From the Global Gag Rule to the Supreme Court, policies put in place during the Trump administration may shape reproductive health in this country for years to come.
F. Perry Wilson, MD: In terms of reproductive health and rights, the arc of history in this country has, with notable fits and starts, tended toward increased access to contraception and abortion services for women. Although each administration has its own take on the government's role in reproductive health, the Trump Administration, bolstered by majorities in both Houses of Congress, has made substantial changes to reproductive health policy in this country.
How will that affect the health and well-being of American women? To discuss the issues with me today is Dr Megan Kavanaugh. Dr Kavanaugh is an internationally renowned public health scientist with a focus on reproductive health and the impacts of healthcare policy on women. She is a principal research scientist at the Guttmacher Institute, which is a research and policy organization focused on sexual and reproductive health that is currently celebrating its 50th anniversary. Dr Kavanaugh, thanks for joining me today.
Megan L. Kavanaugh, DrPH, MPH: Thanks very much for having me.
Wilson: This administration has been more proactive in terms of reproductive health policy than we have seen in a long time. Briefly, how would you characterize their major actions?
The Global Gag Rule
Kavanaugh: Under the current administration, we've seen sustained efforts to broadly reduce access to reproductive healthcare, both in the United States and globally. At the Guttmacher Institute, we've been tracking these efforts very closely and we've characterized them as falling largely into five core areas of focus.
The first is on the international front. There have been several attempts to undermine support for global reproductive health. One example is known as the global gag rule, which the current president reinstated and expanded as soon as he came into office. This rule restricts the US government from funding organizations that provide either information [about abortion] or abortion services. The expansion also prohibits funds from other sources to go to these services.
Wilson: That started with Reagan, I think.
Kavanaugh: That started with Reagan, but the expansion means that [global organizations] can't receive any other sources of funding, which have nothing to do with US government funding, toward either abortion services or just providing information about abortion options.
Wilson: What are the other core areas where we're seeing changes?
Access to Contraceptives
Kavanaugh: The second core area is here in the United States. There have been several attempts to undermine individual access to health insurance coverage here, both broadly and specifically reproductive healthcare coverage, including coverage of contraceptive methods.
Wilson: As a physician, I'm used to prescribing contraceptives of various types. Most private health plans provide reasonable coverage for that. Let's talk about the public health issue here.
If you limit access to insurance-based coverage for contraceptives, what's the downstream impact? The pill is not that expensive, right? It has been around forever. Is there really a measurable impact in terms of public health?
Kavanaugh: There really is. The important piece here is that there is no single best contraceptive method for every woman or every couple. Every couple decides differently, based on a multitude of factors. What private insurance coverage does and what the Affordable Care Act Contraceptive Coverage Guarantee did was to provide coverage for the full range of options so that people didn't have to be swayed by cost as a factor influencing what they wanted to use.
Wilson: What else are you tracking in this administration?
Abstinence-Only Sex Education
Kavanaugh: The third core area is related to increased support and funding for non-evidence-based sexual health education programs. In 2010, the federal government significantly reduced funding for these programs based on overwhelming scientific evidence indicating that the programs were ineffective and potentially harmful.
Wilson: We're talking about abstinence-only education, I assume.
Kavanaugh: They are promoting the message of abstinence-only until marriage. That is the key piece.
Wilson: The data do not support that this reduces the rates of unintended pregnancy, sexually transmitted diseases, or sexual activity?
Kavanaugh: Sexual activity in general—right. In 2010, the federal government followed the evidence to say we shouldn't be funneling funds to support these ineffective programs. However, despite a lack of data, the current administration is now reversing that and putting funds in that direction.
Kavanaugh: Regarding the two last core areas: There has been a lot of attention lately on limiting access to abortion here in this country. We've seen increased attention to this most recently with the nomination of Judge Brett Kavanaugh to the Supreme Court.
Wilson: No relation?
Kavanaugh: No relation.
Wilson: Brett Kavanaugh—I was about to say that he reinvigorated this debate, but this debate seems to be perpetual—has added a bit of fuel to the fire because we are not entirely sure where he stands in terms of Roe v Wade. We may not know until this is brought to the court, assuming he's seated.
What data do we have to assess the public health impact of changing our protections surrounding abortions? Presumably, even if Roe vs Wade were overturned, each state would have its own law, you'd have a state-by-state system, and people could potentially travel from state to state. Is it as disastrous for public health as some people are claiming or is this more of an abstract problem that we may have to face?
Kavanaugh: I think it's fair to say that we don't yet know what Kavanaugh would do, but we do know that there are decisions that he's been involved with that have blocked access to contraception and abortion. We can hypothesize that whoever ends up on the Supreme Court will be the deciding vote in cases related to abortion access.
We have to start considering what the healthcare landscape around abortion would look like in a world in which Roe vs Wade might be overturned. In that situation, it would go back to the states, as you mentioned.
Right now, about 57% of reproductive-aged women in our country live in a state that is considered either hostile or extremely hostile to abortion access. Those states have at least four restrictions in place that either significantly limit access or prohibit access to abortion; 29 states have those restrictions, and four states have "trigger laws." Should Roe v Wade be overturned, abortion would immediately be banned in those four states.
Wilson: Were that to happen—were there to be large swaths of the country where abortion is simply not available—what does the research suggest would be the public health impact?
Kavanaugh: A recent study was conducted by the World Health Organization in conjunction with some of my colleagues at Guttmacher. There are two key findings that I want to underscore that really help us understand what might happen here.
They looked broadly at access to abortion across countries and settings where abortion was broadly legal, highly restricted, or entirely illegal. The two key findings were:
First, there was no difference in the rate of abortion between countries where abortion was more available versus highly restricted.
Second, abortion was obtained in a much safer environment in settings where abortion was broadly available. Most commonly, abortion was obtained in more clandestine manners in settings where it was highly restricted or illegal.
There is no difference in the rate of abortion, meaning that people will always have a need to have abortions, and they will always seek abortions in whatever manner is available to them. In settings where abortion is restricted, what is available is highly unsafe and dangerous to their health. In settings where it's not as restricted, abortion is available in safer settings under medical guidelines. Overwhelmingly, abortion is a very simple and safe procedure when made available.
Wilson: Let's move on to the fifth area you guys are monitoring.
Title X Services
Kavanaugh: That is highly related to the one we just talked about because, as you mentioned, people have a range of feelings and thoughts about abortion, but fundamentally, most people agree that we all want to reduce the need for abortion. There is evidence to indicate that the way [to reduce the need for abortion is by] making contraception broadly available and accessible to people; you make it high-quality, and you provide the full range of services.
The evidence that we have shows that we have made progress in this area over the past decade or so. Between 2008 and 2014, we saw substantial reductions in both the unintended pregnancy rate and the abortion rate here in the United States.
There are several contributing factors that would influence these rates, but the key driver is increased access to and use of moderately and highly effective forms of contraception, including IUDs, implants, birth control pills, patches, rings, and shots.
That leads us to that fifth core area, which is around the publicly funded family planning safety net. I want to pause because I want to give a little history around the Title X program for those who may not know everything about it.
Wilson: Yes. Many of us don't.
Kavanaugh: The Title X program is the sole federally funded program that provides family planning services to individuals who need them, especially for those who are lowest-income and adolescents.
Wilson: Planned Parenthood is coming to mind now, but Title X is more than Planned Parenthood.
Without the Title X sites and the services that are available there, the unintended pregnancy rate and the abortion rate would both be about 30% higher.
Kavanaugh: Title X is way more than Planned Parenthood. It is a program that was established in 1970 with broad bipartisan support and signed into law by President Nixon. Since then, Title X has been guided by regulations and statutes mandating that a broad range of services related to family planning and contraception care be provided. It has to be very high-quality, and there are a range of guidelines that are being followed throughout the Title X program.
The program currently has about 4000 centers across the country in which family-planning services are provided. The most recent data, from 2016, indicate that they provide services to about 4 million women, men, and adolescents across the country.
A huge provider of Title X services, as you mentioned, is Planned Parenthood. Planned Parenthood provides about 40% or so of all Title X–funded services in this country. That is a large proportion.
Wilson: Absolutely. There's been a systematic effort to defund Planned Parenthood because they are an abortion provider.
Kavanaugh: That's where these two last core areas really intersect. Planned Parenthood sits at the crosshairs of being a very large provider of abortion care, but also of being an even larger provider of comprehensive family planning care and even broader healthcare to individuals who access those services.
We know that there are broad benefits that people have experienced by accessing care in these sites. We have evidence to indicate that in 2016 alone, the care that people accessed in Title X sites helped them to avoid over 800,000 unintended pregnancies and almost 300,000 abortions. Without the Title X sites and the services that are available there, the unintended pregnancy rate and the abortion rate would both be about 30% higher than they are currently. These are critical services that are needed and used by a large proportion of the US population.
Wilson: Thank you for giving us the numbers behind that. I think it's so important that, in an issue that can be so emotional for people to deal with, you bring it back to what you do as a researcher. You look at the epidemiology. You look at what happens as we institute programs and as we potentially take programs away.
There's a lot of uncertainty still. There's been a fair amount of movement by the Administration in terms of implementing these policies, but there's a lot more that's up in the air. The nomination of Brett Kavanaugh is perhaps the prototype of that, but there are many things that are being considered.
As you and others at the Guttmacher Institute look forward, what are you planning on tracking? What are the research projects and the studies that you are going to need to focus on in the coming years?
Kavanaugh: We remain committed to providing the evidence to inform well-formed policies that really help to improve the health of individuals, both in the United States and across the world. Right now, given all of these unknowns and these core areas that we've just talked about that seem to be really in the crosshairs of this current administration, we are committed to tracking the impact of what these potential policies may do for individuals who need these services, individuals who rely on these services, and individuals who may need or rely on these services in the future.
We've developed several studies, both domestically and globally, that are designed and set up to go into states and countries in which we know policies are about to go into effect or have just gone into effect. We are setting up longitudinal studies so that we can track the impact of these policies over time and how they impact the health and well-being of individuals and their families.
This interview appeared originally on medscape.com.