Rural America is not just a location; it’s a lifestyle. However, part of what makes rural living charming is also what makes it difficult—miles of land inhabited by few people. This can mean rural residents are hundreds of miles away from their nearest neighbor and even farther from the nearest doctor or healthcare facility. It is easy to see how this is problematic for emergency medical care, but it also complicates receiving even basic healthcare, such as contraception.
In areas where access to healthcare providers is limited, some local health departments do provide contraception and reproductive health services to their communities and these are generally used by many young, uninsured or low-income women. And, since there is usually a health department located in each county, this is often the closest contraceptive provider for under-resourced women in rural areas. Unfortunately, however, their offerings are often severely limited and thus a recent study conducted in four, largely rural Midwestern states attempted to show the extent of women’s contraceptive options in rural areas in particular.
In undertaking their study, Satterwhite et al. gathered data from 237 of the 339 eligible local health departments in Iowa, Kansas, Missouri and Nebraska to determine the availability of contraceptive options, sexual health care, availability and training of clinicians, and the utilization of services. Excepting Nebraska, each of these states has a local health department that serves one county and about three-quarters of these are classified as rural. (In Nebraska, local health departments serve 1 or 2 counties in a region.) The results found that each health department provided care for an average of 2,000 women per year— about a third of whom were uninsured. And thus, particularly in these rural regions where the population density is less than 40 people per square mile, local health departments are an integral component of the healthcare network.
And given that these providers are often the most convenient location to receive reproductive care for rural women, it is concerning that only one-third of local health departments provide at least one short-acting birth control method (e.g. oral contraceptive pills, injections, rings or patches). In Iowa, only about 5 percent of local health departments offer any contraception at all.
Among those that do provide contraceptives, nearly all facilities provided oral contraceptive pills and birth control injections. However, women seeking other forms of birth control, including intrauterine devices (IUD) and subdermal implants (collectively known as long-acting reversible contraceptives or LARCs), could access these options in no more than 17 percent of local health departments, with many of these found in less than 10 percent of offices. Notably (and perhaps not surprisingly), urban local health departments were more likely to provide a broad range of contraceptive methods than their rural counterparts, which illustrates the extent to which restricted access to comprehensive family planning services affects rural populations disproportionately. This is particularly problematic because contraceptives are not one-size fits all, and thus the availability of multiple options is vital to ensure safe and continuous use.
The study also found that health departments that receive Title X funds are more likely to provide multiple contraceptive options than those that do not. Such funds are reserved for providers that offer low-income, uninsured and underserved populations comprehensive family planning and associated preventative services, and all clinics must meet applicable standards and comply with specific rules. In this analysis, Title X health departments offered short-term hormonal contraceptives as a family planning service at about six times the rate of those that did not receive Title X funds. This difference only increases when comparing LARC offerings; about a quarter of Title X local health departments provide IUDs and/or implants, while less than two percent of non-Title X health departments do.
The availability of LARCs in rural communities may have additional importance because they eliminate the need to fill prescriptions monthly or visit a physician annually for prescription reauthorization. Ensuring that these options are available to rural populations therefore helps minimize some of the geographic barriers to care, which may be one reason why rural women are significantly more likely to use LARCs or sterilization as birth control than urban women.
Ultimately then, Satterwhite et al. demonstrates that rural health departments are an important provider of contraception and that Title X funds make it feasible to offer multiple forms of contraception by providing funding for expanded contraceptive inventory and properly trained medical staff. And, in fact, staffing is also a clear challenge for local health departments since, according to the study’s findings, only 13 percent of them staffed a physician at least one day per month and only a third had advanced practice clinicians available. Since most contraceptive methods require a trained physician or advanced practice clinician to write the prescription and/or implant the device, this is another area where Title X funds can help increase the number of family planning services available at health departments. Moreover, the authors note that studies of Federally Qualified Health Centers found that they face similar challenges in inventory costs and staffing, and Title X recipients offer more family planning options than non-recipients.
Indeed, one of the most notable features of Satterwhite et al.’s study is the commentary it offers about the potential impact of changes to Title X. Until 2019, Title X clinics were required to offer “a broad range of acceptable and effective medically approved family planning methods” (§ 59.5). However, the revised rules remove the words “medically approved” and state that sites can offer “only a single method [. . .] as long as the entire project offers a broad range of such family planning methods and services” (§ 59.5). In addition to the other modifications, these changes may drastically alter the landscape of Title X providers. If nothing else, by relaxing the requirements relating to type and variety of contraceptive options offered, established clinics may lose a portion of their funding to clinics that offer fewer and less-effective methods of family planning (e.g. fertility awareness or withdrawal). In fact, the authors themselves note that their findings suggest local health departments in this region “are not prepared to absorb the resulting contraceptive access gap” from the Title X changes.
Accordingly, the study demonstrates the need to focus on expanding access to contraceptive options in rural America, particularly for under-resourced residents. Although the topic is frequently debated, it is commonly forgotten that access to reproductive healthcare is directly related to maternal and infant health outcomes. Access to contraceptives decreases the unintended and teen pregnancy rates, improves infant and maternal morbidity and decreases the risk of some forms of gynecological cancer, all of which, in turn, decrease public healthcare expenses. Satterwhite et al. therefore serves as a reminder that it is imperative to use all possible service providers to ensure accessibility to the full range of contraceptive options if we are to resolve rural health disparities.