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date: 25 September 2022

5 How Do Attitudes and Policies Impact Access to Birth Control?free

5 How Do Attitudes and Policies Impact Access to Birth Control?free

  • Beth Sundstrom
  •  and Cara Delay
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What attitudes and beliefs affect access to birth control in the United States?

p. 128p. 129The vast majority of the American public believes birth control is a fundamental right that all people should have access to. This consensus has persisted for years: in 1937, 61% of Americans polled supported the birth control movement; decades later, in 2010, Americans responding to a poll about the birth control pill affirmed that most saw it as a benefit to families and societies. Half of those polled, in fact, said that the pill changed family life for the better. In a 2015 survey, when asked “if birth control in general was morally acceptable, 89% of the country said it was” (Weldon, 2014).

Despite this public support, women’s health care policies, especially those related to contraception, remain controversial, with some religious groups, states, politicians, and organizations in the United States opposed to increasing access to affordable birth control or actively trying to decrease access to it. These individuals and groups affect public opinion as well as policy decisions and laws (Barrett, Da Vanzo, Ellison, & Grammich, 2014, p. 162).

It is important to note that attitudes concerning birth control change and transform given particular historical and p. 130cultural contexts. In fact, the existence of any widespread opposition to birth control in the United States is a relatively new historical and cultural phenomenon. In the 1950s and 1960s, not only the American public, but also the vast majority of elected officials from both political parties, supported the growing family planning movement and its advocacy of birth control (Aiken & Scott, 2016). Until the 1970s, most Americans, including religious and evangelical Protestants, favored contraception. But birth control became more contested in the 1980s, 1990s, and 2000s. This development coincided with broader religious and cultural movements promoting a new social conservatism marked by evangelical Protestantism, the rise of the “New Right,” and a corresponding glorifying of the nuclear family and Christian motherhood (Barrett et al., 2014, p. 163).

Since the late twentieth century, a powerful antiabortion campaign, which sometimes incorrectly conflates abortion and birth control, also has affected popular views of family planning. A fervent antiabortion movement emerged in the wake of Roe vs. Wade (1973), the landmark Supreme Court ruling that decriminalized abortion nationwide. In response, a corresponding “prochoice” movement was formed, and in the decades since, opinions about abortion have become more and more polarized. The politicization of abortion in the United States from the 1970s to the present day has impacted policies about all aspects of women’s health, including family planning.

Discussions about both contraception and abortion frequently are framed within larger debates about what is best for women, families, and society. These debates, in turn, often center on interpretations of the role of religion in American life. Anticontraception campaigns, for example, gained steam with the support of the Catholic Church in the mid- to late twentieth century. Responding to the creation of the birth control pill and perceptions that a more permissive sexual culture was rising in Europe and the United States, in 1968 Pope Paul VI p. 131published Humanae Vitae, a document that resolutely affirmed the Church’s opposition to birth control. It reads, in part:

Therefore We base Our words on the first principles of a human and Christian doctrine of marriage when We are obliged once more to declare that the direct interruption of the generative process already begun and, above all, all direct abortion, even for therapeutic reasons, are to be absolutely excluded as lawful means of regulating the number of children. Equally to be condemned, as the magisterium of the Church has affirmed on many occasions, is direct sterilization, whether of the man or of the woman, whether permanent or temporary. Similarly excluded is any action which either before, at the moment of, or after sexual intercourse, is specifically intended to prevent procreation—whether as an end or as a means. (Paul VI, 1968)

While the principles outlined in Humanae Vitae and the Catholic Church’s steadfast opposition to “artificial” birth control remain unchanged, a majority of American Catholics use birth control. According to the Guttmacher Institute (2018), 89% of Catholics at risk of unintended pregnancy currently use a method of contraception. In fact, 68% of Catholics use a highly effective method (i.e., sterilization, hormonal contraception, or intrauterine device [IUD]), and only 2% rely on natural family planning. Official views and actual practices, then, do not always align.

In the 1970s and 1980s, certain American Protestant denominations also increased their opposition to birth control. Some evangelical Christian organizations combined forces with a New Right political conservatism, forming a powerful new political movement. This movement asserted that the United States is a Christian nation and, as such, must implement Christian values. According to some within the New Right, p. 132Christianity has been under siege in American politics for decades. This “war on religion,” claim some evangelicals, requires a concerted political response. Since the 1980s, sexuality and reproduction have featured prominently in this response. An extensive proabstinence campaign in the early 1990s, directed primarily at adolescents, denounced contraception, framing it as promoting promiscuity and linking it with abortion and moral decadence. Abstinence (or “purity”) educational campaigns, often supported by federal funding, have urged teenagers to abstain from sex until marriage. These campaigns argue that by encouraging contraception use, American society has promoted sex before marriage. Citing the biblical dictate “be fruitful and multiply,” some of these same evangelicals also oppose the use of all forms of birth control after marriage. According to Nancy Campbell, leader of the conservative Christian movement Quiverfull, “The womb is such a powerful weapon; it’s a weapon against the enemy. . . . My greatest impact is through my children. The more children I have, the more ability I have to impact the world for God” (Hagerty, 2009). Citing Psalm 127:5, which claims that men whose quivers are full of children are blessed, Quiverfull Christians advocate unrestricted reproduction (after marriage) to populate the country with other evangelicals and thus combat what they perceive as an increasingly secular United States that is hostile to religious and moral values.

By interpreting attitudes toward birth control as a “war” on religion and using militaristic language, anticontraception activists and thinkers employ some of the same strategies of those who advocate for birth control. Feminist activists and women’s health organizations argue that attacks on birth control amount to a “war on women.” This war, they claim, has a long history in the United States. According to historian Rickie Solinger (2013), “debates about who should have the power to manage women’s reproductive capacities have often been linked to debates involving larger issues—social, cultural, and economic, across the spectrum” (p. 18). Within this context, p. 133Solinger reminds us, women have often been “excluded from . . . rule-making processes” (p. 18). In the twentieth century and today, feminist activists have argued that “women’s health, safety, dignity, and access to full citizenship depend[s]‌ on their ability to control their own bodies and fertility” (p. 19). Opponents of the “war on women” link bodily autonomy with rights and citizenship, demanding policies and laws that protect practices such as contraception and abortion.

During the 2012 U.S. election and thereafter, when some Republican legislators came out in opposition to the Affordable Care Act’s (ACA) contraceptive mandate (discussed later in this chapter), some Democratic politicians bemoaned that there was still a “war on women” being perpetuated by Republicans. After Barack Obama won the White House for a second term in 2012, polls and studies affirmed that women voters, possibly responding to a perceived attack on contraception and larger “war on women,” were largely responsible for this victory (Deckman & McTague, 2015).

As we discussed in Chapter 2 of this book, popular attitudes toward birth control in the United States are also informed by history and culture. The history of “coercion, cruelty, and brutality” perpetuated on women of color and immigrants has continued in the form of persistent suspicion related to these women’s use of birth control (Silliman, Fried, Ross, & Gutiérrez, 2016, p. 49). It is important to concede that the reasons for some people’s wariness about birth control are complex and deeply rooted in our nation’s history and that, in many cases, this wariness stems from racism and/or misogyny.

Despite current controversies and debates, almost all Americans continue to support birth control. In 2012, 90% of Americans, and 82% of U.S. Catholics, agreed that birth control is moral (Newport, 2012). According to the Guttmacher Institute (2018), 99% of Catholics and Protestants who have had sexual intercourse have ever used some form of contraception. In fact, among those at risk of unintended pregnancy, approximately 73% of Protestants and 74% of evangelicals use a p. 134highly effective method, such as hormonal contraception, sterilization, or an IUD. Although the vast majority of Americans favor unrestricted access to birth control, the issue remains an area of intense debate and disagreement. What has been described as an American culture war—those opposing the “war on religion” against those decrying a “war on women”—affects public policy at both the federal and state level.

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What laws and regulations make it easier for women to access birth control?

Although many individuals and organizations consider birth control to be a global issue that transcends geographic borders, individual governments have their own laws, regulations, and policies. Policy has a significant effect on access to contraception, and birth control access and affordability can transform alongside political and governmental changes, even in developed countries such as the United States. According to Wyer, Barbercheck, Cookmeyer, Ozturk, and Wayne (2014), “the increasing visibility of women’s health care in public policy discussions” over the past few decades is a sign of progress in women’s health in the United States (p. xiv). Indeed, with mostly bipartisan support in the past 60 years, birth control has become safer, cheaper, and more accessible overall (Office of Women’s Health, 2014).

Across the United States, numerous birth control laws and regulations at both the federal and state level have developed over decades. In 1959, President Dwight Eisenhower refused to discuss contraception, declaring, “I cannot imagine anything more emphatically a subject that is not a proper political or governmental activity or function or responsibility.” However, by the 1960s and 1970s, federal U.S. policies and regulations that addressed contraception focused on access and cost. In 1969, Republican President, Richard Nixon famously said, “No American woman should be denied access to family planning assistance because of her economic condition.” Just p. 135a year later, in 1970, the U.S. government passed Title X of the Public Service Act. This act established federally funded family planning centers to assist poorer women with contraception and family planning. It also provided noncontraceptive health-related services, including care for pregnant women, cancer screenings, and sexually transmitted infections testing. Today, Title X helps four million women a year access reproductive health care, and the clinics funded under Title X prevent approximately one million unintended pregnancies each year. Administered by the U.S. Department of Health and Human Services’ Office of Population Affairs, Title X remains the only federally funded assistance program focused on birth control today. As we discuss later in this chapter, however, in the past few years, Title X has come under attack.

Particularly significant in terms of the laws and regulations on birth control was the ACA, implemented under the presidency of Barack Obama in 2012, which we discuss in detail in the next section. The ACA mandated that health insurance plans offer cost-free contraception to women, increasing access for millions of American women.

State laws and regulations on birth control vary widely across the United States. While some states in recent years have attempted to legislate to decrease access to contraception, others have pursued a different tactic. According to the Guttmacher Institute (2016), 28 states currently require their state health insurance plans to cover hormonal contraceptives. More specifically,

11 states require coverage of methods received over the counter; the insurer may still require the enrollee to obtain a prescription.

19 states and the District of Columbia require insurers to cover an extended supply of contraceptives at one time.

6 states require coverage of male sterilization, and 11 states require coverage of female sterilization. (Guttmacher Institute, 2016)

p. 136As of 2019, the following states have policies that provide free birth control to women:

California

Illinois

Maine

Maryland

Massachusetts

New York

Nevada

Oregon

Vermont

Overall, however, it is impossible to generalize about state laws and policies on contraception; evidence demonstrates a wide range of legislation and policies across the United States at the state level.

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How does the Affordable Care Act impact access to birth control?

One of the most significant developments in increasing access to birth control in the United States was the ACA, also known as “Obamacare.” Passed in 2010 under the Obama administration and implemented in 2012, the ACA included a “Women’s Health Amendment” designed to ensure that women would have access to essential services, including preventive care (cancer screenings, prenatal care, mammograms, etc.) at no cost to themselves. The ACA also required most health insurance plans in the United States to cover all methods of birth control approved by the U.S. Food and Drug Administration (FDA). Known as the “contraceptive mandate,” this part of the ACA required companies and businesses with at least 50 employees to offer health insurance plans that would provide cost-free birth control to women. This mandate received p. 137enthusiastic support from some legislators. As Senator Kirsten Gillibrand said during the Senate debates on the ACA,

[N]‌ot only do [women] pay more for the coverage we seek for the same age and the same coverage as men do, but in general women of childbearing age spend 68 percent more in out-of-pocket health care costs than men. . . . This fundamental inequity in the current system is dangerous and discriminatory and we must act. The prevention section of the bill before us must be amended so coverage of preventive services takes into account the unique health care needs of women throughout their lifespan. (Lipton-Lubet, 2014, p. 347)

The ACA requires that employers’ health insurance plans cover 18 FDA-approved methods of contraception free of cost, without charging copays or deductibles (Guttmacher Institute, 2016). The birth control methods covered under the ACA are

Female sterilization surgery (tubal ligation).

Implant.

Copper IUD.

Hormonal IUD.

Shot/injection.

Oral contraceptives.

The patch.

Vaginal contraceptive ring.

Diaphragm.

Sponge.

Cervical cap.

Female condom.

Spermicide.

Emergency contraception.

p. 138The effects of the ACA have been profound. Because of it, out-of-pocket birth control costs in the United States declined significantly (Snyder, Weisman, Liu, Leslie, & Chuang, 2018). With cost issues alleviated for many, more women used birth control, mostly hormonal methods. Significantly, the use of LARC methods increased in the wake of the contraceptive mandate. One study found a substantial increase in IUD use from 2011 to 2013 (Snyder et al., 2018). In 2013, the ACA helped women save an estimated $1.4 billion on the pill. Between October 2013 and March 2014, over four million women received health insurance coverage through the ACA. In the next section, we discuss opposition to the ACA and attempts to roll back the contraceptive mandate.

Some researchers and commentators have criticized the ACA’s focus on women rather than all people. The contraceptive mandate, for example, does not cover the male condom or male sterilization (vasectomy). As the website bedsider.org notes, “this might not seem like a big deal, until you realize that almost 1 in 4 women (23%) rely on their partners’ vasectomies or use of condoms as their main way to prevent pregnancy” (“Men’s Health,” 2018). The ACA’s failure to cover male forms of birth control, some argue, reinforces the idea that fertility control is solely the responsibility of women, leaving men free from such responsibilities.

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What laws and regulations make it difficult for women to access birth control?

As we discussed in Chapter 2, there is a complex legal history of birth control in United States. Changing political administrations have led to significant policy shifts on contraception since the late twentieth century. During the 1980s, for example, the Republican Reagan administration, informed by the New Right and evangelicalism, cut federal funding to Title X programs and initiatives by 25%. Then, with the subsequent election of the Democratic Bill Clinton in 1992, the pendulum p. 139shifted again. Clinton almost immediately raised spending for family planning, with Title X spending increasing by more than 37% in just a few years (Critchlow, 1999, pp. 103–104).

Laws and regulations have changed significantly in just the past few years as well. When the ACA was signed into law in 2010, it increased access to family planning for millions of Americans. After the ACA came into effect, however, some politicians, employers, and organizations protested its contraceptive mandate. Legal challenges to the ACA have been significant; over 80 lawsuits targeting the contraceptive mandate have gone forward. The most well-known of these occurred in 2014, when Hobby Lobby, a major employer that has hundreds of craft supply stores across the United States, challenged the ACA’s directive to offer birth control to its employees. Citing the Religious Freedom Restoration Act of 1993, the owners of Hobby Lobby argued that, by forcing it to provide contraception to its employees, the ACA was infringing on the company’s religious beliefs. As Time magazine summarized, “the company objected to paying for emergency contraception including Plan B, Ella—both commonly known as the morning after pill—plus two types of IUDs. Hobby Lobby said they believe these types of birth control amount to abortion” (Dockterman, 2014).

The case, Burwell vs. Hobby Lobby, eventually made its way to the U.S. Supreme Court. In June 2014, the Supreme Court ruled in favor of Hobby Lobby, writing that any employer “with deeply held religious beliefs” could, under law, “opt out” of covering birth control through its health insurance plans. The ruling effectively meant that the government could no longer require employers to provide insurance coverage for birth control if birth control was seen as conflicting with the employer’s religious beliefs (Lipton-Lubet, 2014, p. 344). The 2014 Supreme Court decision stated that only closely held companies (companies in which five or fewer people own 50% of the company) could exempt themselves from the ACA’s contraceptive mandate.

p. 140When Donald Trump became president, this changed. In early 2017, Trump said in a speech: “We will not allow people of faith to be targeted, bullied, or silenced anymore.” In October 2017, the Trump administration’s Justice Department instructed all American employers that they should feel free to exempt themselves from the contraceptive mandate “on the basis of religious objections.” Simultaneously, the Department of Health and Human Services created new policies that removed the contraceptive mandate for any employer, not just closely held companies, if that employer had religious objections to doing so (Pear, Ruiz, & Goodstein, 2017). Thus far, federal appeals courts have blocked these rulings from being implemented, but as of late 2019, debates and legal maneuverings continue, with some experts predicting that the issue will end up at the Supreme Court.

The Trump administration also has acted to revise Title X. The so-called domestic gag rule (2019) prohibits Title X-funded organizations from providing abortion services or abortion referrals. As a result, some organizations will be forced to either stop providing abortion services and information or leave Title X. In fact, in August 2019, Planned Parenthood announced its intention to exit the Title X program because of the government’s new guidelines. Currently, 40% of women who receive Title X services do so through Planned Parenthood (McCammon, 2019). According to the nonprofit independent news organization Common Dreams, “The loss of $60 million for Planned Parenthood means that 1.5 million low-income women—40 percent of the women across the country who obtain healthcare funded by Title X—could lose the medical care they receive at the group’s clinics” (Conley, 2019).

Other laws and regulations in the United States also prevent people from accessing contraception. In recent years, emergency contraception (EC) has been subject to controversy and challenges. In addition to employer objections, like those highlighted in the 2014 Hobby Lobby case, pharmacists have cited conscience clauses to deny services. Some pharmacists p. 141oppose dispensing EC, claiming that their religious beliefs should exempt them from providing contraceptive services. In addition, some pharmacies refuse to even stock EC. A 2012 study found that some pharmacists who will not dispense EC have serious misconceptions about EC and believe myths about EC, including that it causes birth defects or can induce abortion (Richman et al., 2012). Currently, under law, six U.S. states (Arizona, Arkansas, Georgia, Idaho, Mississippi, and South Dakota) permit pharmacists to deny medications to clients based on religious objections (“conscience clauses”). Meanwhile, eight states (California, Illinois, Nevada, Maine, Massachusetts, New Jersey, Washington, and Wisconsin) “have laws explicitly prohibiting medication refusals” (“Pharmacists Refusing,” 2018).

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Is cost a barrier to consistent use of contraception?

Cost remains a significant barrier to consistent contraceptive use in the United States.

According to a 2012 study, women who had private insurance paid about half of the total cost of their birth control pills. For these women, the cost of the pill constitutes 29% of their out-of-pocket health-care costs. Women who need birth control spend, on average, 68% more on out-of-pocket health-care costs than do men of a similar age (Arons, 2012). As some employers and government officials successfully challenge both Title X and the ACA’s contraceptive mandate, the costs of birth control for many women are increasing.

Millions of people, meanwhile, lack health insurance in the United States. For these people, affording birth control can be challenging. Condoms cost around $1 each. Most birth control pills, without insurance, cost approximately $20 to $50 per month. This adds up to between $240 and $600 per year. The shot costs between $200 to $300 per year. The patch costs about $1,200 per year, IUDs can cost more than $1,000, and the implant costs around $800. This means that the methods that p. 142experts recommend and consider to be most effective (LARC methods) are the most cost-prohibitive for many. People consider cost when choosing a contraceptive method; “among women aged 18–44 surveyed in 2016, more than 70% said that it was ‘extremely or quite important’ for their contraceptive method to be low cost” (Guttmacher Institute, 2016).

Women’s words and narratives affirm their support for low-cost or free contraception. According to one woman, who received Depo-Provera® for free under Title X, “It’s about ‘being able to afford health care and how that can make a person whole, and thrive’ ” (Washington, 2019). Similarly, one of our interviewees linked inexpensive birth control to her overall economic status, saying that for her, access to affordable birth control provided “peace of mind. Not living in abject poverty for my whole life.” Another narrator described the financial obstacles related to health insurance and how essential low-cost services were to her: “I was getting birth control out of the health department. Insurance didn’t pay for it. If you went to the health department, they were free.”

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Does health insurance cover contraception?

Some health insurance providers in the United States are publicly funded; others are private. Public health insurance programs include Medicaid, Medicare, TRICARE, the Indian Health Service (IHS), and Title X funded clinics. Medicaid is a state-federal program that provides health coverage to individuals with low incomes. All Medicaid programs are required to cover family planning services and supplies. In 2011, at least 3.5 million women aged 15 to 49 obtained Medicaid-covered family planning services through family planning waivers (Kaiser Family Foundation, 2015). Although Medicare coverage is primarily for people over 65, about a million younger people with disabilities also qualify for Medicare, and some of these people need birth control (“Does Your Medicare Plan,” n.d.).

p. 143People employed by the U.S. military and their dependents also need access to reliable and affordable contraception. Approximately 95% of American women serving in the military are of reproductive age. TRICARE, the federal military health-care program, provides most birth control free of cost for women on active military duty. Women not on active duty or women dependents of employees of the military must pay copays for contraception. For people on active duty stationed across the world, however, it is sometimes difficult to access birth control; different military health clinics may only have certain forms of contraception available (Grindlay, 2016). On military bases within the United States, approximately 50% to 88% of women use contraceptives regularly. On bases outside of the United States, however, that range decreases to 39% to 77%. Today, “inadequate contraceptive counseling and care before deployment—as well as lack of care and supplies while deployed—may contribute to increased rates of unintended pregnancy among servicewomen” (Rugg & Barry, 2015). The U.S. Department of Veterans Affairs (VA) also offers low-cost or cost-free methods of contraception for women veterans, and some VA medical centers “have a Women Veterans Program Manager to help women Veterans access VA benefits and health care services” (VA, n.d.).

The IHS (n.d.), a federal government division within the Department of Health and Human Services, has a mandate “to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level.” Currently, the IHS provides health care to over two million Americans. It offers contraception coverage as well, although access to contraceptives vary throughout particular IHS facilities. In June 2013, the FDA approved the EC progestin pill One-Step (Plan B) for sale in the United States over the counter for any person of any age. In response, IHS created a new policy stating: “It is IHS policy the Plan B One-Step® emergency contraception pill is easily available through the IHS facilities’ pharmacy, Emergency Department (ED), and in health p. 144clinics that are equipped with secure medication storage areas” (IHS, 2015).

Some private health insurance plans in the United States cover contraception. This differs based on multiple factors, including which state a person lives in and who their employer is. The ACA created the first federal contraceptive coverage requirement for private plans, but as we discussed earlier, employers with religious or moral objections may opt out of the contraceptive mandate.

At the state level, policies and laws on insurance coverage differ. In April 1998, Maryland became the first state to mandate that insurance companies cover birth control. In the years following the ACA, eight states, including California and Massachusetts, expanded access to free contraception. In California, pharmacists can dispense oral contraceptive pills without a physician’s prescription. In 2017, Oregon passed the Reproductive Health Equity Act, which ensures that women not only have access to free birth control, including vasectomies, but also provides for cost-free abortion. Significantly, the act extends these benefits to “women who are undocumented including DACA recipients and women who have held lawful permanent resident status for less than five years” (Oregon Health Authority, n.d.). When she signed the law, Governor Kate Brown said, “Everyone deserves the ability to make informed decisions about their health and to control their bodies, which shouldn’t be dependent upon where they live, where they come from, or how they identify.”

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How does access to contraception vary in the United States, and what are its effects?

As we discussed in Chapter 1 of this book, equal access to contraception is necessary to achieve reproductive justice. Access to contraception, however, remains a serious barrier to consistent use. Today in the United States, a person’s p. 145ability to use birth control consistently depends on various factors, including geography, socioeconomic position, and cultural issues. In a 2015 document, the American Public Health Association (APHA, 2015) noted:

Both in the United States and globally, specific populations encounter greater barriers to contraception access than the general population. These underserved populations include residents of rural areas, adolescents (unmarried and married girls), minority and indigenous communities, groups living in conflict zones or in areas affected by natural disasters, refugees and migrants (especially undocumented migrants), people with mental or physical disabilities, people living in extreme poverty, girls and women in violent intimate relationships, women and girls living in societies where their mobility outside the home is restricted, employees of religious organizations that oppose contraception, and residents of areas where health services are overseen by such organizations.

Particularly troubling is the reality that almost 20 million American women today live in what are called “contraceptive deserts.” This means that they lack reasonable access to birth control because of a lack of health centers or providers. Contraceptive deserts are areas where there is less than one health provider or clinic for every 1,000 women. Today, 1,570,720 women in the United States “live in counties without access to a single health center that provides the full range of methods” (Power to Decide, n.d.). Power to Decide estimates that 97% of women aged 13 to 44 who are in need of contraception currently live in contraceptive deserts.

Many people who live in contraceptive deserts are disadvantaged by other related factors as well, including race or p. 146ethnicity, sexuality, immigration status, and ability. A recent study concluded, for example, that

although young African-American women tend to live closer to pharmacies than their white counterparts (1.2 miles to the nearest pharmacy for African Americans vs. 2.1 miles for whites), those pharmacies tend to be independent pharmacies (59 vs. 16%) that are open fewer hours per week (64.6 vs. 77.8) and have fewer female pharmacists (17 vs. 50%), fewer patient brochures on contraception (2 vs. 5%), more difficult access to condoms (49% vs. 85% on the shelf instead of behind glass, behind the counter, or not available), and fewer self-check-out options (3 vs. 9%). More African-American than white women live near African-American pharmacists (8 vs. 3%). These race differences are regardless of poverty, measured by the receipt of public assistance. (Barber et al., 2019, abstract.)

We must therefore put contraceptive access within a larger context, asking how and why accessing such essential health care remains difficult for so many and considering the intersecting factors that contribute to a lack of access to birth control.

Although many LGBTQ+ people need birth control, misconceptions and ignorance continue to prevent some from accessing it. LGBTQ+ individuals, including transgender men and nonbinary, queer, or bisexual people, can engage in sexual practices that may result in pregnancy. Yet scholarly research on LGBTQ+ access to contraception remains rare, and many health care providers remain ignorant about this population’s contraceptive needs. As Neesha Powell (2017) writes, “when we talk about birth control, we need to remember that cis straight women aren’t the only stakeholders. As a pansexual nonbinary woman, birth control changed my life for the p. 147better, yet narratives like mine are missing from the media.” According to one resident of Texas in their 20s,

I had a tubal ligation done about a year ago. I am a bi transmasculine person. Before I had the procedure, my fertility (the thought of being pregnant) was giving me reoccurring nightmares. I was limiting my sexual encounters out of fear of pregnancy. I’ve never tried any other form of birth control besides condoms and my tubal ligation. After having the surgery I have so much less anxiety around sex. (Bell, 2019)

In addition, thousands of LGBTQ+ people use hormonal forms of birth control for noncontraceptive reasons, including controlling menstruation and treating related conditions.

Another population that is often overlooked in studies of birth control access is incarcerated women. Studies show that providing incarcerated women with reliable birth control before they are released from prison can affect their subsequent unintended pregnancy rates. Women given contraception while in prison are much more likely to use it consistently after their release. Moreover, women who enter prison and may have had unprotected sex in the days before their incarceration need access to EC. According to one recent survey, almost 30% of recently incarcerated women had unprotected sex in the days before entering prison. Some incarcerated women also experience rape and sexual assault during their imprisonment; they, too, need access to EC, as do some incarcerated women who are allowed conjugal visits. Despite these clear needs, prison systems across the United States have a wide variety of policies on providing EC to incarcerated women. As of 2016, only 4% of facilities nationwide had EC on hand (Driver, 2018).

In today’s political and cultural climate, in which migrants, refugees, and asylum-seekers have come under increased p. 148scrutiny, more research needs to be done on what sort of access these groups have to contraception, both during and after their journeys to the United States. Immigrant women in general in the United States tend to have less access to health insurance and contraception, and refugees and asylum-seekers face additional access issues. According to the Women’s Refugee Commission (n.d.), “Not being able to access family planning threatens [refugees’] lives and the well-being of their families.”

Several news stories in 2019 hinted at the realities of reproductive experiences for some migrant women. According to Maylin Nuñez, a 17-year-old Honduran making the journey through Mexico to the United States, preparing for her trip included securing access to birth control. Nuñez, a married mother of one, received a birth control shot before leaving Honduras because she was not sure if she would be able to access contraception while in route. Undocumented women journeying to the United States also are vulnerable to sexual assault. According to Amnesty International, 80% of women migrants experience rape and sexual assault during their migration journeys. These women have little access to EC (Fleury, 2016).

Another vulnerable population that struggles to access birth control is homeless or housing-insecure women. Seventy-three percent of homeless Americans claim that they have health needs that are not being addressed or cared for. American College of Obstetricians and Gynecologists (ACOG, 2013) writes that

women and families are the fastest growing segment of the homeless population, with 34% of the total homeless population composed of families. Of these homeless families, 84% are headed by women. African American families are disproportionately represented among the homeless population, making up 43% of homeless families.

p. 149A 2017 Chicago-based study revealed that “while 94% of the homeless women surveyed wanted to avoid pregnancy, most were using the least effective contraceptive methods. Among the women currently using a method, 59% relied on condoms, while 27% relied on withdrawal” (Corey, Frazin, Heywood, & Haider, 2017).

As we detail in the conclusion, telehealth initiatives and innovations promise to improve some vulnerable groups’ access to birth control.

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What role do regulatory bodies such as the FDA play in birth control?

The FDA is the United States’ regulatory body for all forms of medical devices and drugs. It is responsible for approving forms of contraception and thus allowing them to be marketed and sold in the United States. In 1960, the FDA famously approved Enovid as the first oral contraceptive pill available for contraceptive use. Since 1960, the FDA has approved dozens of forms of birth control for use and consumption in the United States, including LARC methods. Some methods of contraception that are available in other parts of the world, however, have not received FDA approval and thus are not accessible by American women. In the United States, for example, only five types of IUDs are available. In Britain, however, 22 types of IUDs are available to women, and Canadian women have access to 9 kinds of IUDs, all with different shapes (Beaton, 2017). As we discussed in Chapter 2 of this volume, after the Dalkon Shield controversy in the 1970s, the FDA stepped in to regulate IUDs. It currently classifies them as drugs, subjecting them to longer approval processes.

In rare cases, the FDA also has removed approval from certain contraceptives. As we discussed in Chapter 1 of this volume, in 2018, the FDA restricted the sale and distribution of Essure®, an implantable device that leads to permanent sterilization in women. It consists of

p. 150two “soft, flexible inserts” that, in a “gentle, non-surgical” procedure, are passed through the vagina and cervix into the fallopian tubes. There, the inserts, which do not contain or release hormones, help generate scar tissue that blocks the tubes. (Block, 2017)

In 2002, the FDA fast-tracked Essure® for approval. In the years following, thousands of women complained about harmful side effects and damaging consequences; approximately 9,000 American women ultimately had the device removed. These complications sparked serious criticism of the FDA. In 2015, researchers at Yale wrote,

We believe that these safety concerns, along with problems with the device’s effectiveness, might have been detected sooner or avoided altogether if there had been higher-quality premarketing and postmarketing evaluations and more timely and transparent dissemination of study results. (Block, 2017)

The same year, after five women died from Essure® complications, the FDA began a review of the device. This review resulted in the FDA withdrawing its approval from Essure® in 2018.

In recent years, “ ‘femtech’—technology aimed at women’s health, which analysts estimate will become a $50 billion market by 2025,” has exploded in popularity (Lieber, 2018). As part of this phenomenon, “fertility awareness” apps, including Clue, Kindara, Ovia, and Glow, have become more common in the United States. These apps, which assist with natural family planning methods, feature cycle tracking tools. In 2018, the FDA caused some controversy when it approved one of these apps, Natural Cycles, as a form of contraception. Once a woman enters her menstrual cycle details and basal body temperature readings, the app informs the woman which days p. 151of the month she will be fertile. The FDA expedited the approval process for Natural Cycles and ultimately categorized it as a medical device. This, in turn, resulted in criticisms by some physicians and experts, who argue that natural family planning techniques are problematic and should not be categorized as contraception. As Lieber (2018) reported:

Lauren Streicher, a professor of clinical obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine, said an app like Natural Cycles is “problematic on so many levels.” She said the FDA’s approval of the technology left her infuriated and speechless. “This isn’t science; this is craziness,” Streicher said. “We’ve already developed good, safe, reliable methods of contraception that are available to us. This app is completely taking women back in time.”

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What education about birth control is available today?

In 1912, American social worker and reformer Jane Addams wrote: “The child growing up in the midst of civilization receives from its parents and teachers something of the accumulated experience of the world on all other subjects save upon that of sex” (Addams 1912). In the early twentieth century, Addams and other reformers began to advocate for sex education in public schools. Linked to the growth of the federal government, the public school revolution, and the popularity of hygiene movements, sex education increased across the country (Zimmerman, 2015). By the postwar era, new technologies were enhancing the options for sex education. Educational films in the late 1940s and 1950s, for example, became ubiquitous learning tools for many American students. Although sex education in public schools in the mid-twentieth century did not offer comprehensive information on birth control, this changed by the 1970s and 80s, when evidence p. 152suggesting that adolescents were increasingly sexually active combined with the AIDS crisis to create a sense of urgency (Ashbee, 2014, p. 102).

Here, again, however, we see shifts in practices because of larger political changes. In the 1980s, the rise of the New Right and the evangelical purity movement began to have effects on sex education. Abstinence-only education teaches that no sex before marriage should be the norm. These programs generally do not teach about birth control or sexually transmitted infections. So-called abstinence-only programs became more common in the 1980s and 1990s, and increasingly received not only greater federal support but also funding. Meanwhile, support for contraceptive education declined. When George W. Bush became president in 2001, he increased funding for abstinence-only education. In the years since, abstinence-only education continues to dominate in the United States.

Studies and surveys by the Centers for Disease Control and Prevention and others have shown that almost all American adolescents—approximately 95%—receive some sort of sex education. From 2006 to 2013, however, as data from the National Survey of Family Growth demonstrated, teenagers’ knowledge of, and education about, contraception declined sharply. According to Planned Parenthood: “21% of females and 35% of males report not receiving information about birth control from either formal sources or their parents” (“Planned Parenthood | Official Site,” n.d.).

Women we interviewed in the past decade almost uniformly expressed a lack of education about contraception throughout their childhoods and adolescences, both at home and at school. A major theme around birth control in childhood was silence. One participant discussed how “contraception is . . . not something that was talked about often either because that meant you were having sex.” Another told us about sex in general: “My parents never really, they were just kind of like don’t do it. So honestly I was a little bit in the dark. p. 153I wasn’t reading magazines at the time that would have maybe put things into layman’s terms for me.” Another said, “My father, I remember being in elementary school, and he wouldn’t even let us see cats being born on TV. And I lived on a farm but I had no idea what was going on.” Our participants also clearly linked a lack of early education about birth control to later practices. One participant noted, “But for somebody in my demographic, that’s a woman, who comes from a place that—we didn’t really have means . . . your options are limited, and when you don’t know any better, you can’t do any better.”

Today, regional variations in funding and educational content, abstinence-only education in many public schools, a continued reluctance by parents and guardians to discuss a full range of options, and lack of physician education and knowledge about birth control all contribute to a persistent and troubling ignorance about contraception.

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What is the status of birth control in the United States today?

As this chapter has demonstrated, policies relating to birth control are always shifting. As of late 2019, this pattern continues. So do debates and controversies. Currently in focus are the Trump administration’s changes to the Title X program, continued divisions over abortion, and legal wrangling associated with the contraceptive mandate. According to the Guttmacher Institute,

reproductive health programs and key providers of reproductive health care are under siege in the United States. Social conservatives in Congress are attempting to wipe out funding for the Title X national family planning program, negate the guarantee of contraceptive coverage under the Affordable Care Act (ACA) and defund Planned Parenthood at the national and state levels. (Barot, 2015)

p. 154A recent poll conducted by the Kaiser Family Foundation (2019a) revealed that a majority of American women “are concerned that access to women’s reproductive health and preventive care services may be limited by the Trump administration’s changes to Title X, the nation’s federal family planning program.”

Still, the most prominent scientific, medical, and public health associations support unrestricted access to cost-free contraception. The ACOG (n.d.), which is the main professional organization for obstetricians and gynecologists in the United States, for example, notes: “Ob-gyns, physicians whose primary responsibility is women’s health, are dedicated to providing scientific information and access to contraception for their patients.” The APHA (n.d.), according to its website,

champions the health of all people and all communities. We strengthen the public health profession. We speak out for public health issues and policies backed by science. We are the only organization that combines a nearly 150-year perspective, a broad-based member community and the ability to influence federal policy to improve the public’s health.

In 2015, the APHA (2015) affirmed its support for birth control, stating:

This policy supports the universal right to contraception access in the United States and internationally. Contraceptive use confers significant health benefits through reductions in unwanted and high-risk pregnancies, maternal and infant morbidity and mortality, unsafe abortions, and medical therapy. These benefits are so significant that universal access to contraception is accepted internationally as essential to human rights.

p. 155These organizations recognize the importance of contraceptive access and advocate for continued education, resources, and support for birth control. Similarly, our interviewees articulated not only their support for birth control but their awareness that in the United States today, access remains problematic. As one said, “I think we’ve come a far way, you know, I think there’s a lot more work to be done.”

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What are global or transnational policies on birth control?

In 1994, the United Nations (UN) Population Fund declared reproductive rights, including universal access to contraception, to be fundamental human rights. At the same time, the UN “also identified four ‘interrelated and essential’ principles that constitute the right to the highest attainable standard of health: availability, accessibility, acceptability, and quality” (APHA, 2015). In the years since, the international community has overwhelmingly affirmed its support for birth control access and education.

Improving access to family planning services can help lower unintended pregnancy rates and reduce maternal deaths. According to the Kaiser Family Foundation, “Each year, an estimated 303,000 women die from complications during pregnancy and childbirth. . . . Approximately one-third of maternal deaths could be prevented annually if women who did not wish to become pregnant had access to and used effective contraception” (Kaiser Family Foundation, 2019b). Today across the world, however, around 214 million women who need or want contraception are not able to access it and/or afford it (Guttmacher Institute, 2016).

International health-focused organizations have been working for decades to increase birth control education, affordability, and access across the globe. These organizations are generally divided into three groups: multilateral organizations, bilateral organizations, and nongovernmental organizations (NGOs). Multilateral organizations are formed p. 156by multiple nations (usually at least three) to explore certain issues affecting the global community. The UN, WHO, and World Bank are examples of multilateral organizations working on global health care. Bilateral organizations may be linked with or sponsored by a particular government or may be NGOs. They are usually based in one country but conduct research about and work in areas other than their home country. The Centers for Disease Control and Prevention and U.S. Agency for International Development (USAID) are two bilateral organizations working on global health care. NGOs are nonprofit organizations, not linked with any particular government, that address particular transnational issues including health care. Health-care focused examples include Doctors Without Borders and the Kaiser Family Foundation (Center for Global Health, n.d.).

The previously mentioned international health-based organizations consistently advocate for birth control access and availability in our world today. Indeed, there is a consensus among these organizations that birth control is a fundamental right and that all people, across national borders, should have affordable access to it. The UN Family Planning Association (UNFPA) is the UN’s sexual and reproductive health unit. It publishes information and research that can help different governments and NGOs develop policies about birth control. The UNFPA (n.d.) “calls for the realization of reproductive rights for all and supports access to a wide range of sexual and reproductive health services—including voluntary family planning, maternal health care and comprehensive sexuality education.” It argues that “access to safe, voluntary family planning is a human right. Family planning is central to gender equality and women’s empowerment, and it is a key factor in reducing poverty” (UNFPA, n.d.). Similarly, the WHO (2018) argues, “Promotion of family planning—and ensuring access to preferred contraceptive methods for women and couples—is essential to securing the well-being and autonomy p. 157of women, while supporting the health and development of communities.”

Despite the consensus among NGOs, multilateral organizations, and bilateral organizations that birth control is essential in the twenty-first century, actually implementing policies to facilitate greater access and education can be difficult. This is complicated in different parts of the world by various factors. As the WHO summarizes, people in developing countries sometimes confront the following obstacles:

limited choice of methods;

limited access to contraception, particularly among young people, poorer segments of populations, or unmarried people;

fear or experience of side effects;

cultural or religious opposition;

poor quality of available services;

users and providers bias; and

gender-based barriers. (WHO, 2013)

As this chapter has outlined, however, the challenges and obstacles are not limited to the developing world. In the United States, various factors, including lack of knowledge/education, restrictive legislative measures, and prohibitive cost prevent some people from accessing contraception.