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 Start Program, 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.
While Mississippi is a bit less forward about abortion and focuses on providing other services, Missouri’s programs seem to have the primary goal of deterring residents from terminating their pregnancies. Georgia appears to have the widest range of options for its residents, although there are some pitfalls as well. All in all, state health officials are not standing idle when it comes to the health of their communities, but they have a long way to go — and legislators and dissenters to deal with.
Reproductive health in Alabama and Arkansas will be discussed in Part 2.
Featured image via Pixabay