Season 3, Episode 9: New research frontiers in women’s health equity
A woman’s health and her choices about it are linked to where she’s grown up, her access to resources, and even where she works. Often, that might mean limiting choices for some women and built-in assumptions on the part of providers. How can we create more robust standards for sexual and reproductive equity that benefit all women in the United States?
In this episode, we hear from Dr. Sonya Borrero, professor of medicine at the University of Pittsburgh and director of CONVERGE, the Center for Innovative Research on Gender Health Equity, about how research can provide a lens to inform public policy that reflects the needs, preferences, and values of women from a myriad of backgrounds.
The National Health Interview Survey uses household interviews gleaned from Census participants to develop information about the habits and health of those in the US.
The Behavior Risk Factor Surveillance System offers a window into Americans’ chronic health conditions and whether they use preventative services.
CONVERGE advances research around gender health equity, through the University of Pittsburgh. Learn more and sign up for their newsletter.
The landmark Turnaway Study involved following 1,000 women from several states who sought abortions, to determine the effect of access to that choice, on their lives. Read more about the study.
IQVIA is a leading global provider of advanced analytics, technology solutions, and clinical research services to the life sciences industry. IQVIA creates intelligent connections across all aspects of healthcare through its analytics, transformative technology, big data resources and extensive domain expertise.
The National Health and Nutrition Examination Survey, which combines interviews and physical examinations, is a program of studies designed to assess the health and nutritional status of adults and children in the United States.
Dr. Ellen Beckjord: In this episode, we talk with Dr. Sonya Borrero, professor of medicine at the University of Pittsburgh and director of CONVERGE, the Center for Innovative Research on Gender Health Equity and co-director of the VA [Veterans Administration] Advanced Fellowship Program in Women’s Health. And we’ll be talking with Dr. Borrero about developments in research surrounding women’s health and some of the recent endeavors that she’s been up to.
Dr. Borrero, thank you so much for joining us on Good Health, Better World.
Dr. Sonya Borrero: Well, thank you for having me.
Dr. Ellen Beckjord: So, if we can start with a broad question, I’d love to hear anything specific from you that you care to share about your own work and your career. But from your perspective, how have women’s health studies evolved over time and what’s really standing out to you most in your career focused on women’s health and gender health equity?
Dr. Sonya Borrero: I think a lot of things have shifted. So I started working in this space about 20 years ago and my focus has really been on sexual and reproductive health, and actually, I would say the intersection of sexual and reproductive health and health equity.
And when I first started out, I felt like that was not an intersection that was being explored, which was really surprising to me. I think in the 20 years since then, there has been much more robust attention, not just in women’s health, but I think across the biomedical spectrum, around the social and structural determinants of health, and, in particular, how some of these social and structural factors shape people’s reproductive choices, their reproductive decision-making, and their outcomes. And again, I think that’s not necessarily unique to women’s health. But when it comes to reproduction, to paraphrase Professor Dorothy Roberts, who is a well-known social justice activist and scholar, she has said that if you want to understand how society views a community, there’s no better way than to understand their reproduction.
And so I think reproductive health in particular needed that attention to social and structural determinants because there has been a long history of interlocking systems of oppression that really shape people’s ability to lead the sexual and reproductive lives that they want to. So I think that has been a huge and welcome change in the arena of women’s health.
I think the other thing that has been happening — again, not unique to women’s health research specifically, but again, I think really intimately connected — is our understanding of the other populations that we need to be thinking about and paying attention to if we really are going to achieve gender health equity, including the LGBTQ population. And I think that we are still really behind the times, but trying to really embrace their unique perspectives and needs in order to really achieve gender health equity. So I think those are two of the sort of the fundamental shifts I’ve seen over the course of my research career.
Dr. Ellen Beckjord: So, as you are talking, I’m thinking that while reproductive health is not totally encapsulating of women’s health, it is so significant because of the unique associations between aspects of reproductive health and female biological gender. And I’m wondering if you can share anything about big trends that we may be seeing as a society and a culture around the reproductive choices that women are making. Because I’ve been reading and sort of hearing that decisions to have children are changing, that more and more people are choosing not to reproduce. Of course, there are lots of sociocultural things that have shifted around the accessibility of tools and access to care that allow people to be really in control of their reproductive destiny. Are there big-picture trends that are happening? Are there real shifts that are occurring, do you think, in this space?
Dr. Sonya Borrero: I really appreciate that question. You know, and I really love that you pointed out that while reproductive health does not completely overlap with women’s health, it has traditionally; not only I would say because of biological considerations, but also social ones. Right? Reproduction and the burden of pregnancy prevention or pregnancy attainment has been cast as a women’s issue. So I do want to say that that was one of the reasons that we changed.
Our center originally was called the Center for Women’s Health Research and Innovation, and we changed it in the last year again, to, I think, reflect some of the trends that I talked about earlier, but also in an attempt to advance this notion that sexual and reproductive health should not be a gendered issue. Right? And again, traditionally, well, I will first say that controlling people’s reproduction has been a longstanding way of enacting both racial and gender oppression. And so we have all sorts of interesting and concerning and problematic sociocultural issues with regard to reproduction, and specifically women’s reproduction. We are moving away from that gendered, or at least trying to move away from that gendered, a very normative gendered responsibility for pregnancy prevention, pregnancy attainment so that there is more universal and mutual responsibility, care, nurture.
I’m seeing that as a trend. And I think it’s harder than ever because of some of the developments that we’ve seen in the last year around reproductive health access, which again, has recast all of these issues as a women’s health issue, and really, I think this is a much broader societal issue, and frankly, a public health crisis that affects all of us — women, men, nonbinary folks, children, older people. I think we are still trying to understand the far-reaching impact that abortion restrictions are going to have on our society. And I think that’s a really active area of research for us.
Dr. Ellen Beckjord: Those are always the most fascinating and hardest to see, those sort of consequences that are so many moves down the chessboard or the way that population dynamics changing will have an effect down the road. So appreciate your pointing that out.
I would love to hear from you, an overview of, or some of either the research that you have recently been or are currently engaged in, or some of the professional endeavors that you’ve most recently been engaged in. And if we could hear a little bit about what those have included.
Dr. Sonya Borrero: I would love to talk about it. I’m just coming back from a year where I got to serve as the chief medical and scientific advisor at the U.S. Department of Health and Human Services in the Office of Population Affairs.
The Office of Population Affairs, or OPA, is the federal entity that oversees the National Family Planning Program. So while in this role, I was doing a number of things, including overseeing the overhaul of the clinical guidelines for family planning care.
So that was already slated to happen prior to Dobbs. And we’ve had to shift and sort of rethink how we can ensure equitable access to reproductive health care services. So I got to work there, and that has been an incredible experience. I’m back now at Pitt where I, as you mentioned, I direct CONVERGE and I’m picking up where I left off. I’m working on a number of projects. One of them is at the VA [Veterans Administration], working to ensure both contraceptive and now abortion care access for women veterans. This is an area when I started working at the VA that had not really been investigated. And our work has really helped to illuminate the landscape of reproductive health care for the increasing number of women, military, and then subsequently, veterans.
I’m proud that our work really supported some fundamental policy changes last year, which were allowing abortion access for select cases. So prior to last year, the VA had the most stringent abortion policy of any federal institution. Most federal institutions allow abortion in cases of rape, incest, or life endangerment. And the VA had an absolute ban. And this was particularly troubling, given that women veterans represent a population that has significant medical and psychiatric disease burden, which can render undesired pregnancies even more fraught.
So our work really helped to support a change in their policy to now allow it at least on par with other federal institutions.
Dr. Ellen Beckjord: When did that policy change occur?
Dr. Sonya Borrero: It happened the week before I left for the Biden administration. So I think September … of 2022, somewhere around that time.
Dr. Ellen Beckjord: But until then?
Dr. Sonya Borrero: Yes, until then. And of course, implementation of that is tough. There’s already lawsuits and challenges to the federal supremacy clause because the VA, of course, is a federal entity. And so it [the VA] should be able to provide abortion care on its grounds, even in states where there are abortion bans. But, of course, this is being challenged by state attorneys general.
So implementation has been tough, but the policy changes are a major one. And another one is that allowing for 12 months of contraceptive supplies to be given at a single fill so that people have a full year supply. Our work helped to move that forward so that the VA work is really exciting. And there’s really a great opportunity for research to policy translation there. The other pieces I’m working on is sterilization, understanding and supporting people’s decision-making. We do a lot of work around supporting counseling and supporting informed value, concordant decision making, even shared decision-making around contraception. So we have, at CONVERGE we actually have a whole division that is dedicated to Femtech solutions. So we have a number of tools that are mostly decision support tools that are linked by a variety of underlying principles. So health equity, patient centeredness, justice, stakeholder involvement from the get-go. So we work very much in collaboration with end users and community organizations to ensure that we’re meeting their needs. And then finally, reproductive autonomy I think is the one of the most sort of central tenets of our work that we are here not to produce any preconceived public or clinical outcomes, but rather support people’s own self-determination of what they want in their sexual and reproductive lives. So we have a number of those kinds of tools and do a lot of work in that space. And then finally, I would say another area that we have a lot of work in is measurement. So…
Dr. Ellen Beckjord: Always so important.
Dr. Sonya Borrero: As we keep moving towards and, I would say, progressing towards these models of autonomous patient-centered care our measures are lagging far behind, right? In research, we’re still sort of stuck on using either hard clinical outcomes that are incongruent with what people want in their sexual and reproductive lives or are using ones that I think have been really imbued or are imbued with white middle-class norms that don’t necessarily fit everyone’s desires. So an example of that is in our field, for a long time, unintended pregnancy and teen pregnancy were sort of the main outcomes or metrics by which we could gauge our success, our social success in public family-planning efforts.
What we’ve learned is that, in fact, neither teen pregnancy or unintended pregnancy are necessarily catastrophic for everyone. And there are times that unintended pregnancies are welcome, happy surprises. So how do we, in fact, develop and utilize measures that are more accurate and representative of people’s structural realities and what they want for themselves? That is really tricky. But we are building a portfolio of new patient-centered measures that we hope can be used in a variety of settings, not just research, but public epidemiologic surveillance, clinical outcomes, that kind of thing.
Dr. Ellen Beckjord: So we’re recording really close to the time when the announcement has come out about the availability of over-the-counter birth control pills. And I believe you had played a role in advising some of that policy.
Of course, there are other over-the-counter contraceptives, but I’d love to hear your thoughts on it, the work that you’ve done around that. But when you were talking about measurement, I’m wondering if this does create any measurement challenge around the fact that there will be no more claims data to represent all biologically female health care consumers who are choosing to use a birth control pill. And now that won’t be trackable in the same way, which is not to say that it should have had any bearing on the decision, but does that create a measurement challenge that didn’t exist before, at least as far as that contraceptive method is concerned?
Dr. Sonya Borrero: Absolutely. In fact, we were just talking about it last week because I was just thinking that, you know, are there databases that are going to allow us? I’m wondering if IQVIA, for example, would allow us to get some information. So we have to figure that out. Similarly, there are so many challenges around data collection in this space in general. And so another area that I’d love to talk about is the impact of the Dobbs [v. Jackson Women’s Health Organization] decision. Prior to Dobbs, our best estimates indicated that about 1 in 5 pregnancies every year end in an abortion. So given the ubiquity, really, of abortion need and the profound social, economic, and health consequences of being denied abortion care when needed — and that’s really been illuminated by the landmark Turnaway Study — I really think that Dobbs is probably among the most monumental U.S. health policy decisions ever, and we have to urgently evaluate its impact. How to do that is incredibly challenging.
Again, from a measurement standpoint, abortion has been systematically excluded from both public and many private insurers, and so [we] can’t use claims-based data to even understand incidence, and nor can we use it now. The big question is who among those who need or want an abortion, who is able to get it or not get it? And we were never even able to capture who was able to get it.
Now it’s even more challenging given how not just how stigmatized abortion is, but also it’s now criminalized. How are we going to be able to determine who is and is not able to get a needed abortion? And so a lot of this work relies on survey data. And I think that that is the type of work we’re going to have to move to use to collect information about over-the-counter access. And from a reproductive justice standpoint, we really do want to open up the avenues in which people are able to get the contraceptive and reproductive health care they need. Right? In many ways, we’ve overmedicalized sexual and reproductive health care. And I think to rectify that, we really do need to work on ensuring that people can get care both inside and outside of the health care system in a safe and effective way. And so I really applaud the over-the-counter. But you’re right, it brings up challenges in terms of how we are going to track usage.
I think we’ll just have to — we are already innovating study design around the Dobbs decision. And so this will be another one. We welcome these kinds of changes in terms of, again, expanding access. And we’re just going to have to evolve our study designs to ensure we can capture it.
Dr. Ellen Beckjord: Two quick follow-up questions. One is, are you aware of … I’m sure there are more than these three, but when I think of the big national surveys, like the Behavioral Risk Factor Surveillance System [BRFSS], National Health Interview Survey [NHIS], National Health [and Nutrition] Examination [Survey], NHANES. Are they preparing to potentially include content, questions that would cover some of this if they haven’t already? And the other follow-up question is, you mentioned something, the landmark Turnaway Study — I’d love to hear a little bit more about that.
Dr. Sonya Borrero: Let me start with that. So The Turnaway Study and there’s a book and multiple publications. Diana Greene Foster was the principal investigator out of UCSF [University of California, San Francisco], and just designed a brilliant study to really understand the short- and long-term consequences of being denied abortion care.
Prior to her time, the control study, the control groups of abortion studies, was always very flawed because it was often comparing people who didn’t want an abortion to people who did. And I think the genius of hers is, all of the study participants desired an abortion, and some of them were turned away because of gestational age limits or, you know, other logistical issues. So they’re, she’s comparing people who did desire an abortion, those who were able to obtain one and those who were not and followed them out for five years. And so the breadth of the outcomes is really illuminating for understanding the real-world impact.
Dr. Ellen Beckjord: And this study was done before Dobbs. Correct?
Dr. Sonya Borrero: Correct. There is now a Turnaway 2.0 trying to assess the impact of Dobbs. But as far as I know, nothing has been published yet from that.
So thank you for raising the question about the publicly available datasets. The big one, BRFSS [Behavioral Risk Factor Surveillance System] certainly has a family-planning module, and the other big one in the arena of sexual and reproductive health is the National Survey of Family Growth, NSFG. The Department of Health and Human Services just instituted a reproductive health task force, and I was leading the data and research workgroup of that. So I worked very closely with NHIS [National Health Interview Survey], the branch of the CDC [Centers for Disease Control and Prevention] that runs a lot of these. So I really, really tried to get some of these new items embedded into the research design. Unfortunately, it takes years to get … it’s just a very slow process.
Dr. Ellen Beckjord: And the real estate is limited and there’s legacy questions, and these are not — it’s not easy to, if everybody could have a question …
Dr. Sonya Borrero: Correct, it’s not easy. I’ve given them some … so hopefully, they said they would consider them in 2024 for the next round.
Dr. Ellen Beckjord: Is it an annual survey?
Dr. Sonya Borrero: The NSFG is continuous, but they do it in four-year chunks. And so I think getting onto the next iteration takes a couple of years, but hopefully we’ll keep those conversations going. And BRFSS actually was about to discontinue its family-planning module. So our task force had a strong statement encouraging them not to discontinue it at this time. And so they’re going to keep that. So we were able to keep that going. It’s mostly about contraception, though, and which is great. I mean, obviously contraception is a critical tool in our toolbox to help people achieve reproductive autonomy. So understanding how this landscape sort of impacts people’s contraceptive decision-making and their ability to get their preferred method will be really important as well.
Dr. Ellen Beckjord: [I] appreciate the view into those national surveys … and then as you mentioned, you know, many listeners may know the publicly available data that they generate, which is the foundation of so much secondary data analysis that’s really at the core of a lot of research that folks do, observational researchers, epidemiologists, and the like. Wonderful to know that there’s advocacy for inclusion of more items about reproductive health and the preservation of that module in BRFSS.
The last question that I would love to ask you is, and what a wonderful vantage point you are able to see this entire space from, especially now, having spent a year working at the highest level of the federal government. What are you most hopeful about?
Also, fair to ask if you’d like to share anything that you’re most concerned about, but curious about what you feel most hopeful about as well?
Dr. Sonya Borrero: Maybe I’ll start with what I’m concerned about because I think it leads into where I’m finding some hope.
So while I was at the government, I think there was a tremendous opportunity to be part of these discussions. And there is very much an interest in preserving sexual and reproductive health care access. However, what I learned was that, number one, because democracy is messy and because every four years we have a potential change in administration, it was so hard, if not impossible, to come in with what I wanted to, to develop and implement a long-term vision for how we get to sexual and reproductive health equity in this country. So that was like the first sort of disillusioning moment for me when everyone was like, “Well, we only have a year.“ So, that was one lesson, right? While that was sort of a disappointing lesson for me while I was there, it really honed my appetite for coming back to my academic position because I realized that it actually takes all of us and I have a small lane, right?
I realize that I love research. That research to policy translation is sort of, you know, that’s where my passion does lay. But we need everyone, right? We need the advocates. We need community members. We need our legislators. We need all hands on deck to push the government because it will react. It will definitely, sort of — that’s the place where policy change is happening at the broadest level. But it takes so much effort from us. So I think that I’ve come back with a renewed energy for at least working in my lane and producing knowledge and helping to connect the dots between that knowledge and where policy efforts could lie.
Dr. Ellen Beckjord: Well, I want to thank you so much for the work that you do. And what a wonderful conversation. Hearing your insights and your experience has just been fantastic. Thanks so much for joining us on Good Health, Better World.
Dr. Sonya Borrero: Thank you. This was such a pleasure.
Dr. Ellen Beckjord: The scope and study of women’s health has grown measurably but still has a long way to go as it continues to evolve. Staying up-to-date on all topics related to women’s health is key in being a part of health improvement for all women. Check the show notes for this episode at postindustrial.com/goodhealth for more information.
Dr. Ellen Beckjord, MPH, is host of the Good Health, Better World podcast.
Ellen is a behavioral scientist, epidemiologist, and licensed clinical psychologist working at the intersection of population and digital health. A long-time member of the Society of Behavioral Medicine, Ellen currently serves on the board of directors as president-elect.
Her work focuses on promoting health, wellness, and health behavior change. She is vice president of population health and clinical optimization for UPMC Health Plan based in Pittsburgh.
Ellen trained at the University of Vermont, where she worked with cancer survivors and their families, at Vanderbilt University, and at the Johns Hopkins Bloomberg School of Public Health.
She completed post-doctoral research at the National Cancer Institute in the Health Communication and Informatics Research Branch within the Division of Cancer Control and Population Sciences. She spent nearly five years in academic medicine at the University of Pittsburgh and Hillman Cancer Center.
Ellen also is the co-author of “Porchtraits” in which she interviewed people in Pittsburgh during the early months of the COVID-19 pandemic about what they were learning, missing, enjoying, what surprised them, and what they felt hopeful about.
Ellen’s guiding principle: “Lead with love.”
This podcast is proudly presented by