a growing movement to acknowledge family planning services as care that should be addressed at every interaction with the health care system. This should include hospital admission for nongynecologic reasons. There are not yet studies indicating how often inpatients are screened for contraceptive needs. It is an area that requires study, but on the basis of our experience, it is uncommon. There are precedents for the strategy of expanding hospitalist services to address a public health need, such as smoking cessation and influenza vaccination. Similarly, hospitalists have recently been identified as having an important role in initiating treatment of substance use disorders (4), which historically has been initiated by outpatient clinicians. Increasingly, hospitalists are embracing this role, providing an existing framework to assume a more expansive role in holistic care of patients, including contraceptive care. Accessing primary care can be challenging for persons with substance use disorders, so it is particularly important for hospitalists to consider contraceptive needs in this population (5). Substance use disorders are common in women of reproductive age, and women with substance use disorders have lower levels of contraception use. Physician counseling on contraception can increase use among women with substance use disorders (5) in general, so it stands to reason this would be the case for hospitalized patients as well. One challenge to overcome in hospitalists addressing family planning is the inadequate training in and knowledge of contraceptive counseling that is reported by many physicians (6). Undergraduate, graduate, and continuing medical education should evolve to address this. The Centers for Disease Control and Prevention has straightforward medical eligibility criteria that assist with selection of preferred contraceptive methods in medically complex patients (7). These may be a foundation for point-of-care decision support to help address this knowledge gap. Developing electronic medical record–based alerts that are age appropriate, have appropriate exclusions, and provide treatment guidance may be helpful. Medroxyprogesterone injections and levonorgestrel implants are longer-acting methods with few contraindications that could be administered in the hospital, and a prescription for emergency contraception could be given with discharge prescriptions. Initiating these conversations is an important first step. If a hospitalist decides it is infeasible to provide these services during the admission, they could still refer patients to an easily accessed resource (such as Planned Parenthood or public health clinics). Although better than not addressing contraceptive needs at all, this strategy is less appealing because it risks nonadherence due to factors out of the patient's control, such as insurance coverage, taking additional time off from work, and transportation. If adopting this strategy, discharge planners can schedule these appointments instead of leaving patients to navigate them on their own—just as is done for primary and subspecialty appointments after discharge. Another option could be a dedicated nonphysician team (such as pharmacists and nurses) who is available to discuss and provide contraception to patients, as has been adopted for other high-priority patient needs, such as diabetes education and antimicrobial stewardship. Although such a teammay not be profit generating (particularly in states where the provision of inpatient contraception is uncompensated), hospitals could embrace this as part of their responsibility to promote population health. Adopting a team-based approach may help overcome concerns about hospitalists not having enough time to address contraceptive needs in addition to their other duties. Professional development and learning in this area should include culturally competent, nonjudgmental counseling around contraception. As part of counseling, it is important to understand both the ambivalence many have around pregnancy (8) and the importance of