Access to Reproductive Health Services Position Statement
I. ASTHO Supports Access to Quality Reproductive Health Services
The Association of State and Territorial Health Officials (ASTHO) affirms that reproductive health services improve birth outcomes for both mothers and infants through preconception, prenatal and inter-conception care; increase access to education and contraception for males and females to enable responsible and respectful sexual activity; and are critical to safeguarding and promoting public health. Reproductive health services yield numerous benefits, including reducing unintended pregnancies, reducing the incidence and prevalence of sexually transmitted infections (STIs) and related rates of cancer and infertility; reducing pre-term births and infant mortality; improving educational attainment, improving health equity; and potentially helping to address child poverty and other important determinants of health. ASTHO supports individuals having access to affordable, evidence-based, medically accurate and effective reproductive health services. Consumer and provider awareness of family planning options should be maximized and healthcare and family planning visits should be recognized as an opportunity to link individuals to additional services.
II. ASTHO Recommends that State and Territorial Health Agencies help lead and implement the following strategies:
Promote Access to Services to:
- Ensure that everyone has access to medically appropriate and effective reproductive health services and continue to support public health and family planning clinics to ensure that priority populations have access to affordable reproductive health services.
- Promote consumer access to services regardless of age, geography, disability, race, ethnicity, religion, sex, gender, gender identity, sexual orientation, education, income, country of origin, marital status, language, or provider beliefs, where and when it is appropriate.
- Coordinate efforts with local health departments and other reproductive health/family planning providers to ensure access to high quality reproductive health services and partnerships.
- Strengthen links between reproductive health providers and other state- and community-funded programs to facilitate access to a broad range of health and social services and to reduce service duplication.
Maximize Funding and Health Insurance to:
- Coordinate and leverage public and private funding sources, including the Patient Protection and Affordable Care Act provisions, the Title X Family Planning Grant, the Title V Maternal and Child Health Block Grant, Medicaid, the Social Services Block Grant, Temporary Assistance for Needy Families, the 340B Drug Pricing Program, and the §1115 Medicaid waiver option for reproductive health services, and collaborate with programs related to breast and cervical cancer, STIs, and positive youth development.
- Enable and support integrating reproductive health services in primary care settings, including those that do not have Title X funds.
Promote Education and Awareness to:
- Promote reproductive health within the context of health across the lifespan in order to prevent or take into account the effect of early life influences, behaviors, and environmental factors on later adult outcomes.
- Educate, empower, and collaborate with primary care providers so that those providers are culturally competent, have access to and use the best public health science about reproductive and sexual health, and are supported in efforts to study, improve, and understand the importance of reporting on public health outcomes concerning reproductive and sexual health.
- Inform consumers and providers about enrollment in health insurance and any changes related to essential health benefits, networks of providers, and expansion of coverage for youth under 26 years of age.
- Recognize the family planning visit as an opportunity to link individuals to additional service providers, including family practitioners, pediatricians, obstetrician-gynecologists, social workers, mental health providers, lactation consultants, nutritionists, home visitors, and public health workers.
- Facilitate strategies to promote preconception health and reproductive life planning within existing reproductive health, primary care, and public health settings.
- Provide or assure provision of comprehensive reproductive, sexual, and healthy relationship education that is evidence-based, scientifically and medically accurate, and culturally and linguistically appropriate. Work with departments of education to ensure that K-12 school-based education is taught in a nonjudgmental manner, is age appropriate, and encourages positive parent and child communicaion.1
Promote the Collection of Data and the Evaluation of Services and Programs to:
- Ensure comprehensive collection and compilation of reproductive health data, including access to reproductive health services, contraceptive use, unintended pregnancy, rates of prenatal care, rates of adverse births outcomes, rates of sexually transmitted infections, and inter-group variation between populations in states, territories, and tribal nations. These data should be stratified by important demographic variables to identify health inequities.
- Measure and report the effect of health policy at various levels on reproductive health and access to services, particularly among priority populations.
- In partnership with public and private payers, take steps to align and report on clinical performance measures for reproductive health with population-based estimates obtained from state-based surveillance systems.
Educate Regarding Laws and Regulations to:
- Inform providers, clients, and educators about state and federal laws on reproductive health, such as access to confidential services, requirements for medically accurate reproductive health information, and adolescent access to reproductive health services and mandatory reporting.
III. ASTHO Recommends that the Federal Government help lead and implement the following strategies:
Promote Access to Services to:
- Support access to medically accurate, science-based information and services that are age appropriate and culturally competent.
Maximize Funding and Health Insurance to:
- Provide adequate funding to support quality, accessible, and effective reproductive health services, including funding for infrastructure and workforce needs.
- Develop flexible policy and funding mechanisms that allow programs to address the specific needs of the populations served.
Promote the Collection of Data and the Evaluation of Services and Programs to:
- Ensure comprehensive collection and compilation of reproductive health data, including access to reproductive health services, contraceptive use, unintended pregnancy, rates of prenatal care, rates of adverse birth outcomes, rates of sexually transmitted infections, and inter-group variation between populations in states, territories, and tribal nations. These data should be stratified by important demographic variables to identify health inequities.
Education Regarding Laws and Regulations to:
- Develop laws and regulations to ensure that provider conscience safeguards do not violate a patient’s right to access services. These laws must support health professionals in their obligation to ensure their patients receive complete and accurate information about their treatment options.
- Address policies established by insurers to access contraceptive services regardless of setting, such as eliminating prior authorization and extending required access to the immediate post-partum setting.
Reproductive health addresses the maintenance of one’s reproductive health system and fertility at all stages of life.2 Unmet need for contraceptive health services and education contributes to an estimated 3 million unintended or mistimed pregnancies each year. Approximately half of all births each year are unintended, with 31 percent of births occurring within 18 months of a previous birth.3,4 Unintended pregnancies and short inter-pregnancy intervals are associated with higher rates of preterm birth, low birth weight, and other negative maternal and infant health outcomes.5,6,7 In 2013, an estimated 38 million women of reproductive age were in active need of contraceptive care. More than half of these women, 20 million, qualify for publicly-funded family planning services (i.e., were either 250 percent below the poverty line or under the age of 20).8 Publicly supported reproductive health services, such as those provided through Title X and Medicaid, helped women avoid 2 million unintended pregnancies nationally, and therefore about 1 million unintended births and nearly 700,000 abortions.9
Publicly funded family planning services remain critical. Adolescents continue to see barriers to accessing reproductive services, particularly when it comes to confidentiality.10 Approximately 70 percent of youths who had not told a parent about clinic visits said on a nationwide survey that they would not seek family planning services, and 25 percent would have unsafe sex if they could not have confidential services.11
Title X-supported clinics offer a wide range of preventive health services, including family planning services that help individuals achieve their desired number and spacing of healthy children (e.g., contraception, basic infertility services and services to achieve pregnancy, pregnancy testing and counseling, and STI and other preconception health services) and related preventive health services (e.g., breast and cervical cancer screening).12 In addition, services provided at Title X-supported centers, including Pap and human papillomavirus (HPV) testing and administering the HPV vaccine, identified 1,900 cases of cervical cancer and prevented 1,100 cervical cancer deaths.13 One in three women and half of all poor women who received HIV testing or underwent testing, treatment, or counseling for other STIs did so at a publicly funded family planning center.14 Most publicly funded family planning centers also offer services to men, and the percentage of male clients increased from 4 percent in 2001 to 8 percent in 2010.15
Additionally, Title X is critical for serving those not eligible for Medicaid. Title X also distributes funding to grantees that operate their own programs, enabling targeted support to local areas. This funding can be used for services, outreach, medications, and staff salaries, often enabling clinics to obtain the infrastructure they need to claim Medicaid reimbursement for eligible clients.16 In 2010, every dollar spent on services provided by publicly funded family planning clinics saved an estimated $7.09 in Medicaid and other public expenditures. These savings can be attributed to preventing unintended pregnancies and reducing the incidence and impact of preterm and low birth weight births, STIs, infertility, and cervical cancer secondary to public investment in family planning programs. In this same time period, publicly funded clinics saved federal and state governments an estimated $13.6 billion. Services provided at Title X supported clinics accounted for $7 billion of that total.17
A Centers for Medicare and Medicaid services (CMS)-funded study of six state family planning (§1115) waiver demonstration sites found that expansions in family planning services were not only budget neutral but, in one state (Arkansas) also resulted in significant cost savings of up to $30 million in one year.18 Medicaid is the major source of public funds for family planning services, providing 75 percent of the $2.37 billion spent by federal and state governments in 2010.19
ASTHO position statements relate to specific issues that are time sensitive, narrowly defined, or are a future development or interpretation of ASTHO policy. Statements are developed and reviewed by appropriate policy committees and approved by the ASTHO Board of Directors. Position statements are not voted on by the full ASTHO membership.
Access Policy Committee review and approval: Feb. 2016
ASTHO Board of Directors review and approval: March 2016
Policy expires: March 2019
ASTHO policies are broad statements of enduring principles related to particular policy areas that are used to guide ASTHO’s actions and external communications.
Related ASTHO Documents
- APHA. Policy Statement Database: “Sexuality Education As Part Of A Comprehensive Health Education Program in K-12 Schools.” Policy Statement 2005-10. Available at https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/01/23/09/37/sexuality-education-as-part-of-a-comprehensive-health-education-program-in-k-to-12-schools. Accessed 10-22-2015.
- Office of Population Affairs. “Reproductive Health.” Available at: http://www.hhs.gov/opa/reproductive-health/. Accessed 12-1-15.
- Finer LB and Zolna MR. “Shifts in intended and unintended pregnancies in the United States, 2001-2008.” American Journal of Public Health. 2014. 104(S1): S44-S48. Available at: http://www.guttmacher.org/pubs/journals/ajph.2013.301416.pdf. Accessed 10-22-2015.
- CDC National Center for Health Statistics. “National Survey of Family Growth (NSFG). Available at: http://www.healthypeople.gov/2020/data/Chart/4461?category=1&by=Total&fips=-1. Accessed 10-16-2015.
- Conde-Agudelo A, et al. “Birth Spacing and Risk of Adverse Perinatal Outcomes: A Meta-analysis.” JAMA. 2006. 295(15):1809-1823. Available at http://jama.jamanetwork.com/article.aspx?articleid=202711. Accessed 10-22-2015.
- The National Campaign to Prevent Teen and Unplanned Pregnancy. “Unplanned Pregnancy.” Available at: http://thenationalcampaign.org/why-it-matters/unplanned-pregnancy. Accessed 11-16-2015.
- Guttmacher Institute. “Unintended Pregnancy in the United States.” Available at: https://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.pdf. Accessed 11-16-2015.
- Frost JJ, Frohwirth L and Zolna MR. “Contraceptive Needs and Services, 2013 Update.” New York: Guttmacher Institute. 2015. Available at: http://www.guttmacher.org/pubs/win/contraceptive-needs-2013.pdf. Accessed 10-26-2015.
- Frost JJ, Zolna MR and Frohwirth L. “Contraceptive Needs and Services, 2010.” New York: Guttmacher Institute. 2013. Available at: http://www.guttmacher.org/pubs/win/contraceptive-needs-2010.pdf. Accessed 10-26-2015.
- National Institute for Health Care Management Foundation. “Protecting Confidential Health Services for Adolescents and Young Adults: Strategies and Considerations for Health Plans, May 2011.” Available at: http://www.nihcm.org/images/stories/NIHCM-Confidentiality-Final.pdf. Accessed 10-25-2015.
- Benson Gold R. “Unintended Consequences: How Insurance Processes Inadvertently Abrogate Patient Confidentiality.” Guttmacher Policy Review. 2009. 12(4):12-16. Available at: http://www.guttmacher.org/pubs/gpr/12/4/gpr120412.pdf. Accessed 10-25-2015.
- Office of Population Affairs. “History of Title X.” Available at: http://www.hhs.gov/opa/title-x-family-planning/. Accessed 10-25-2015.
- Frost, JJ, et al. “Return on Investment: A Fuller Assessment of the Benefits and Cost Savings of the US Publicly Funded Family Planning Program.” The Milbank Quarterly. 2014. Available at: https://www.guttmacher.org/pubs/journals/MQ-Frost_1468-0009.12080.pdf. Accessed 10-26-2015.
- Guttmacher Institute. “Publicly Funded Contraceptive Services in the United States, 2015.” Available at: http://www.guttmacher.org/pubs/fb_contraceptive_serv.html. Accessed 10-16-2015.
- Frost JJ, Gold RB, Frohwirth L and Blades N. “Variation in Service Delivery Practices Providing Publicly Funded Family Planning in 2010.” New York: Guttmacher Institute, 2012. Available at: http://www.guttmacher.org/pubs/clinic-survey-2010.pdf.
- Gold RB. “Stronger Together: Medicaid, Title X Bring Different Strengths to Family Planning Effort.” Guttmacher Policy Review. 2007. 10(2):13-18. Available at: http://www.guttmacher.org/pubs/gpr/10/2/gpr100213.html. Accessed 10-25-2012.
- Frost et al, 2014.
- Edwards J, Bronstien J, Adams K. Evaluation of Medicaid Family Planning Demonstrations. The CNA Corporation. 2003. CMS Contract No. 752-2-415921.
- Sonfield A and Gold RB. “Public Funding for Family Planning, Sterilization, and Abortion Services, FY 1980-2010.” New York: Guttmacher Institute. 2012. Accessed 10-26-2015.