Proceedings of a Workshop—in Brief

Pressing Issues Around Contraception Access Following the Repeal of Roe v. Wade

Proceedings of a Workshop—in Brief

OVERVIEW

On February 20, 2024, the National Academies of Sciences, Engineering, and Medicine Standing Committee on Reproductive Health, Equity, and Society held a virtual public webinar to discuss issues around the accessibility of contraception since the 2022 Dobbs v. Jackson Women’s Health Organization U.S. Supreme Court decision, which overturned the 1972 Roe v. Wade ruling.¹ This workshop was the fifth in the After Roe webinar series organized by the Standing Committee.² The series is designed to consider society-wide effects of limits on access to reproductive health care and to elevate challenges and strategies to protect health and well-being.

A panel explored the changing landscape of contraceptive access, including issues around postabortion and adolescent contraception access, how changes affect reproductive health and health care, and practices and policies that could positively impact equity in contraception access.

This Proceedings of a Workshop—in Brief is a high-level summary of the topics and discussions that occurred during the workshop. It should not be viewed as providing consensus conclusions or recommendations of the National Academies.

OPENING REMARKS

Moderator Alina Salganicoff, KFF, opened by explaining that presentations during the webinar would highlight many of the pressing issues related to contraception access, with particular focus on the early effects related to the Dobbs decision. Salganicoff offered a reminder that contraceptive care is not a replacement for access to abortion care, explaining, “even if everyone who wanted contraception had access to the method of their choice, there would still be a need for abortion care” in the United States. She also noted that, even before Dobbs, “not all have had equal access to high-quality contraceptive care” and that the U.S. Supreme Court decision has put contraceptive care in the spotlight. Salganicoff discussed some of the barriers to accessing contraceptive care, including cost and access to high-quality care and information. She also explained that the Dobbs decision has influenced how clinicians provide care to their patients, noting research from KFF showing that 55 percent of obstetrician-gynecologists in states that have enacted abortion bans reported that Dobbs affected their ability to practice within the standard of care. Salganicoff emphasized the effect of misinformation and disinformation on patients’ ability to access high-quality infor-

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mation about contraceptive care, noting that although the pills are legal in all states many women reported not knowing if emergency contraception pills were legal in their own states. She presented KFF polling data showing that less than half of women living in states with abortion bans know emergency contraception is legal, with 7% incorrectly believing it is illegal, and 43% stating they are unsure.³ Addressing this kind of misinformation is increasingly important because misinformation is beginning to shape policies in some states, she said, and that the lack of evidence-based sex education across the United States is contributing to misinformation.

Salganicoff added that there are currently many opportunities to improve access to contraceptive care. Referring to the “rapid growth in telehealth or tele-contraception platforms,” she explained that people seeking contraceptives have many options even outside of traditional clinical settings and noted that the first oral contraceptive approved by the U.S. Food and Drug Administration for over-the-counter sales would soon be available at retailers.

CONTRACEPTION THROUGH A SEXUAL AND REPRODUCTIVE HEALTH EQUITY LENS AFTER ROE

Jamie Hart, Coalition to Expand Contraceptive Access (CECA), shared an overview of sexual and reproductive health equity priorities for expanding and protecting contraceptive care, as well as areas for action identified by CECA. The coalition, which began in 2019, works on ensuring contraceptive access as part of a broader vision to achieve sexual and reproductive health equity in the United States. Hart defined sexual and reproductive health equity as occurring when:

all people have access to the sexual and reproductive health care they need, free of bias and barriers, and that the government has a real responsibility for ensuring that people are treated fairly and justly.

Hart shared findings from the coalition’s work with expert stakeholders to understand the effect of the Dobbs decision on contraceptive access and to identify five focus areas that offer opportunities for action.

• CECA Focus Area 1: Secure and preserve the right to contraception. Hart explained the importance of ensuring a right to contraception as part of a broader right to reproductive freedom at the federal and state level. Hart said that a “coordinated and evidence-informed legal framework” is necessary to secure a right to contraception. She suggested establishing and enacting standards for evidence-based, comprehensive information about contraception in schools. She went on to note that improving enforcement of existing statutes and regulations, including the Affordable Care Act contraceptive coverage mandate and the Medicaid free choice provider requirement, provides another opportunity to bolster efforts to secure and preserve the right to contraception.
• CECA Focus Area 2: Combat misinformation and disinformation. Hart emphasized that, despite contraception remaining legal, health care organizations, providers, and patients may “fear criminalization often because of misinformation and disinformation and the complex rapidly evolving legal landscape.” To address this, Hart said that it is critical to “provide clear and accurate information about contraception.”
• CECA Focus Area 3: Improve and enhance infrastructure. Hart touched on the role of building workforce capacity to advance access to contraceptive care, explaining that clinicians are challenged by shifting demands, particularly in states that restrict access to abortion and contraception, and that improving guidance and resources provided to clinicians is essential. Hart added that “addressing [clinician] burnout and expanding the scope and capacity for advanced practice nurses, nurses, and allied health professionals” is another area for action.
• CECA Focus Area 4: Promote research and innovation. Hart emphasized that expanding access to contraceptive care demands leaning into opportunities for research and innovation. She explained that, because traditional approaches to contraceptive care do not always meet patient needs, advancing “novel approaches, research, and

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innovation in all aspects of contraceptive care” is essential.

• CECA Focus Area 5: Advance sexual and reproductive health equity. Hart said that supporting equity-informed research as well as reviewing and updating existing policies and programs are key to advancing sexual and reproductive health equity for all people. She discussed a framework for equity informed research that includes updating program and policy evaluations so that community stakeholders are embraced as experts, are appropriately compensated and valued, and are incorporated throughout the research process, and stated that those relationships should be ongoing. She also discussed expanding grant opportunities to clinics providing contraceptive care, updating clinical guidelines so that they are evidence-based and patient-centered, and developing new measures for contraceptive care and sexual and reproductive health care more broadly that are focused on “patients’ desires, not demographics.”

Hart closed by emphasizing that efforts to expand and protect contraception access in the United States should be grounded in sexual and reproductive health equity. She added that it is important to reject “language or actions that present contraception as a solution for limited abortion access” and to center those who are most adversely affected by the consequences of the Dobbs decision.

THE RISK OF CONTRACEPTIVE COERCION AFTER ROE

Kavita Shah Arora, University of North Carolina at Chapel Hill, examined contraceptive coercion, the effects of the Dobbs decision, and centering patient needs in contraceptive decision-making discussions. Arora began with a history of contraceptive coercion in the United States and emphasized that it is critical for clinicians to be aware of this history, noting that it “needs to be in the back of our minds, and really in the forefront, because it still is for our patients.” Arora referred to oral contraceptive pill trials in Puerto Rico carried out without informed consent and coercive sterilization performed on Black and Brown women referred to as “Mississippi appendectomies.” She noted that coercive sterilization is not limited to the past, noting that as recently as 2010, there have been reports of coercive sterilizations in the California penal system of 150, mostly Latina, inmates being sterilized without proper informed consent. Arora added another example of a Tennessee judge offering reduced times in prison for women who receive the Nexplanon implant and men who receive a vasectomy.

Clear cases of unethical practices, Arora said, are not the only examples of contraceptive coercion, which can also take subtle forms. Arora explained that many public health campaigns have promoted long-acting reversible contraception methods, for example. Although these forms of contraception have been lauded as first-line contraceptive methods by clinical organizations, nonprofit groups, and public health organizations, Arora noted that patients consider many factors when making decisions about contraception, not just efficacy or length of use or reversibility. She emphasized that there is no single best contraceptive method for everyone, and indicating otherwise can risk prioritizing public health goals—reducing unintended pregnancy rates—over patient needs and goals. This is especially true when such efforts are focused on specific sections of the population including groups that have been marginalized, Arora said, explaining that these initiatives can send messages about “who we, as a society, want to parent, and who we do not.”

Arora explained that it is essential to use individual-oriented approaches when conceptualizing and engaging in contraception decision-making and care. She offered the person-centered contraceptive care framework as a socioecological model that acknowledges the layers of influence behind a person’s health decisions and behaviors. At the core of this model is the individual and their private choices, including preferences related to efficacy or side effects. Next, there is the interpersonal level that involves recommendations from friends and family. Following that, there is the institutional level of health systems and the environment, which includes considerations such as costs associated with specific methods or insurance coverage. Finally, there is the structural level that includes broader policy and historical concerns that “serve as a backdrop for this entire framework given the multidimensional ways that racism, sexism, stigma, and bias impact” our health decisions.

Arora described the effects of the Dobbs decision on contraceptive coercion. She said that since the decision the problem of contraceptive coercion has been exacerbated as state abortion bans have come into effect. Arora noted that qualitative studies show this exacerbation has manifested bidirectionally with patient requests for contraception increasing and clinician colleagues around the country sharing that they are increasingly discussing contraception. She highlighted the gender inequities around these experiences noting that “people with the capacity to get pregnant have been bearing the brunt of this increased need rather than the people with the capacity to get others pregnant.” She also pointed out the increase in requests for permanent contraception procedures among males (vasectomies) and females (tubal ligations), however current evidence shows these rates returning to a baseline level. Arora said there are many reasons that contraception does not offer a solution to abortion restrictions; one is that even the most effective options “are still not perfect.”

In closing, Arora explained that clinicians must find the right balance to ensure patient needs are prioritized. She emphasized that practicing shared decision-making can help achieve this goal. This goal is not achieved when contraceptive counseling sessions begin based on assumptions about what is important to the patient, like assuming that efficacy is the primary concern and beginning by discussing those options. Shared decision making should be done in three phases, Arora said. The first is the “choice talk,” during which the clinician informs the patient about all options, including not using contraception; the second is the “options talk,” during which the clinician and patient review the “patient’s priorities for their own care;” and third is the “decision talk,” in which the clinician and patient “arrive at a decision jointly.”

POST-ABORTION CONTRACEPTION ACCESS

Cynthia Harper, University of California, San Francisco School of Medicine, discussed the implications of the Dobbs decision for post-abortion contraception. She described “key, ongoing challenges to accessing contraception in abortion care” as well as new hurdles that have emerged and promising paths forward.

Among these longstanding challenges are “specific policies to isolate abortion care from health insurance programs and contraceptive funding programs” that result in higher costs for patients. Harper said, funding for contraception and abortion care, such as through Medicaid, can affect the patient’s ability to initiate the contraceptive method they selected at the time of abortion care. There are other challenges beyond cost, including “strained clinic resources and clinic staff” or lack of “specific training for contraception care.” Staff trained in providing abortion care might not be trained in contraceptive counseling, Harper explained, and “contraceptive coercion can occur in these ‘hurry up’ contexts where patients do not have a chance to fully explore methods or their preferences.” Additionally, she noted that several studies show patients may prefer to obtain contraception outside of abortion care settings.

Harper also described some new challenges that have emerged since the Dobbs ruling. She said that travel for care has increased, meaning patients are not necessarily visiting their usual source of care or their usual source may have closed because of new restrictions in their home states. On the other hand, in states that protect access to abortion care, there are difficulties in scheduling and care delays at clinics because of increases in patients visiting the facilities, Harper noted, adding that counselors and clinicians are also facing burnout. Patients may not receive contraceptive care in the same clinic where they receive abortion care, she said. Particularly as patients “rely more on telemedicine abortion, mailed abortion pills, or advanced provision,” they may not receive contraceptive care at the time of abortion. Harper added that misinformation and confusion about new laws regarding care create additional challenges.

Harper next highlighted several promising changes that can help improve contraception access in abortion care settings. She said that clinicians can now offer a wider range of contraceptive methods to patients. Harper explained that there has historically been “hesitation about several methods, post-abortion”—particularly as related to medication abortions, which account for over half of abortions in the United States—but that there has been recent research to “show that most methods can be used right after medication abortion, including combined

oral contraceptives and etonogestrel implants.” There are also more options that preserve patient autonomy, she added, noting for example that “providers are starting to become familiar with self-administered Depo-Provera,” which allows patients to get refills from a pharmacy instead of returning to a clinic. Harper said that there is “room to grow” in this area because roughly 70 percent of practices do not give patients this option, which ties into the opportunity to continue increasing access points for patients.

Harper referenced a survey⁴ that found that “three-quarters of people wanted to obtain contraception from several sources,” meaning that it is critical to take such actions as connecting patients with online pharmacies, ensuring that they are aware of over-the-counter contraception methods, and providing multiple refills. Harper touched on the need to train providers on telemedicine skills and inform patients about the option to obtain contraception through telemedicine. She noted that her team released the Protocol for the Provision of Contraceptive Services via Telehealth⁵ that includes a section on telehealth tips for post-abortion contraceptive care. She added that many patients do not want contraceptive counseling at the time of abortion care and “telehealth can be used to have discussions beforehand or after.”

Further exploring the issue of provider training, Harper shared initial findings from a contraceptive pilot program for abortion patients that her team is implementing with the Southwest Contraception Access Network. The pilot program is reaching patients in several states that have protected abortion access and serves patients who travel to the states for care. Harper said that the contraceptive counseling training given to clinic staff covers all contraception methods and focuses on “addressing biases and care and misinformation and coercion.” The program is also “partnering with abortion funds to provide free access to contraception” and with online pharmacies, she explained. Harper explained that training for clinic staff helps increase patient access to a wider range of contraception methods. She emphasized that it is imperative to train “a broader set of health providers” in contraceptive care, including primary care, Federally Qualified Health Centers, school health, and emergency medicine departments. Part of comprehensive training includes teaching providers how to combat misinformation and confusion, she noted. Harper said that her training team has trained more than 13,000 providers to date, who are then “reaching 8 million patients each year.”

Harper closed by emphasizing the importance of high-quality resources to inform patients and the need to scale interventions. She noted her team’s work with Power to Decide⁶ to launch a contraception information source that goes beyond the standard effectiveness chart and delves into multiple factors patients have in mind when choosing contraceptive methods. Harper said scaling efforts to “increase reproductive autonomy with interventions that leverage partnerships and engage communities” should be a priority.

ADOLESCENT CONTRACEPTION ACCESS

Kami Geoffray, Geoffray Strategies, LLC, shed light on concerns about contraception access specific to the adolescent population, particularly in Texas, and some steps that can expand access. Geoffray began by providing an overview of barriers adolescents face in accessing contraception. Confidentiality is among the most significant barriers to contraceptive care reported by adolescents, she said, noting that “about one in five teens would not seek reproductive health care if there were a risk of their parents finding out.” Geoffray explained that minor consent laws vary across states and “only 25 states and the District of Columbia explicitly allow minors to consent to contraceptive care services.” Availability of confidential contraceptive services for adolescents has decreased since 2019. Geoffray noted that “1.8 million youth, age 15 to 17, lost access to confidential family planning care” because of clinic closures following a rule change to the Title X Family Planning Program⁷ prohibiting Title X-funded clinics from discussing abortion with patients. She added that misinformation and disinformation are important factors to consider, explaining that adolescents “increasingly turn to social media platforms like TikTok to gain

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information about reproductive health and contraception care, and they are very often met with incorrect health information.”

Geoffray turned to recent events in Texas, adding that the state has taken steps to “restrict access to the full range of sexual and reproductive health care” for many years. She described the 2020 lawsuit Deanda v. Becerra,⁸ which challenged the “administration of Title X and its longstanding requirement that services be provided confidentially, including to minors, without parental consent or notification.” Geoffray explained that the plaintiff in this case objected to a Title X-funded clinic “marketing family planning services to minors.” The lawsuit “asked the court to declare that Texas state law granting parents the right to consent to their children’s medical care, applies to all Title X grantees” in the state, she said. The judge ruled in the plaintiff’s favor and, since 2022, Geoffray said that minors seeking contraceptive care in Title X-funded clinics must have parental consent as a result of the judgment.

Although the full effects of this ruling are not yet known, she noted that Title X grantees in the state are compiling data that will illustrate the effect of Deanda v. Becerra decision on contraceptive care for minors in Texas. Geoffray noted that this decision significantly limits access for minors, adding that, although Title X providers “have always encouraged family participation, the reality is that not all adolescents feel safe engaging their parents in these conversations.” Geoffray shared that the University of Houston has released its analysis of CDC data⁹ showing that Texas’s teen birth rate modestly increased in 2022—a reversal of a 15-year trend of declining teen birth rates in the state.

There are multiple ways to expand access to contraceptive care among adolescents, Geoffray said. She remarked on the importance of supporting “legislative efforts to establish the right to contraception” and the critical need to ensure that young people are not left out of such legislation, emphasizing that adolescents should “receive the same access as everyone else.” Geoffray noted that at the national level members of Congress have introduced a Right to Contraception Act,¹⁰ which would “protect both people who are seeking to use birth control and providers who are offering birth control services.” At the state level, several ballot initiatives have been introduced around the right to abortion, contraception, and reproductive health more generally. In discussing opposing legislation to restrict access to contraception for adolescents, she added that there is potential for the effects of the Deanda v. Becerra ruling to spread beyond Texas, saying “We should expect to see restrictive states seeking to limit access for adolescents, including by requiring parental consent or notification for contraceptive care.” Geoffray stated that “sexual health education in this country is dire,” noting recent data from the Sexuality Information and Education Council of the United States (SIECUS) of an 800 percent increase in antisex education bills in 2023 compared to 2022 and more than 100 regressive bills introduced across 31 states, and 9 bills passed in 8 states last year. She noted that the data also shows a 20 percent increase in positive sex education bills during the 2023 legislative cycle. Geoffray closed by emphasizing that it is critical to ensure that efforts to expand and protect access to over-the-counter contraception include access for adolescents.

DISCUSSION

To close the webinar, speakers responded to questions posed by the moderator and audience.

Speakers were asked if there are changes in policy and practice that could be addressed immediately. Geoffray said that ensuring providers understand what the laws are in their states around adolescent access is one such opportunity. She said noted that there are “a lot of providers who are not well versed in contraceptive counseling for adolescents,” adding that training is available to help providers feel more comfortable to have these conversations with young people. Arora said that there are changes individuals can make to prevent subtle forms of contraceptive coercion. She said these changes could include addressing word choice, for example public health advocates discussing “one best type of contraception” or, in clinical settings, evaluating tier-based charts

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that suggest “there is a hierarchy of what type of contraception is preferred or not preferred.”

Hart highlighted that updating the federal sterilization—or permanent contraception—consent form and policy is one opportunity, explaining that this policy has not been updated since the 1970s. Hart added that organizations can take steps to ground their work in sexual and reproductive health equity by doing such things as ensuring it is integrated into grant applications, guidance, and evaluation criteria, and by addressing it when designing programs and policies. Harper emphasized training opportunities for providers, noting that “provider training can be low cost with high impact,” including in states where there are restrictions on contraceptive access and abortion care.

Arora was asked to discuss the role that ableism plays in both sterilization practices and opinions about the value of abortion. She stated that historically people who have been forcibly sterilized in the United States have often been Black and Brown women in underresourced communities and people with mental health conditions and disabilities. Arora emphasized that this history continues to influence attitudes about “whose reproductive goals we value and whose we don’t,” adding that such factors as state laws with “various consent requirements in place, depending on decision-making capacity guardianship, and so on” can contribute to ongoing contraceptive coercion.

Speakers were asked to share their thoughts on actions that can be taken to keep oral contraceptives affordable or low cost. Hart stated that ACA guidance needs to be expanded to include over the counter contraception coverage along with “greater clarity from the Department of Health and Human Services, Department of Labor, and the Department of Treasury and a proposed rule to make this happen.” Geoffray noted that without more federal guidance there may be greater limits to oral contraception access for groups such as adolescents and immigrant populations, among others in restrictive states.

Speakers closed the meeting with their insights on existing research gaps. Harper said that more information is needed around avenues for care outside of clinical settings, noting that it is a “very fruitful area to find out how we can be most strategic and make the most headway” and to find out how to best reach people. Hart reelevated the issue of misinformation and disinformation that speakers discussed in their individual remarks. She stated there is growing evidence around the extent, nature, source, and impact of misinformation and disinformation and that strategies should be informed by these findings to effectively address and combat these issues. Arora explained that gaps exist in understanding and assessing what high-quality contraceptive care looks like. She noted that there are some mechanisms for assessing contraceptive coercion, but they do not cover the various settings or all of the methods of contraception and there is not a way to “easily implement this at a population level to know whether we are actually doing high-quality level contraceptive care across a population.” Geoffray said that research focusing on adolescents has always been lagging behind, adding that she is concerned that states opting out of reporting information about adolescents exacerbates this problem.

DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by Jamie Durana as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

COMMITTEE MEMBERS Claire Brindis (Chair), University of California, San Francisco; Andreia Alexander, Indiana University School of Medicine; Elizabeth Ananat, Barnard College, Columbia University and National Bureau of Economic Research; Wanda Barfield (ex officio member), Centers for Disease Control and Prevention; Bruce N. Calonge, Colorado School of Public Health; Alison N. Cernich (ex officio member), Eunice Kennedy Shriver National Institute of Child Health and Human Development; Judy Chang, University of Pittsburgh School of Medicine; Ellen Wright Clayton, Vanderbilt University; Cat Dymond, Atlanta Birth Center; Michelle Bratcher Goodwin, Georgetown University Law Center; Barbara J. Grosz, Harvard University; Vincent Guilamo-Ramos, Johns Hopkins School of Nursing; Lisa Harris, University of Michigan; Justin R. Lappen, Cleveland Clinic and Case Western Reserve University School of Medicine; Monica McLemore, University of Washington School of Nursing and School of Public Health; Rebecca R. Richards-Kortum, Rice University; Sara Rosenbaum, George Washington University; Yvette Roubideaux, Colorado School of Public Health; Alina Salganicoff, KFF; Susan C. Scrimshaw, University of Illinois at Chicago; LeKara Simmons, AMAZE; Melissa Simon, Northwestern University; Lisa Simpson, AcademyHealth; Tracy A. Weitz, American University and Center for American Progress; Katherine L. Wisner, Northwestern University Feinberg School of Medicine.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Tashuna Albritton, The City College of New York, and Ronna Popkin, Eunice Kennedy Shriver National Institute of Child Health and Human Development. Leslie Sim, National Academies of Sciences, Engineering, and Medicine served as the review coordinator.

SPONSOR This workshop was supported by the National Academy of Sciences W.K. Kellogg Foundation Fund.

STAFF Julie Pavlin, Senior Board Director; Ashley Bear, Board Director; Natacha Blain, Senior Board Director; Priyanka Nalamada, Program Officer; Laura DeStefano, Director of Strategic Communications & Engagement; Melissa Laitner, Senior Program Officer, Special Assistant to the President; Adaeze Okoroajuzie, Senior Program Assistant; Kavita Shah Arora, Consultant.

For additional information regarding the workshop, visit http://www.nationalacademies.org/our-work/standing-committee-on-reproductive-health-equity-and-society. For information regarding other workshops in this series, visit https://www.nationalacademies.org/our-work/after-roe-a-webinar-series.

SUGGESTED CITATION National Academies of Sciences, Engineering, and Medicine. 2024. Pressing issues around contraception access following the repeal of Roe v. Wade: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/27795.

Health and Medicine Division Division of Behavioral and Social Sciences and Education National Academy of Medicine Policy and Global Affairs Copyright 2024 by the National Academy of Sciences. All rights reserved.