July 29, 2018 Liz Borkowski, MPH 0Comment

The comment deadline on the Trump administration’s Title X gag rule is Tuesday, July 31. More than 100,000 comments have come in already, reflecting the rule’s high stakes for public health. If implemented, it will severely damage a successful program that previously enjoyed bipartisan support and that has helped millions of low-income people access high-quality reproductive healthcare.

I wrote before about this proposed rule; basically, by putting onerous restrictions on providers that offer abortions  and prohibiting providers from giving clients complete information and referrals about pregnancy options, it would drive experienced providers out of the Title X family-planning program. By changing the requirements for the family-planning services providers must offer, it would replace the departed experienced providers of high-quality family planning service with organizations that oppose abortion and don’t offer some of the most effective forms of contraception. With fewer experienced providers and more lower-quality services in the Title X program, low-income clients will find it harder to access their preferred forms of contraception — as well as other forms of reproductive healthcare, like cervical cancer screenings and STI testing. As a result, we’ll see more unintended pregnancies, while abortion becomes increasingly difficult to access. (If you want more details, the comment I wrote for the Jacobs Institute of Women’s Health is here.)

Researchers, providers, and organizations have been sounding the alarm about this proposal. Here are three good pieces about it.

Dr. Julie Chor, an ob/gyn, in the New York Times:

For several years, I worked at a Title X-funded clinic on the West Side of Chicago, caring primarily for patients who lacked insurance. I saw firsthand what it meant for people to have access to both preventive care and providers who were able to counsel them effectively — and what it meant when they didn’t.

I remember one patient in particular. She was in her late 30s, and uninsured. She came to our clinic with an unintended pregnancy. She had been told, inaccurately, that because of a medical condition, no method of hormonal birth control was safe, so she relied on condoms alone; in other words, she had received the sort of misinformation that Title X-funded clinics can help to combat.

She also had a history of heart disease. She knew that, for her, a pregnancy presented significant health risks.

At our clinic, I was able to counsel this patient on all of her options: These included continuing her pregnancy with dedicated care to address her cardiac risks, and abortion. After careful consideration, she opted for an abortion, and I was able to help her obtain one. Thanks to Title X funding, afterward, she was able to get a safe, effective method of contraception. The availability of these options, and the ability to obtain care, provided this woman with the autonomy to make informed decisions that were best for her. A ban that would have prevented me from counseling and helping her get the care that she needed would have forced me to violate my oath to do what is in the best medical interest of my patients.

Jody Steinauer & Philip Darney in The Lancet:

The potential violations of medical ethics go beyond withholding information and making unethical referrals. Delaying access to abortion care has serious health risks. Although abortion is safe overall, patients who obtain abortions late in pregnancy have increased risks of complications, few providers, and high costs. Research findings show that carrying an unwanted pregnancy to term is more dangerous to a woman’s health than abortion, especially for patients with conditions that increase the health risks of pregnancy, such as hypertension and diabetes. These conditions are more prevalent in low-income women and women of colour—the population most likely to depend on Title X providers.
The proposed regulation also violates the fundamental principle of justice in health-care provision. Implementing this rule would create a stratified system in which access to information to make fully informed medical choices is a benefit conferred upon those with the means to afford it. The harm of denying referrals exceeds basic unfairness; it has the potential to drive low-income patients further into poverty. Compared with women who received abortion care, women denied a wanted abortion had four times greater odds of being below the Federal Poverty Level.

Janet M. Brownstein in the New England Journal of Medicine:

Absent funding that would enable sites that provide both abortions and family-planning services to hire additional staff, purchase new equipment, and rent new space and absent a willingness of these clinics to diminish their quality of care by segmenting medical records, facilities, and clinicians, these sites will probably exit the Title X program. In fact, such an exodus may well be the actual intent of the proposed regulations, since eliminating Planned Parenthood’s access to Title X funding is a long-standing policy goal for abortion opponents. Other providers who are unwilling to violate ACOG recommendations for ethical care may also exit.
What types of providers would take their place? The new regulations eliminate the requirement that Title X sites follow the Centers for Disease Control and Prevention family-planning quality-of-care guidelines and emphasize that not every Title X site must offer a broad range of acceptable, effective family-planning methods and services, as long as a broad range is offered within the grantee’s overall project. They also note that natural family planning is an acceptable contraceptive service that should be provided at Title X sites. Combined with the elimination of the requirement to refer pregnant clients to abortion services on request, the new regulations open the Title X system to sites that are opposed to abortion use on principle and that offer only less effective fertility-awareness methods of contraception. Given their small scale, it’s unlikely that these new providers and the remaining Title X sites will be able to handle the patient volume of the exiting providers. Thus, the proposed regulations will leave Title X clients in many communities with more limited access to family-planning care, lower-quality care, and care that prioritizes less effective family-planning services.

Planned Parenthood provides resources for commenting on the proposed rule by the July 31 deadline.

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