Ingrid Hein

May 16, 2017


Deciding who should or should not have a child is not the role of a physician, according to an expert speaking at the American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting in San Diego.

"The real goal is to empower women, not to reduce pregnancy," said Neha Bhardwaj, MD, from the Mount Sinai Health System in New York City.

"If someone wants to have children in their teens, you can't tell them not to, she told Medscape Medical News.

"We really have to reframe the conversation," Dr Bhardwaj stressed in her presentation on contraception and coercion. "You can't think of teen pregnancy as a disease. If you offer a long-acting reversible contraceptive device and your patient doesn't want it, don't try to convince her; move on."

The coercion discussion is gaining momentum because doctors sometimes feel they need to convince adolescent patients to use contraception, even if they don't want to.

An opinion issued by the ACOG Committee on Adolescent Health Care applauds the fact that the adolescent birth rate in the United States has reached an all-time low, as detailed in a report by the Centers for Disease Control and Prevention, but warns that healthcare providers need to take care in "resisting potential coercion."

"An increase in the use of contraception is a good indication that access is much better, but it's important to remember that pregnancy should not be looked at only through a statistical lens," said Dr Bhardwaj.

"We've been using the framework that pregnancy is a social ill," she explained. "We need to be careful."

Teen Pregnancy Is Not a Disease

It's time to take a step back and look at our goals, said Dr Bhardwaj. The real goal is to empower women to make decisions; it's not about coercion either way.

Discussion about teen pregnancy often happens at the same level as discussion about disease, she noted.

For example, someone who lives in poverty and has social disadvantages is less likely to go to college or make money if she has a baby. "Physicians tend to think they can save women only if they can give them good contraception," she pointed out.

"Teen pregnancies may contribute to high dropout rates, incarceration rates, and social costs," but you still have to look at contraception through the lens of choice, she said.

"We shouldn't judge women who want to have babies in their teens. Just because it's not a decision we, or I, would make, that doesn't mean it's a wrong decision," Dr Bhardwaj added. Contraception is not going to eliminate poverty or social disadvantage.

There are many reasons someone might want to have a child young, and they are often based on cultural or familial history, she said. And there are risks in having children later in life, such as higher rates of chromosomal abnormalities.

One can argue that there is no right age to have a child, she said.

The Ideal Mother

American history is littered with ideas of the "ideal mother" and forced sterilization, Dr Bhardwaj explained, citing a report that looked at sterilization throughout history (Curr Opin Obstet Gynecol. 2014;26:539-544). In the 1900s, 32 states authorized sterilization of those "unfit" to reproduce. From 1909 to 1979, there were more than 60,000 forced sterilizations in the United States, and a disproportionate number of those affected black, Hispanic, working-class, and poor women.

It was not until 2014 that California banned the forced sterilization of women in prison.

On the other side of the discussion, women who choose to be sterilized can run into roadblocks put in place by laws designed to combat coercion, Dr Bhardwaj noted.

Some women, especially those who want the procedure performed immediately after they give birth, are stymied by the federal regulation that requires consent to be given 30 days prior to a sterilization procedure, as reported by Medscape Medical News.

"These issues are really difficult to resolve. This 30-day period is too long and a real barrier to care. I'm interested to see what happens in the near future, especially as people lose their insurance," she explained.

Bundled payments can also adversely affect access, because sterilization is not something that can be "bundled" into labor and childbirth costs, she added.

"We need to take a step back and think. It's not about convincing your patient to do something. We're here to ask, 'What is medically beneficial and what are the options?' We still have many injustices in our system. It's important that we get involved to figure out how to combat them," she said.

Dr Bhardwaj has disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2017 Annual Meeting. Presented May 6, 2017.

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