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Adolescent Reproductive Health Without Planned Parenthood

      How would the health of adolescents in the United States be affected if Planned Parenthood (PP) were to be “defunded”? I know that in writing about this possible eventuality and the problems it would cause for adolescents and young adults that we care for and care about, I risk angering some of my colleagues who firmly believe that this “defunding” would be a very positive thing. And honestly, I hesitated briefly before writing this editorial for that reason. There are also people who believe that there would be little effect on girls' and women's health if PP were to go away—that that other publicly-funded clinics would be able to provide care. Unfortunately, because three-quarters of PP patients had incomes at or below 150% of the federal poverty level, these women would need to rely on community health centers that are woefully unprepared to provide reproductive healthcare in lieu of PP.
      The prospect that adolescents and young women (and men) would lose the opportunity to access preventive care at PP health centers seems to me unimaginable and unconscionable. The Journal of Pediatric and Adolescent Gynecology regularly publishes studies supporting the need for the provision of reproductive health services to adolescents and young adults. The evidence from articles published in the Journal of Pediatric and Adolescent Gynecology and other medical journals indicates that reproductive health services are health-promoting for US teens. One in 5 American women has received care from PP at least once in her lifetime (http://www.plannedparenthood.org), and thus it's likely that you, someone in your family, or someone you know well is healthier now because of PP.
      To be clear, PP funding is not a line item in the federal budget. “Defunding” PP means blocking nearly 1.6 million Medicaid patients from accessing preventive care at PP health centers. Currently, federal funding is not used for any abortions, as was mandated by the 1976 Hyde Amendment that prevents federal dollars from paying for abortions. Thus “defunding” would not prevent abortions, but the health care at PP that would be prevented includes other reproductive health services and prevention, including contraception and sexually transmitted disease services, as well as cervical and breast cancer screening. In fact, if contraceptive services were limited, the number of abortions might well increase. In 2010, publicly funded clinics averted 1.7 million unwanted pregnancies, including 374,000 teen pregnancies (information from the Guttmacher Institute; http://www.guttmacher.org).
      The Title X National Family Planning Program is administered by the US Department of Health and Human Services, and is the only federal program dedicated to supporting the delivery of family planning and related preventive health care through grants to public health departments and other private nonprofit agencies, including PP. Title X family planning clinics provided care to more than 4 million people in the United States in 2015.
      • Fowler C.I.
      • Gable J.
      • Wang J.
      • et al.
      Family Planning Annual Report: 2015 National Summary.
      Approximately 25% of all Title X money goes to PP affiliates, and approximately one-third of all people that the Title X program serves are seen at PP centers (www.plannedparenthoodaction.org/issues/health-care-equity/title-x). One-third of women who received contraceptives from a publicly funded clinic that offers at least some of their patients free or reduced-price care, did so at a PP. At PP affiliates, 45% of services provided were for sexually transmitted infection (STI) screening/treatment, 30% for contraception, 7% for cancer screening, and only 3% for abotions (date from https://www.plannedparenthood.org/uploads/filer_public/18/40/1840b04b-55d3-4c00-959d-11817023ffc8/20170526_annualreport_p02_singles.pdf). In 2015, Title X provided nearly 800,000 Pap tests, 1 million breast exams, nearly 5 million STI tests, and 1 million tests for HIV. Six of 10 women who receive care from a family planning health center consider it their main source of health care, and for 4 in 10, it's their only source of care.
      • Frost J.J.
      U.S. Women's Use of Sexual and Reproductive Health Services: Trends, Sources of Care and Factors Associated with Use, 1995-2010.
      • Frost J.J.
      • Gold R.B.
      • Bucek A.
      Specialized family planning clinics in the United States: why women choose them and their role in meeting women's health care needs.
      The dismantling of federal protections for girls' and young women's health is truly alarming. When we think about adolescent health and reproductive health services, as well as teen childbearing, we note that adolescents are twice as likely to have an unplanned pregnancy compared with older women.
      • Finer L.B.
      Unintended pregnancy among U.S. adolescents: accounting for sexual activity.
      Teens are also less likely to seek contraception when low-cost options are not available, making them more vulnerable to cuts in public funding and services to PP.
      • Frost J.J.
      • Zolna M.R.
      • Frohwirth L.
      Contraceptive Needs and Services, 2010.
      While I looked for an analysis regarding the effects of removing reproductive health protections specifically on adolescent and young adult health, I was unable to find data that were presented according to age. However, we know that adolescents need reproductive health care, and if the trend of declining rates of adolescent pregnancies is to continue, accessible and affordable reproductive health care will be important on an ongoing basis.
      PP and Title X clinics provide a true safety net for reproductive health care.
      On April 13, 2017, President Trump signed a law that permitted states to deny funding for PP. Despite congressional efforts for defunding, there is widespread support for PP among the general public. A recent poll found that most voters in 13 Republican-held districts oppose defunding PP and the Republican Obamacare repeal bill (http://thehill.com/policy/healthcare/331498-poll-majority-of-voters-in-13-gop-districts-oppose-defunding-planned). The Washington Post has reported that the Congressional Budget Office concluded that cutting off federal funding for PP would actually increase public spending by an estimated $130 million over 10 years as a result of additional Medicaid births (https://www.washingtonpost.com/news/business/wp/2015/09/24/defunding-planned-parenthood-would-actually-increase-government-spending/?utm_term=.840f5f848d12).
      Several states are enacting laws that affect state funding for PP clinics. Iowa PP clinics are facing closure. Effective in 2013, Texas enacted laws excluding PP from receiving state fee for service family planning funds. Research conducted after this measure went into effect showed a reduction of 35.5% in medical and pharmacy claims for long-acting reversible contraception methods and of 31.1% for claims for injectable contraceptives.
      • Stevenson A.J.
      • Flores-Vazquez I.M.
      • Allgeyer R.L.
      • et al.
      Effect of removal of Planned Parenthood from the Texas Women's Health Program.
      Fewer women returned for a subsequent on-time injection of depot medroxyprogesterone acetate after the exclusion. In addition, the rate of childbirth covered by Medicaid increased 27.1% from baseline within 18 months.
      • Stevenson A.J.
      • Flores-Vazquez I.M.
      • Allgeyer R.L.
      • et al.
      Effect of removal of Planned Parenthood from the Texas Women's Health Program.
      Although these data were observational and cannot prove causation, and additionally, were not broken down according to age, it is clear that low-income women of all ages had interruptions in their use of contraceptives, and that there was an increase in the rate of childbirth. These lessons from Texas have implications for the likely consequences of defunding PP nationally.
      A policy analysis from the Guttmacher Institute, first published online on April 6, 2017, highlighted how the Affordable Care Act (ACA) health insurance marketplaces have made sexual and reproductive health care accessible for millions of women, and that there would be serious consequences to removing these protections, especially for lower-income women of reproductive age (https://www.guttmacher.org/gpr/2017/04/how-dismantling-acas-marketplace-coverage-would-impact-sexual-and-reproductive-health). The ACA dramatically decreased (by more than one-third) the number and percentage of low- and middle-income women of reproductive age who were uninsured. In addition, the ACA mandated a set of 10 “essential health benefits,” including maternity care and preventive services such as contraception, Pap tests, human papillomavirus vaccination, counseling, and screening to prevent HIV and other STIs, and screening for intimate partner violence.
      Girls and young adult women growing up in the United States today deserve to have access to the reproductive health services they need to prevent unintended pregnancies, to be screened and treated for sexually transmitted diseases, to gain information about their sexuality, and to access other preventive health services such as screening for cervical cancer precursors. Title X funding through PP clinics is essential to providing accessible services. Because of the realities of the political climate in the United States today, I firmly believe that we must all work tirelessly to support healthy choices for the adolescents and young adult women we serve, and must loudly advocate for ongoing funding of programs that include comprehensive sexuality education that will support and empower girls to either remain abstinent or to choose effective contraceptive methods. In addition, all contraceptive choices must remain a viable and accessible option, especially long-acting reversible contraception methods. Reproductive services such as screening and managing STIs must also continue to be readily available, accessible, and affordable. Support for PP and Title X clinics must continue!

      References

        • Fowler C.I.
        • Gable J.
        • Wang J.
        • et al.
        Family Planning Annual Report: 2015 National Summary.
        RTI International, Research Triangle Park, NC2016
        • Frost J.J.
        U.S. Women's Use of Sexual and Reproductive Health Services: Trends, Sources of Care and Factors Associated with Use, 1995-2010.
        Guttmacher Institute, New York2013
        • Frost J.J.
        • Gold R.B.
        • Bucek A.
        Specialized family planning clinics in the United States: why women choose them and their role in meeting women's health care needs.
        Womens Health Issues. 2012; 22: e519
        • Finer L.B.
        Unintended pregnancy among U.S. adolescents: accounting for sexual activity.
        JAdolesc Health. 2010; 47: 312
        • Frost J.J.
        • Zolna M.R.
        • Frohwirth L.
        Contraceptive Needs and Services, 2010.
        Guttmacher Institute, New York2013
        • Stevenson A.J.
        • Flores-Vazquez I.M.
        • Allgeyer R.L.
        • et al.
        Effect of removal of Planned Parenthood from the Texas Women's Health Program.
        N Engl J Med. 2016; 374: 853