Bridging the Divide
A persistent gap exists between the women’s health research and policy advocacy communities. The two communities are united by their commitment to women’s health but divided by their different methods and language and by the lack of a connector that facilitates translation and communication between the two in a timely manner. The Jacobs Institute’s Bridging the Divide team seeks to serve as a connecting entity and link between the two groups.
The goal of the project is to engage the health research community and policy and advocacy networks in two-way communication. To accomplish this, Bridging the Divide is conducting a series of activities on timely women’s and reproductive health topics. Activities have addressed:
- Medication abortion
- Long-acting reversible contraception
- Pregnant women and substance use
- State-level abortion restrictions
A two-page summary of the project is available here
Medication abortion (also called medical abortion) is a safe method of abortion available for the past 15 years in the US. The Bridging the Divide white paper summarizes the scientific evidence related to the current medication abortion process and potential changes to the process that could make it even safer and more accessible for patients, as well as policy considerations and directions for future research.
In the fall of 2000, the US Food & Drug Administration (FDA) approved the drug Mifeprex© (generic: mifepristone) for use in medication abortions. That approval included requirements that affect both patients and providers and that are far more specific than typical requirements for prescription drugs. The package insert (also known as the product label) indicated procedures for mifepristone prescribers to follow, based on the regimen used during the drug’s pre-approval clinical trials. FDA has not approved any other abortion drugs besides Mifeprex.
Fifteen years later, in March 2016, the FDA approved an updated label for Mifeprex, marking an important step forward for access to abortion care and for evidence-based policy. Although the new label is progress toward policy that is informed and driven by scientific research, the change came many years after research data had demonstrated the safety and efficacy of widely used evidence-based protocols. In the intervening years, some states took advantage of the outdated requirements in the product label and implemented restrictive policy measures that prevented their residents from accessing care based on the latest evidence and best practice.
The Bridging the Divide white paper on the current state of medication abortion evidence and policy can be found below, along with a shorter summary document for policy-makers and a recently published commentary from the journal Women’s Health Issues.
Medication Abortion: Overview of Research & Policy in the United States
Medication Abortion: Overview of Research & Policy in the United States - Key Points for Policymakers
Medication Abortion References by Topic
Commentary: For Medication Abortion, Science Should Guide Policy
Long-acting reversible contraceptive (LARC) methods – specifically, intrauterine devices (IUDs) and subcutaneous hormone-releasing implants – demonstrate great potential in reducing unintended pregnancy. Although LARC methods have had a rocky history in the US and use rates have remained low here in comparison to other countries where the methods are available, there has been a significant increase in uptake of newer LARC products in recent years. Researchers have identified this change as a likely contributor to the declines seen in unintended pregnancy, abortion, and teen pregnancy rates.
Decades of research have shown that current LARC methods are highly safe and effective, yet research has identified many barriers that may prevent a woman who chooses a LARC as the contraceptive method that best meets her needs and preferences from getting it. These include inadequate provider knowledge and training, lack of awareness and education among potential users, and financial and health system barriers. There are also, however, encouraging research findings from assessments of interventions designed to reduce these barriers.
Despite the recent advances, some barriers to full, voluntary, and successful use of LARC methods remain but have the potential to be addressed through policy: implementation of insurance coverage for LARC insertion and removal, both under private plans and public programs, such as Medicaid; development of clinical performance measures for clinicians and/or health centers; and establishment of practices that ensure confidentiality and non-coercive provision of LARC methods, particularly for vulnerable populations.
The Bridging the Divide white paper on the current state of LARC evidence and policy can be found below:
Current Research and Policy on Long-Acting Reversible Contraception (LARC): Key Points for Policymakers
Long-Acting Reversible Contraception: Summary Tables
History of Long-Acting Reversible Contraception (LARC) in the United States
Long-Acting Reversible Contraception (LARC): State-Level and Regional Research on Reducing Barriers to Access
Most U.S. states have tried to prosecute pregnant women for exposing their fetuses to drugs, although some have gone further than others in focusing on prosecutions instead of on prevention and treatment. In Alabama, as a result of state court rulings, drug use while pregnant is treated as chemical endangerment of a child, and in South Carolina the courts have determined that the word “child” in its criminal laws includes viable fetuses, making every law using that term, including the state’s child endangerment law and its homicide by child abuse laws, applicable to pregnant women. Other states consider certain drug use during pregnancy to be grounds for civil commitment, and may involuntarily detain women in inpatient treatment programs. Several states require healthcare providers to report suspected prenatal drug use. When such reporting results in children being removed from their mothers and placed in foster care, both mothers and children can suffer.
Knowing of such potential consequence can discourage pregnant or parenting women from disclosing drug use to providers; research has found that some women delay or forego prenatal care in order to avoid having drug use discovered. When women receive less prenatal care or fear speaking openly with their providers, they can miss out on opportunities for receiving advice or care that could improve their health and that of their infants. Punitive policies for substance use during pregnancy also tend to have a disproportionate impact on low-income women and women of color, and thereby exacerbate existing health disparities.
In contrast to punitive measures, a public health approach to substance use emphasizes harm reduction and treatment. It recognizes that, while substance use may have negative consequences, imposing legal punishments on people with substance use disorders often leads to worse outcomes. A public health approach emphasizes access to complete information and appropriate services to help women and their children live healthy lives.
Reducing substance use can often benefit women’s long-term health as well as the health of their infants, and pregnant women are often highly motivated to stop using substances. However, pregnant women who need assistance to stop or reduce their substance use often find it hard to access treatment. In 2014, only 20% of treatment facilities offered programs for pregnant or postpartum women. A minority of facilities offer childcare and other services that make treatment more feasible for parenting women.
Public Health Impacts of State-Level Abortion Restrictions
In the United States, abortion is extensively regulated and has been extensively studied. A first-trimester abortion is one of the safest medical procedures, and carrying a pregnancy to term involves far greater risks of serious complications and death than abortion does. However, the recent wave of regulations reducing access to abortion care is not based on compelling evidence that these additional limitations will improve public health. In fact, a growing body of research documents the ways in which public health suffers when laws reduce abortion access.
This paper reviews several types of restrictions that affect abortion access and summarizes recently published scientific evidence on the public health impacts of state-level abortion restrictions not rooted in science. These include restrictions on insurance coverage, gestational limits, waiting periods, state-mandated information, restrictions on medication abortion, and requirements on abortion facilities and providers that are far more burdensome than necessary to ensure patient safety.
In many states, women seeking abortions encounter multiple barriers simultaneously. As new laws lead to clinic closures and require multiple clinic visits 24-72 hours apart, women face difficulties securing appointments and traveling to facilities far from their homes. As travel and procedure costs rise but laws prohibit insurers from covering abortions, women with lower incomes are particularly affected. Delays can result in women having later abortions than they desired, and in some cases prevent them from receiving desired abortions at all.
The 2016 Supreme Court decision in Whole Women's Health v. Hellerstedt, which struck down two provisions of a Texas law that led to clinic closures, emphasized the importance of evidence in evaluating whether abortion restrictions place an "undue burden" on those seeking the procedure. This paper reviews the high-quality research that provides such evidence, and may be useful to those considering policy changes that will affect abortion services.