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The Future of the Public's Health in the 21st Century | The National Academies Press
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Key topics in the Supplement include: How to clearly define the public health workforce challenges using cause-and-effect diagrams and a concise roadmap. How the CDC conducts workforce development within its own organization. Do students who receive adequate training in Public Health and Community Medicine tend to practice in areas with physician shortages?
How do we count public health workers? How can we define public health workers properly? We recognize that state health officials have obligations to enforce health-related laws developed by state legislatures; however, we are concerned about the role that health departments have played in HB2 and similar cases. As an alternative to continuing to allow legislators to define the abortion-related activities in which health departments engage, we propose what health departments might do if they used an accepted public health framework to guide their abortion-related activities.
Drawing on our collective experience in public health research and practice, we propose a 21st-century public health approach to abortion that is based in an accepted public health framework and thus considers the role of public health agencies beyond collection of vital statistics data and enforcement of antiabortion legislation.
Presenting a New Vision for Public Health in the 21st Century
Our proposed approach describes what health department activities related to abortion might look like if health departments were to use an accepted public health framework to guide their abortion-related activities rather than focus primarily on enforcing abortion-related laws. We offer this description to current and new public health professionals, who may be asked or have the opportunity to use the health department infrastructure to engage in public health services related to abortion. We base this analysis on a widely accepted public health framework—the 10 Essential Public Health Services.
Multiple federal, state, and local governments have used these essential services to guide, categorize, and assess their public health activities and identify gaps in what they should be doing. In the box on the next page, we apply the framework to abortion and offer examples of what each Essential Public Health Service could look like for abortion.
Gather and share vital statistics data about number of abortions and demographics of women having abortions and improve vital statistics data gathering systems.
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- A 21st-Century Public Health Approach to Abortion | AJPH | Vol. Issue 12.
Apply principles for data collection for other vital statistics data collection to abortion data. For example, all data collected should serve a public health purpose, protect patient and provider privacy, and minimize compliance burden on providers. Investigate reports of increases in unsafe abortion and evaluate whether they are increasing, and, if so, identify factors that have contributed to this increase.
Offer agenda-free options counseling about abortion, adoption, and birth at health department clinics and by health department staff caring for pregnant women. Develop health education strategies to inform women about state abortion laws, including how they might affect their experiences with obtaining—or their ability to obtain—an abortion and steps they can take to overcome these obstacles.
Inform the public, providers, and policymakers about the evidence regarding the safety of abortion, including the effects on mental and physical health of having an abortion versus giving birth. Develop and implement harm reduction health education strategies for women who have decided to attempt to self-induce an abortion. Engage stakeholders to successfully implement new abortion services, including medication abortion, second trimester, and later services when those services are otherwise unavailable.
Gather and engage stakeholder perspectives on policies to reduce morbidity and mortality from abortion. Engage stakeholders to develop systems and programs to support women unable to obtain abortions because of state laws and other barriers to abortion care. Develop policies and plans to reduce and eliminate challenges women and providers have in enrolling in pregnancy-specific Medicaid and getting it to pay for abortion.
ISBN 13: 9780309087049
Promote the use of a scientific knowledge base in policy and decision-making about abortion, including but not limited to policies related to safety of abortion and health outcomes from abortion. License and inspect facilities in which abortions are performed using similar approaches to other non—hospital-based outpatient procedures.
Develop and implement evidence-based policies and plans to reduce abortion-related morbidity and mortality, including from unsafe abortion. Ensure that the best available scientific evidence is considered in the process of developing regulations, standards, recommendations, and guidelines that apply to abortion provision. Provide transportation and other enabling services to help women get to and from their abortion appointments.
Provide incentives to health care providers to offer abortions when abortion services are otherwise unavailable; in cases where incentives are insufficient, the health department should offer abortions directly. Identify unmet abortion care needs of women and barriers to care, in particular second trimester and later abortion care when there is already documented unmet need. Explore, develop, implement, and evaluate efforts to centralize entry to abortion care delivery system.
Plan and implement trainings for public health department health inspectors who inspect abortion facilities. Plan and implement trainings for public health department staff and other local service providers who may be in contact with women who may be considering abortion.
Collaborate with abortion providers to conduct quality improvement activities when data indicate a need. Provide guidance for—and, when evidence indicates a need, conduct—clinical quality assurance and improvement programs. Evaluate efforts to improve the effectiveness, accessibility, and quality of abortion care in the abortion care delivery system. Conduct research or collaborate with external researchers to understand how state laws regulating abortion affect women and providers.
Conduct research or collaborate with external researchers to document disparate impact of state laws regulating abortion on different groups of women. Some of the abortion-related Essential Public Health Services we have outlined and summarized are well within current health department practices e. However, there are short-term opportunities for health departments to improve the quality of their abortion-related work and begin to expand their abortion-related Essential Public Health Services.
Report at a Glance
They can do this by looking to other health departments and drawing on experiences from services already provided in related areas. In this section, we describe a few examples. Services such as developing or enforcing facility standards and conducting quality assurance and improvement work a value-neutral description version of what HB2 required the Texas Department of State Health Services to do, if that work were based in evidence are within the domain of health departments.
Some health departments—such as those of Maryland and North Carolina—have developed abortion facility standards in a way that incorporates the best available scientific evidence and conforms to standards for evidence-based public health. Local health departments set facility standards for abortion in the s, and both local health departments and the federal government engaged in clinical quality improvement for abortion in the s through s.
Yet these services are not unusual for health departments to engage in; many health departments provide transportation support and ensure local availability of prenatal care providers, and some directly provide health care services for pregnant women planning to give birth. Public health professionals in a variety of settings should consider and engage with this list of essential abortion-related services to improve it.
Public health professionals should consider not just what is feasible, but what health departments should be doing if politics and resources were not barriers. Public health professionals should then revise and enhance descriptions of abortion-related Essential Public Health Services. Research will be needed to understand barriers to carrying out this work in health departments. Public health professionals will need to map the abortion-related Essential Public Health Services in which other nongovernmental organizations already engage.
Public health professionals will then have to consider which services should reside within health departments versus which should be carried out by other organizations. There is no question that this process will be challenging.
However, the alternative is to have legislators define how the public health infrastructure is employed in relation to abortion. The consequences of allowing legislators to decide has already been documented in states where health departments have enforced restrictive abortion laws, resulting in women who seek abortions obtaining them later in pregnancy or being unable to obtain an abortion altogether. This is a key moment in the history of public health and abortion in the United States.
We see this commentary as a first step to inspire a crucial conversation about how health departments should engage with abortion. Our list is by no means exhaustive, and we welcome feedback and thoughts about how to continue this conversation.