Reproductive Health Care Access in the United States: A Review of Literature
By Madison Dufek, Biological Sciences with an emphasis in Neurobiology, Physiology, and Behavior, Minor in Communications, ’17
“Reproductive health care/family planning refers to services that provide birth control, prenatal care, and pregnancy termination procedures. This is a subset of health care that is in my opinion talked about too much but not enough – especially when it comes to abortion. I initially wrote this piece for an upper division writing class focusing on women’s health; but reproductive health care access soon transformed into a cause that is now a great passion of mine. The results from the literature had me fiercely enraged yet profoundly inspired. Women all over the world today are denied necessary health care because of skewed perceptions of family planning and women as a whole. Abortion services – be it via medication or surgical procedure – are vital to communities, not just women. What troubled me most was discovering that the women who are already struggling suffer the greatest from abortion restrictions – women who already have mouths to feed, who are working multiple jobs just to make ends meet, who are uninsured, and often have no support system at all. It saddens me to know that the needs of these women are so often disregarded as communities make judgements, and as lawmakers work to regulate women’s reproductive rights. Deciding to have an abortion can take a huge psychological and physical toll on women and their families; and abortion restrictions only make this experience more trying for them. This, however will not prevent women from seeking abortions, it will only cause more of them to suffer major health complications or even die trying to obtain an abortion. This piece is for anyone out there like me: someone who wants to get educated, who wants to join the conversation, and who wants to become a stronger advocate for women’s reproductive rights!”
This review of literature aims to assess the overall status of reproductive health care access nationwide. It investigates how statewide perceptions, stigmas, and policies affect access to this kind of health care, with an emphasis on abortion services. It was found that conservative states were positively correlated with having stricter reproductive health care restrictions. Three components: state legislation, perceptions, and stigmas have been shown to influence each other and shape regional access to reproductive health care. This paper investigates the unique experiences and struggles women face when seeking these services and are met with access restrictions. Women experienced significant economic and psychological stress as the level of abortion restrictions increased, which also affected their family planning decisions including if, when, and where they want to obtain contraceptives, prenatal care, or an abortion. Physicians also played a role in providing access to these services and influencing women’s health care decisions. With this knowledge, policy makers, physicians, and communities can better understand the world of reproductive health care and become better advocates for the improvement of access to these services on a national and even global scale. Additionally, this insight has the potential to influence the progression of women’s reproductive rights, which will in turn improve the health and well-being of women, their families, and communities alike.
Keywords: abortion, reproductive health care access, family planning, United States, policies, perceptions, abortion stigma, abortion restrictions, physician’s role, social conservatism, reproductive health care knowledge, health care decisions, experiences
Abortion access in the United States is a heavily debated issue and has kept the country politically and socially divided for decades. The question of how accessible abortion services are to women remains varied across state lines. Statewide perception, knowledge, and opinion regarding abortion have a great ability to affect statewide policies, how women access family planning services, and how they make their health care decisions.2,3,10-12,15 Restrictions such as gestational age limits, longer waiting periods, and an increased number of visits to abortion facilities have been shown to cause a major strain in the lives of women.6 Women are forced to sacrifice more time, energy, and money to undergo this process, with low-income women bearing the hardest burden.6,8 The Guttmacher Institute, a leader in sexual and reproductive health research, reported an implementation of 334 abortion restrictions between 2011 and 2016 nationwide by states including Texas, Michigan, Missouri, and Alabama.12 Seventeen of these states had also recently motioned to eliminate funding for abortions and family planning service providers like Planned Parenthood.12 These motions could have serious implications for women if enacted across the country. Women seeking abortions and are living in many of these communities that are misinformed and disregarded by lawmakers and health care professionals will not only find themselves struggling to find an abortion-providing facility, but will suffer greater health risks due to the lack of well-trained professionals. This review of literature works to reveal and understand the statewide societal perceptions surrounding abortion and how they influence public policy and social views regarding reproductive health. The unique experiences and struggles women face as a result of these views and policies are investigated to better understand the effects abortion restrictions have on women. In the wake of current upheaval regarding reproductive health care access, it is vital that this topic be discussed to further protect women’s rights.
Regional Influences on Family Planning: Perceptions, Stigma, and Policy
Statewide perceptions and attitudes toward reproductive health care services such as abortion have been found to impact their level of accessibility to women. Factors including socioeconomic status and the amount of accurate abortion information provided to women show to have the largest effect.4,5,8-13 Attitudes regarding abortion are not only present at the societal level, but also infiltrate state legislation.1,2,15 Therefore, it is important that varying regional perceptions and stigmas be investigated to understand how they affect policy and women’s accessibility to reproductive health care services.
Perceptions and Stigma
Current literature suggests that socially conservative states tend to have negative views on unplanned pregnancy, non-abstaining forms of birth control, and abortion.3,9,13,15 These states have also been found to provide less accurate abortion information to women than socially liberal states.3 These attitudes and lack of education regarding family planning can play a major role in the way women make important family planning decisions.10,11,13,14 Studies looking at the relationship between social ideologies and knowledge and perceptions of family planning have revealed some insightful results. Daniels et al. compared statewide accuracy of embryonic and fetal development information provided to women seeking abortions. They revealed that one-third of the information deemed inaccurate by specialists were congregated in Southern and Midwestern states – otherwise, typical conservative states.4 These results could explain findings from a 2016 study which assessed Texan women’s knowledge and support of abortion restrictions. A large proportion of women believed that abortion was morally wrong and were in support of restricted access.15 Women with these views were more likely to be from socially conservative groups (conservative Republican or Catholic) compared to their more liberal Democrat or Protestant counterparts.15 However, over half the participants were either completely unaware or had little knowledge of current legislation on this topic.15 According to Smith et al., social attitudes and widespread inaccurate reproductive health knowledge appears to have a major impact on the women seeking abortion services in other conservative states.13 A study conducted in Alabama revealed that although most women know there is a high abortion rate in the state, women who obtain abortions are highly judged by their communities, causing it to be a hushed or hidden occurrence.13 Smith’s study is just one example of how negative perceptions regarding unplanned pregnancy and abortion can reinforce socially conservative views that are already unsupportive of reproductive health services. This cycle thus appears to be more prolific in socially conservative states, where more inaccurate reproductive health information is provided to communities, as observed in states like Alabama and Texas. These factors therefore play a major role in the public’s attitude regarding this issue, which can reflect voting patterns, policies, and the ways in which women make their health care choices. On the other hand, a study done by Aiken and Scott did not find a strong correlation between voting patterns of state legislators and stances on family planning.1 More research should be conducted to explain the relationship between voting habits and statewide perceptions of abortion.
How Perceptions Influence Policy
Perceptions and stigma regarding abortion and unplanned pregnancy can impact both women’s health care decisions, and state policies on abortion access.2,5,6,13,14 Although Bessett et al.’s study comparing attitudes and related state policies between conservative Republican “red states” and liberal Democrat “blue states” did not find a strong correlation between the two, the Guttmacher Institute’s most recent census on American reproductive health care access and related laws reported that 17 states, predominantly from the South and Midwest, passed 46 new abortion restrictions in 2016.3,12 These restrictions required abortion providers to obtain unnecessary hospital admitting privileges, withhold funding to abortion-providing facilities, deny women insurance coverage, and enforce gestational age limits.12 Counter regulations, however, have also been implemented to help increase access such as broadening women’s eligibility for insurance coverage, as well as supreme court overturns of major abortion restrictions.12 Therefore, although many states are working to further restrict abortion access, many others are working to increase accessibility and improve family planning for their female residents.12
The Effects of Abortion Restrictions on Women
Public knowledge and perception regarding abortion and family planning not only influence local policy, but also the experiences and reproductive health care decisions of women seeking these services.2,13 Kimball and Wissner’s assessment of state-level social determinants of health found that religiosity, social conservatism, and voting preferences were positively correlated with teen birth, abortion, and infant mortality rates, with the highest correlation being with social conservatism.9 Secondary factors such as gestational age limits, financial cost, and harassment found by Jerman and Jones, which are more common in socially conservative states, cause psychological and economic stress for women seeking abortions.6 Between 2011 and 2012, women paid an average of $480 for abortion procedures, and found it more difficult to access facilities that would perform abortions as the gestational age increased. These same women also faced picketing and entry blockage at 84% of the abortion clinics visited nationwide. With these issues being more common in socially conservative areas, this could explain why Midwestern and Southern conservative states have the highest abortion rates but the fewest abortion-providing facilities.6,7,13 As a result, women seeking abortion procedures in these states are forced to travel much further, as well as struggle to find childcare, take time off work, face judgement, and even reduce food budgets for their families.2,6,8,11,13 This may elucidate why many women either hesitate to have or completely forgo abortion procedures.13 These examples are typical situations for most women seeking abortions in conservative regions of the United States, with low-income women suffering the greatest strain.2 Thus, these social and economic restrictions prove to not only affect women’s well-being, but also the well-being of their families.2,8,9,11,13
Conservative states (particularly Midwestern and Southern ones) are characterized as having several layers of abortion restrictions, which in turn negatively influence abortion rates and the well-being of women and their families living in these areas.2,6,8,9,11,13 If restrictions continue to prove effective at limiting access to accurate information, specialized physicians, abortion facilities, and related affordable reproductive health care services, women will continue to either forgo the care they need or find much riskier solutions, which could result in major health complications.
The Physician’s Role in Family Planning
A physician’s role in the family planning process is vital to women’s health and the future of their families. Although it is the duty of a physician to provide care regardless of personal beliefs or attitudes, many physicians either refuse to perform abortions even when qualified to do so, or fail to support the needs of their patients when discussing family planning options.10 Therefore, assessing physicians’ abilities to provide accurate health care information and patient advocacy is an essential component to understanding abortion access nationwide. Although, physicians self-reported being able to overcome their personal opinions regarding abortions in a 2016 national study, female patients were seen as more worthy of empathy and abortion access by their physicians if they acted more feminine and expressed emotional remorse.10 In addition, physicians were more likely to delegitimize women’s needs for abortion and limit access if their patients elected to undergo the procedure rather than if they required one for a fetal anomaly, maternal health risk, or incest.10 Margo et al.’s study of South Carolina revealed that many public health providers caring for women seeking abortion services imposed anti-abortion judgements on them, making many of these women doubt their original health care decisions and experience more self-judgement.11 These studies reveal how influential the support and advice of physicians are to women making important family planning decisions. Physicians are seen as “gatekeepers” to essential reproductive health services for women; therefore, supporting their female patients’ wants and needs for these services is of crucial importance to improving women’s health and well-being.7,10,11,14
There are many factors that influence women’s reproductive health care decisions. Statewide perceptions, stigmas, knowledge, and implementation of access policies can determine if a woman receives proper care. 2-15 Conservative states in the South and Midwest present the greatest reproductive health care access limitations in the country, and thus, reflect the largest proportion of poor health outcomes for these women.2-4,6-8,11-13,15 This review, however is not able to fully reflect nationwide abortion access. With the literature showing a greater focus on conservative statewide family planning access, the experiences of women who seek these services in liberal states remains underlooked and cannot be objectively compared to women’s experiences in conservative states. The studies reviewed which assessed liberal state reproductive health care access showed to have major biases and lacked diverse samples of women.5 This is unfortunately a common limitation in abortion access studies, where only women who successfully underwent abortions are sampled.2,5,6,11,13 With abortion access in liberal states typically being less restrictive compared to that of conservative states, it could explain why research in these areas is in short supply and might be more challenging to conduct. It is vital, however, that more data be collected in liberal states and from more diverse samples of women to adequately observe, assess, and improve reproductive health care access nationwide.
The various regional factors reported in the recent literature that influence women’s access to abortion services proved to be very insightful into the world of reproductive health care. These findings reveal several ways in which access to reproductive health care can be improved such as: (1) providing more accurate family planning information to communities, (2) making abortion-providing facilities more widely available, (3) supplementing these facilities with well-trained and empathetic physicians who perform affordable procedures, and (4) increasing insurance coverage for reproductive health care services overall. These are all excellent potential steps to not only improving reproductive health care, but the lives of women and their collective reproductive rights.
- Aiken ARA, Scott JG. Family planning policy in the United States: The converging politics of abortion and contraception. Contraception. 2016;93(5):412–420. https://www.ncbi.nlm.nih.gov/pubmed/?term=Family+planning+policy+in+the+United+States%3A+the+converging+politics+of+abortion+and+contraception. Published January 13, 2016. Accessed February 18, 2017.
- Baum SE, White K, Hopkins K, Potter JE, Grossman D. Women’s experience obtaining abortion care in Texas after implementation of restrictive abortion laws: A qualitative study. PLOS ONE. 2016;11(10):1–14. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0165048. Published October 16, 2016. Accessed February 18, 2016.
- Bessett D, Gerdts C, Littman LL, Kavanaugh ML, Norris A. Does state-level context matter for individuals’ knowledge about abortion, legality and health? Challenging the “red states v. Blue states” hypothesis. Culture, Health & Sexuality. 2015;17(6):733–746. http://www.tandfonline.com/doi/full/10.1080/13691058.2014.994230. Published January 26, 2015. Accessed February 18, 2017.
- Daniels CR, Ferguson J, Howard G, Roberti A. Informed or misinformed consent? Abortion policy in the United States. Journal of Health Politics, Policy and Law. 2016;41(2):181-109. http://jhppl.dukejournals.org/content/41/2/181.long. Published January 05, 2016. Accessed February 18, 2017.
- Dennis A, Manski R, Blanchard K. A qualitative exploration of low-income women’s experiences accessing abortion in Massachusetts. Women’s Health Issues. 2015;25(5):463-469. http://www.sciencedirect.com/science/article/pii/S1049386715000572. Published June 13, 2015. Accessed February 18, 2017.
- Jerman J, Jones RK. Secondary measures of access to abortion services in the United States, 2011 and 2012: Gestational age limits, cost, and harassment. Women’s Health Issues. 2014;24(4):e419–e424. https://www.ncbi.nlm.nih.gov/pubmed/?term=Secondary+measures+of+access+to+abortion+services+in+the+United+States%2C+2011+and+2012%3A+gestational+age+limits%2C+cost%2C+and+harassment. Published June 30, 2014. Accessed February 18, 2017.
- Jones RK, Jerman J. Abortion incidence and service availability in the United States, Perspectives on Sexual and Reproductive Health. 2017;49(1):1–11. http://onlinelibrary.wiley.com/doi/10.1363/psrh.12015/full. Published January 17, 2017. Accessed February 18, 2017.
- Karasek D, Roberts SCM, Weitz TA. Abortion patients’ experience and perceptions of waiting periods: Survey evidence before Arizona’s Two-visit 24-hour mandatory waiting period law. Women’s Health Issues. 2016;26(1):60–66. http://www.sciencedirect.com/science/article/pii/S1049386715001619. Published November 25, 2015. Accessed February 18, 2017.
- Kimball R, Wissner M. Religion, poverty, and politics: Their impact on women’s reproductive health outcomes. Public Health Nursing. 2015;32(6):598–612. http://onlinelibrary.wiley.com/doi/10.1111/phn.12196/abstract. Published April 16, 2015. Accessed February 18, 2017.
- Kimport K, Weitz TA, Freedman L. The stratified legitimacy of abortions. Journal of Health and Social Behavior. 2016;57(4):503–516. http://journals.sagepub.com/doi/pdf/10.1177/0022146516669970. Published November 16, 2016. Accessed February 18, 2017.
- Margo J, McCloskey L, Gupte G, Zurek M, Bhakta S, Feinberg E. Women’s pathways to abortion care in South Carolina: A qualitative study of obstacles and supports. Perspectives on Sexual and Reproductive Health. 2016;48(4):199–207. http://onlinelibrary.wiley.com/doi/10.1363/psrh.12006/abstract. Published November 28, 2016. Accessed February 18, 2017.
- Nash E et al.; Guttmacher Institute. Laws affecting reproductive health and rights: state trends at midyear. http://repositorio.gire.org.mx/bitstream/123456789/2095/1/Laws%20Affecting%20Reproductive%20Health%20and%20Rights_%20State%20Trends%20at%20Midyear%2c%202016%20_%20Guttmacher%20Institute.pdf. Published September 1, 2016. Accessed February 20, 2017.
- Smith W, Turan JM, White K, et al. Social norms and stigma regarding unintended pregnancy and pregnancy decisions: A qualitative study of Young Women in Alabama. Perspectives on Sexual and Reproductive Health. 2016;48(2):73–81. http://onlinelibrary.wiley.com/doi/10.1363/48e9016/epdf. Published May 11, 2016. Accessed February 18, 2017.
- Wallace ME, Evans MG, Theall K. The status of women’s reproductive rights and adversebirth outcomes. Women’s Health Issues. January 2017:1-8. http://www.whijournal.com/article/S1049-3867(16)30408-X/abstract. Published January 25, 2017. Accessed February 18, 2017.
- White K, Potter JE, Stevenson AJ, Fuentes L, Hopkins K, Grossman D. Women’s knowledge of and support for abortion restrictions in Texas: Findings from a statewide representative survey. Perspectives on Sexual and Reproductive Health. 2016;48(4):189–197. http://onlinelibrary.wiley.com/doi/10.1363/48e8716/abstract. Published April 15, 2016. Accessed February 18, 2017.