December 11, 2022 Liz Borkowski, MPH 0Comment

In 2009, the Colorado Family Planning Initiative (CFPI) allowed Title X clinics — which use federal funds to provide sexual and reproductive healthcare to people who might otherwise be unable to afford it — to begin offering all forms of FDA-approved contraception to clients at no charge. The initiative, which was launched with private foundation funding, provided training and technical assistance to these clinics and supported their purchases of contraceptive methods like IUDs and contraceptive implants. With the removal of some of the barriers that often prevent patients from accessing their preferred forms of contraception, more clients began using IUDs and other long-acting forms of contraception. Rates of abortion, teen births, and preterm births all dropped. Now, researchers are examining some of the longer-term impacts, like completion of a college degree.

Colorado’s Success Story

In a study published in the journal Health Affairs, Sara Yeatman of University of Colorado Denver and colleagues examined completion of a bachelor’s degree by age 22-24 among women who were and were not high school students in Colorado during 2010-2014, when they would have had free access to all forms of contraception from Title X providers. The authors used Census Bureau data to compare the group exposed to the CFPI intervention to women who completed high school before the intervention fully took affect and those who completed high school in other states. Yeatman and colleagues found that exposure to CFPI was associated with an increase of 1.8 – 3.5 percentage points in women obtaining bachelor’s degrees by age 22-24 — which, they note, translates to an additional 2,300 Colorado women from the 1992-1994 birth cohorts graduating from four-year college programs. Given that college completion is associated with better health outcomes, findings suggest that access to contraception in adolescence could lead to better health for many years into the future.

One might assume that this result occurred because women who might have otherwise gotten pregnant in high school or college and delayed, skipped, or dropped out of college as a result were instead able to avoid undesired pregnancies and continue their education. The authors considered that possibility but determined that the size of the effect was too large to be explained solely by averted pregnancies. Yeatman and colleagues write, “[W]e suspect that part of the initiative’s impact on college completion worked through increasing confidence among women and their families that investments in higher education would not be derailed by an unanticipated pregnancy.” In other words, the decision to start college isn’t just influenced by whether adolescents have gotten pregnant, but whether they think they will be able to avoid pregnancy in the coming years.

A Worrisome National Picture

Colorado’s success story was only possible because of its network of Title X clinics, which were already providing high-quality reproductive healthcare to people with low incomes and just needed a bit of a boost to start offering things like free same-day IUD placement. For decades, the nationwide Title X network was a public health success story, but that changed when the Trump administration enacted the Title X gag rule in 2019. The rule barred Title X providers from providing comprehensive, patient-centered care to pregnant people; clinicians could no longer make abortion referrals for patients who desired them, and they had to refer these patients for prenatal care regardless of whether the patients wanted to continue their pregnancies. Title X providers faced the wrenching choice of whether to accept federal funding that let them offer services to their communities when the condition for doing so was to give incomplete, biased care that conflicted with ethical standards. The Guttmacher Institute calculated that within a few months of the policy’s implementation, 1.6 million clients — nearly half of those the program previously served — lost access to services.

The Biden administration rescinded the Title X gag rule and began the process of rebuilding the Title X network, but capacity that vanished during the Trump years won’t return overnight. And if the program is going to truly meet the nation’s need, it needs a big boost in Congressional appropriations rather than the flat funding Congress has granted in recent years. The Expanding Access to Family Planning Act (introduced by Senators Tina Smith, Patty Murray, and Elizabeth Warren in July) would provide $500 million per year for the next 10 years to the Title X program, a move that would substantially increase its funding and insulate it from political challenges over the next decade. The Act would also require that “pregnancy counseling include information about prenatal care and delivery, infant care, foster care, adoption, and pregnancy termination, unless a patient does not have any interest in receiving information about an option.” However, time is short for passing legislation in the current Congress, and the proposal would face a rocky path in the next one. The Title X program enjoyed bipartisan support for decades, but has come under Republican attacks in recent years; a Republican-controlled House of Representatives is unlikely to pass a bill that would limit opportunities political meddling in reproductive health.

Another thing that’s changed in the reproductive health landscape is, of course, access to abortion. Following the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision, several states have banned abortion and others are making it more difficult to access. Yeatman and colleagues suggested that Colorado’s initiative worked in part by helping young people feel confident that they could prevent pregnancy while earning a college degree. As Justices Sonia Sotomayor, Stephen Breyer, and Elena Kagan wrote in their dissent, the majority revoked the constitutional right to abortion “without so much as considering how women have relied on the right to choose or what it means to take that right away.” Will young women and others who could become pregnant now hesitate to take a preferred path in life because they know it could be derailed by a pregnancy their state forces them to continue?

Although higher college completion rates are good for the economy, the important point here is that easy access to contraception and abortion allow people the ability to shape the course of their lives by letting them decide whether and when to become parents. This human right is one that state and federal governments should protect and support by removing abortion restrictions and fully funding programs like Title X.

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