A Comprehensive Look Into Reproductive Health in States That Restrict Abortion (Full Version)
Alabama. Arkansas. Georgia. Kentucky. Louisiana. Mississippi. Missouri. Ohio. Utah.
The list of states that have passed restrictive abortion laws (or “heartbeat bills”) has been growing for weeks, and while several have been blocked by federal judges, the trend has left many worried about the future of reproductive justice and Roe v. Wade in the United States. While these laws may seem to materialize out of thin air at the hands of legislators, in many cases, they are actually the culmination of previous restrictions put into place. Mississippi, for instance, placed extensive regulations on abortion clinics, such as an annual $3,000 licensing fee, specific building regulations that controlled floorplans as well as the distance between clinics and other institutions like schools and hospitals, and stipulations about the presence of medical professionals and maintenance of records. Additionally, they had already banned dismemberment abortion, a controversial practice that is often discussed by pro-life advocates as a reason to ban all forms of abortion. Many states institute a waiting period of 24 hours or longer to deter the termination of pregnancy, and some have attempted to pass abortion bans in the past without success. Some women, particularly in rural states, often have to travel far distances to terminate their pregnancies. Along the same vein, Missouri made the news recently because of how close its sole abortion clinic came to closure.
Although several of the aforementioned states do have programs in place to assist with family planning, there is no doubt that the restrictions placed on therapeutic abortions remove a fundamental option for women (and other people with uteruses) to make decisions about their reproductive health. Research has shown that unintended pregnancies are associated with adverse birth outcomes and risks to the mother, which can lead to an increase in maternal and infant mortality rates. Critics of the recent legislation have noted that the states passing the most restrictive laws have some of the highest maternal and infant mortality rates in the nation, presumably as a result of their policies. This is even without taking into consideration the health of incarcerated women and undocumented immigrants.
However, several of the methods used to confront maternal mortality (or pregnancy-related death) and infant mortality overlap with the methods used to prevent unintended pregnancy in the first place, such as providing health education and access to contraceptives. Therefore, I began researching the structures that were in place to administer reproductive healthcare in five states: Mississippi, Missouri, Georgia, Alabama, and Arkansas. This includes policy, sex education, and healthcare programs, and will primarily focus on Medicaid, as Medicaid-insured individuals are the most likely to be at risk. I will also discuss public datasets and how that data is reported, as well as how states encourage certain healthcare practices.
Mississippi faces several challenges in the public health sphere, as many of its residents live in rural, impoverished areas and rely on Medicaid. The state receives a large portion of its income from federal funding, and approximately $4.42 billion in Medicaid funds come from the federal government, which comprises 75% of the nearly $6 billion budget. This in itself poses an issue, as the Hyde Amendment bars the use of federal funds for abortion, which likely factors into state policy as well. Thus, Medicaid plans geared toward pregnancy or family planning focus on prenatal care and reducing repeat or teenage pregnancies.
Notably, the state Medicaid division has instituted the Family Planning Waiver (FPW). This insurance waiver is available for people ages 13 to 44 who do not have health insurance and are capable of reproducing. It covers four annual “family planning” visits, testing and treatment for sexually transmitted infections (STIs), pap smears, and sterilization. If someone becomes pregnant while on the waiver, they will automatically be transferred to pregnancy insurance, but if one does not become pregnant, coverage automatically expires after a year and they have to re-enroll.
On the surface, this appears to be a solid plan, and it is indeed backed by research performed by the Mississippi State Department of Health. However, the state health department receives the least funding from legislators, meaning they have a limited budget to provide services. Additionally, in the 2017 FPW Demonstration Report, it was stated that the initiative failed to reduce repeat births or teenage pregnancy, one year after Mississippi was ranked 3rd in the nation for teen birth rates. While a survey showed that a majority of parents supported comprehensive sex education in schools, many schools still adhere to abstinence-only curriculums. However, there are sites dedicated to sex education and pregnancy prevention supported by the health department.
The health department also aims to improve access to long-acting reversible contraception (LARC) like intrauterine devices (IUDs). Minors are allowed access to contraceptives if they are married or have at least one child, but they must also get a referral.
The state health department has also conducted extensive research on infant mortality and negative birth outcomes, and as a result of their studies, the Perinatal High-Risk Management/Infant Services System (PHRM/ISS) was formed. This program includes health education, nutritional counseling, and other services meant to improve the health of a child, and therefore improve the health of the mother as well. The Jackson-Hinds Comprehensive Health Center, which serves uninsured and underserved populations, also instituted the Strong StartProgram, which aims to lower early elective delivery rates (the practice is common in Mississippi, to the detriment of infant and maternal health) and prevent premature birth. Enrollment in both programs is contingent on the patient’s enrollment in Medicaid as well as meeting the risk criteria delineated by each program, meaning that those who do not meet the criteria may be left out.
Most programs and policies mentioned above do not explicitly mention abortion unless it is to say that abortion is not covered by Medicaid. Even the state health department itself does not seem to mention it at first glance, but the information is there. They provide an informed consent pamphlet on the women’s health page, and a lot of data can be found in vital statistics. Mississippi publicizes data on “induced termination” within the contexts of race, ethnicity, marital status, age group, and education via the Mississippi Statistically Automated Health Resource System (MSTAHRS). This information can be found under pregnancy statistics. Some of the data is uncertain, but can be seen in the chart below:
The rates were off-putting at first because they appeared to be rather high; however, as the footnote states, these rates are out of 1,000. MSTAHRS reports that the number of live births from ages 15 to 19 in 2013 is 4,343. To get the rate shown in the table, one would divide 619 by 4,343 to get 0.1425, then multiply by 1,000 to get 142.5. The rates fluctuate over the years but the actual numbers don’t seem to vary much.
Still, the use of “all births” as the denominator raised some questions. What if the population was “All Pregnancies” instead? If this were the case, the rate of induced terminations for 15 to 19-year-olds in 2013 would be 123.5 per 1000 pregnancies (with 5,011 pregnancies total), which is not a very large difference but still lower than indicated. Regardless of which rate may be considered more accurate, the data shows that most pregnancies were not terminated, and thus, were likely supported by the previously mentioned programs.
Similar to Mississippi, Missouri has a large rural population and its residents face challenges in accessing healthcare. Of the state’s 115 counties, 101 are rural. 43 out of 101 counties do not have hospitals, and 26 counties have hospitals without obstetric beds. 17.5% of pregnant women in Missouri did not receive prenatal care in the first trimester in 2017. Those living in urban areas were said to struggle with access as well, and as a whole, parents believed they had to seek out and acquire services on their own without assistance. In the five-year plan created in 2016, the state listed reducing C-sections and improving pre-conception, prenatal, and postpartum care as some of their priorities.
Missouri’s Medicaid service is called MO Healthnet, and it offers three main healthcare plans: Home State Health, United Healthcare, and MissouriCare, the latter of which is administered by the state. Each plan is required to provide the same basic services, but there is some variation; for example, Home State Health offers “maternity benefits”, the Start Smart program which assists beneficiaries through pregnancy, postpartum home nurse visits, birth control, and family planning. For low-income women ages 18 to 55 who are ineligible for Healthnet, Missouri instituted the Uninsured Women’s Health Services Program. This program provides “approved methods of contraception”, pap smears, pelvic exams, STI testing, family planning, counseling, birth control education, and access to any treatment prescribed as a result of the aforementioned services. Minors are allowed access to contraceptives if they are married, but not if they are unmarried with offspring. HIV education is mandatory, but sex education is not, and it is not required to be medically accurate. However, it is supposed to emphasize healthy decision making and avoiding coercion.
The state maintains updated statistics on indicators of reproductive health through the Missouri Public Health Information Management System (MOPHIMS), which gives insight into things like teen pregnancy rates, repeat births before age 20, four or more live births, and repeated births less than 18 months apart. The data discussed in this article is from the time frame 2013-2017. Although the teen fertility rate for ages 15 to 17 is 10.55 per 1,000 teens, the rate of repeat births under the age of 20 was only 1.1 per 100 births, which appears to be positive but could be subject to error. Missouri also has years of data on infant and mortality rate and most recently passed a bill (HB 447) establishing a Pregnancy-Related Mortality Review Board.
Like Mississippi, the state offered a Family Planning waiver, which aimed to reduce pregnancy rates and increase access to contraception among other goals. The 2015 report notes that “11.7% of the population had at least one claim for contraceptive supplies or services”, not including condoms, sponges or emergency contraception. Missouri also administers the “Alternatives to Abortion” program through the Department of Social Services. It focuses on services such as prenatal care, ultrasounds, “establishing and promoting responsible paternity”, educational services, and other services to help pregnant people with financial stability. The program itself is actually a good thing; helping people get back on their feet will ideally lead to happier residents and more benefits for the state. However, the obvious implications cannot be ignored. The program exists for the same reason that the state also awards tax credits to those who donate to maternity homes or pregnancy resource centers (otherwise known as crisis pregnancy centers); the state is actively encouraging its residents to carry to term.
MOPHIMS also contains data on abortion, including “repeat abortions” and abortions performed on minors. The rate of the former is 37.99 per 1,000 abortions, and it makes me wonder what circumstances led to each patient having more than one abortion and whether they had access to contraceptives. The rate of the latter is 15.97 per 100 pregnancies among people under 18. This raised the question of how the data would change if the denominator was out of all performed procedures rather than all teen pregnancies, and upon further examination yielded a rate of 31.4 out of 1,000 procedures. How many “repeats” were teenagers? Why are “repeats” tracked anyway? Although uncertainty still lingers, this data opens a window into the inner workings of Missouri’s healthcare.
Home to the Centers for Disease Control and Prevention (CDC), Georgia can be considered one of the hotspots for public health.
The state Department of Public Health offers family planning services such as birth control access (including LARCs, emergency contraception, pills, and other forms of contraception), STI and HIV screening plus testing and treatment, pregnancy testing and counseling and abstinence education. Their website states that health departments are accessible from all 159 counties, and these services are on a sliding scale. In 2005, the state legislature passed the Woman’s Right to Know Act, which ensured that pregnant patients would be informed about the potential risks of termination as well as potential risks of carrying to term. It also declares that minors must be accompanied by a parent or guardian or the parent or guardian must be notified 24 hours prior to the procedure (in 2018, 374 of 498 minors who sought abortions were able to get the procedure after parents were notified). However, Georgia also requires fetal remains to be cremated or buried after a pregnancy is terminated. Both sex education and HIV education are mandatory in Georgia, but teachers must stress abstinence, waiting for marriage, and negative outcomes of sex.
Some of Georgia’s priorities until 2020 include improving access to family planning and preventing maternal and infant mortality. In 2017, 16% of women in the Georgia Family Planning Program (GFPP) were using LARCs, and by 2020 the state aims to increase the percentage of teens using LARCs and the percentage of unique visitors in family planning clinics by 5%. The GFPP created a marketing campaign to promote their services to women ages 18 to 49, and their audience heard their 30-second radio ad an estimated 3.3 million times. GFFP also aims to help enrollees create reproductive life plans, and the state has instituted a Planning for Healthy Babies (P4HB) waiver which is similar to the family planning waivers in other states. P4HB provides annual exams, birth control services and supplies, family planning visits, pregnancy tests, pap smears, STI testing and treatment (except HIV and Hepatitis treatment), sterilization, pharmacy visits, vitamins, and select immunizations for ages 18 to 20. In contrast to the programs in other states, P4HB decreased unintended pregnancies and teen births while increasing the age of first births and eliminating very short intervals between pregnancies.
Right from the Start (RSM) is an umbrella for Medicaid programs geared towards low-income families, including pregnant women. In addition to P4HB, RSM for Pregnant Women covers expecting individuals throughout the pregnancy and up to 60 days postpartum. Beneficiaries are said to have full access to Medicaid services such as doctor visits, prescriptions, and any other pregnancy-related cost.
Pregnancy and termination data can be found publicly on OASIS, the health department’s hub for vital statistics. In 2017, the induced termination rate was only 8.3 per 1,000, and the rate has declined over the years.
This is likely due to increased access to birth control and education, meaning that comprehensive healthcare and knowledge is better for adults and children alike.
Alabama has come under fire numerous times due to their treatment of pregnant women, most recently including their indictment of Marshae Jones on manslaughter charges after she was shot, which led to the death of her unborn child. Additionally, controversy ensued when lawmakers rejected an amendment to their abortion law which would allow the practice in cases of rape or incest. However, how does this treatment translate into healthcare?
First, like other states at the forefront of the reproductive health debate, Alabama has a large rural population, with 55 counties considered rural and 12 classified as urban. These counties are then further classified by their geographic position (like Rural North) or degree of “ruralness.” Alabama declined federal funds to expand Medicaid, meaning that there may be coverage gaps for people who need it. However, there are still programs in place to assist those in need, and many of the state’s practices are backed by research.
In part one of this series, I referenced the fact that unintended pregnancies were more likely to result in problems like low birth weight or preterm delivery due to a lack of preparation for the situation. The 2015 PRAMS report states that 49.6 percent of births during that year were unintended and approximately 7.2 percent of pregnancies were unwanted. The highest percentage of unintended pregnancies occurred among women who already had at least two children, and the birth was at least their third child. 64.3 percent of births to women on Medicaid were unintended, compared to 33.1 percent of women who were not on Medicaid. The report notes what percentage of mothers participated in programs like WIC (54.6 percent), had medical problems (64.9 percent), showed signs of postpartum depression (8.9 percent felt down all the time while 48.5 percent felt down sometimes or rarely) or continued smoking or drinking regularly during pregnancy (11 and 5 percent respectively). It also notes practices like whether the mother received dental care during pregnancy or if they breastfed their child or laid them down on their backs to sleep. Thus, state programs created for maternal and infant health often focus on health education and ensuring access to resources.
Similar to the programs instituted in Mississippi, Missouri and Georgia, Alabama has implemented the “Plan First” program, a family planning initiative for women ages 19 to 55. Plan First is intended to provide access to underserved women, who benefit from yearly exams, support from social workers and nurses, birth control, pregnancy and STI testing, and planning pregnancies. Sterilization for men and women is also offered above the age of 21, but informed consent has to be given at least 30 days in advance. The state Medicaid division also provides general family planning services for “females of childbearing age, 8 [eight] through 55” and sexually active men of all ages. Provided services include initial visits, annual visits, four periodic revisits per year, one home visit 60 days postpartum, one extended postpartum consultation, pregnancy tests, STI tests, Pap smears, urinalysis and general bloodwork. Birth control methods that are covered include pills, jellies, diaphragms, creams, IUDs, injections, and implants. Removal of long-acting contraceptives like IUDs are not covered by family planning insurance, even if it is for a medical reason. Hysterectomies are not covered by either Plan First or the Family Planning program.
So, how is this program being utilized? The 2018 Plan First report revealed that participation in the demonstration decreased between 2017 and 2018, but noted that this was potentially due to more patients enrolling in Insurance Affordability Plans instead. This reveals that there are at least multiple options for low-income patients to receive reproductive care, but whether these options are sufficient for Alabama residents is another question.
In terms of education, the state health department shares various educational resources relating to family planning, ranging from fact sheets on contraceptives to guides on how to discuss puberty, abuse, birth control and other topics with loved ones. The state also instituted WHI-FI, or the “Women’s Health Information for the Incarcerated” program, which provides health resources and education to incarcerated women as a joint partnership between the Aid to Inmate Mothers organization and the Department of Public Health Office of Women’s Health. Incarcerated women can learn about HIV, sexually transmitted infections, human sexuality and various conditions that can impact maternal and infant health. They can also get referrals for birth control, STI screenings, cancer early detection programs and WIC services among other services.
The outlook on education for teens is a bit more variable; the Guttmacher Institute says that Alabama does not mandate sex education in schools, but HIV education is mandatory. When sex education is offered, abstinence must be stressed, and LGBT people are portrayed in a negative light. The state also manages ARPREP, a federally funded teen pregnancy prevention program. ARPREP funds five community-based programs to prevent pregnancy and STI transmission, and it intends to teach teenagers about healthy relationships, adolescent development, and the development of healthy values.
One of the most notable things about reproductive health in Alabama is the emphasis on HIV transmission. To reduce perinatal HIV transmission, all pregnant women are tested for HIV in accordance with CDC guidelines. HIV prevention guidelines also encourage preconception counseling for HIV-positive women and state that “all HIV-infected women contemplating pregnancy should be on a maximally suppressive antiretroviral regimen”. The state also takes care to discourage premastication, or pre-chewing food to give to infants, although the risk of HIV transmission through saliva is low. All babies born to an HIV-positive mother have to be tested for HIV at birth and must take antiretroviral drugs for up to 6 weeks. This is not for no reason – in 2016, there were approximately 13 new cases of HIV in Alabama per 100,000 residents. This is also likely the reason why HIV education is mandated in the state.
Arkansas faces “geographic maldistribution” of medical professionals, and over 500,000 residents live in health professional shortage areas (HPSAs). Out of 75 counties, 36 are primary care HPSAs, 20 are dental HPSAs, and 69 are mental health HPSAs. A large number of residents are uninsured, and as 20 percent of adults read at or below a 5th-grade level, health literacy is limited.
In a sharp contrast to the other states examined in this series, neither sex education nor HIV education are mandated in Arkansas (which reflects in the fact that 46 percent of survey respondents who became pregnant in 2017 were using the withdrawal method as a form of birth control). An attempt to pass a sex education bill in 2019 failed after lawmakers attempted to add amendments barring the participation of Planned Parenthood. If sex ed is offered, it must stress abstinence, as the state wants to “discourage sexual activity among students”, despite the fact that not talking about sex does not discourage it from occurring. School districts can establish health clinics for students, but they cannot use state funds to purchase contraceptives for students and the student must have parental consent to receive contraceptives from the clinic. The CDC had previously identified 16 critical sexual education topics (now 19), and only 20 percent of Arkansas schools taught all 16 in 2017.
However, despite the pitfalls in education, there are some bright spots. The state health department provides low-cost or no-cost prenatal, postpartum and counseling services to women via local health units. Family planning services are available in all counties, including contraceptives, physical exams, pap smears, STI testing and other lab tests, education, counseling and referrals. There are also several community health centers designated to eliminate health disparities in the state. Officials have also partnered with organizations like Sisters United and Brothers United to support the health of black communities, and anyone who goes through the proper training can become a lay midwife. Some goals of the health department are to reduce teen birth rate, improve neonatal hospital care and prevent unplanned pregnancy. The health department website also tracks successes in changing hospital policy to support infant health.
In addition to WIC, all pregnant women within the income threshold are eligible for Medicaid. 52.2 percent of pregnant women got prenatal care covered by Medicaid or ARKids First in 2017. However, Arkansas seems to lack the various family planning waivers that can be found in other states.
There is no doubt that the state of reproductive health in the U.S. is bleak—maternal mortality is still high, especially among black women, and the recent abortion bans have created more anxiety. However, health professionals and advocates are still working to ensure that pregnant people and children receive the care that they deserve. In May, the Alabama Women’s Center said they would continue to provide care for as long as they could, and state health departments continue to play a major role in ensuring the health of the nation as a whole. In times like these, it may be difficult to remain optimistic, but one thing that we need to remember is that we are not alone in our fight. When we invest in education and adequate healthcare, we invest in healthy families and a better society.