Dr. Angela Chaudhari (Host): Welcome to Parts and Labor, a roundtable discussion with the OB-GYN experts here at Northwestern Medicine. My name is Dr. Angela Chaudhari, and I'm a minimally invasive gynecologic surgeon and serves as the Chief of Gynecology and Gynecologic Surgery at Northwestern Medicine. I will be your host today discussing a specialty in OB-GYN that many may have not heard about and isn't often discussed, complex family planning.

Our panel today are some of our brilliant fellowship trained subspecialists in complex family planning here at Northwestern Medicine. First up, Dr. Cassing Hammond is the Section Chief of the Division of Family Planning and directs the Northwestern Center for Complex Family Planning. His varied clinical and research interests include contraception and abortion among medically compromised patients, first and second trimester medical and surgical abortion, and sterilization as well as the care of HIV and LGBTQT plus patients. He has previously served as the Chair of the Board of Directors for the National Abortion Federation and is a founding member of the Society of Family Planning.

Next, Dr. Leanne McCloskey is an Assistant Professor and the Fellowship Director for the Fellowship in Complex Family Planning here at Northwestern. She completed both her residency and fellowship here at Northwestern University in 2015, and her academic interests focused on the efficacy and adherence to contraception in medically complex patients and in our overweight and obese populations, in addition to her focus in medical education.

And last, but certainly not least, Dr. Ashley Turner is an Assistant Professor in the Section of Complex Family Planning and the Ryan Residency Program Director in Family Planning. She completed her residency at the University of Wisconsin in 2018 and her Family Planning Fellowship here at Northwestern in 2020. Her academic interests cross multiple areas of family planning and obstetrics and gynecologic care, and she's an active member of our regional district's American College of OB-GYNs advisory and legislative committees with a focus on advocacy.

Welcome to all three of you! I'm so excited to be talking all things family planning today. For many of our listeners out there, I'm not even actually sure they know what the specialty of complex family planning is all about. So, Dr. Hammond, can you start us off? What is this subspecialty?

Dr. Cassing Hammond: Well, in a nutshell, complex family planning is the fifth ACGME-approved subspecialty of OB-GYN, and it's the subspecialty that trains physicians and physician scientists in complex abortion and contraception, both in the care of patients who are requiring complex abortion and contraception care, and also in research related to abortion and contraception and formal professional advocacy related to abortion and contraception.

Host: Oh my gosh, that seems to encompass so much. Can you tell us how the specialty came about and how it's changed over the years?

Dr. Cassing Hammond: Well, it really came about because of an informal gathering that occurred in the early 1990s in San Francisco. There were some thought leaders who had gotten together largely at an informal, I'm told, a party and were lamenting the fact that despite the centrality of abortion and contraception in clinical practice, taking care of young women, residents were at that point very undertrained in contraception and abortion. And there was a dearth of contraception and abortion research in most departments. And as they kind of tossed around ideas and said, "Well, what can we do about this?"

One of the notions that came forward from an OB-GYN who was there was it will never have credibility, abortion and contraception will never have credibility until there is a subspecialty on par with Maternal-Fetal Medicine, Infertility, Gyne-Oncology. And they just happen to have a philanthropist who is present who said, "That sounds like a great idea. I think I will fund an academic subspecialty." What a strange event, right? But it happened.

And they started this as a pilot project in 1991 at the University of California, San Francisco. They enrolled the first fellow then. The second fellow, who's actually an alumnus of Northwestern Feinberg School of Medicine, he started his fellowship in '92 and then took the show on the road in 1994 and started the second fellowship at Magee Women's in Pittsburgh. And by 2002, we had become the 11th of what are now 30 fellowships in complex family planning across the United States.. We are very proud of this process. I mean, it's taken 30 years to get from an informal congregation of family planners to now a formal ACGME-approved subspecialty. But I think we've been successful.

I love to point out that northwestern alone, our fellowship, now has graduates everywhere from Helsinki, Finland, to San Diego, California. And more importantly, they're doing exactly the kind of things that those people in that kind of thought leaders party that I mentioned, the very things that they wanted them to do. They're leading academic divisions at major universities. And by that, doing research, they're teaching people, they're doing advocacy, but they're also associated with organizations such as the World Health Organization. They're associated with the International Planned Parenthood Foundation. They are often serving as medical directors of large family planning clinics. We even have a former graduate who's the CMO of a startup that's developing really cutting edge contraceptives.

Host: What an impact this fellowship has really had on sort of the international scene and the care of our patients really around the world. It's really so, so impressive. I'm just sad that we missed that party, Dr. Hammond, really. I mean, that sounds like the place to be. It's like people talk about the room where it happened. That was the room or the party, right?

Now, we talked a lot about ACGME and ABOG accreditation. And as we kind of talked about in our introductions and in what Dr. Hammond just said, this family planning fellowship training that we have here at Northwestern just seems so, so special. I know, Dr. McCloskey, you were a trainee here. You did your fellowship here years ago. And now, you run this amazing fellowship that's setting these people out into the world. Can you just share a little bit more about what the details of this fellowship are?

Dr. Leanne McCloskey: I often joke with Cassing that he just can't get rid of me. I was a resident and a fellow and then I stayed, so he stuck with me for life. But no, I think this fellowship is truly very special. I mean, it started in 2002 as Dr. Hammond mentioned and he actually was the foundation of the formation of the fellowship, so let's not just make light of that.

But since then, the fellowship has really It blossomed into this ACGME-accredited program. The accreditation took place in 2020. It focuses truly on complex contraception, complex abortion care, advocacy for women's reproductive health care. Secondary to being Northwestern and a huge referral center, we have a great relationship with Maternal-Fetal Medicine. We see a lot of complex maternal conditions that might necessitate a little higher level abortion care, complex fetal conditions. We are also very lucky to have an access to a lot of high advocacy representatives. And so, our fellows get to go to Springfield and they get to lobby. They get involved with ACOG. So, I think the diversity of the fellowship has really made it one of the leading programs in the nation.

Host: Well, I would say so, based on the spread of really what's happened from our fellowship starting, you know, as the 11th fellowship in the country, but now sending fellows all over the country. I know we really have a focus too on residency education, right? And Dr. Turner, you run this Ryan-- you have to correct me and tell me what the name of this-- the Ryan Residency Training Program. Is that true?

Dr. Ashley Turner: Yeah, yeah.

Host: Fantastic.

Dr. Ashley Turner: Yeah. And so, its full name is the Kenneth J. Ryan Residency Training Program, and it's built upon a network of academic institutions focused on formal resident education and contraception, abortion care and advocacy for reproductive rights. And so, Northwestern started this training program here at our institution in 2008, and it's been really a vital part of the complex family planning education within the OB-GYN residency program. This rotation routinely ranks among one of the highest in terms of resident satisfaction and learning opportunities. And they often try to return to our service for additional time with the faculty and clinic and in the OR on their off rotations. And so, you know, we try to keep them up-to-date on evidence-based practices. We do weekly didactics with the residents and fellows as well as simulation exposure for complex family planning related procedures.

Dr. Leanne McCloskey: And I will say, actually, as a former resident, it is definitely something that is a huge draw for the residents to our program. I think knowing, especially now post-obs, knowing that Illinois is kind of what is called a Safe Haven state. Many of us like to call it just a standard-of-care state. But even prior to that, residents truly, we get high level residents and high level fellows applying to the program, because they know we do such high level, complex family planning care.

Host: Well, I have to say, in my former hat and being part of residency leadership years ago, this is exactly what I would hear as well. You know, can we spend more time with our family planning docs and really get this sort of critical education? I think it just goes to show not just your impact with your fellowship training, but how many residents, we have 12 a year here at Northwestern that get to work with these amazing doctors and really understand a lot of the basics of what goes in to what complex family planning is all about.

You know, Dr. McCloskey, you had mentioned all the different types of patients that you might see. I'd love to hear from all of you, you know, really, where are these patients coming from? Who are you collaborating with in our community? Who are the people who should be reaching out to us to get patients to you?

Dr. Ashley Turner: Yeah. So from the standpoint of our abortion practice, we're really getting a lot of referrals from the general OB-GYNs around the city and around the neighboring states as well and from Maternal-Fetal Medicine specialists. And then, we also receive referrals from the emergency department and immediate care centers and primary care. So, we're really seeing, you know, basically, any type of person that can become pregnant at this point. From the complex contraception standpoint, we're getting a lot of referrals from doctors such as neurologists who are taking care of patients with epilepsy, patients with complex cardiac conditions, our hematologists who have patients with coagulopathies and clotting disorders. And so, we're getting a lot of referrals from those specialties.

Host: Such a wide variety of patients that really you care for that really I think so many of our general OB-GYNs or primary care doctors are not totally comfortable giving this kind of care to. I really love to hear all sort of the work you guys are doing and how varied that is. You know, I'd love to hear how you guys are working to really enhance education and awareness for our primary care physicians and general OB-GYNs as well as our docs in other subspecialties.

Dr. Leanne McCloskey: So, I think, first and foremost is getting people exposed to what exactly complex family planning is is important. I mean, a lot of conversations that I've had with people are when I say I do complex family planning, they say, "Oh great, you get women pregnant." And my response is, "Well, family planning is not just about getting people pregnant. While yes, I do aid in the ability of people to get pregnant when they want to be. I also aid them in preventing a pregnancy when they don't want to be pregnant."

So, I think really getting out there, outreaching to primary care or to other subspecialties just to let them know like what family planning actually is is first and foremost. And then, collaborating with these departments, so like neurology, with hematology, with knowing that we are a referral center, they can send us. We are more than happy to see their patients. We often go and we talk to them, we give them lectures, we talk about the contraception that we have offered, the complex medical conditions that we see.

I personally, when I was a fellow and then starting off as an academic generalist, I made a collaboration with the GI department and the bariatric surgeons. So bariatric surgery, weight loss surgery, these patients, it's really recommended that they not get pregnant for the first 18 months following their surgery. And a lot within their checklist was not, "What is your contraceptive plan?" They weren't even considering asking people about how they were going to prevent them from getting pregnant.

So, I worked with them, created a checklist with them, added contraceptive discussion, a referral basis to make sure that they got referred to us so we could discuss contraception with them. And much to many of my fellow chagrin, we even went to the OR with them. We put in IUDs. I made them do tubals through GI ports, which they were not happy about, but we got the women the contraception they needed to ensure that they were safely caring for their health and then the future health of their pregnancy.

Host: I can imagine that kind of education awareness program with just one group in our hospital. Think about how we could expand that across surgical subspecialties, medical subspecialties. I mean, really, everyone needs to be asking these questions. And we know so many of our docs listening do really do a great job. Our primary care doctors are out there on the front lines doing this work. But I really reach out to our surgical subspecialist as well and say, "Remember when you operate on a patient of reproductive age, there is the chance they could be pregnant or become pregnant in the future." Even if it's a devastating diagnosis, this is something to remind them about because this can really become something that really is a really hard question and answer.

You know, we're talking a lot about contraception, obviously, but we know that, unfortunately, there are some times when patients are pregnant and they cannot be for a variety of reasons. And I know you guys care for those patients as well. I always feel like, you know, when we hear about complex family planning, so many people are out there asking the question of what impacts are you guys seeing as our subspecialists from the reversal of Roe v. Wade and the ongoing restrictions to abortion access?

Dr. Cassing Hammond: Yeah. We certainly have been affected by the Dobbs decision. It's affected our state, it's affected the city, and it's affected our community and our institution here at Northwestern. And it's a dramatic change that we see almost on a daily basis in our clinic.

Illinois, as Leanne was saying, is a haven or a standard-of-care state. We are surrounded by states that have restricted access to abortion. And as a result, not surprisingly, Illinois has seen a dramatic, perhaps a 70%, increase in the rate of abortions since the Dobbs decision was decided in the summer of 2022.

Many of the patients who are coming for abortions are obviously from out of state. One of the clinics that we work very closely with here at Northwestern, prior to Dobbs, on a monthly basis, about 14% of their patients were from out of state. But now, they average about 28%, so clearly a doubling of the out-of-state patients that they're seeing.

I think the thing that we're also seeing here at Northwestern, we're seeing this increase, we've had about a one-third increase in volume of our second trimester patients. And it's just so heartbreaking. And I think Dr. Turner and Dr. McCloskey would certainly agree, because we're seeing everything that listeners are probably hearing about on TV, but it's up close and personal for us. We're seeing patients from states as far away as Texas, Louisiana, Tennessee, let alone the more close bordering states like Missouri, and the stories they say are often over and over the same. "I was in a room, they found out that my baby was anencephalic. And the doctor just stopped. He left. He didn't talk to me. He couldn't tell me how to even get abortion or talk about abortion, because they were afraid to discuss it." I had a patient from Missouri where she said, "You know, as soon as I got this diagnosis of a severe genetic abnormality, he said, 'I can't talk to you about this in the office. I'm going to have to call you on my cell phone later.'" And then, they described the ordeal of finding us in Chicago and trying to get abortion care at a time when they were already quite vulnerable.

Dr. McCloskey has already mentioned the extent to which I think Dobbs has also affected our training programs and the fact that we now have medical students that I am advising who are looking at other residency programs and saying, "Can I really go train in a state that doesn't have good abortion laws?" Not just because they want to train to do abortions, but because of the collateral benefits of being in a place that has good abortion training. The kind of training they need to take care of miscarriages and ectopic pregnancies is all impacted.

But finally, I just want to say the one good thing that might have come out of Dobbs, if you can call it that, in a very perverse way, is that it's really reminded all of us of how lucky we are to be in Illinois and what a fantastic abortion community we have in Illinois.

I just want to mention we started a small group anticipating Dobbs in the winter of 2022. It's called the Illinois Coalition of Abortion Providers. And we thought it would start out just as an informal call of a few abortion providers. We'd kind of tried to plan for what might have happened in the summer. And instead, we've continued to meet, in fact we had a meeting this week, and it now includes almost every abortion provider in the state, providers from Missouri, Tennessee, other neighboring states. It includes representatives of the governor's office, IDPH, you name it, all there, updating each other, working together and making real progress. We've already started something called the CARLA project, a navigator that's going to help sick patients get from clinics to hospital-based care. And we've got a lot of plans to do so much more. And all of this has happened, because we have come together in response to this Dobbs decision and said we are going to be there for our patients. We are not going to run away from them. We, as complex family planners, are going to be here supporting reproductive justice.

Host: Oh, Dr. Hammond, I mean, really, it does make me feel so grateful and privileged to work in a state that recognizes that access to care is standard of care, as you guys have said it again and again. And, you know, hearing that work you do and hearing the stories of your patients and, you know, we can read about them in the news and you guys see them in your office every day. You know, I just want to say thank you all for doing the work that you do every day in caring for these patients.

And I know, actually, you guys have really taken this work, you know, between the coalition, the CARLA project, and really as clinical academicians, really started thinking about like what type of research can we do to bring awareness to both physicians and policymakers around the country so people can really recognize the importance of access to care for both contraception and abortion care.

Dr. Turner, I know you recently published on a study regarding induction for termination of pregnancy with severe fetal anomalies in later gestations. I'd love to hear a little bit about that work.

Dr. Ashley Turner: Yeah. So, you know, as many of us know, the vast majority of abortions happen in the first trimester and in the early second trimester, but some abortions need to happen at a later gestational age, and this is an area of abortion care that's not studied as often as these earlier gestations. And we know that we need to be able to safely take care of our patients through those time periods too. And so, here in Illinois, you know, we're lucky enough to be supported in that. And this study was looking at our abortion care at Northwestern for patients with severe fetal anomalies at those later gestational ages and what their outcomes were, how we went about doing their induction to help to support the literature for having a safe way to help them to complete the abortion process, as well as looking at the other studies that do exist about caring for patients within these gestational age ranges and the safety of this.

Host: Really, thank you for that research, doing safety, looking at these particular patient populations because, of course, these are often the worst times in these patients lives, right? The absolute worst. And to also add on the risk that they take in trying to get through deliveries, you know, and get to that point, this type of research is just so important.

And honestly, we need more of it, right? To show some of the safety around the country about what really patients need everywhere. I know that the division, the section does a lot of other research as well. I'd love for you guys to share any other research that you think our listeners might be interested in.

Dr. Leanne McCloskey: So yeah, so some of the research that I've done recently, it's been, you know, published in the Green Journal, you know, the Obstetrics and Gynecology Journal, has been really looking at stigma around abortion and specifically looking at abortion stigma during the time of COVID when, you know, access to medical care was already a concern of both patients and providers and how the need to still obtain your abortion really impacted that. I've also done some research looking at maternal outcomes at the time of second trimester induction of labor for either fetal demise, fetal anomalies, you know, history of cesarean sections. And that actually is soon to be presented as abstract at Society for Maternal-Fetal Medicine at their annual clinical meeting.

And then more recently, something that I'm really proud of that one of our current fellows is doing and I'm helping her through this, is she's actually looking at education in the emergency department and OB-GYN residents for trauma-informed care, for really looking at what trauma, how it relates to patients, how women perceive trauma and how we can better inform our care for those patients to make sure that we don't re-traumatize them for any reason.

Dr. Cassing Hammond: And I think what I'd pick up on, since we have subspecialists from other areas of medicine who are listening, are the kind of collaborations that we have had in research over the years with so many people and so many disparate specialties in our medical center who might not think that they have any intersection with complex family planning. I can't go through them. I've done this for over 20 years. I would expand the length of this show way too much. But let me just mention about two or three collaborations so people get an idea.

One of my former fellows Was very interested in medical education. And so, she wanted to develop a simulator for second trimester abortion. And the first step was to collaborate with biomedical engineering at the main campus because we had to build an artificial cervix. And so, we got five really enthusiastic young women biomedical engineering students who came into the OR and they looked and they said, "Oh my God, that's a cervix," and they were so impressed. And then, they helped us develop a model for that, we developed a model. And then, she worked with the medical education people here to do learning curve analyses of all of our residents when they took that model and used it to help them on the rotation.

Now, conversely, sometimes we've collaborated with basic scientists. I did a project with one of our virologists. It sounds really great when you say the title, because we were looking at the motility of HIV virus in cervical vaginal mucus. You know, talk about a dinner table killer to bring that up. But it's actually very important because different progestational states, which might be influenced by hormonal use, contraception use, might influence how people could contract HIV, and we were looking at a model that might help us explain that.

And then finally, my last of many examples, but we recently partnered with Lurie and their center that takes care of trans and non-binary adolescents. And we did, in essence, a needs analysis of contraception among that population. So, we are here. We want to collaborate with people in the medical center. There are all sorts of things that might be of interest and necessary to study for your reproductive age patients. And we're here to work with you.

Host: Literally, complex family planning intersects with every aspect, not just of every medical profession, but maybe society too, between like working with basic scientists, working with our engineers, working with our surgical subspecialists and our medical specialists, as well as just with patients all over the world who are trying to get pregnant, prevent pregnancy, all those different things. I mean, I really am just so impressed hearing more about your specialty. Frankly, as not a family planning doc who's worked with all of you for many years, I have learned so much in this session today. So, thank you all for being here. I would love in our wrap-up really to have any final words from any of you guys that you'd like to share with our listeners.

Dr. Leanne McCloskey: Just, you know, we're here, we're here for you. If you're a medical provider, if you're a patient, we will take care of you. We will welcome you with open arms.

Dr. Ashley Turner: We feel so lucky to do the jobs that we do and to take care of the patients that we take care of and then to train the future providers.

Dr. Cassing Hammond: And now more than ever, we need people from all medical specialties to realize the very stakes that they have in reproductive justice. The importance of helping patients and helping those people who are helping patients who are often now restricted in access to what's very necessary medical care. We thank you for your support and we are here, as always, to make sure that Northwestern is providing the best care for these patients.

Host: Thank you all again so much for the work you do and being here today. And thank you to all of our listeners. Please tune in to our next episode of Parts and Labor.