Dr. Melissa Gilliam Featured in AP News Story on Contraception Access

AP Photo

Section Chief Dr. Melissa Gilliam was featured and quoted in an Associated Press news story regarding Illinois’ recent effort to ensure comprehensive and continuous birth control coverage for those with Medicaid.

The story, which has been picked up by outlets nationwide including CBS News, discusses a plan from Illinois Gov. Pat Quinn’s administration to improve access to family planning services for individuals with Medicaid, including long-acting birth control methods, by increasing reimbursement and education. The plan was announced at last month’s Illinois Contraceptive Equity Summit, an event hosted by the Section and EverThrive Illinois. The public is invited to comment on the plan until September 15.

According to the article, the current Illinois Medicaid payment system creates a financial barrier to doctors for offering LARC methods. For example, IUDs cost doctors’ offices between $300 and $800 each to keep in stock. Clinics pay the upfront cost of an IUD and absorb the loss of denied or delayed Medicaid claims. By implementing the Illinois Family Planning Action Plan,  the state would double doctors’ reimbursement rates for inserting IUDs and performing vasectomies, thus alleviating the cost for both patient and provider.

Dr. Gilliam commented on access to contraceptive methods within Medicaid, saying that “for some providers, [the state’s plan] will make a very big difference and will be a very welcome change.”

Photo: M. Spencer Green, AP

Abortion & Reproductive Health Care for Incarcerated Women

orange-is-the-new-black-01Orange is the New Black returned for a second season to Netflix last Friday and continued a major plot line involving a pregnant inmate and the father of her baby, who happens to be a guard in the prison. What started as a secret romance escalated quickly due to the difficulties pregnant women face while behind bars. Legally speaking, a sexual relationship between an inmate and prison official can never be considered consensual and so the characters hatched a series of plans about how to deal with the pregnancy. Could she secretly terminate the pregnancy without anyone finding out? Could she continue the pregnancy and receive adequate health care? Could she hide the pregnancy and the true father? What happens when she goes into labor? What punishment(s) will the couple endure for their actions?

While the TV show mixes fact and fiction, it does honestly depict the reality of what happens when a woman becomes pregnant in prison or enters prison already pregnant. In addition to this ongoing pregnancy plot line, in the first season an inmate entered prison pregnant, went into labor and delivered in a hospital, and was separated from her baby shortly afterwards and returned to prison. Between six and 10 percent of women are already pregnant when admitted to a prison or jail and they can become pregnant during private visits with partners, home visits, while in work release programs, or as a result of sexual assault [ACOG]. Studies also show that approximately 14 percent of girls are pregnant when they arrive to juvenile detention.

In recognition of the prevalence of these realities, the Section published a policy brief on Abortion & Reproductive Health Care for Incarcerated Women. Although our brief focuses on Illinois policies and programs, incarcerated women in state and federal facilities across the United States face myriad barriers to receiving reproductive heath care, including abortion services. Despite having the constitutional right to have an abortion (as guaranteed under Roe v Wade), accessing the procedure while incarcerated presents many challenges, including facilities’ ad hoc responses to abortion requests and the logistics and challenges of organizing transportation and payment.

The brief also discusses the practice of shackling, prison nursery programs, and policy reforms needed to address the gendered needs of women prisoners.

Although Orange is the New Black errs on the dramatic side of storytelling, it does provide an overdue platform for discussing the basic human rights of incarcerated women who have the same rights as civilians to make decisions about their own bodies.

Emergency Contraception Controversy & Gender-Based Violence

Access to emergency contraception (EC) has a storied history in the USA and directly impacts victims of sexual violence. Ci3 and the Section of Family Planning & Contraception Research, along with the Center for the Study of Gender and Sexuality hosted a challenging and informative presentation that explored this intersection. Dr. Susan F. Wood, Associate Professor of Health Policy and Director of the Jacobs Institute of Women’s Health at The George Washington University spoke about her role and observations surrounding over-the-counter EC access.

As Assistant Commissioner for Women’s Health at the FDA, Dr. Wood directed the FDA Office of Women’s Health from 2000 to 2005, at which point she resigned on principle over the continued delay of approval of EC over-the-counter.

Dr. Susan F. Wood

Dr. Susan F. Wood

Dr. Wood’s talk, Controversy over Contraception: From Emergency Contraception to Contraceptive Coverage to the Affordable Care Act, began with the historical context of women’s health and federal funding and ended with the implications of the ACA specifically regarding contraceptive coverage and access.Her talk focused primarily on the ongoing struggle to make EC available to all women over the counter.

In her role at the FDA, Dr. Wood witnessed the agency’s attempts to regulate the practice of medicine and pharmacy when it came to emergency contraception, an unprecedented course of action not only in its role as a government agency but also because of the impact on women’s access to family planning services.

The FDA approved Plan B as EC in 1999 as a prescription product for all women of childbearing potential. The manufacturer sought over-the-counter (OTC) approval in 2003.

At this early stage, it was already known that:

  • EC is safe and suitable for all women.
  • EC does not cause an abortion (“The only relation between EC and abortion is that EC prevents the need for an abortion,” says Dr. Wood.)
  • EC needs to be taken soon after (within hours of) intercourse to be the most effective.
  • EC provides victims of rape the option to prevent an unwanted pregnancy.

Despite these facts and extensive studies on the safety for women of all ages, politics and myths about EC — that it would increase adolescent sexual activity, encourage pedophilia, or cause an abortion — delayed FDA approval.

Not until August 2006 did the FDA approve Plan B over-the-counter (OTC) at pharmacies and health clinics, and this approval was limited to women 18 years and older; younger women would still require a prescription. Between 2003-2006, recommendation for approval had been overruled several times, Dr. Wood resigned, and activists across the country lobbied the FDA to make decisions that reflect good medicine and public interest.

In March 2009, a US district court ruled that the FDA decision to restrict access to women under 18 was “arbitrary and capricious” and ordered the FDA to lift restrictions on 17-year-olds within 30 days. Also in 2009, the FDA approved One Step (a one-dose version of Plan B) and Next Choice (a two-dose generic version), but the age restriction remained at 17. In 2010, with the age restriction still in place, The Center for Reproductive Rights filed for contempt of court citing the delays.

In 2011, Teva (One Step) released new data and filed an application to lift the age restriction. With the age restriction ready to be lifted, the FDA was overruled by Health and Human Services Secretary Kathleen Sebelius, who cited the lack of evidence on 11- to 12-year-olds’ ability to use the product. Although this argument was unprecedented and unfounded, President Obama agreed with Kathleen’s lack of evidence argument and the age restriction remained.

It took until June 2013 for the FDA to approve Plan B One Step OTC for all women without age restriction. That is, it took 10 years for women to have OTC access to a safe medicine approved by the FDA for women of all ages.

Plan B as seen over-the-counter. Image from Dr Wood's presentation 11/19/13.

Plan B as seen over-the-counter. Image from Dr. Wood’s presentation 11/19/13.

How does this history of EC approval, restrictions, stigma, and accessibility relate to gender-based violence and the 16 Days of Activism Against Gender-Based Violence campaign?

  1. EC is an essential contraceptive option for women who experience sexual violence. According to the FDA: “Seven out of every eight women who would have gotten pregnant will not become pregnant after taking Plan B, Plan B One-Step, or Next Choice.” Dr. Wood adds, “There isn’t any difference in efficacy for the use of EC for victims of sexual violence.”
  2. EC potentially prevents the extra burden of an unwanted pregnancy for rape victims.
  3. The cost of EC may be prohibitive; EC costs about $50 OTC in most pharmacies. Under the Affordable Care Act, the cost should still be covered through prescription. According to Dr. Wood, in the cases of rape, specifically for populations who cannot afford the $50, access to EC through family planning clinics may reduce the cost.
  4. If a victim of sexual violence seeks care at an emergency room, EC should be provided as part of her treatment.
  5. Even though EC is available OTC, doctors should continue prescribing and counseling EC, especially for victims of sexual violence. According to Dr. Wood, “Time is of the essence, so provision of information, and advance provision of EC can be helpful for all women. In addition, awareness by providers of other EC methods, such as insertion of copper IUD or use of Ella (a prescription only emergency contraception that is effective for up to 5 days) is important.”

Policy Trends and Research Updates on the 40th Anniversary of Roe v. Wade

On January 22, 1973, the Supreme Court of the United States decided the landmark case Roe v. Wade, which established the right to abortion.  Forty years later controversy still surrounds this decision and attempts to restrict and regulate abortion care have continued. In 2011 and 2012, the United States saw more regulation of abortion care and access at the state level than in the past 40 years, making it more and more difficult for women to exercise their rights.[1]

State lawmakers are continuing to find new avenues through which to restrict access to abortion; 2012 saw trends in proposed and passed legislation that restrict insurance coverage, require provision of unnecessary procedures or misleading information to women, target abortion providers, and seek to ban abortions at later gestational ages based on theories regarding fetal pain.

Eight states now have laws that require a doctor to perform an ultrasound and show her the image or offer to do so before a woman can receive an abortion.[2] Doctors already perform ultrasounds if they are needed to provide abortion care; enacting legislation to require the procedure and viewing of the image appears aimed solely at trying to dissuade women from choosing abortion. A 2012 study researching the effects of ultrasound viewing on women seeking abortion found that women can respond differently – some women felt dissuaded, some women experienced emotional difficulty, and some women reported a better ability to cope with their abortion. Given these varied outcomes, the authors suggest that the decision to view an ultrasound should be left to the doctor and patient.[3] The leaders of five well-regarded professional physician organizations agree. Responding in part to the ultrasound mandates, they published a commentary in 2012 voicing concerns over legislative interference with the patient-physician relationship; they assert that such legislative intervention undermines the ability of physicians to give, and patients to receive, the highest quality care and medical guidance.[4]

In a large number of states, a waiting period is required before receiving an abortion. In addition, doctors must provide mandatory counseling prior to abortion; in some states, specific language must be read, including information that is not supported by science regarding links between abortion and breast cancer and mental health risks. Not only do such mandates require physicians to provide misinformation, but a study conducted in June 2012 found that 87% of women are confident about their decision to make an abortion before visiting a clinic, suggesting that blanket regulations requiring counseling and waiting periods only interfere with a woman’s ability to receive personalized care.[5]

These misleading practices can be amplified by Crisis Pregnancy Centers (CPCs), which often give the impression that they offer abortion services, but in fact typically only offer pregnancy tests and ultrasounds and are usually established expressly to discourage abortion. In a recent study, researchers contacted 32 CPCs in North Carolina and seventeen (53%) provided at least one misleading or inaccurate piece of information, including inaccurate information about links between abortion and breast cancer, mental health hazards, and infertility.[6] Scholar Joanne Rosen also discussed the public health risks of CPCs in a 2012 commentary in Perspectives on Sexual and Reproductive Health, claiming that CPCs, which operate under the notion of informed consent, are actually, “contrary to the legal and ethical standards of informed consent”, given their practices of distributing misleading information.[7]

In 2012, three states (Arizona, Kansas and Missouri) enacted new “conscience provisions,” expanding the types of entities that can refuse to provide care or insurance to patients or employees.[8] Many states already have provisions in place that exempt individuals from providing these services on moral or ethical grounds, but new measures allow insurers to exclude coverage for contraception, abortion and sterilization.[9]  As Lisa Harris points out in a recent article in The New England Journal of Medicine, these measures allow for “conscience based refusals,” but there is little legal protection of “conscience based provision” of such services.[10]

In the past year, there has been an onslaught of legislation establishing targeted restrictions on abortion providers (referred to as TRAP laws). Bills were proposed in twelve states that would place burdensome restrictions on clinics through building regulation mandates and new employee requirements. Last month, Governor Rick Snyder of Michigan signed a bill which requires clinics that regularly perform abortions to meet the same building license requirements as surgical outpatient facilities. This bill and others like it will likely result in not only the closing of many existing clinics, but will make the building of new clinics more arduous.[11] Some women must already travel hundreds of miles to the nearest clinic, as this map demonstrates. These types of restrictions will make access even more difficult.

With the passage of the Affordable Care Act and the resulting creation of new state exchange programs, many legislatures have made efforts to curtail coverage for abortion. Four states in the past year passed bills which prohibit abortion coverage through their exchange programs, while a number of other states are working toward abortion care bans both within and beyond the exchange. In addition, many states continue to pursue a ban on abortion at earlier gestational ages. Eight states in the past year saw bills that proposed abortion bans as early as twenty weeks post fertilization, which precedes the current legal viability mark.[12] These bans likely impact the most vulnerable women; in a recent study, researchers found that patients seeking second trimester abortions were often younger (age 19 and below), Black, less-educated, lower-income, had experienced more disruptive life events, and were more likely to have been exposed to intimate partner violence.[13]

A major victory for women in the year 2012 was the passage of the Shaheen provision in the National Defense Authorization Act, which provides military servicewomen and military families the same abortion coverage as other federal employees. Previously, insurance for these women only covered abortions when a woman’s life was at risk, but the Shaheen provision allows for additional coverage in the case of rape or incest.[14] This change is especially welcome given the findings of a recent study which showed a number of challenges women in the military face when seeking contraception; one third reported that they were unable to access a method they might want for deployment, certain methods were reportedly discouraged or not available for some women (including intrauterine devices and sterilization), and 41% of women requiring refills found them difficult to obtain.[15]

Looking back on 2012, we can celebrate the reproductive justice achievement in the Shaheen provision, and applaud the successes that legislatures and reproductive justice advocates had halting the passage of proposed bills that would restrict access. However, some measures did pass which limit the ability of women to obtain supportive and quality reproductive care. As we move into 2013, there are promising ways to advance the rights articulated in Roe v. Wade. Such initiatives might include efforts to preserve insurance coverage and expand public funding for abortion care, expand sexual education, promote public awareness of issues related to reproductive justice and abortion, and increase women’s access to reproductive care.

[1] 2012 Saw Second-Highest Number of Abortion Restrictions Ever. New York: Guttmacher Institute, January 2, 2013.

[2] State Policies in Brief: Requirements for Ultrasound, New York: Guttmacher Institute; 2013.

[3] Kimport K., et al. Women’s Perspectives on Ultrasound Viewing in the Abortion Care Context.  Women’s Health Issues. 2012, 22(6): e513- e517.

[4] Weinberger SE, et al. Legislative Interference with the Patient-Physician Relationship. The New England Journal of Medicine. 2012, 367: 1557-1559.

[5] Foster DG, et al. Attitudes and Decision Making Among Women Seeking Abortions at One U.S. Clinic. Perspectives on Sexual and Reproductive Health. 2012, 44(2): 117- 124.

[6] Bryant A, Levi E. Abortion misinformation from crisis pregnancy centers in North Carolina.  Contraception. 2012, 86(6):752-756.

[7] Rosen JD. The Public Health Risks of Crisis Pregnancy Centers. Perspectives on Sexual and Reproductive Health. 2012, 44(3):201-205.

[8] 2012 Year-End Report. New York: Center for Reproductive Rights, 2013.

[9] State Policies in Brief: Restricting Insurance Coverage of Abortion, New York: Guttmacher Institute; 2013.

[10] Harris L. Recognizing Conscience in Abortion Provision. The New England Journal of Medicine. 2012, 367: 981-983.

[11] Marty R. “Michigan Governor Snyder Signs Abortion Superbill into Law”. RH Reality Check, 2012.

[12] 2012 Year-End Report.  New York: Center for Reproductive Rights, 2013.

[13] Jones RK, Finer B. Who has second-trimester abortions in the United States? Contraception. 2012, 85(6):544-551.

[14] Senate Votes to Ease Ban on Abortion Coverage for Military Servicewomen; Bill Now Moves to Conference Committee” New York: Center for Reproductive Rights, 2012.

[15] Grindlay K, Grossman D. Contraception access and use among US servicewomen during deployment. Contraception. 2012, 87(2): 162-169.

Contraception as Preventive Medicine

Updates in Clinical Care provided by The Ryan Center at the University of Chicago

An Ounce of Prevention 
Given the current climate of change and controversy surrounding contraceptive access, we should once again examine the importance of contraception as a tool for preventive medicine.

Contraception is the key to prevention.
More than half of all US women will experience an unintended pregnancy at some point in their lives, and nearly one-third will have an abortion (1, 2). Unfortunately, the rate of unintended pregnancy in the United States has seen no improvement in recent years, and there was a slight increase from 2001 to 2006, from 50 to 52 per 1,000 reproductive-aged women. Poor and low-income women are at even higher risk of unintended pregnancy: the rate for women at or below the poverty limit is 66 per 1,000 women, compared to 10 per 1,000 women who are at >200% of the poverty limit (1).

Although incorrect and inconsistent use of contraception account for some unintended pregnancies, the majority (52%) occur among the small percentage of women (16%) who are not using any contraception (3).

On a note of positive change, we have seen teen pregnancy in the United States decline significantly since the mid-1990s. Although abstinence has played a role, several analyses have confirmed that contraception is responsible for the majority of the decline in teen pregnancies (4, 5). To review some of the latest research in the area of contraception, see recent studies highlighted on our Reproductive Health & Justice Research blog.

Increasing access to contraception, especially highly effective methods of contraception, is a vital public health issue.

1.  Finer LB and Zolna MR, Unintended pregnancy in the United States: incidence and disparities, 2006, Contraception, 2011, 84(5):478–485.
2.  Jones RK and Kavanaugh ML, Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion, Obstetrics & Gynecology, 2011, 117(6):1358–1366.
3.  Gold RB et al., Next Steps for America’s Family Planning Program: Leveraging the Potential of Medicaid and Title X in an Evolving Health Care System, New York: Guttmacher Institute, 2009.
4.  Santelli J, et al. Explaining Recent Declines in Adolescent Pregnancy in the United States: The Contribution of Abstinence and Improved Contraceptive Use, Am J Public Health, 2007, 97:150–156.
   5.  Teen Births at Record Low Thanks to Improvements in Contraceptive Use, New York: Guttmacher Institute, April 11, 2012, available at: http://www.guttmacher.org/media/inthenews/2012/04/11/index.html.


The Ryan Center & Contraceptive Care
We are pleased to announce two new exciting programs offered by the Ryan Center.

Carol’s Contraceptive Access Project (CCAP)
Due to a generous donation, we are now able to provide contraception for patients at the Ryan Center, regardless of insurance or ability to pay. We have low-cost options and financial assistance for:

  • Immediate insertion of intrauterine devices and implantable contraception (e.g. Implanon®)
  • Same-day injections of Depo-Provera®
  • Combined hormonal contraceptives (the pill, patch, and ring)

Center for Contraceptive Management
We offer the full range of contraceptive options, including, but not limited to:

  • Intrauterine device (IUD) and Implanon®/Nexplanon® insertion
  • Depo-Provera injections
  • Surgical and “no-cut” Essure® tubal sterilization
  • Prescriptions for: oral contraceptive pills, the contraceptive vaginal ring (NuvaRing®), the contraceptive patch (Ortho Evra®), and emergency contraception

      *We specialize in contraception for medically complicated patients.

Contact us at 773-702-6118 to make an appointment.


IUD Clinical Trial
Are you or your patient interested in receiving an investigational IUD for long-term birth control? Participants will be compensated up to $900 over the course of 5 years. Click here for more information. UPDATE: This study is now closed.

Race and Reproductive Politics: An Editorial

In Race, Reproductive Politics and Reproductive Healthcare in the Contemporary United States, an editorial published in Contraception, authors Carole Joffe and Willie Parker discuss how the United States, a country marked by extreme stratification on both racial and economic grounds, has had a history of both targeting the birth rates of people of color while also fueling deep political divisions about the provision of reproductive healh services – particularly abortion and contraception.

The authors discuss their dismay at the contemporary state of reproductive politics in the United States, particularly the manipulation of racial themes by opponents of abortion and birth control.  However, they reference the “mixed legacy” of the United States history and acknowledge the complexity of alandscape “containing both liberatory and coercive possibilities, and always with particular implications for people of color in a white-dominated society.” Ultimately, the authors warn against the “manipulation of the history of race and reproduction by those involved in the [recent anti-abortion] billboard campaigns” and similar efforts which obscure “the contemporary facts of life faced by the most vulnerable black women.”

The authors note that the current climate has galvanized a countermovement of health activists  and they see hope for women’s reproductive rights. At the same time, the authors conclude that “the stakes in this “war” are inevitably the highest for the most vulnerable in our society; Parker calls on fellow health care providers “to trust women to make the good and tough decisions about when and whether to expand their families” and assure them the resources to do so.

Oral Contraception Linked to Women’s Wage Gains

In The Opt-In Revolution? Contraception and the Gender Gap in Wages, by Bailey et al., published in the National Bureau of Economic Research, reports that from 1979 to 1989, median wage and salary earnings of full-time, working women increased from approximately 60% of men’s earnings to 69% of men’s earnings.  This marked a striking departure from the stability of women’s relative pay during the 1970s, narrowing the wage gap during the 1980s.  Authors utilized data from the National Longitudinal Survey of Young Women, which includes interviews starting in 1968 with 5,159 women ages 14 through 24, with 21 follow-up interviews.

Authors examined state-level variation within birth cohorts for early legal access (ELA) to the pill, and although the timing of ELA implementation differed significantly from state to state, every state gave physicians the ability to prescribe the pill to unmarried women younger than age 21 without parental consent.  The researchers used respondents’ legal state of residence at age 21 to determine whether they would have had ELA.  Authors then utilized the 1970 National Fertility Survey, which includes data on ever-married women’s pill use during the 1960s, in order to specifically look at pill use among women who were married by 1970 and those who were ages 18 through 21 before 1970.

Researchers determined that although the hourly and annual wages of women who had ELA were lower in their early 20s than the earnings of women who did not have ELA, “their wage and salary earnings grew more rapidly than their counterparts as they aged.”  Specifically, the researchers found that women ages 20 through 24 with ELA earned 3% less hourly and 9% less annually, compared with their peers. Read more of this post

U.S. Second Trimester Abortions: Who Is Most Likely To Have Them?

In Who Has Second Trimester Abortions in the United States? [PDF] published in Contraception, authors Rachel K. Jones and Lawrence B. Finer looked at a national sample of 9493 women who obtained abortions in 2008.  They examined and compared the demographic characteristics of women having abortions at 13 or more weeks since their last menstrual period (LMP) and women having abortions at 13–15 weeks since their LMP.

The authors found that 10.3% of abortions in the United States were 13 weeks LMP or later, including 4.0% at 16+ weeks, and that the individuals most likely to have abortions at 13 weeks or later included black women, women with less education, those using health insurance to pay for the procedure and those who had experienced three or more disruptive events in the last year.  Individuals who were more likely to have an abortion at 16 weeks or later included black women, higher income women and those paying with health insurance.

Jones and Finer conclude that women, notably those with less education, would most benefit from increased availability of first-trimester abortion services, and that an increased emphasis should be placed on the provision of these services to this population.

Contraceptive Care in the Veterans Healthcare System

In Contraceptive Care in the VA Healthcare System,published in Contraception, authors Sonya Borrero, et al, highlight how little is known about contraceptive care within the Veterans Affairs (VA) health care system.  This study was conducted to assess the prevalence of documented contraception by race and ethnicity within the VA and to examine the association between receiving primary care in women’s health clinics (WHCs) and having a documented contraceptive method.

The authors examined data from 103,950 female veterans aged 18-45 years from the year 2008.  Attention was paid to the associations between race/ethnicity and receipt of care in a WHC with having a method of contraception.

Results indicated that a meager 22% of women veterans had a documented method of contaception during 2008. Hispanic and African-American women were significantly less likely to have a method compared to whites, and women who went to WHC’s were significantly more likely to have a method of contraception compared to women who went to traditional primary care clinics.

The authors concluded that overall contraceptive prevalance in the VA is low, but receiving care in a WHC is associated with a significantly higher likelihood of having a contraceptive method.

Veteran’s Affairs and Reproductive Health Services

In Availability of Gynecologic Services in the Department of Veteran’s Affairs, published in Contraception, authors Michelle D. Seelig, et al, evaluated on-site availability of gynecologic services, clinic type and staffing arrangements, and the impact of having a gynecology clinic and/or an obstetrician gynecologist routinely available.

Results indicate that of the 133 sites that they evaluated, fifty-eight percent (77 sites) offered services directly though an OBGYN, forty-two percent (56 sites) did not have an OBGYN and fifty-four percent (72 sites) had a women’s health clinic (WHC).  Of the sites that provided services directly from an OBGYN, more services were offered.  Of these additional services, those clinics with an OBGYN were more likely than those without to offer the following services: endometrial biopsies (91% vs. 20%), IUD insertion (85% vs. 14%), infertility evaluation (56% vs. 23%), infertility treatment (25% vs. none), gynecologic surgery (65 vs. 28%).

The authors conclude that as the VA learns new avenues to accomodate the rising number of woman veterans, there should be an increased focusing on establishing WHC for primary care and routine availability of OBGYN or other qualified clinicians.