The Future of Family Planning: Where Are We Headed?

Kay Steiger

The nation's family planning program, Title X, is effective but needs an overhaul, a new Guttmacher study finds. Gains made against unintended pregnancy are stagnating, and funding is flat.

After objections from conservative Republicans, Congress quickly
withdrew a provision from the stimulus package that would have made it easier
for states to extend to women Medicaid coverage for family planning services.
It was a stark reminder that family planning is more controversial in this
country than it ought to be. After all, as a comprehensive study from
Guttmacher Institute released today points out, using birth control is a
"nearly universal" experience in this country – more than 98 percent of women
use birth control at some point during their reproductive lives.

However, the study also revealed that the use of
contraceptives is becoming less common in this country for woman who are black,
Hispanic, and low-income. Gaps between usage levels among white women and other
populations that had been narrowing during the 1980s and early ‘90s have been
widening again. Only 7 to 10 percent of white women from 1982 to 2002 (the most
recent year data is available) did not use contraception, but rates among black
and Hispanic women actually rose to 15% and 12%, respectively, in 2002, figures
that had dropped to 10% and 9% in 1995. And the gap isn’t just race-based. Now,
about 20 percent of women who are at risk of unintended pregnancy who are at or
below the poverty line aren’t using contraception, a rate that had dropped to
just 8% in 1995. 

As a result, unintended pregnancy is on the rise for
minority and low-income groups.  Though
the overall national rate of unintended pregnancy has held steady in recent
years, falling rates among affluent women masked an increase among poor and
low-income women. "Between 1981 and 1994, the national rate of unintended
pregnancy fell 14%, from 60 to 51 unintended pregnancies per 1,000 women aged
15-44. But between 1994 and 2001, that overall national rate stagnated. Worse
yet, rates among poor and low-income women rose considerably over the latter
period, even as they continued to fall among more affluent women, thereby
exacerbating already substantial disparities," reported to study, called "Next
Steps for America’s Family Planning Program." (PDF

"We were seeing the successes of the family planning efforts
in this country [that were giving] poor and low-income women equal access to
contraception in this country and seeing that translate into reduced levels of
unintended pregnancy and increased levels of contraceptive use to the point
where there was very little difference between a low-income woman and a higher
income woman in this country," said Adam Sonfield, Senior Public Policy
Associate at the Guttmacher Institute and one of the co-authors of the study.
"To see that reversing itself during the late 1990s was a really disturbing
trend for us." 

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The study examines both how
important family planning is in today’s medical landscape but also reveals that
family planning, a program that has had flat funding for the last eight years
and hasn’t been reevaluated for the last 25, leaving the program with an
"antiquated structure." There are often needless overlaps and bureaucratic
loopholes that create an inefficient use of family planning funds.
Additionally, the funding isn’t adequate for newer, more expensive family
planning technologies. 

Startlingly, six in ten of all
women who visit Title X-funded family planning clinics say the clinics are
their primary source of medical care. Like upper-income women, these women
might go to a gynecologist for an annual exam, but might also get referrals to
other doctors for other forms of care. "It’s their entry into the health care
system," Sonfield said. In fact, of women who are on Medicaid, some other form
of public insurance, or are uninsured, 67%, 78%, and 75% of them respectively
consider family planning centers their "usual" source of medical care. 

Medicaid, while it does address
family planning needs, is funded separately from Title X funds. The funds for
Title X are distributed in large operational grants to individual clinics or
care centers, while providers charge Medicaid on a per-service basis. A family
planning provider might receive both Title X and Medicaid funding, but because
there are more restrictions on how Medicaid reimbursements are processed,
Title X fills important gaps that
might otherwise cause a provider to turn away someone in need of family
planning services. 

Title X family planning funds
can provide increased quality of service by paying for counseling and other
kinds of services not covered by Medicaid. And increasingly, Title X provides funding
to clinics to serve those for those who don’t qualify for Medicaid, notably immigrants. "That’s one big piece of the puzzle is the extensive
counseling and education that women need," Sonfield said. "The average woman
uses four different methods of birth control over the course of her life. It’s not
just the first-time users. Women have different needs over the course of their
lifetimes." 

Even though women use many
different types of birth control over the courses of their lives, family
planning clinics all too often can only offer a narrow range of options. New
technologies in contraception, like the NuvaRing, the patch, and IUDs, do a
better job of preventing unintended pregnancy but they are also much more
expensive. With funding remaining stagnant the last eight years, what to offer
patients becomes a difficult choice for many clinics. "These new technologies
are wonderful for their clients but on limited or stagnant funding it creates a
real dilemma for them," Sonfield said. "‘Do we make these methods available for
our clients and therefore be able to serve fewer clients or reduce our hours or
do things like that? Or do we limit women’s choices so that we are able to
serve more women?" 

The first step to improving
access to family planning will be to increase levels of funding. Laurie
Rubiner, Vice President for Public Policy at Planned Parenthood Federation of
America, an organization whose clinics are one of the largest recipients of
Title X funding, said that they’re asking for a total of $700 million to bring
funding levels up to inflation-adjusted rates that match those in 2000. Current
funding levels are at about $300 million. "The money is obviously key," Rubiner
said. 

But it is about more than just
increasing funding. The Guttmacher study outlines a number of steps that would
make the relationship between Medicaid and Title X funding to work more
seamlessly together. Some of the changes are straightforward, like the Medicaid
family planning waiver that was proposed for inclusion in the stimulus package. 

"Unfortunately there was a lot
of misrepresentation about what that bill would have done," Rubiner said. "It
doesn’t cost $200 million. It actually saves money." Though the Medicaid waiver
is a bureaucratic savings, reducing the amount of paperwork to obtain a waiver,
the Guttmacher report also shows that for every dollar invested in family
planning, Medicaid saves $4.02 in expenses on pregnancy-related care. 

An earlier report from
Guttmacher by Rachel Gold that was released last summer showed that
many clinics are still behind in providing bilingual services, and are lacking
in evaluating patients for substance abuse or if they are victims of domestic
violence. These are all things that require clinic administrators to spend
more, not less time with their patients. Currently, family planning
effectiveness is measured by the number of patients served and the amount of
dollars spent. Rather than just focusing on the number of total patients,
Sonfield said, perhaps they could look at the number of months of contraceptive
use provided for. A one-time visit is a one-time visit, regardless of the
method of contraception received. "Right now, inserting an IUD counts the same [in
congressional evaluations] as giving a woman a condom," he said. 

Some of the biggest changes in
the US approach to family planning, though, might be ideological ones. The Bush
administration appointed Susan Orr, who came from the anti-choice and
anti-contraception group the Family Research Council, to be deputy assistant
secretary of Health and Human Services and head the Office of Population
Affairs, the office primarily responsible for overseeing the distribution of
Title X funds. "This past administration, the Bush administration, is one that
just put evidence- and science-based evidence to the side in favor of ideology,"
Rubiner said. "We’d like to see evidence and clinical guidelines put back in
place so that’s what’s driving policy." 

With the Health and Human
Services Secretary yet to be confirmed, changes to the OPA, an office within
HHS, may be a while in coming. Still, the Guttmacher report and PPFA urge
Congress and the administration to take on legislation that would increase
access to family planning services sooner rather than later.

Analysis Politics

The 2016 Republican Platform Is Riddled With Conservative Abortion Myths

Ally Boguhn

Anti-choice activists and leaders have embraced the Republican platform, which relies on a series of falsehoods about reproductive health care.

Republicans voted to ratify their 2016 platform this week, codifying what many deem one of the most extreme platforms ever accepted by the party.

“Platforms are traditionally written by and for the party faithful and largely ignored by everyone else,” wrote the New York Times‘ editorial board Monday. “But this year, the Republicans are putting out an agenda that demands notice.”

“It is as though, rather than trying to reconcile Mr. Trump’s heretical views with conservative orthodoxy, the writers of the platform simply opted to go with the most extreme version of every position,” it continued. “Tailored to Mr. Trump’s impulsive bluster, this document lays bare just how much the G.O.P. is driven by a regressive, extremist inner core.”

Tucked away in the 66-page document accepted by Republicans as their official guide to “the Party’s principles and policies” are countless resolutions that seem to back up the Times‘ assertion that the platform is “the most extreme” ever put forth by the party, including: rolling back marriage equalitydeclaring pornography a “public health crisis”; and codifying the Hyde Amendment to permanently block federal funding for abortion.

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Anti-choice activists and leaders have embraced the platform, which the Susan B. Anthony List deemed the “Most Pro-life Platform Ever” in a press release upon the GOP’s Monday vote at the convention. “The Republican platform has always been strong when it comes to protecting unborn children, their mothers, and the conscience rights of pro-life Americans,” said the organization’s president, Marjorie Dannenfelser, in a statement. “The platform ratified today takes that stand from good to great.”  

Operation Rescue, an organization known for its radical tactics and links to violence, similarly declared the platform a “victory,” noting its inclusion of so-called personhood language, which could ban abortion and many forms of contraception. “We are celebrating today on the streets of Cleveland. We got everything we have asked for in the party platform,” said Troy Newman, president of Operation Rescue, in a statement posted to the group’s website.

But what stands out most in the Republicans’ document is the series of falsehoods and myths relied upon to push their conservative agenda. Here are just a few of the most egregious pieces of misinformation about abortion to be found within the pages of the 2016 platform:

Myth #1: Planned Parenthood Profits From Fetal Tissue Donations

Featured in multiple sections of the Republican platform is the tired and repeatedly debunked claim that Planned Parenthood profits from fetal tissue donations. In the subsection on “protecting human life,” the platform says:

We oppose the use of public funds to perform or promote abortion or to fund organizations, like Planned Parenthood, so long as they provide or refer for elective abortions or sell fetal body parts rather than provide healthcare. We urge all states and Congress to make it a crime to acquire, transfer, or sell fetal tissues from elective abortions for research, and we call on Congress to enact a ban on any sale of fetal body parts. In the meantime, we call on Congress to ban the practice of misleading women on so-called fetal harvesting consent forms, a fact revealed by a 2015 investigation. We will not fund or subsidize healthcare that includes abortion coverage.

Later in the document, under a section titled “Preserving Medicare and Medicaid,” the platform again asserts that abortion providers are selling “the body parts of aborted children”—presumably again referring to the controversy surrounding Planned Parenthood:

We respect the states’ authority and flexibility to exclude abortion providers from federal programs such as Medicaid and other healthcare and family planning programs so long as they continue to perform or refer for elective abortions or sell the body parts of aborted children.

The platform appears to reference the widely discredited videos produced by anti-choice organization Center for Medical Progress (CMP) as part of its smear campaign against Planned Parenthood. The videos were deceptively edited, as Rewire has extensively reported. CMP’s leader David Daleiden is currently under federal indictment for tampering with government documents in connection with obtaining the footage. Republicans have nonetheless steadfastly clung to the group’s claims in an effort to block access to reproductive health care.

Since CMP began releasing its videos last year, 13 state and three congressional inquiries into allegations based on the videos have turned up no evidence of wrongdoing on behalf of Planned Parenthood.

Dawn Laguens, executive vice president of Planned Parenthood Action Fund—which has endorsed Hillary Clinton—called the Republicans’ inclusion of CMP’s allegation in their platform “despicable” in a statement to the Huffington Post. “This isn’t just an attack on Planned Parenthood health centers,” said Laguens. “It’s an attack on the millions of patients who rely on Planned Parenthood each year for basic health care. It’s an attack on the brave doctors and nurses who have been facing down violent rhetoric and threats just to provide people with cancer screenings, birth control, and well-woman exams.”

Myth #2: The Supreme Court Struck Down “Commonsense” Laws About “Basic Health and Safety” in Whole Woman’s Health v. Hellerstedt

In the section focusing on the party’s opposition to abortion, the GOP’s platform also reaffirms their commitment to targeted regulation of abortion providers (TRAP) laws. According to the platform:

We salute the many states that now protect women and girls through laws requiring informed consent, parental consent, waiting periods, and clinic regulation. We condemn the Supreme Court’s activist decision in Whole Woman’s Health v. Hellerstedt striking down commonsense Texas laws providing for basic health and safety standards in abortion clinics.

The idea that TRAP laws, such as those struck down by the recent Supreme Court decision in Whole Woman’s Health, are solely for protecting women and keeping them safe is just as common among conservatives as it is false. However, as Rewire explained when Paul Ryan agreed with a nearly identical claim last week about Texas’ clinic regulations, “the provisions of the law in question were not about keeping anybody safe”:

As Justice Stephen Breyer noted in the opinion declaring them unconstitutional, “When directly asked at oral argument whether Texas knew of a single instance in which the new requirement would have helped even one woman obtain better treatment, Texas admitted that there was no evidence in the record of such a case.”

All the provisions actually did, according to Breyer on behalf of the Court majority, was put “a substantial obstacle in the path of women seeking a previability abortion,” and “constitute an undue burden on abortion access.”

Myth #3: 20-Week Abortion Bans Are Justified By “Current Medical Research” Suggesting That Is When a Fetus Can Feel Pain

The platform went on to point to Republicans’ Pain-Capable Unborn Child Protection Act, a piece of anti-choice legislation already passed in several states that, if approved in Congress, would create a federal ban on abortion after 20 weeks based on junk science claiming fetuses can feel pain at that point in pregnancy:

Over a dozen states have passed Pain-Capable Unborn Child Protection Acts prohibiting abortion after twenty weeks, the point at which current medical research shows that unborn babies can feel excruciating pain during abortions, and we call on Congress to enact the federal version.

Major medical groups and experts, however, agree that a fetus has not developed to the point where it can feel pain until the third trimester. According to a 2013 letter from the American Congress of Obstetricians and Gynecologists, “A rigorous 2005 scientific review of evidence published in the Journal of the American Medical Association (JAMA) concluded that fetal perception of pain is unlikely before the third trimester,” which begins around the 28th week of pregnancy. A 2010 review of the scientific evidence on the issue conducted by the British Royal College of Obstetricians and Gynaecologists similarly found “that the fetus cannot experience pain in any sense prior” to 24 weeks’ gestation.

Doctors who testify otherwise often have a history of anti-choice activism. For example, a letter read aloud during a debate over West Virginia’s ultimately failed 20-week abortion ban was drafted by Dr. Byron Calhoun, who was caught lying about the number of abortion-related complications he saw in Charleston.

Myth #4: Abortion “Endangers the Health and Well-being of Women”

In an apparent effort to criticize the Affordable Care Act for promoting “the notion of abortion as healthcare,” the platform baselessly claimed that abortion “endangers the health and well-being” of those who receive care:

Through Obamacare, the current Administration has promoted the notion of abortion as healthcare. We, however, affirm the dignity of women by protecting the sanctity of human life. Numerous studies have shown that abortion endangers the health and well-being of women, and we stand firmly against it.

Scientific evidence overwhelmingly supports the conclusion that abortion is safe. Research shows that a first-trimester abortion carries less than 0.05 percent risk of major complications, according to the Guttmacher Institute, and “pose[s] virtually no long-term risk of problems such as infertility, ectopic pregnancy, spontaneous abortion (miscarriage) or birth defect, and little or no risk of preterm or low-birth-weight deliveries.”

There is similarly no evidence to back up the GOP’s claim that abortion endangers the well-being of women. A 2008 study from the American Psychological Association’s Task Force on Mental Health and Abortion, an expansive analysis on current research regarding the issue, found that while those who have an abortion may experience a variety of feelings, “no evidence sufficient to support the claim that an observed association between abortion history and mental health was caused by the abortion per se, as opposed to other factors.”

As is the case for many of the anti-abortion myths perpetuated within the platform, many of the so-called experts who claim there is a link between abortion and mental illness are discredited anti-choice activists.

Myth #5: Mifepristone, a Drug Used for Medical Abortions, Is “Dangerous”

Both anti-choice activists and conservative Republicans have been vocal opponents of the Food and Drug Administration (FDA’s) March update to the regulations for mifepristone, a drug also known as Mifeprex and RU-486 that is used in medication abortions. However, in this year’s platform, the GOP goes a step further to claim that both the drug and its general approval by the FDA are “dangerous”:

We believe the FDA’s approval of Mifeprex, a dangerous abortifacient formerly known as RU-486, threatens women’s health, as does the agency’s endorsement of over-the-counter sales of powerful contraceptives without a physician’s recommendation. We support cutting federal and state funding for entities that endanger women’s health by performing abortions in a manner inconsistent with federal or state law.

Studies, however, have overwhelmingly found mifepristone to be safe. In fact, the Association of Reproductive Health Professionals says mifepristone “is safer than acetaminophen,” aspirin, and Viagra. When the FDA conducted a 2011 post-market study of those who have used the drug since it was approved by the agency, they found that more than 1.5 million women in the U.S. had used it to end a pregnancy, only 2,200 of whom had experienced an “adverse event” after.

The platform also appears to reference the FDA’s approval of making emergency contraception such as Plan B available over the counter, claiming that it too is a threat to women’s health. However, studies show that emergency contraception is safe and effective at preventing pregnancy. According to the World Health Organization, side effects are “uncommon and generally mild.”

News Abortion

Study: United States a ‘Stark Outlier’ in Countries With Legal Abortion, Thanks to Hyde Amendment

Nicole Knight Shine

The study's lead author said the United States' public-funding restriction makes it a "stark outlier among countries where abortion is legal—especially among high-income nations."

The vast majority of countries pay for abortion care, making the United States a global outlier and putting it on par with the former Soviet republic of Kyrgyzstan and a handful of Balkan States, a new study in the journal Contraception finds.

A team of researchers conducted two rounds of surveys between 2011 and 2014 in 80 countries where abortion care is legal. They found that 59 countries, or 74 percent of those surveyed, either fully or partially cover terminations using public funding. The United States was one of only ten countries that limits federal funding for abortion care to exceptional cases, such as rape, incest, or life endangerment.

Among the 40 “high-income” countries included in the survey, 31 provided full or partial funding for abortion care—something the United States does not do.

Dr. Daniel Grossman, lead author and director of Advancing New Standards in Reproductive Health (ANSIRH) at the University of California (UC) San Francisco, said in a statement announcing the findings that this country’s public-funding restriction makes it a “stark outlier among countries where abortion is legal—especially among high-income nations.”

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The researchers call on policymakers to make affordable health care a priority.

The federal Hyde Amendment (first passed in 1976 and reauthorized every year thereafter) bans the use of federal dollars for abortion care, except for cases of rape, incest, or life endangerment. Seventeen states, as the researchers note, bridge this gap by spending state money on terminations for low-income residents. Of the 14.1 million women enrolled in Medicaid, fewer than half, or 6.7 million, live in states that cover abortion services with state funds.

This funding gap delays abortion care for some people with limited means, who need time to raise money for the procedure, researchers note.

As Jamila Taylor and Yamani Hernandez wrote last year for Rewire, “We have heard first-person accounts of low-income women selling their belongings, going hungry for weeks as they save up their grocery money, or risking eviction by using their rent money to pay for an abortion, because of the Hyde Amendment.”

Public insurance coverage of abortion remains controversial in the United States despite “evidence that cost may create a barrier to access,” the authors observe.

“Women in the US, including those with low incomes, should have access to the highest quality of care, including the full range of reproductive health services,” Grossman said in the statement. “This research indicates there is a global consensus that abortion care should be covered like other health care.”

Earlier research indicated that U.S. women attempting to self-induce abortion cited high cost as a reason.

The team of ANSIRH researchers and Ibis Reproductive Health uncovered a bit of good news, finding that some countries are loosening abortion laws and paying for the procedures.

“Uruguay, as well as Mexico City,” as co-author Kate Grindlay from Ibis Reproductive Health noted in a press release, “legalized abortion in the first trimester in the past decade, and in both cases the service is available free of charge in public hospitals or covered by national insurance.”