UAB — recognized for excellence in women’s health — responds to misleading media report

On May 13, 2024, TIME published a story that mischaracterized the University of Alabama at Birmingham’s commitment to providing empathetic, evidence-based reproductive care and access to contraception for patients of all backgrounds.

It is important to note that UAB is consistently recognized for excellence in women’s health practice areas, including Obstetrics, as determined by Centers for Medicare and Medicaid Services data, accreditation information, and surveys from thousands of women to determine which measures are most important to them.

While UAB answered the reporter’s questions, the article ignored important facts and context provided to the reporter over several weeks. It is important for our community and the people we serve to understand UAB’s role in supporting our patients throughout their reproductive health journey, including our commitment to health equity and fighting health disparities.

THE FOLLOWING INFORMATION WAS PROVIDED TO THE REPORTER BY UAB

On March 15, 2024, UAB provided the following responses to the reporter’s questions:

We strongly disagree with assertions you’ve made and are eager to share the following facts:   

As is common among hospitals nationwide, the University of Alabama at Birmingham follows guidance from the American College of Obstetricians and Gynecologists recommending post-placental LARC placement as something that should be routinely offered as standard care.

At UAB, all patients are counseled on contraception and options available to them throughout the course of their pregnancy, which begins in their first obstetrics appointment and throughout the duration of their subsequent prenatal care visits. These conversations are documented and confirmed upon admission for delivery. If the patient remains undecided upon admission to the hospital, they are again given information about the options that are actionable at the time (e.g., post-placental IUD, immediate postpartum Nexplanon). If the patient chooses to proceed with their agreed-upon contraceptive plan, consents are signed and the LARC is inserted after delivery. Every patient makes her own decision on contraception, and our team supports them in the decisions they make about their health.

Providing LARCs to women immediately postpartum is often the most convenient, comfortable and affordable option for women who desire long-acting contraception. One of the benefits to post-delivery placement (within 10 minutes of placental delivery) is that the pain control selected for delivery is still in effect, while that pain control would not be an option in an outpatient setting. Additionally, many obstetrics patients have limited insurance that is active only during pregnancy and through the six-week postpartum window. This and the aforementioned pain management aspects make the post-placental placement the preferred method for many women who desire long-term contraception.

While privately insured patients have long been covered for and utilized the post-placental IUD option, post-placental IUDs were not covered by Medicaid. UAB secured grant funding for contraceptive health equity and was involved in the Medicaid changes to equalize health access. As a result of this funding, Medicaid patients and privately insured patients alike have equal access to post-placental LARC placement care.  

Again, ACOG recommends that post-placental LARC should be routinely offered as standard of care, and UAB follows standard practice of post-placental IUDs. At UAB, all patients are counseled on contraception and options available to them throughout the course of their pregnancy, which begins in their first obstetrics appointment throughout the duration of their subsequent prenatal care visits. Written consent is obtained prior to delivery so that the LARC is in the room at the time of delivery. For women with no contraindications (i.e., hemorrhage, infection), we confirm verbally with the patient that she still desires the post-placental LARC. Then, the intrauterine device is placed at the fundus or top of the uterus within 10 minutes of the placenta’s delivery in patients who delivered vaginally. In patients with a Cesarean delivery, the LARC is placed during closure of the uterus, once the baby and placenta have been delivered. 

For your reference, here is some important background and context that should be helpful to you and your readers if you are reporting on UAB: 

UAB Hospital is a leading academic medical center and the eighth-largest hospital in the United States and welcomes almost 2 million patient visits a year. It is the only American College of Surgeons-recognized Level I trauma center in Alabama. UAB Hospital is a public safety net facility that cares for any patient who needs our services regardless of their ability to pay; we proudly provide more than $70 million in un-reimbursed charity care every year. We also assumed management responsibilities for Cooper Green Mercy Health in 2019 and recently announced an expansion in eligibility criteria to help more people. UAB has also invested millions of dollars in Live HealthSmart Alabama, our transformational movement to improve the health of all Alabamians.  

UAB is a state and national leader in maternal health initiatives — here are just a few examples of our intentional investments and results: 

• UAB Hospital’s Department of Obstetrics and Gynecology collected 1,309 Mothers on Respect Index (MORi) surveys (see attached) in 2022, where patients were asked 14 questions about their care. Patients were asked to score each response from 1 to 6, with 1 representing “feelings of low respect” from caregivers and 6 representing “feelings of high respect” from caregivers. The average total score from all questions was 75.4 out of a possible 84 points (~90th percentile) — a number which indicates that our patients are largely feeling respected.
• UAB Hospital was rated as “high-performing” — the highest level possible — in the 2022-2023 U.S. News & World Report Best Hospitals for Maternity Care rankings. 
• UAB’s Department of Obstetrics and Gynecology programs were ranked No. 5 in the nation in the 2022 U.S. News & World Report survey, which evaluated obstetrics and gynecology programs at 233 United States hospitals.
• UAB received nine 2023 Women’s Choice Awards designations — which represent the top 10 percent of hospital practices nationally — for women’s health practice areas, including Obstetrics. Best Hospital designations were awarded based on the hospital’s achievement in clinical excellence and patient experience and satisfaction.
• The UAB Medicine Community Health Equity service line was created in 2021, dedicated to addressing underlying economic and social inequities that affect community health outcomes, and Verlon Salley, MHA, was named VP of Community Health Equity. 
• UAB’s Martha Wingate, DrPH, directs the Alabama Maternal Health Task Force created to improve maternal health across Alabama.
• UAB’s Rachel Sinkey, M.D., helped found (with the Alabama Department of Public Health) and chaired the Maternal Mortality Review Committee, which examines each maternal death to learn about causes and contributing factors.
• Obstetrics and Gynecology Assistant Professor and Residency Program Director Audra Williams, M.D., educates and leads training sessions on Black maternal health and disparities in care.
• The Department of Obstetrics and Gynecology holds a quarterly health equity conference that focuses on the social determinants of health and how they affected care and patients’ outcomes here at UAB Hospital. 
• UAB Hospital provides Implicit Bias Training to staff, including nurses, providers and everyone who works in labor and delivery.
• We introduced full-time perinatal nurse navigators to our prenatal system. All patients are immediately connected with a perinatal nurse the moment they call UAB to establish prenatal care. 
• We have created the UABaby birth journey program, which empowers our OB patients to make decisions regarding their birth journey based on their wishes. 
• A team from the Center for Women’s Reproductive Health at UAB is serving as the coordinating center for a national network, leveraging expertise to help train the next generation of pregnancy health equity researchers, providing consultation and guidance, compiling data reports, and coordinating the administration of the initiative.
• UAB faculty is leading the P3 Providing an Optimized and emPowered Pregnancy for You (P3OPPY) study to evaluate promising interventions to reduce disparities and improve health care access and quality among pregnant women and their infants from historically marginalized communities. 

We are committed to a transparent and open dialogue with the patient and their family to answer questions and address any concerns and give them opportunities to raise concerns. There are many opportunities for patients to raise concerns about their care, including:

• Upon admission to UAB Hospital, all patients in the Maternity Evaluation Unit, Mother-Baby and High-Risk Obstetrics receive a printed UAB Medicine welcome guide booklet that includes instructions on how to provide feedback and a Patient Bill of Rights. The UAB Medicine Patient and Visitor Guide booklet is also posted online. 
• Signs directing patients on who to connect with if they have issues with their care are prominently displayed in our Maternity Evaluation Unit, Mother-Baby Unit and High-Risk Obstetrics Unit. 

• If a patient voices any complaint or concern to a member of their care team, the provider immediately informs the patient how to contact a trained patient advocate.
• We send digital surveys to patients post-discharge.
• Nurses and nurse leaders round on patient floors to encourage real-time dialogue about the care experience. 
• The UAB Hotline allows people — including patients — to anonymously submit concerns via online form or phone.  
• The following is from a webpage dedicated to directing patients to share concerns: 
  • Where should I direct any concerns or grievances? If you have issues with any aspect of your care, feel free to address them using any or all of the following resources: Contact Guest Services by dialing *55 on any in-house telephone or calling 205-934-CARE (2273). If you have a problem or complaint, you may talk with your health care team to resolve the problem. If unresolved, you have the following contact options:

• Contact Guest Services to request assistance from a patient advocate by dialing *55 from an in-house phone or 205-934-CARE (2273).
• Send a written letter of unresolved grievance to: UAB Hospital/Ambulatory Clinics, Chief Operating Officer, Suite 502, 500 22nd Street South, Birmingham, AL 35233

UAB tracks patient concerns and takes any complaint from any patient seriously; we follow up on every complaint. Regardless of the nature of the complaint, we connect with all of those involved and make every effort to resolve the situation.

On March 24, 2024, UAB provided the following responses to follow-up questions:

• Q: Do you know when UAB secured grant funding for contraceptive health equity and began offering IUDs to women on Medicaid?
  • A: 2017 

• Q: Does UAB still have that grant funding?
  • A: We do not, as patients with Medicaid now have LARCs covered.
    
    

On April 30, 2024, UAB provided the following responses to the reporter asking for comment on specific allegations she said would appear in the article. Specific questions asked and details from the reporter are omitted to protect patient privacy and/or any identifying patient information.

UAB is a leader in fighting health disparities on local and national levels, and — as a public safety net hospital — provides equal, consistent care to patients regardless of their background or ability to pay. UAB follows the same standard of care for all patients whether they receive Medicaid or are privately insured.  

We continue to strongly disagree with assertions you’ve made, which include factually inaccurate statements. This hearsay is largely addressed — to the extent we can within the law — in the lengthy answers, facts, information about our processes, and context we provided on March 15. Again, all patients at UAB are counseled on contraception and options available to them throughout the course of their pregnancy, and these conversations are documented and confirmed upon admission for delivery. If the patient remains undecided upon admission to the hospital, they are given information about the options that are actionable at the time. Consents are signed for the chosen plan. Every patient makes her own decision on contraception, and our team supports them in the decisions they make about their health.  

As you know, federal patient privacy laws prohibit us from commenting on a patient’s care, so we are unable to respond directly to the accusations made. 

Below is some general information and context we can provide without violating patient privacy; but I respectfully ask that you also carefully review our previous response, which largely addresses your latest inquiry: ­

• In your email, you mention sterilization. Every question thus far has been in relation to LARC care, and we want to emphasize the difference between sterilization — like a tubal ligation — versus removable contraceptive care (LARC) like an intrauterine device (IUD). Regardless, as stated, documented conversations with patients about a wide range of contraceptive care begin at their first prenatal appointment. 

• Decisions about vaginal or c-section birth are made in the best interest of a mother and baby’s health and safety. If a c-section is performed, it is because there is a medical indication. Conversations, which may occur in clinic during a prenatal appointment or during labor if it is deemed medically crucial to change course, are documented.  
  • For clarity, every patient gives written informed consent for a full range of services upon admission for labor in our Maternity Evaluation Unit. This happens before any obstetrics services are provided. This includes consent for a c-section if deemed medically necessary. 

• UAB is one of the largest and most advanced academic medical centers in the nation, so patients benefit from the expertise of highly trained care teams who provide a patient with evidence-based care. Our standard practice includes verbal consent obtained prior to the care. There are instances where immediate and/or emergent care needs to be provided to a patient for her and/or the baby’s health and safety. In those cases, the patient’s prior written consent covers the care provided. That said, medical students are not involved in hands-on care in delivering a baby without support and guidance from an attending physician/supervisor and written and verbal consent from the patient.*

• While the medical team requires a baby have a bowel movement before leaving the hospital after birth as standard of care, it is not the industry standard of care to require the mother to have a bowel movement prior to discharge after delivery (in fact, most women do not have a bowel movement for several days post-delivery).  
• UAB provides equal care to all patients, regardless of their gender, sexual orientation, race, religion, etc. To not offer any patient a form of contraception based on their sexual orientation would be discriminatory.  

• As a public safety-net hospital, UAB follows the same standard of care for all patients, whether they receive Medicaid or are privately insured. Our care protocols and documentation methods are consistently applied. 

• As outlined in our previous statement, UAB is a leader in fighting health disparities in many ways; in fact, we helped bring about health equity on this very issue.

*Editor's note: UAB originally stated that medical students are not involved in hands-on care in delivering a baby but updated this information to be more clear in what role a medical student plays in care and with what supervision and consent.