A 14-year-old girl presents with vaginal bleeding after failed home abortion. She needs assistance with judicial bypass and in-clinic abortion. I entered the clinic examination room to find a young woman named Claudia sitting alone. Her voice shook with fear; she whispered as she spoke. Claudia had recently emigrated from Guatemala. After missing her period a few weeks prior, a home pregnancy test confirmed her suspicions. Unsure of where to turn, she had asked her friend in Guatemala for help obtaining an abortion. Within days, she received misoprostol in the mail, a medication that her friend had purchased off the street. She took the medication at home.

That’s when the bleeding and cramping started. It wouldn’t stop. This situation left our medical team with a desire to do more than provide medical care. We felt compelled to provide care beyond merely controlling her bleeding and cramping. The encounter highlighted the need for training that could prepare, and empower, residents to address both the medical and social complexities of her situation.

Claudia’s case illustrates the importance of understanding reproductive justice and its effect on adolescent health. Reproductive justice is defined as “the human right to maintain personal bodily autonomy, not have children or have children and parent in safe and sustainable communities.”1,2 

Although the reproductive justice and reproductive rights movements sound similar, their focus is different. The reproductive rights movement, which led to cases like Roe v Wade in 1973,3  focuses on the legal right to reproductive health and abortion services. In contrast, the reproductive justice movement, launched by Black women in the 1990s, established a holistic approach to reproductive rights that considers factors such as race, language, and socioeconomic status on the reproductive health of women.1,2 

Claudia’s story is just one example of how access to reproductive health can be shaped by social, linguistic, and economic factors. For example, Claudia skipped school to attend the visit. She felt self-conscious about her English proficiency and waited until her symptoms were unbearable to call for an appointment. She spent the last of her money on a bus ride to the clinic. Meeting Claudia illustrated how access to reproductive health services alone is insufficient, without also accounting for the deeply intertwined social, economic, and cultural barriers that influence adolescent health.

Worse still, Claudia intended on going through it alone. “My parents can’t know about this,” she said between tears.

Claudia is not alone in choosing to refuse parental involvement in reproductive health care. Currently, 37 states require parental involvement in a minor’s decision to have an abortion. However, most states with these laws offer alternative legal mechanisms for minors seeking to obtain an abortion without knowledge from their legal guardian.4  This process, called “judicial bypass,” was established by the Supreme Court’s 1979 ruling in Bellotti v Baird, a case that ruled that mature minors have the right to make informed abortion decisions.5 

But although judicial bypass offers a legal pathway to accessing abortion, the process can also have psychosocial implications. For example, the process involves disclosing sensitive information in front of a court, which may lead to psychological distress and embarrassment. The judicial bypass process can also potentially delay medical care as patients await the court’s decision.68  Historically marginalized populations are overrepresented in the judicial bypass system. In a study of adolescents who underwent abortions in Massachusetts, those relying on judicial bypass compared with parental consent were disproportionately Black, Latinx, and of low socioeconomic status.6  In addition, states with more restrictive abortion legislation are more likely to have their abortion petitions denied.8  These findings have important implications on the health of minority adolescents like Claudia.

Our clinic team helped Claudia navigate the judicial bypass process, and, a few days later, her request was granted, at which point she returned for an operative abortion.

After the procedure was over, she asked, “Can I get birth control today?” Caring for Claudia highlighted the importance of supporting a patient’s reproductive goals and decision-making regarding contraception. Reflecting on Claudia’s circumstances emphasized that concerns about finances, transportation, and privacy can affect the ability of adolescents to obtain contraception. In addition to these barriers, it is important to recognize that attitudes toward contraception among Black and Latinx communities have been shaped by a long history of reproductive abuses. For example, during the 20th and 21st centuries, the eugenics movement amplified racism and sexism, leading to the forced sterilization of Black, Latinx, and Indigenous women.9  Even today, studies show that provider bias exists in the promotion of long-acting reversible contraception (LARC) to minority patients and that patients of color are more likely to perceive coercion during contraceptive counseling.10,11 

After counseling Claudia on her options, she chose the Nexplanon implant. Our team placed the implant and sent her home with birth control that aligned with both her reproductive goals and her desire for an inconspicuous method.

Soon, people like Claudia may face even more barriers to care. Although she was able to obtain abortion services, reproductive health care policies in the United States are becoming more restrictive.

Recently, the American Academy of Pediatrics joined 38 other physician groups in opposing the passage of Texas Senate Bill 8.12  The bill, which went into effect in September 2021, bans abortions and support services if provided 6 or more weeks after a pregnant person’s last menstrual period, a timeframe in which most women do not yet know they are pregnant. Specifically, this ban directly contradicted the legal precedent protecting access to abortions in the first 2 trimesters established with Roe v Wade. On January 20, 2022, the US Supreme Court rejected an attempt by Texas abortion providers to block Texas’ 6-week abortion ban, allowing the ban to remain in effect indefinitely. Since the Texas bill, several other states have introduced similar bans. In fact, more than 100 state-level abortion restrictions were enacted in 2021 alone, the highest number since Roe v Wade.13 

These recent challenges to reproductive rights represent an opportunity for pediatric training programs to incorporate additional advocacy and training opportunities related to reproductive health care and justice.

Unfortunately, the Accreditation Council on Graduate Medical Education does not currently require pediatric residency programs to include education or clinical experiences in reproductive health care. The lack of exposure to these topics is not without consequence. For example, pediatrics residents report less comfort and familiarity with LARC insertion and contraceptive counseling compared with obstetrics and gynecology and family medicine colleagues, who receive additional training in these areas.14 

Inspired by Claudia and other patients like her, we sound a national call to action for pediatric residency programs to formalize training in reproductive health and justice. Now more than ever, training programs should ensure that pediatric residents competently provide culturally sensitive, nonjudgmental counseling around abortion care, contraception, and judicial bypass.15  Residency programs should consider integrating didactics on reproductive justice, social determinants of health, and advocacy in adolescent medicine and primary care rotation curricula. Additionally, programs should enable pediatric trainees to gain experience in contraceptive counseling and LARC insertion.

As restrictions to reproductive rights increase across the country, the pediatric community has an opportunity to advocate for reproductive policies that expand access to care for adolescent patients.16  The time could not be more opportune for pediatric trainees to develop the skills, knowledge, and resources to confidently serve as leaders in reproductive health.

The authors thank Drs Kirsten Austad, Heather Hsu, Thomas Kuriakose, Sonia Taneja, Priscilla Gonzalez, and Ramya Ramadas and the rest of the Boston Combined Residency Program Health Equity Rounds team for their support and contributions to this work.

Dr Isbell conceptualized and designed the manuscript outline, drafted the initial manuscript, and critically reviewed and revised the manuscript; Dr Javalkar conceptualized and designed the manuscript outline, provided substantial contributions to the writing of the manuscript, and critically reviewed and revised the manuscript; Drs Brewster and Soderborg provided substantial contributions to the writing of the manuscript and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

     
  • LARC

    long-acting reversible contraception

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