Analysis Law and Policy

Dominican Republic Gains a National Policy of Teenage Pregnancy Prevention

IPPFWHR

In the Dominican Republic, groups have been working to secure political and public support for reducing teenage pregnancy and ensuring access to youth-friendly health services and education. In the Dominican Republic, high rates of adolescent fertility and maternal mortality have attracted the attention of national authorities and civil society organizations.

In 2009, the Dominican Republic adopted a new constitution that rolled back gains on comprehensive sexual and reproductive health services. Given the relationship between unsafe abortion and maternal mortality, the new constitution was a serious blow to women’s health and rights. Within an already challenging landscape, it created new barriers for women — particularly young women — who sought to access sexual and reproductive health care.

It was in the midst of these challenges that IPPF/WHR’s Member Association in the Dominican Republic, Profamilia, joined the Voices project. Since then, Profamilia has been working to secure political and public support for reducing teenage pregnancy and ensuring access to youth-friendly health services and education. In the Dominican Republic, high rates of adolescent fertility and maternal mortality have attracted the attention of national authorities and civil society organizations.

In a culture where there is little civil society participation in government decision-making, Profamilia’s progress has been significant. The organization conducted an analysis of the country’s public budget — with a focus on reproductive health — and submitted their recommendations to the health authorities. Profamilia then conducted another study aimed at identifying risk factors for teenage pregnancy in the Dominican Republic. The results provided a solid foundation for Profamilia to discuss the need for a government policy to address teenage pregnancy.

Profamilia was invited to join a government committee that advocates for the incorporation of a gender perspective into the health policies developed by the various government agencies. It quickly assumed an active advocacy role and included maternal health and preventing unwanted teenage pregnancy as a priority for the group’s objectives. As a result of these efforts, the government worked with Profamilia to develop a new policy and plan to reduce teenage pregnancy.

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Myrna Flores, the Voices Project Coordinator at Profamilia, stated, “The Voices project gives us tools to build citizenship. We have learned to solicit concrete answers from governments, and the importance of translating the specific needs of communities into projects, programs, and budgets.” Profamilia continues to partner with government authorities as they implement the Plan to Reduce Teenage Pregnancy nationwide this year.

Commentary Contraception

The Promotion of Long-Acting Contraceptives Must Confront History and Center Patient Autonomy

Jamila Taylor

While some long-acting reversible contraceptive methods were used to undermine women of color's reproductive freedom, those methods still hold the promise of reducing unintended pregnancy among those most at risk.

Since long-acting reversible contraceptives (LARCs), including intrauterine devices and hormonal contraceptive implants, are among the most effective means of pregnancy prevention, many family planning and reproductive health providers are increasingly promoting them, especially among low-income populations.

But the promotion of LARCs must come with an acknowledgment of historical discriminatory practices and public policy related to birth control. To improve contraceptive access for low-income women and girls of color—who bear the disproportionate effects of unplanned pregnancy—providers and advocates must work to ensure that the reproductive autonomy of this population is respected now, precisely because it hasn’t been in the past.

For Black women particularly, the reproductive coercion that began during slavery took a different form with the development of modern contraceptive methods. According to Dorothy Roberts, author of Killing the Black Body, “The movement to expand women’s reproductive options was marked with racism from its very inception in the early part of [the 20th] century.” Decades later, government-funded family planning programs encouraged Black women to use birth control; in some cases, Black women were coerced into being sterilized.

In the 1990s, the contraceptive implant Norplant was marketed specifically to low-income women, especially Black adults and teenage girls. After a series of public statements about the benefits of Norplant in reducing pregnancy among this population, policy proposals soon focused on ensuring usage of the contraceptive method. Federal and state governments began paying for Norplant and incentivizing its use among low-income women while budgets for social support programs were cut. Without assistance, Norplant was not an affordable option, with the capsules costing more than $300 and separate, expensive costs for implantation and removal.

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Soon, Norplant was available through the Medicaid program. Some states introduced (ultimately unsuccessful) bills that would give cash rewards to entice low-income women on public assistance into using it; a few, such as Tennessee and Washington state, required that women receiving various forms of public assistance get information about Norplant. After proposing a bill to promote the use of Norplant in his state in 1994, a Connecticut legislator made the comment, “It’s far cheaper to give you money not to have kids than to give you money to have kids.” By that year, as Roberts writes, states had spent $34 million on Norplant-related care, much of it for women on Medicaid. Policymakers thought it was completely legitimate and cost-effective to control the reproduction of low-income women.

However, promoting this method among low-income Black women and adolescents was problematic. Racist, classist ideology dictating that this particular population of women shouldn’t have children became the basis for public policy. Even though coercive practices in reproductive health were later condemned, these practices still went on to shape cultural norms around race and gender, as well as medical practice.

This history has made it difficult to move beyond negative perceptions, and even fear, of LARCs, health care, and the medical establishment among some women of color. And that’s why it’s so important to ensure informed consent when advocating for effective contraceptive methods, with choice always at the center.

But how can policies and health-care facilities promote reproductive autonomy?

Health-care providers must deal head on with the fact that many contemporary women have concerns about LARCs being recommended specifically to low-income women and women of color. And while this is part of the broader effort to make LARCs more affordable and increasingly available to communities that don’t have access to them, mechanisms should be put in place to address this underlying issue. Requiring cultural competency training that includes information on the history of coercive practices affecting women of color could help family planning providers understand this concern for their patients.

Then, providers and health systems must address other barriers that make it difficult for women to access LARCs in particular. LARCs can be expensive in the short term, and complicated billing and reimbursement practices in both public and private insurance confuse women and providers. Also, the full cost associated with LARC usage isn’t always covered by insurance.

But the process shouldn’t end at eliminating barriers. Low-income Black women and teens must receive comprehensive counseling for contraception to ensure informed choice—meaning they should be given information on the full array of methods. This will help them choose the method that best meets their needs, while also promoting reproductive autonomy—not a specific contraceptive method.

Clinical guidelines for contraception must include detailed information on informed consent, and choice and reproductive autonomy should be clearly outlined when family planning providers are trained.

It’s crucial we implement these changes now because recent investments and advocacy are expanding access to LARCs. States are thinking creatively about how to reduce unintended pregnancy and in turn reduce Medicaid costs through use of LARCs. The Colorado Family Planning Initiative has been heralded as one of the most effective in helping women access LARCs. Since 2008, more than 30,000 women in Colorado have chosen LARCs as the result of the program. Provider education, training, and contraceptive counseling have also been increased, and women can access LARCs at reduced costs.

The commitment to LARCs has apparently yielded major returns for Colorado. Between 2009 and 2013, the abortion rate among teenagers older than 15 in Colorado dropped by 42 percent. Additionally, the birth rate for young women eligible for Medicaid dropped—resulting in cost savings of up to an estimated $111 million in Medicaid-covered births. LARCs have been critical to these successes. Public-private partnerships have helped keep the program going since 2015, and states including Delaware and Iowa have followed suit in efforts to experience the same outcomes.

Recognizing that prevention is a key component to any strategy addressing a public health concern, those strategies must be rooted in ensuring access to education and comprehensive counseling so that women and teens can make the informed choices that are best for them. When women and girls are given the tools to empower themselves in decision making, the results are positive—not just for what the government spends or does not spend on social programs, but also for the greater good of all of us.

The history of coercion undermining reproductive freedom among women and girls of color in this country is an ugly one. But this certainly doesn’t have to dictate how we move forward.

News Abortion

Anti-Choice Group Wants National Abortion Data Reporting Law

Teddy Wilson

Anti-choice activists claim that despite the evidence, the number of complications from abortion is higher than is being reported. States that track abortion care data have shown the procedure to be exceedingly safe.

A leading anti-choice organization is calling for a national database of abortion statistics and increased reporting requirements for states—proposals seen as part of a strategy to justify laws restricting access to abortion care.

The U.S. Supreme Court in June struck down provisions of Texas’ omnibus anti-choice law known as HB 2. The ruling relied heavily on research that showed abortion care was a safe and well regulated procedure. Anti-choice activists have long disputed those claims.

Clarke Forsythe, acting president of Americans United for Life (AUL), told Politico that there is not enough data on abortion. “The abortion advocates like to talk in vague terms about abortion but we need specifics,” Forsythe said. “We don’t have a national abortion data collection and reporting law.”

The Centers for Disease Control and Prevention (CDC) has collected “abortion surveillance” data since 1969. The CDC published the most recent report on abortion statistics in 2012.

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Abortion surveillance reports are created by compiling data from health agencies, provided voluntarily to the CDC, in all 50 states as well as the District of Columbia and New York City. The data includes deaths from abortion related complications, but does not include the number of complications that don’t result in deaths.

Reporting requirements for abortion statistics vary from state to state, with 46 states requiring that abortion providers submit regular reports, according to the Guttmacher Institute. Most states report the number of abortion procedures performed as well as the type of procedure, the gestation of the pregnancy, and demographic data of the patient.

There are 27 states that require providers to report the number of complications from abortion procedures.

The self-described “legal architect” of the anti-choice movement, AUL has been heavily involved in lobbying for state and federal laws that restrict access to abortion. The organization creates copycat legislation and distributes anti-choice proposals to state lawmakers, who then push the measures through legislatures.

Forsythe took a victory lap Monday for the organization’s role in promoting bills from the AUL’s “playbook of pro-life legislation” that were introduced this year in state legislatures. “AUL continued to assist states considering health and safety standards to protect women in abortion clinics,” Forsythe said in a statement.

Dozens of bills to increase reporting requirements have been introduced in state legislatures over the past several years. These proposals include several types of reporting requirements for abortion providers, and many of the provisions are similar to those found in AUL model legislation.

Arizona legislators in 2010 passed SB 1304, which required abortion providers to submit annual reports to the state and required the state Department of Health Services (DHS) to publish an annual report.

The Republican-backed legislation is similar to copycat legislation drafted that same year by AUL.

Since the law’s passage there have been very few complications resulting from abortion procedures reported in the state: from 2011-2014, less than 1 percent of abortions procedures in the state resulted in complications.

Arizona reported that 137 patients experienced complications out of 12,747 abortion procedures in 2014; 102 patients experienced complications out of 13,254 abortion procedures in 2013; 76 patients had complications out of 13,129 abortion procedures in 2012; 60 patients experienced complications out of 14,401 abortion procedures in 2011.

Dr. Daniel Grossman, a physician at the University of California, San Francisco who studied the impact of HB 2 for the Texas Policy Evaluation Project (TxPEP), told Politico that abortion has been shown to be exceptionally safe medical procedure.

“There’s already a lot of data that have been published documenting how safe abortion is in the U.S.,” Grossman said.“The abortion complication rate is exceedingly low.”

Anti-choice activists claim that despite the evidence, the number of complications from abortion is higher than is being reported. Joe Pojman, the executive director of the Texas Alliance for Life, told Politico that “better data” is needed.

Texas has required reporting of the number of complications from abortion procedures since 2013, and the data has shown that abortion complications are exceedingly rare. There were 447 complications out of 63,849 procedures in 2013 and 777 complications out of 54,902 procedures in 2014.

Pojman said that the Texas data “defies common sense” and that the complications are “are much smaller than what one would expect.”

The Texas abortion statistics reveal that it is safer to have an abortion than to carry a pregnancy to term in the state. Between 2008 and 2013, the most recent years for which data is available, there were 691 maternal deaths in Texas, compared to one death due to abortion complications between 2008 and 2014.

“There’s no sign that there’s a hidden safety problem happening in Texas,” Grossman said.

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