“My Body, My Choice!”
“Abortion Stops a Beating Heart!”
We’ve all heard the arguments and likely chosen a side. Few issues are as divisive as abortion, and — news flash — we aren’t ever going to agree. The Supreme Court’s decision today to overturn Roe v. Wade will allow states to regulate abortion as they wish. It has ignited the pro-choice movement like nothing else in decades.
In the aftermath of the decision, more than 20 states are expected to significantly limit or ban abortion. According to the Guttmacher Institute, a research group that supports abortion rights, an estimated 58% of women of reproductive age — about 40 million — live in states that are “hostile” to abortion.
Options for reinstating abortion rights are limited in the foreseeable future. Yet the consequences of denied abortions, documented in the University of California San Francisco’s (UCSF) Turnaway Study, are substantial, including increased poverty and poor pregnancy outcomes.
Though we may agree on little else, most people on both sides of the debate want to reduce unintended pregnancies that lead to abortions. Could we come together to support women, in a post-Roe U.S., by providing universal access to contraception?
‘Contraceptive Deserts’
We are fortunate today to have many safe and effective contraceptive options. There are pills, patches, rings and implants. Most methods involve hormones, but some don’t. Birth control pills require daily use, while copper intrauterine devices (IUDs) are effective for 10 years. Typical failure rates for hormonal birth control are about 7% for pills and patches and less than 1% for implants and IUDs. Most options are inexpensive and well-tolerated.
Nearly nine in 10 women use birth control at some point during their lives. Yet millions struggle to obtain their methods of choice. According to Power to Decide, a nonprofit dedicated to preventing unplanned pregnancy, more than 19 million women of reproductive age live in “contraceptive deserts,” areas without access to the full range of contraceptive options.
Many others are limited by lack of health coverage. “One of the biggest barriers to [contraceptive] access is really the access to insurance,” said Dr. Kimberly Carter, District XI (Texas) Section officer for the American College of Obstetricians and Gynecologists (ACOG). Women who are uninsured are less likely to use effective birth control and are more likely to experience an unintended pregnancy.
In the 12 states that have yet to extend Medicaid to low-income adults, the situation is particularly difficult. In Texas, “we have the highest number of uninsured women of reproductive age per capita, and we have restricted public funds from going to places that provide contraceptive care, such as Planned Parenthood,” Carter said. Consequently, large parts of the state have no providers with the skills to place IUDs and hormonal implants, the most effective methods, known as long-acting reversible contraceptives (LARCs).
In other areas, religious organizations own hospitals and can limit certain forms of birth control or add barriers to make access more difficult. Women who have just given birth, for example, are often eager to start contraception, and many will request LARC placement immediately postpartum, a practice that is recommended by many physicians. But in some hospitals, LARCs are prohibited.
Restricting reproductive services exacerbates preexisting health disparities. Those with connections can still find resources, but women who are isolated and lack means forgo needed care. This situation will become more common with the overturn of Roe.
Solutions
First and foremost, expanding insurance coverage would allow more women to connect with health-care providers and start birth control. As Carter pointed out, “Studies show that abortion rates decline when access to health care improves.”
Training more health-care providers to offer LARCs would also decrease unplanned pregnancies by improving availability of these highly effective methods. Programs like UCSF’s Beyond the Pill not only teach providers how to place IUDs, but also educate office staff to counsel patients on birth-control options.
Telemedicine also offers new opportunities for women to receive care. “Especially during the ongoing pandemic, being able to have a patient visit virtually from the comfort of their own space has been a true benefit for patients, ensuring that they can still access critical sexual and reproductive health care like birth control services,” said Dr. Krishna Upadhya, vice president of quality care and health equity at Planned Parenthood Federation of America.
The Food and Drug Administration could further improve access by allowing birth-control pills to be sold and dispensed without a prescription. Oral contraceptives have been used for 62 years with a solid safety record. Granting over-the-counter status could reduce unintended pregnancies by an estimated 7% to 25%. Major medical organizations like ACOG and the American Academy of Family Physicians support lifting restrictions. Over 100 other countries allow birth-control pills to be sold without a prescription. But, in the U.S., we’re still waiting.
Other policy options to increase access include enforcing and expanding the Affordable Care Act’s contraceptive mandate and increasing funds for Title X, the federal program that helps fund family-planning services for low-income women.
Needless Barriers
Unfortunately, many anti-abortion groups are not promoting contraception — or other solutions — to reduce unplanned pregnancy. National Right to Life, for example, says it “does not take a stance on anything that prevents fertilization.” In an emailed statement, the group said it opposes “any device or drug that would destroy a life already created at fertilization.” This position has created confusion about the way certain contraceptives work, potentially jeopardizing future access to some of the most effective methods. When I asked which strategies the group recommends to reduce unintended pregnancies, I got no response.
As a practicing family physician for many years, I couldn’t believe the hoops women had to jump through to get birth control: find a clinic, schedule an appointment, perhaps meet with an eligibility specialist to enroll in a publicly funded family-planning program, bring in a slew of paperwork, see the provider and ultimately get a prescription or an injection. In the not-too-distant past, we required pelvic exams. At my clinic, if a woman wanted a LARC, we had to refer her elsewhere, hand her a bag of condoms and cross our fingers.
“Access to birth control is not nice to have; it’s necessary,” Upadhya said. “Nearly 9 in 10 adults agree that everyone deserves access to the full range of birth control methods — no matter who they are, where they live or what their economic status is.”
We can do better. We can make contraceptives accessible and free. We can make birth-control pills available over the counter, without age restrictions, covered by both public and private insurance. We can increase access to same-day insertion of LARCs by training more providers and supporting clinics. Birth control is not a panacea. It won’t eliminate unplanned pregnancies and abortions. But increasing access could significantly reduce both — and save lives.
Lisa Doggett, senior medical director of HGS AxisPoint Health, is a columnist for Public Health Watch. The views expressed in her column do not necessarily reflect the official policy or position of HGS AxisPoint Health or Public Health Watch.