Impact of State-Level Reproductive Health Legislation on Access to and Use of Reproductive Health Services and Reproductive Health Outcomes: A Systematic Scoping Review in the Affordable Care Act Era

Abortion Provision at New York State Regional Perinatal Centers Following Implementation of the Reproductive Health Act

OBJECTIVE

Signed in 2019, New York State's Reproductive Health Act enabled expansion of abortion care up to 28 weeks for any indication. This study aimed to describe how implementation of the New York State Reproductive Health Act affected abortion provision among the state's regional perinatal centers (RPCs)-tertiary referral centers for complex pregnancies that may care for patients seeking abortion later in pregnancy. A secondary objective was to identify barriers to and facilitators of expanding abortion care.

METHODS

From January to May 2023, we recruited clinicians from the 17 New York RPCs, including family planning specialists, maternal-fetal medicine specialists, and genetic counselors. Respondents completed an online survey. We then invited respondents to complete an in-depth interview. We calculated descriptive statistics to characterize the study population and summarize survey responses. We analyzed qualitative interview data using thematic analysis.

RESULTS

Twenty-nine respondents completed the survey, representing 16 of 17 New York State RPCs. Seventeen respondents, representing 11 RPCs, completed an interview. All institutions provided abortion care. Twenty-three of 29 survey respondents (79%) reported barriers to providing abortion for any indication after 24 weeks from last menstrual period (LMP). Eighteen of 29 (62%) reported barriers to providing abortion after 24 weeks LMP for maternal or fetal indications. The most commonly reported barriers in the survey results were staff resistance and institutional policy. During interviews, respondents identified staff discomfort, restrictive institutional policies, and lack of clarity around policy as barriers, while highlighting advocates and collaboration within their institutions as facilitators to expansion of abortion services later in pregnancy.

CONCLUSIONS

RPCs in New York State face barriers in providing abortion, especially after 24 weeks LMP, even though they are ideally situated to provide such care. These barriers exist despite the legality of abortion after 24 weeks in New York and policy efforts to expand access to abortion.

Factors affecting women's access to primary care in the United States since the Affordable Care Act: A mixed-methods systematic review

BACKGROUND

In the United States, the Affordable Care Act (ACA) expanded public and private health coverage, increased health insurance affordability, reduced healthcare costs, and improved healthcare quality for many. Despite ACA provisions, lack of insurance and other factors continue to affect working-age women's access to primary care services.

METHODS

We conducted a mixed-method systematic review to identify factors that affect women's access to primary care services since the ACA. In January 2021, MEDLINE, CINAHL, PsycINFO, and Web of Science were searched from 2010 to 2021 and an updated search was conducted in October 2023. We included 26 quantitative and qualitative studies reporting determinants, barriers and facilitators of women's primary care access for women (18 to 64 years). Studies reporting measures of potential access, such as health insurance, and measures of realized access-healthcare service utilization, were included. The Mixed-Methods Appraisal Tool (2018) was used to rate the quality of studies. Andersen's Behavioral Model of Health Services Use guided the narrative synthesis.

FINDINGS

We found consistent evidence that ACA provisions expanding state Medicaid eligibility led to improved insurance coverage, especially for lower-income groups. We found mixed evidence of associations between individual-level determinants, such as age, education, race/ethnicity, income, and different measures of access. Limited qualitative evidence suggests that insurance coverage, low-cost care, positive patient-provider relationships, social support, and translation services enhance access for immigrants and refugees. Barriers include lack of coverage, high healthcare costs, culturally unresponsive healthcare services, poor patient-provider relationships, and transportation issues.

CONCLUSION

Adoption of ACA's expanded Medicaid eligibility criteria would expand insurance coverage to women living in non-expansion states. Innovative healthcare policies, programs, and interventions at the federal, state, and local levels are needed. Suggested strategies include interventions expanding primary healthcare service availability and patient navigation services, and promotion of health literacy, culturally sensitive services, and provider bias education/training.

Prescriptive Authority for Direct Entry Midwives in Washington State: Increasing Client Access to Contraception

Improving health and achieving health equity includes access to sexual and reproductive health care for all populations, especially those most in need. However, access to life-saving and life-affirming contraception with an individual's chosen perinatal provider can be impeded by restrictive regulations that limit scope and practice authority. This is especially true for the majority of community and direct entry midwives in the United States who have historically been unable to legally provide effective contraceptive methods. Recently, licensed midwives in Washington state were the first in the nation to achieve prescriptive authority, enabling their clients to directly obtain contraception and access to medications for common prenatal and postpartum conditions. Sustained advocacy efforts in the state's capitol enabled the Midwives' Association of Washington State to build relationships over time with legislators and government agencies to achieve this long-term goal. We present a successful midwifery-led innovation that achieved scope expansion for licensed midwives whose practice authority was limited by restrictive laws. Lessons learned are described and strategies offered to aid midwives and their advocates in other locales who want to improve health equity and access to contraception. Midwives are well positioned to provide this essential care to individuals living in underserved rural and urban areas and those from historically marginalized communities, but their ability to do so is limited by restrictive legislation.

Association of Medicaid Reimbursement Policies with Provision of Long-Acting Reversible Contraception in the Postpartum Period, 2012-2018

Background: To address reimbursement challenges associated with long-acting reversible contraception (LARC) in the postpartum period, state Medicaid programs have provided additional payments ("carve-outs"). Implementation has been heterogeneous, with states providing separate payments for the device only, procedure only, or both the device and procedure. Methods: Claims data were drawn from 210,994 deliveries in the United States between 2012 and 2018. Using generalized estimating equations, we assess the relationship between Medicaid carve-out policies and the likelihood of LARC placement at (1) 3 days postpartum, (2) 60 days postpartum, and (3) 1 year postpartum, in Medicaid and commercially insured populations. Results: Among Medicaid beneficiaries, the likelihood of receiving LARC was higher in states with any carve-out, compared with states without carve-outs, at 3 days (adjusted odds ratio [aOR] 1.49 [95% confidence interval: 1.33-1.67], p < 0.001), 60 days (aOR: 1.40 [95% CI: 1.35-1.46], p < 0.001), and 1 year postpartum (aOR: 1.15 [95% CI: 1.11-1.20], p < 0.001). Adjustments were made for geographic region, seasonality, and patient age. Heterogeneity was observed by carve-out type; device carve-outs were consistently associated with greater likelihood of postpartum LARC placement, compared with states with no carve-outs. Similar trends were observed among commercially insured patients. Conclusion: Findings support the effectiveness of Medicaid carve-outs on postpartum LARC provision, particularly for device carve-outs, which were associated with increased postpartum LARC placement at 3 days, 60 days, and 1 year postpartum. This outcome suggests that policies to address cost-related barriers associated with LARC devices may prove most useful in overcoming barriers to immediate postpartum LARC placement, with the overarching aim of promoting reproductive autonomy.

Association of Reproductive Autonomy and Rates of State-Level Racialized Disparities in Preterm Birth and Low Birthweight

Introduction

Reproductive policies' impact on disparities in neonatal outcomes is understudied. Thus, we aimed to assess whether an index of reproductive autonomy is associated with black-white disparities in preterm birth (PTB) and low birthweight (LBW).

Methods

We used publicly available state-level PTB and LBW data for all live-births among persons aged 15-44 from January 1, 2016, to December 31, 2018. The independent measure was an index of state laws characterizing each state's reproductive autonomy, ranging from 5 (most restrictive) to 43 (most enabling), used continuously and as quartiles. Linear regression was performed to evaluate the association between both the index score (continuous, primary analysis; quartiles, secondary analysis) and state-level aggregated black-white disparity rates in PTB and LBW per 100 live births.

Results

Among 10,297,437 black (n=1,829,051 [17.8%]) and white (n=8,468,386 [82.2%]) births, rates of PTB and LBW were 6.46 and 8.24 per 100, respectively. Regression models found that every 1-U increase in the index was associated with a -0.06 (confidence interval [CI]: -0.10 to -0.01) and -0.05 (CI: -0.08, to -0.01) per 100 lower black-white disparity in PTB and LBW rates (p<0.05, p<0.01), respectively. The most enabling quartiles were associated with -1.21 (CI: -2.38 to -0.05) and -1.62 (CI: -2.89 to -0.35) per 100 lower rates of the black-white disparity in LBW, compared with the most restrictive quartile (both p<0.05).

Conclusion

Greater reproductive autonomy is associated with lower rates of state-level disparities in PTB and LBW. More research is needed to better understand the importance of state laws in shaping racialized disparities, reproductive autonomy, and birth outcomes.

Development of a Composite Risk Index of Reproductive Autonomy Using State Laws: Association With Maternal and Neonatal Outcomes

OBJECTIVE

We developed a composite index to quantify state legislation related to reproductive autonomy and examined its association with maternal and neonatal outcomes. We hypothesized that greater reproductive autonomy would be associated with lower rates of severe maternal morbidity (SMM), pregnancy-related mortality (PRM), preterm birth (PTB), and low birthweight.

DESIGN

A Delphi panel was used to inform development of the index. Restrictive policies were assigned values of -1 and enabling policies +1. Publicly available data were used to conduct a cross-sectional study among all live births in the 50 U.S. states to people aged 15 to 44 between January 1, 2016, and December 31, 2018, to examine the association between the risk index and PRM, SMM, PTB, and low birthweight. We used linear regression with state scores and quartiles, adjusted for state-level proportions of White, Black, and Hispanic live births; percent living in rural areas; percent of population foreign born; Health Resources and Services Administration spending on maternal and child health; and the Opportunity Index, a composite measure of indicators of the economy, education, and community.

RESULTS

From 2016 to 2018, there were 11,530,785 births, 2,846 pregnancy-related deaths, and 154,384 cases of SMM. The Delphi panel resulted in a summed state measure of 106 laws in 8 categories that could affect reproductive autonomy. In adjusted analyses, states in the most enabling (most reproductive autonomy) quartile had a 44.7 per 10,000 higher rate of SMM compared with the most restrictive quartile. However, the most enabling quartile was associated with a 9.87 per 100,000 lower rate of PRM and 0.67 per 100 lower rate of PTB compared with the most restrictive quartile (least reproductive autonomy).

CONCLUSIONS

A composite policy index of reproductive autonomy was found to be associated with higher rates of SMM but lower rates of PRM and PTB. Further research is needed to understand how reproductive autonomy in the cumulative index may influence these and other maternal and birth outcomes.

Patient concerns about accessing sexual and reproductive health services outside of primary care: A survey in rural and urban settings in the Pacific Northwest

OBJECTIVES

While primary care providers are a major source of sexual and reproductive health (SRH) services in the United States, particularly in rural areas, not all primary care settings offer a full range of SRH services. We aimed to understand primary care patient concerns regarding accessing SRH services, including abortion care, outside of their primary care clinic and if those concerns differed by urban or rural setting.

STUDY DESIGN

An anonymous survey was distributed over a 2-week period between December 2019 to March 2020 to all adult patients in four primary care clinics in Idaho, Washington, and Wyoming. The survey assessed patient concerns regarding accessing SRH services outside of their primary care clinic and their willingness to travel to access SRH services.

RESULTS

The overall response rate was 69% (745/1086). Over 85% of respondents identified at least one concern to seeking SRH services outside of a primary care setting, with cost, insurance coverage, length of wait time, and lack of an established relationship being the most frequently reported concerns. A majority of respondents were willing to travel a maximum of 1 hour for most SRH services. Respondents from rural-serving clinics were significantly more likely to be willing to travel longer amounts of time for medication abortion, aspiration abortion, and intrauterine device placement.

CONCLUSION

Our findings highlight that a majority of both urban and rural primary care patients have concerns regarding accessing SRH services outside of their primary care clinic and are unwilling to travel more than 1 hour to access most SRH services.

IMPLICATIONS

A majority of primary care patients have concerns regarding accessing SRH services outside of primary care settings. Health care policy changes should aim to strengthen the SRH services available in primary care settings to alleviate the burdens primary care patients face in accessing SRH services outside of their primary care clinic, particularly for rural populations.

Evaluation of a fertility awareness-based shared decision-making tool part 1: Study design and impact on clinician knowledge

Objective

To assess the impact of a Shared Decision-Making (SDM) tool for fertility awareness-based methods (FABMs) of family planning.

Methods

Clinicians familiar with at least one FABM were randomly invited to participate in a prospective cross-over study to compare usual practice to the use of the SDM tool when discussing FABMs with patients. Patients completed surveys pre- and post-office visit and six months later. The primary outcome explored the effect of online education on use of the SDM tool on clinicians' knowledge of FABMs.

Results

Of 278 clinicians contacted, 54% could not be reached, and 15% did not provide women's health services. The 26 clinicians enrolled were experienced, with more than half recommending FABMs for ≥10 years, and 73% recommending more than one FABM to patients. Knowledge scores significantly improved after online training and use of the SDM tool (baseline mean score = 9.54 (scale of 0-12); post-training mean score = 10.73, p < 0.002).

Conclusions

Education about FABMs and training on use of the SDM tool improved knowledge scores even among an experienced cohort of clinicians.

Innovation

The novel SDM tool can better equip clinicians to meet the rising patient interest in FABMs.

Obamacare: A bibliometric perspective

Obamacare is the colloquial name given to the Affordable Care Act (ACA) signed into law by President Obama in the USA, which ultimately aims to provide universal access to health care services for US citizens. The aim of this paper is to provide an overview of the political-legal, economic, social, management (or administrative), and medical (or health) repercussions of this law, using a bibliometric methodology as a basis. In addition, the main contributors to research on ACA issues have been identified in terms of authors, organizations, journals, and countries. The downward trend in scientific production on this law has been noted, and it has been concluded that a balance has not yet been reached between the coexistence of private and public health care that guarantees broad social coverage without economic or other types of barriers. The law requires political consensus to be implemented in a definitive and global manner for the whole of the United States.