On Friday, the Trump administration outraged reproductive rights advocates when it announced a plan to cut off federal family planning funds for American health care centers that provide or refer patients to abortion services — even if clinics use different sources to cover costs for the procedure. The proposed change follows a previous White House move, called the “global gag rule,” that curtailed funding for international organizations that provide family planning services and other health and nutrition services to mothers and children.
While the precise nature of the new restrictions on U.S. facilities is still being debated, the impacts will almost certainly fall most directly on poor and disenfranchised women: The clinics, health departments, and community health centers that receive these federal funds primarily serve women under 30 who are living at or below the federal poverty level. More than half the patients identify as people of color, according to the Guttmacher Institute, a private research and policy organization that advocates for reproductive health.
The funds fall under a program called Title X, the nation’s only grant program dedicated to providing comprehensive family planning and related health services. The program currently provides funds to help provide reproductive health services to some 4 million patients at more than 4,000 health centers nationwide — including the nonprofit Planned Parenthood, which provides roughly 40 percent of Title X-funded services, according to the Guttmacher Institute.
The federal Office of Management and Budget is still evaluating the proposed new restrictions, which social conservatives have long supported, but aside from making it more difficult to access abortions, the proposal could also have a chilling effect on access to other safe and highly effective options for contraception. Such options include long-acting reversible contraception (LARCs) such as IUDs and implants that help to prevent fertilization.
In 2014, the U.S. Centers for Disease Control and Prevention, along with the Office of Population Affairs, recommended that family planning services provide a full complement of options for contraception, including these long-acting, “set-it-and-forget-it” approaches. As of 2013, more than 11 percent of U.S. women used LARCs, and their popularity has risen in the past 15 years, according to National Center for Health Statistics data.
And yet, according to a recent, nationally representative survey, patients already routinely face barriers to getting IUDs and implants. The analysis, published in the May issue of the journal Contraception, surveyed 1,615 administrators of federally funded U.S. health centers providing family planning services between 2013 and 2014. Only half of the centers — typically those receiving federal funding — offered these long-acting options on site, which the study authors call “optimal.” Even when funded, however, more than 20 percent of the centers surveyed had no staff trained in how to use and insert the devices, respondents said. (Nurse practitioners, physician assistants, and certified nurse-midwives often do these procedures.)
If clinics choose to forgo Title X funds in order to maintain abortion services, the same clinics that are more likely to offer IUDs and implants will likely have to shrink their budgets unless administrators can find new sources of revenue, making it harder for staff to provide a full suite of birth control options.
Supporters of the proposed rule say that facilities called federally qualified health centers, which also are part of the health care safety net for underinsured patients, could pick up the slack for reproductive health care. But those centers would have to at least double their contraceptive care caseloads to meet that need, the Guttmacher Institute reported last year. And these health centers do not specialize in family planning, which a study published in 2012 shows that women prefer for their expertise, commitment to confidentiality, respectful staff, and lower-cost services.
The administrator survey findings seemed to reinforce the work of Megan Evans, an assistant professor at Tufts Medical Center with a specialty in obstetrics and gynecology, who presented research on barriers to long-acting reversible contraception access at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists in April.
Evans’ survey of a national sample of 4,284 medical residents taking an annual in-service exam in 2016 found that nearly a third of all respondents and 40 percent of residents working in the South reported that financial issues get in the way of their training and experience with LARC methods. Some clinics cannot afford to pay up-front for IUDs and implants, so they do not keep them in stock, or patients lack insurance to cover the cost, she says.
Medical residents also may rotate through religiously affiliated training sites that object to long-acting reversible contraception and prohibit its use. Most of the doctors around the country who replied to Evans’ survey did not report this as a major barrier because their program has no affiliation with a religious hospital or clinic or it doesn’t affect their training. But 27 percent of residents in the Midwest reported this religious opposition as a factor.
Evans was not looking forward to an imposition of any type of gag rule nationally.
“It’s a very difficult position to be in as a provider. You’re not providing that comprehensive care that we provide in women’s health,” she says. “Abortion is part of women’s health care and we know that one in four women will have an abortion in her lifetime.”