Valerie Tarico asks: Guess Who Dropped Delaware’s Abortion Rate by a Third Without Reducing Access for Those Who Need It?
I’m as fiercely pro-choice as they come. I owe my beloved first daughter to the fact that my husband and I were able to terminate a toxoplasmosis-infected pregnancy. My most read article ever was titled, “Why I’m Pro-Abortion, Not Just Pro-Choice.” But let’s get real. Abortion is an expensive, invasive medical procedure that can be painful and nausea inducing and, for some, emotionally fraught. For many, it’s a heck of a lot better than a mis-timed or unwanted pregnancy, which can give a young family a rotten start; or stack the odds against flourishing kids; or derail dreams or first steps towards a better future.
But even for those of us who find the moral equation to be pretty darn simple—meaning that individuals, not churches or governments, should get to decide whether and when to bring a child into the world, and meaning that all prospective parents should have equal access to abortion care—it can still be complicated by logistics, finances, partnerships, hormones, ambivalence, regret, or even a gauntlet of fundamentalists outside the clinic door.
People have abortions for complex reasons. But usually when a person needs an abortion, they were not intending to become pregnant in the first place. Why mitigate harm, when you can simply prevent it?
That’s what happened in Delaware.
The Guttmacher Institute recently released a report that showed abortion rates dropping across most of the country. But Delaware anchored one end of the spectrum, contrasting Pennsylvania’s 4 percent decline with a dramatic drop of 37%.
A statewide upgrade in contraceptive services that allowed people to better align their pregnancy intentions and actual lived experience. Under then Governor Jack Markell, Delaware partnered with a non-profit, Upstream USA, that provides technical assistance to healthcare systems, working with everyone from receptionists and billing offices to counsellors and clinicians to upgrade family planning care.
The goal is for all Delaware residents to have access to the full range of contraceptives, including IUDs and implants, which under real world conditions (in the complicated lives of real people) work 20 times better than the pill at preventing unwanted pregnancy. Upstream worked with hospitals, Medicaid providers, Planned Parenthood, and private practices to provide state-of-the-art care, same day, one visit, without cost barriers. They even offered free Uber rides to get people to the provider of their choice and home again.
And it worked. As uptake of better birth control rose, mistimed and unwanted pregnancies are estimated to have fallen, in addition to the decline in abortions. Before the program started, 57 percent of Delaware pregnancies were unintended, the highest unplanned pregnancy rate in the country. That is higher than the national average but by less than you might think. The percent of new mothers who say, after the fact, that their pregnancy was unintended or that they were unsure hovered around 50 percent for decades. It is finally dropping as young women shift over to more effective birth control devices like the Mirena, Paragard, Liletta, and Nexplanon that take human error out of the equation for years at a time.
Young people are choosing these methods not only because they are easy and work well. They are also readily reversible, some within a single cycle, with no long-term effects on fertility. They are as effective as tubal ligation, so mothers can choose one instead of sterilization if they think they might be done having kids but aren’t sure.
Addressing Race and Class Disparities
The technology transition to long-acting contraceptive devices has understandably created worries about racial and class justice.
On the one hand are advocates who worry that poor women, or women of color may get pressured to use the new devices. The concerns are grounded in a long history of coercive practices—with black women being pressured (or forced or raped) to have babies during slavery, and then pressured (sometimes with unconsented tubal ligations) to not have babies after. The same thing has happened around the world, with women being pressured to have babies for economic or state or religious reasons (e.g. in Rumania and Vietnam, now China), or pressured not to when a lower birthrate was deemed valuable to society (e.g. China, Vietnam). Some communities are rightly wary about enthusiasm for new methods, especially those that are controlled by a doctor rather than a woman herself.
On the other hand are advocates who worry that poor women and people of color will get left out of the revolution in contraception and will be forced to rely on methods that are cheaper but don’t work as well. If upper and middle class women can afford expensive IUDs and Implants but poor women can’t—or if more privileged women get the memo that these options are available but low income women don’t—then the impacts of mistimed and unwanted pregnancy fall disproportionately on those who are already facing more challenges. That could widen class and race disparities.
Healthcare data and survey research from Delaware suggests that health systems there are threading the needle between pressure and lack of access. Counselors were trained to open family planning conversations with a pregnancy intention screening question, asking each patient whether they would like to become pregnant in the next year. The answers can range from “No” and “Yes” to “I’m not sure” or “I’m OK either way.” The answer was documented in the patient’s medical record so that any conversation about family planning could be tailored to the patient’s goals, including preconception and prenatal care.
Follow-up surveys at Upstream-trained providers showed that 98-99% of patients felt respected and said they had chosen their own method; that they were not pressured to choose or continue a contraceptive. Additionally, Upstream USA worked with insurance plans and state officials to ensure that women can get their implant or IUD removed when they feel ready, without cost and logistical barriers.
No method works for everyone, but the data suggest that providers can improve care and birth timing while also improving patient autonomy. A growing number of young men would like a reliable contraceptive of their own, so that they too could manage their own fertility and become fathers only when they feel ready. Research, though underfunded, is underway to make that aspiration a reality. I personally see it as a matter of gender justice. For now, programs like the one in Delaware mean that individuals have more access to healthcare that can help ensure that they won’t be facing a surprise pregnancy and a tough decision in the coming year.
She writes about religion, reproductive health, and the role of women in society.