Seizing the Moment: Hospitalists’ Roles in Reproductive Care

A 25-year-old woman is admitted to your service with acute kidney injury due to lupus nephritis in the setting of chronic kidney disease, diabetes, and hypertension. She mentions having menstrual cramps, and upon review of her labs, you see she has a negative human chorionic gonadotropin. In your social history, you recall her mentioning she has one child and is sexually active with her husband. On review of her medications, you do not see contraception listed. How would you approach talking with her about pregnancy intentions, prevention, and contraception, if desired?

Almost half of all pregnancies in the U.S. are unintended.¹ Among adolescents, this rate exceeds 80%.² Several factors contribute to this high incidence, including the unpredictability of ovulation, the longevity of sperm viability post-intercourse (up to five days), and constraints related to limited contraceptive access and literacy.³ The unintended pregnancy rate is a crucial indicator of reproductive health outcomes and reflects whether women and their partners have access to pregnancy prevention resources that support reproductive justice and autonomy.⁴

Women experiencing unintended pregnancy face higher risks of complications, with significantly increased odds of maternal depression during pregnancy and postpartum.^5,6 Additionally, it is linked with poor outcomes in infants, including prematurity and low birth weight.⁵ Ensuring the delivery of sexual and reproductive healthcare for all women of reproductive age, particularly for those facing barriers to access, is a critical responsibility of all clinicians, including hospitalists.^2,4

Despite common perceptions, hospitalists can play an important role in identifying unmet needs and managing contraceptive care.⁷ During hospital admissions, hospitalists can identify sexual and reproductive health needs and counsel all patients who can get pregnant on contraception and unintended pregnancy prevention. Certain populations are particularly vulnerable to experiencing an unintended pregnancy, including:

• Adolescents and young adults frequently encounter barriers to accessing primary and preventive care.⁸ One study found that only 38% of adolescents had preventive care visits in the past 12 months, with lower rates among low-income and uninsured adolescents, and only 40% had time alone with their providers.⁹ Hospitalizations present a critical opportunity to address adolescents’ reproductive health.
• Patients with underlying mental health and/or substance use disorders are also at increased risk for unintended pregnancy.^10,11
• Women experiencing intimate partner violence may have limited reproductive autonomy. A meta-analysis including data from 29 countries showed that women’s experience of intimate partner violence was associated with a 51% increase in the risk of pregnancy and a 30% increase in the risk of unintended pregnancies that resulted in live births.¹²
• Postpartum women are an important population to offer pregnancy prevention and contraception care during hospital admission. More than half of the unintended pregnancies experienced by parous women in the U.S. occur within two years after delivery, and 35% of women have interpregnancy intervals of less than 18 months.¹³

Although studies on how often inpatients are screened for contraceptive needs are lacking, evidence from other contexts, such as substance use disorder, indicates that hospitalists can play an essential role in initiating treatment during inpatient care instead of waiting for outpatient follow-up.¹⁴

Hospitalists should therefore be proactive and well-informed when discussing reproductive and sexual health, pregnancy intentions, and contraception options. Opening questions like, “Are you planning on trying to become pregnant in the next six months?” can open the conversation to identify unmet needs. If the patient reports no intention of near-future pregnancy, further questions like, “Are you sexually active with someone with whom you could become pregnant? What are you doing to prevent pregnancy?” should follow.

Counseling about contraception methods, including emergency contraception (EC) and condom use, is recommended by national evidence-based guidelines.¹⁵ For those who report current sexual activity and desire pregnancy prevention, hospitalists can discuss contraception options and can offer a quick start (i.e., same-day initiation) for those who are interested. Early identification of a possible need for EC is critically important and can be identified using the question, “Have you had unprotected or under-protected sexual activity in the past five days?” For those who report unprotected or under-protected sexual activity in the past five days, and who do not desire pregnancy, counseling about EC use should be offered and prescribed immediately if desired.

Additionally, if patients desire long-acting reversible contraception, consultation or referral to a clinician who can offer this method (e.g., primary care, Title X clinic, gynecologist) is warranted. If unable to initiate long-acting reversible contraception during a hospital admission, hospitalists can discuss the use of shorter-term contraception options and consider prescribing regular hormonal contraception as a bridge method.

Here are essential facts for hospitalists about reproductive and sexual care including contraception to inform these discussions with patients, peers, and trainees:

1. Contraception methods include barrier methods, hormonal methods (such as oral contraceptive pills, implants, injectables, progestin intrauterine devices, and emergency contraception), as well as non-hormonal intrauterine devices and tubal ligation. For men, there are only two methods available: vasectomy and condoms.
2. Condoms are effective, but only if used correctly; they should be offered as part of dual protection. Under perfect use, condoms are 98% effective; however, with typical use, their effectiveness drops to 87%.¹⁶ The advantages of condoms include their relative affordability and protection against most sexually transmitted infections. It is crucial to discuss dual protection even when choosing a long-term contraceptive method, as this also provides an opportunity to prevent sexually transmitted infections. Half of reported cases of chlamydia, gonorrhea, and syphilis cases in the U.S. in 2022 were among adolescents and young adults aged 15–24 years.¹⁷ Therefore, these discussions should be particularly emphasized within this population.
3. An oral contraceptive called Opill is now available over the counter in the U.S.¹⁸ This is a progestin-only pill that is approved by the U.S. Food and Drug Administration and, when used correctly, is 98% effective at preventing pregnancy. Since it is over the counter, it may not show on pharmacy records, underscoring how important it is for all patients—including at admission, during hospitalization, and discharge—to have accurate medication reconciliation.
4. Hospitalists can and should offer—and where desired, provide—emergency contraception to women who determine themselves to be at risk for an unintended pregnancy. It can prevent up to 95% of pregnancies when taken within five days after intercourse. There are four medically appropriate forms of emergency contraception, but two that are most germane to hospitalists: ulipristal (Ella) and levonorgestrel (Plan B). Ulipristal is preferred because it is more effective later in the five-day window and appropriate for use in women who are overweight, although levonorgestrel is available over the counter.
5. Vasectomies are safe and effective and should be encouraged. Data indicate that individuals who have undergone vasectomies often report enhanced sexual satisfaction.¹⁹ Hospitalists can talk with patients about vasectomies, highlighting these benefits, and how pregnancy prevention is the responsibility of both partners, not just the partner who can become pregnant.
6. Adolescents and young adults necessitate confidential access to sexual and reproductive healthcare services. The U.S. Supreme Court determines that minors have the right to privacy regarding access to contraceptive services. Presently, no state mandates parental consent or notification for minors to access these services.²⁰ However, Texas and Utah specifically require parental consent for state-funded contraceptive services. Additionally, 27 states, along with the District of Columbia, explicitly permit minors to access contraceptive services without parental involvement. In contrast, 19 states recognize this right only for specific categories of minors, such as those who are married or parenting, and four states lack explicit statutes or policies in this area. Despite the absence of a parental consent requirement, concerns about confidentiality continue to restrict adolescents’ access to and use of contraceptives and other reproductive health services.
7. Hospitalists who wish to learn more about providing contraception can consider downloading and using the Centers for Disease Control and Prevention’s Contraception app, available via https://www.cdc.gov/reproductive-health/hcp/contraception-guidance/app.html.

In conclusion, addressing reproductive health and contraception during hospital admissions is an important step toward reducing unintended pregnancy rates and improving overall maternal and fetal health. Hospitalists play an important role in identifying unmet contraceptive needs, providing timely counseling, and initiating contraception when desired, ensuring that patients receive comprehensive reproductive care.

Back to the case: We recommend asking the patient in our case, “Are you planning on trying to become pregnant in the next six months?” Depending on her answer, you can then begin a conversation about her contraceptive options, offer her sexual and reproductive healthcare and resources, and connect her with a specialist such as a gynecologist (via consult or referral) to meet her immediate and ongoing needs.

Dr. Masonbrink

Dr. McFadden

Dr. Barrett

Dr. Bezerra

Dr. Masonbrink is a pediatric hospitalist at Children’s Mercy Kansas City and an associate professor of pediatrics at the University of Missouri-Kansas City School of Medicine in Kansas City, Mo. She currently conducts research focused on adolescent health, including substance use treatment and sexual and reproductive health access. She currently receives funding from the National Institute On Drug Abuse of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr McFadden is a pediatric hospitalist and interim division chief at the Medical College of Wisconsin in Milwaukee, Wis. She conducts research focused on addressing adolescent sexual and reproductive health in the hospital setting. Dr. Barrett is a rural hospitalist, senior medical director, and vice-president of quality at WorkItHealth, and also president-elect of the American Medical Women’s Association. Dr. Bezerra is a postdoctoral research fellow at Massachusetts General Hospital in Boston and is applying for an internal medicine residency.

References

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