Developing an interactive reproductive health equity session for pre-clerkship medical students

ABSTRACT

In the United States, sexual, reproductive, and perinatal health inequities are well documented and known to be caused by a history of systemic oppression along many axes, including but not limited to race, ethnicity, gender, socioeconomic position, sexual orientation, and disability. Medical schools are responsible for educating students on systems of oppression and their impact on health. Reproductive justice advocates, including lay persons, medical students, and teaching faculty, have urged for integrating the reproductive justice framework into medical education and clinical practice. In response to medical student advocacy, we developed introductory didactic sessions on social and reproductive justice for preclinical medical students. These were created in a team-based learning format and include pre-course primer materials on reproductive justice. During the sessions, students engaged with hypothetical clinical vignettes in small groups to identify oppressive structures that may have contributed to the health outcomes described and potential avenues for contextually relevant and level-appropriate advocacy. The sessions took place in November 2019 (in-person) and 2020 (virtually) and were well attended by students. We highlight our experience, student feedback, and next steps, including further integration of reproductive health equity into medical school curricula in concert with department-wide education for faculty, residents, nursing, and allied health professionals. This introduction to social and reproductive justice can be adapted and scaled across different medical school curricula, enhancing the training of a new generation of physicians to become critically aware of how oppressive structures create health inequities and able to mitigate their impact through their roles as clinicians, researchers, and advocates.

KEYWORDS:

• Reproductive justice
• racial health disparities
• health equity
• team-based learning
• preclinical medical education

Introduction

Healthcare providers are bound by the ethical principle of justice and must be committed to providing equitable care for every patient. This commitment must be carried through with a distinct understanding of the various social circumstances that shape each patient’s life, impacting the healthcare they receive and their health outcomes. In the U.S., intersecting systems of oppression along multiple axes, including but not limited to race, ethnicity, gender, socioeconomic position, sexual orientation, and disability, impact reproductive health, leading to well-documented disparities across the sexual, reproductive and perinatal health spectrum [1,2]. Undergraduate medical education does not always provide students with the appropriate tools to recognize and address how structural oppression and interpersonal discrimination contribute to health disparities as they advance in their training and become independent, practicing physicians. Medical educators have not relied on appropriate expertise to teach students about inequality [3,4]. Increasingly, there have been calls from medical students and educators to integrate ‘structural competency’ into medical school curricula, and such courses have been developed at various institutions [5]. Structural competency is defined as the ability of healthcare workers to appreciate how upstream societal structures, such as mass incarceration, residential redlining, police brutality, and voter suppression influence clinical problems, diseases, and attitudes toward patients [6].

Nationally, public health experts have called for physicians to take greater responsibility in addressing health inequities by fighting structural racism [7] and other forms of systemic oppression through research and clinical care [6]. One stark manifestation of systemic injustice in obstetrics and gynecology is the racial disparities in maternal and perinatal morbidity and mortality in the United States. Black persons are 3 to 4 times more likely to die of pregnancy-related complications than White persons [8]. More recent evidence shows that the site of delivery contributes to the disparity in severe maternal morbidity between Black and White people [9]. Even within hospitals, there are disparities in severe maternal morbidity between Black, Latina, and White people, irrespective of health insurance status [10]. In light of such inequality, there have been calls to incorporate social and reproductive justice frameworks into reproductive health clinical practice [11]. In recent years, the concept of social justice has been somewhat incorporated into medical school curricula, but not necessarily that of reproductive justice. In 2017, a perspective written by a Family Planning fellow addressing racial injustice within the subspecialty recommended including the adoption of the reproductive justice framework in undergraduate and graduate medical education, the provision of trauma-informed care, and efforts to diversify the workforce [12]. Reproductive justice is a framework that was first articulated in 1994 by a group of Black women who sought to expand the idea of ‘pro-choice’ to include the perspectives of indigenous women, women of color, and trans people [13]. Consequently, the women of color reproductive justice collective, now known as SisterSong, was created to shine a greater light onto the intersection of human rights, reproductive rights, and the structural barriers that influence the aforementioned, such as mass incarceration, inequality, and various forms of discrimination [13]. Reproductive justice is defined as ‘the human right to maintain bodily autonomy, have children, not have children, and parent children in safe and sustainable communities.’ [14–16]

We sought to incorporate this framework into the medical school curriculum at the preclinical level by designing an interactive session during which students discus the ways that social structures of oppression and interpersonal discrimination contribute to sexual, reproductive, and perinatal health disparities. We included core elements of reproductive justice education outlined by a collaborative of reproductive justice advocates and academics [15].

Approach

A group of clinical fellows, faculty in obstetrics and gynecology, and medical students convened to develop an introductory social and reproductive justice session to take place in the last of the 8 pre-clerkship master courses of our 18 months long pre-clinical curriculum, the Across the Lifespan Master Course. This course encompasses aspects of human development from conception to senescence, including reproductive health (obstetrics, gynecology, male reproduction, gender issues). One lecture in particular (“Maternal and Perinatal Mortality and Morbidity) stimulated students’ discussion of the role of racism in the poorer outcomes of Black people and the concept of reproductive justice and motivated some of them to reach out to the course director requesting to formally add a session covering this concept to the curriculum. Our new social and reproductive justice (SRJ) session was designed as an overview of social and reproductive justice, aimed to equip learners with tools to identify, question, and combat structures of oppression within and outside of healthcare, specifically, how they contribute to sexual, reproductive, and perinatal health inequities. By engaging with pre-class content, reading clinical vignettes, group discussion, and self-reflection, the learners could explore the themes and concepts individually and in small and large group discussions with the faculty’s guidance to encourage students to become patient advocates during their future clinical rotations.

The sessions had four learning objectives. First, students would be introduced to the historical context and its impact on inequities in sexual, reproductive, and perinatal health. Second, students would identify how structures of power and oppression manifest themselves within healthcare systems and impact sexual, reproductive, and perinatal health outcomes. Third, students would reflect and become familiar with their own biases and privilege regarding patient interactions, their relationship with structures of oppression, and practices for self-reflection. Lastly, students would consider ways to center a reproductive justice framework and use structural analysis tools to advocate for patients during clinical rotations.

Preparation

The course design was informed by the faculty’s clinical experience, as well as available educational materials, including four short videos from the course ‘Structures and Self: Advancing Equity and Justice in Sexual and reproductive health.’ developed by the Innovating Education in Reproductive Health team at the University of California, San Francisco Bixby Center for Global Reproductive Health [17,18]. This course is built on the following pillars: acknowledging our own legacy, recognizing structures of oppression, checking oneself (recognizing own biases, privilege, and relation to structures of oppression), and taking action (identifying ways to center a justice framework to promote optimal health outcomes).” [17] Faculty designed hypothetical clinical scenarios based on these pillars, and sourced from their own real life clinical encounters.

The clinical scenarios included obstetrics, family planning, gynecologic oncology, reproductive endocrinology, and infertility cases. Appendix 1 contains the clinical scenarios and associated questions. The obstetrics case is about a Black patient who suffered neurological complications from postpartum preeclampsia with severe features, in part due to clinical oversight during an emergency room visit. The family planning case focuses on barriers to access abortion care, including state law, insurance policies, and economic stability. This case further delves into a reproductive endocrinology and infertility case focusing on health insurance and economic barriers to accessing assisted reproductive technologies. Lastly, the gynecologic oncology case focuses on cervical cancer in a patient with mental illness and limited English proficiency, several missed opportunities to prevent said cancer, and issues with follow-up and social support.

Ahead of the course, students were provided with educational materials that served as primers, including four short videos from the ‘Structures and Self: Innovating Education in Reproduction Health’ course website [17] and a 2-page essay about racial justice in obstetrics and gynecology [19].

Implementation

The first iteration of the session occurred in person, lasted one hour, and was designed in team-based learning (TBL) format with five faculty and fellow facilitators. The TBL format was selected because it is known to increase student engagement and satisfaction, especially when discussing medical ethics, compared to the conventional didactic format [20].

At the beginning of the session, each student took a short quiz (readiness assessment) that served as a refresher for the primer materials. The faculty facilitated an interactive discussion with the students on the answers to the quiz. Subsequently, the students were divided into small groups and given one clinical scenario at a time with questions aimed to guide their group discussion to identify structural barriers that influenced the clinical scenarios, and tools clinicians could use to mitigate the impact of these barriers. After each small group discussion of the scenario, a class-wide discussion ensued, led by faculty facilitators. Four scenarios were planned for a presentation focusing on family planning, obstetrics, gynecologic oncology, reproductive endocrinology, and infertility. The session was concluded by faculty highlighting the role that students can play in addressing reproductive injustices in patient care and providing additional resources that could be helpful to students during their forthcoming clinical rotations. Of note, the second iteration of the course occurred virtually as a result of the COVID-19 pandemic. The same materials were presented. However, the students were divided into small groups virtually for a brief discussion of the case scenarios and then reconvened for discussion with the facilitators as a whole group. In addition, for the second iteration of the course, we held two separate 50 minutes sessions.

Reflections

Students’ active participation was a requirement for this class. Unlike other TBL sessions in the preclinical curriculum at the time, this newly developed session was not mandatory for the students, but attendance was higher than that of previous non-mandatory lectures, with over one-third of the class present. In their post-course feedback, students emphasized the need for this session to be longer than one hour due to the breadth and depth of the topics. In response to this feedback, the second iteration occurred over two separate 50 minutes sessions. However, there was still inadequate time to delve as deeply into the issues, partly due to the need to build up momentum to foster in-depth engagement. Since then, we have led a 2-hour session (rather than 2, separate 50 minute sessions) and taken care to ensure that each of the four cases could be discussed with the students. Another consideration is to pare down the breadth of content included. A narrower scope may allow for more in-depth classroom discussion and engagement on these complex and sensitive topics.

Because we received few evaluations after the first iteration of the session, we were more intentional in seeking feedback for the second one, conducted virtually. Among 29 participating students (class of 104 students) during the second iteration, 24 filled out evaluation surveys. The majority of respondents rated the session as excellent (55.6%, n = 15) or above average (33.3%, n = 9). Students had the opportunity to leave comments on the evaluation. Positive comments highlighted the importance of learning more about shared decision-making, social determinants of health, and how to advocate for patients ahead of clinical rotations. However, few comments highlighted the need to increase student engagement and actively encourage various perspectives, particularly when it came to controversial issues like abortion care. In particular, a few students commented that they did not feel the session was a safe space for them to voice their opinion if they held minority views on highly polarizing topics like abortion or crisis pregnancy centers. Although we do not have course evaluations from the first iteration of the session held in person, the virtual format of the second iteration may have contributed to the difficulty in discussing sensitive and complex topics. Making explicit that the information presented is evidence-based, highlights the ethical principles of autonomy and justice [21,22], underscoring the importance of intellectual diversity, and acknowledging the presence of varying views on sensitive topics could help foster a safe space for students to not only share their views but also listen to different or opposing views respectfully.

These comments prompt an important question: how do we best foster a learning environment for social and reproductive justice that promotes the core ethical principles of justice and autonomy when students may hold personal beliefs in conflict with these principles? Furthermore, they highlight the importance of educating students about professional responsibility when their personal beliefs are in conflict with providing care that is necessary for patients [23].

Another important lesson from our experience is to clarify ahead of time that we use specific characteristics (e.g., patient’s race, age, primary language) in some clinical vignettes to highlight unique barriers different patients may face, and not to promote the use of those terms in clinical encounters in ways that contribute to stereotyping patients.

This course was designed to be introductory and calls for more space in curriculum design for longitudinal integration of reproductive justice education beyond the preclinical years, including the obstetrics and gynecology, pediatrics, primary care, and psychiatry clerkship rotations. Our medical school initiated a pre-clerkship health equity thread in 2020, in collaboration with the faculty leads for the health equity, epidemiology and public health (now named Populations and Methods course), professionalism, ethics and responsibility threads, as well as the directors of the 8 master courses, to integrate the tenets of social and reproductive justice in the medical school curriculum. The Health Equity Thread now spans all four years of the core curriculum and includes 8 domains (from the initial 4) with specific objectives. We continue to work with the Health Equity Thread leaders to modify and update our Reproductive Health Equity sessions to ensure that they complement other sessions that were introduced in the pre-clinical curriculum after ours was created. Additionally, we acknowledge that medical education does not happen in a vacuum, and that for this education to be sustainable, the clinical training environment must also embrace reproductive justice. Therefore, department-wide reproductive justice sessions for faculty, house staff, nurses, and other key staff members involved in patient care are necessary. While the need is ever present, the need is glaring considering recent events, including the 2022 Supreme Court of the United States decision in the Dobbs v Jackson Women’s Health Organization case, amounting to an assault on the right to abortion. Since 2020, the department of Obstetrics and Gynecology and Reproductive Sciences at our institution has put together a diversity, equity and inclusion (DEI) task force with 3 distinct sections, including one for medical education. Mandatory faculty DEI training has taken place and grand rounds include DEI topics monthly. All departments at our institution are now required to have a DEI program in place.

Conclusion & next steps

In the U.S., sexual, reproductive, and perinatal health outcomes are plagued by persistent and substantial inequities along multiple axes, including but not limited to race, socioeconomic position, sexuality, and disability. Medical schools are responsible for developing a medical curriculum that gives students the tools to provide the most equitable care possible to patients. Medical education must include teaching students how structural oppression and interpersonal discrimination perpetuate inequities in health outcomes. A reproductive justice-informed curriculum is an overdue first step in training medical students to recognize and address the disparities in sexual, reproductive, and perinatal health outcomes. The next steps from this standalone session include embedding reproductive justice principles in the obstetrics and gynecology core clinical clerkships and electives curriculum. This is being actively pursued by our Health Equity Thread leaders in conjunction with clerkships and electives directors. We are also seeking to continue to increase the time devoted to this session in the upcoming years. This education will allow trainees and providers at all levels to provide patients with the best care, regardless of their future or current medical specialty. Preclinical education has limitations, as the hidden curriculum during clinical rotations shapes students’ attitudes and behaviors toward patients [24]. For instance, a study showed that hearing negative comments about Black people from educators is associated with worsening implicit attitudes towards Black people among medical students [25]. Additionally, the negative racial climate in medical school decreases students’ interest in serving underserved and minority populations [26]. Another study showed that medical students routinely witness discrimination against patients during clinical clerkships. For some, this leads to normalizing such behavior, while for others, it heightens commitment to equity [27]. As such, educators (residents & faculty) and other clinical staff have an important role in modeling behavior that upholds equitable care as a key value. To that effect, medical students’ reproductive justice education should occur in parallel with education efforts within different departments. This model of introducing medical students to reproductive justice could be adapted and scaled across sexual, reproductive, and perinatal health curricula into medical education across the United States, in agreement with the joint statement from obstetrics and gynecology organizations’ collective action addressing racism [28].

Acknowledgments

The authors would like to thank Sydney Green and Sahana Kribakaran for their initial contributions to the conception of this session.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2024.2364984

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.