Women's experiences seeking publicly funded family planning services in Texas

Minors' Experiences Accessing Confidential Contraception in Texas

PURPOSE

Texas is one of 24 states that restricts minors' ability to obtain contraception without parental consent, unless they access confidential services at federally funded Title X clinics. This study explores Texas minors' reasons for and experiences seeking confidential contraception.

METHODS

Between September 2020 and June 2021, we conducted in-depth phone interviews with 28 minors aged 15-17 years. Participants were recruited via the text line and Instagram account of an organization that helps young people navigate Texas' parental consent laws. Interview transcripts were coded and analyzed using inductive and deductive codes in our thematic analysis.

RESULTS

Participants wanted to be proactive about preventing pregnancy by using more effective contraceptive methods but faced resistance from adults when they initiated conversations about sex and contraception or tried to obtain consent. In the absence of adult support, they turned to online and social media resources for information about types of contraception but encountered challenges finding accurate information about where to obtain methods in Texas without a parent. Only 10 participants were able to attend an appointment for contraception. Parents' increased monitoring of minors' activities during the COVID-19 pandemic, combined with transportation and appointment-scheduling barriers, made it difficult for minors to attend in-person visits, particularly if clinics were farther away.

DISCUSSION

Minors in Texas faced a range of barriers to finding accurate information and obtaining confidential contraceptive services, which were exacerbated by the COVID-19 pandemic. Expanding options for accessible confidential contraception, along with repealing parental consent laws, would better support minors' reproductive autonomy.

Association Between Publicly Funded Contraceptive Services and the Abortion Rate in Texas, 2010-2015

OBJECTIVE

To evaluate how the availability of contraceptive services was associated with a change in the abortion rate before and after Texas' legislative changes to the family planning budget in 2011 and abortion access in 2013.

METHODS

In this cross-sectional study, we obtained 2010 and 2015 data on contraceptive provision (number of publicly funded clinics and number of contraceptive clients served per 1,000 reproductive-aged women) from the Guttmacher Institute and county-level abortion data from the Texas Department of State Health Services. We categorized counties as having an abortion rate that increased or declined less than the national rate between 2010 and 2015 ( low-decline counties ) compared with those having an abortion rate that declined equal to or greater than the national rate between 2010 and 2015 ( high-decline counties ). We evaluated differences in contraceptive provision between high-decline and low-decline counties and evaluated county characteristics (racial and ethnic composition, unemployment, poverty, uninsured, education, distance to an abortion clinic, deliveries covered by Medicaid, and Catholic hospital marketplace dominance) as potential confounders.

RESULTS

Of 157 counties that had at least one contraceptive clinic in either 2010 or 2015, 49 were low-decline counties and 108 were high-decline counties. Although the total number of publicly funded family planning clinics increased by 10.8%, there was a 4.7% decrease in the total number of contraceptive clients served statewide. Compared with low-decline counties, high-decline counties had a higher median number of contraceptive clients served per 1,000 women aged 18-44 years (31.9 vs 60.7, P <.05) in 2015. Between 2010 and 2015, the abortion rate decreased 19.7% for each 1.0% increase in contraceptive clients served.

CONCLUSION

Texas counties with higher abortion-rate declines had more publicly funded contraceptive clinics and served more contraceptive clients than counties with lower declines, which may indicate the importance of greater access to publicly funded contraceptive services.

A Prospective Cohort Study of Changes in Access to Contraceptive Care and Use Two Years after Iowa Medicaid Coverage Restrictions at Abortion-Providing Facilities Went into Effect

Inequities in access to contraception based on ability to pay can interfere with individuals’ reproductive autonomy. This study examines the impact of a 2017 state-level policy in Iowa restricting Medicaid coverage at abortion-providing health care centers on patients’ access to contraceptive care and subsequent contraceptive use. We draw on a unique panel dataset of individuals who originally sought care at a publicly supported family planning site in Iowa in 2018–2019 and then participated in subsequent follow-up surveys every 6 months for 2 years to examine an effect of access to care on contraceptive use. Among our final analytic sample of 368 individuals, our findings indicate that receipt of recent contraceptive care decreased over the study period; this coincided with patients shifting away from getting contraceptive care at sites potentially impacted by the 2017 Iowa Medicaid policy restriction while those getting this care at non-impacted sites remained relatively steady over the study period. At the same time, nonuse of contraception increased while use of a contraceptive method that carries cost, use of a provider-involved method, and satisfaction with one’s method decreased. We find that, after controlling for patient characteristics, those who shifted toward receiving contraceptive care experienced increases in these three contraceptive outcomes. We interpret this as preliminary descriptive evidence demonstrating an impact of disruptions in access to contraceptive care on contraceptive outcomes. Supportive payment and funding strategies for contraception, rather than policies that impede or restrict access, are needed to enable people to realize full reproductive autonomy.

Influences on Women's Care Seeking at Planned Parenthood Health Centers in Two Southern States

INTRODUCTION

In the context of a shifting health care landscape, better understanding of the factors that motivate women to seek services from specialized family planning clinics like Planned Parenthood (PP) can provide insights about potential changes in the role of specialized family planning clinics.

METHODS

We surveyed 725 women seeking services at two PP health centers in Louisiana and Kentucky from March 2016 to May 2017. We examined differences in care-seeking between women who had varying levels of access including those who did and did not have insurance instability or a regular source of care (RSOC) besides the clinic.

RESULTS

More than 60% of women attending the health centers did not have a regular source of care and nearly 40% experienced instability in insurance. Women who experienced insurance instability and a lack of a regular source of care more frequently sought primary preventive services such as pap tests and well-woman care at PP than women with better access. For women with better access, PP health centers also served important roles for those seeking contraceptive and sexually transmitted infection-related services. The most frequent reasons for choosing the PP were that it was faster to get an appointment, wanting to go to the PP clinic more than other clinics, and the confidentiality of services.

CONCLUSIONS

Our analysis suggests that PP health centers in Southern states still provide vital services for women with and without other sources of care and are critical for women needing access to timely services for preventative and sexually transmitted infection-related care.

Differences in abortion rates by race-ethnicity after implementation of a restrictive Texas law

OBJECTIVE

To evaluate the association between a restrictive Texas law, House Bill 2 (HB2), and receipt of in-clinic abortion by patient's race-ethnicity.

STUDY DESIGN

In this retrospective cohort study, we collected Texas state statistics on number of abortions, abortions per county, and abortions per county by race-ethnicity for 2012, before HB2 was enacted, and 2015, after HB2 was in effect. Using female reproductive-aged population estimates, we calculated the abortion rate and percent change in the abortion rate between the two time periods by county, patient residence in a county with an open clinic or HB2-related clinic closure, and change in distance to an open clinic for each race-ethnicity. We also used geospatial analyses to depict the greatest decrease in abortion rate by race-ethnicity and county.

RESULTS

In Texas, there were 64,716 reported abortions in 2012 and 54,253 in 2015. Statewide, there was a 20% decrease in the abortion rate affecting all racial-ethnic groups, yet the reduction was greater among Hispanic women compared to White women (-25% vs. -16%, respectively). The abortion rate also decreased more among those living in a county with an HB2-related clinic closure, especially for Hispanic women (-41% Hispanic vs. -29% White vs. -30% Black vs. -3% Other). Hispanic women whose travel distance increased 100+ miles had the greatest reduction in the abortion rate (-43%). Geospatial mapping confirmed our quantitative findings.

CONCLUSION

HB2 led to a disproportionate reduction in the abortion rate among Hispanic women in Texas, including those living in counties with a closed clinic or traveling long distances to obtain in-clinic abortion care.

IMPLICATIONS

Restrictive abortion policies in Texas may disproportionately burden Hispanic women and those affected by clinic closures.

Women's Postabortion Contraceptive Preferences and Access to Family Planning Services in Mississippi

BACKGROUND

Women's preferences for postabortion contraceptive care vary, and some may experience difficulties realizing their preferences owing to health systems-level barriers. We assessed Mississippi women's interest in postabortion contraceptive counseling and method use and the extent to which their method preferences were met.

METHODS

In 2016, women ages 18 to 45 completed a self-administered survey at their abortion consultation visit in Mississippi and a follow-up phone survey 4-8 weeks later. Thirty-eight participants were selected for in-depth interviews. We computed the percentage of women who were interested in contraceptive counseling, initiating a method, and who obtained a method at the clinic. We also calculated the percentage who were using their preferred method after abortion and the main reasons they were not using this method. We analyzed transcripts using a theme-based approach.

RESULTS

Of 323 women enrolled, 222 (69%) completed the follow-up survey. Of those completing follow-up, more than one-half (58%) reported that their consultation or abortion visit was the best time for contraceptive counseling, and 69% wanted to initiate contraception at the clinic. Only 10% obtained a method on site, and in-depth interview respondents reported they could not afford or did not like the options available. At the follow-up survey, 23% of respondents were using their preferred method. Women cited cost or lack of insurance coverage and difficulties scheduling appointments with community clinicians as reasons for not using their preferred method.

CONCLUSIONS

Mississippi women have a large unmet demand for postabortion contraception. Policies that support on-site provision of contraception at abortion facilities would help women to realize their contraceptive preferences.

Providing Family Planning Services at Primary Care Organizations after the Exclusion of Planned Parenthood from Publicly Funded Programs in Texas: Early Qualitative Evidence

OBJECTIVE

To explore organizations' experiences providing family planning during the first year of an expanded primary care program in Texas.

DATA SOURCES

Between November 2014 and February 2015, in-depth interviews were conducted with program administrators at 30 organizations: 7 women's health organizations, 13 established primary care contractors (e.g., community health centers, public health departments), and 10 new primary care contractors.

STUDY DESIGN

Interviews addressed organizational capacities to expand family planning and integrate services with primary care.

DATA EXTRACTION

Interview transcripts were analyzed using a theme-based approach. Themes were compared across the three types of organizations.

PRINCIPAL FINDINGS

Established and new primary care contractors identified several challenges expanding family planning services, which were uncommon among women's health organizations. Clinicians often lacked training to provide intrauterine devices and contraceptive implants. Organizations often recruited existing clients into family planning services, rather than expanding their patient base, and new contractors found family planning difficult to integrate because of clients' other health needs. Primary care contractors frequently described contraceptive provision protocols that were not evidence-based.

CONCLUSIONS

Many primary care organizations in Texas initially lacked the capacity to provide evidence-based family planning services that women's health organizations already provided.

Unmet demand for short-acting hormonal and long-acting reversible contraception among community college students in Texas

OBJECTIVE

To identify preferences for and use of short-acting hormonal (e.g., oral contraceptives, injectable contraception) or long-acting reversible contraception (LARC) among community college students in Texas.

PARTICIPANTS

Female community college students, ages 18 to 24, at risk of pregnancy, sampled in Fall 2014 or Spring 2015 (N = 966).

METHODS

We assessed characteristics associated with preference for and use of short-acting hormonal or LARC methods (i.e., more-effective contraception).

RESULTS

47% preferred short-acting hormonal methods and 21% preferred LARC, compared to 21% and 9%, respectively, who used these methods. A total of 63% of condom and withdrawal users and 78% of nonusers preferred a more effective method. Many noted cost and insurance barriers as reasons for not using their preferred more-effective method.

CONCLUSIONS

Many young women in this sample who relied on less-effective methods preferred to use more-effective contraception. Reducing barriers could lead to higher uptake in this population at high risk of unintended pregnancy.

Short Interpregnancy Intervals: Results from the First Baby Study

BACKGROUND

Short interpregnancy interval (SIPI), defined as 18 months or fewer between delivery and subsequent conception, has become an independent marker of maternal and child health.

METHODS

We performed a secondary analysis of 18 months of data from The First Baby Study, a prospective cohort of women followed from pregnancy through 3 years after their first birth. Women with SIPIs by 6, 6 to 12, and 12 to 18 months were compared with those without conceptions at those times. We then analyzed pregnancy intention of the subpopulation of women with a SIPI of 18 months or fewer. Logistic regression analyses determined associations between maternal characteristics, including sociodemographic and reproductive indicators, and SIPI incidence and intention.

FINDINGS

Of 3,006 participants, 795 (26.5%) had a repeat pregnancy within 18 months: 58 (1.9%) occurred within 6 months, 242 (8.1%) between 6 and 12 months, and 495 (16.5%) between 12 and 18 months. Incidence of SIPI at each interval differed by maternal characteristics, including income, marital status, and intention. Most women (84%) with a SIPI of 6 months or less classified them as unintended. Less than 2% of women with SIPIs of 18 months or fewer reported any contraceptive use in the postpartum period and no pregnancies occurred with the use of very effective methods, including long-acting reversible contraception.

CONCLUSIONS

The population of women at risk for SIPI is not homogenous. Among those with SIPIs, there is a stark contrast in intention between those who conceive early (≤6 months) versus later (≥12 months). Given that almost no pregnancies occurred when women used postpartum contraception, contraceptive counseling and unfettered access should be available for those at greatest risk for an early, repeat, unintended pregnancy.

A Systematic Review of Apps using Mobile Criteria for Adolescent Pregnancy Prevention (mCAPP)

Background

Adolescents in the United States and globally represent a high-risk population for unintended pregnancy, which leads to high social, economic, and health costs. Access to smartphone apps is rapidly increasing among youth, but little is known about the strategies that apps employ to prevent pregnancy among adolescents and young adults. Further, there are no guidelines on best practices for adolescent and young adult pregnancy prevention through mobile apps.

Objective

This review developed a preliminary evaluation framework for the assessment of mobile apps for adolescent and young adult pregnancy prevention and used this framework to assess available apps in the Apple App Store and Google Play that targeted adolescents and young adults with family planning and pregnancy prevention support.

Methods

We developed an assessment rubric called Mobile Criteria for Adolescent Pregnancy Prevention (mCAPP) for data extraction using evidence-based and promising best practices from the literature. mCAPP comprises 4 domains: (1) app characteristics, (2) user interface features, (3) adolescent pregnancy prevention best practices, and (4) general sexual and reproductive health (SRH) features. For inclusion in the review, apps that advertised pregnancy prevention services and explicitly mentioned youth, were in English, and were free were systematically identified in the Apple App Store and Google Play in 2015. Screening, data extraction, and 4 interrater reliability checks were conducted by 2 reviewers. Each app was assessed for 92 facets of the mCAPP checklist.

Results

Our search returned 4043 app descriptions in the Apple App Store (462) and Google Play (3581). After screening for inclusion criteria, 22 unique apps were included in our analysis. Included apps targeted teens in primarily developed countries, and the most common user interface features were clinic and health service locators. While app strengths included provision of SRH education, description of modern contraceptives, and some use of evidence-based adolescent best practices, gaps remain in the implementation of the majority of adolescent best practices and user interface features. Of the 8 best practices for teen pregnancy prevention operationalized through mCAPP, the most commonly implemented best practice was the provision of information on how to use contraceptives to prevent pregnancy (15/22), followed by provision of accurate information on pregnancy risk of sexual behaviors (13/22); information on SRH communication, negotiation, or refusal skills (10/22); and the use of persuasive language around contraceptive use (9/22).

Conclusions

The quality and scope of apps for adolescent pregnancy prevention varies, indicating that developers and researchers may need a supportive framework. mCAPP can help researchers and developers consider mobile-relevant evidence-based best practices for adolescent SRH as they develop teen pregnancy prevention apps. Given the novelty of the mobile approach, further research is needed on the impact of mCAPP criteria via mobile channels on adolescent health knowledge, behaviors, and outcomes.

Change over time in attitudes about abortion laws relative to recent restrictions in Texas

OBJECTIVE

Over the past 5 years, Texas has become a hotbed of debate on abortion rights and restrictions. Legislation in 2011 and 2013 made it more difficult for women to obtain abortions and for clinics to provide the procedure, laws which have resulted in practical obstacles and the closure of clinics. Less is known about whether that political activity has extended to public opinion on abortion in Texas, especially in the national context of increasing partisanship.

STUDY DESIGN

Data from the cross-sectional Houston Area Survey (HAS; n=4856) were used to compare attitudes about abortion at three time points: in 2010 before the major waves of legislation, in 2012 after the 2011 legislation, and in 2014 after the 2013 legislation. Logistic regressions estimated support for legal abortion over time, after adjusting for personal characteristics, views on other social issues, religiosity, political party identification and political ideology.

RESULTS

At all three time points studied, slightly more than half of Houstonians supported legal abortion for any reason a woman wanted to obtain one. Compared to 2010, support was significantly higher in 2012 and 2014, whereas the decline in support between 2012 and 2014 was not statistically significant after adjusting for religiosity and politics.

CONCLUSIONS

This study identified increased public support for legal abortion following the Texas state legislature's restrictive laws in 2011 and 2013.

IMPLICATIONS

As the Texas legislature increasingly restricts access to abortion, residents of the state's largest and most diverse city do not hold attitudes in line with those restrictions. Clinicians may thus have more public support for their services than the divided political climate would suggest.