On June 24, the Supreme Court upheld Mississippi’s fifteen-week abortion ban and overturned nearly half a century of legal precedent of the federal right to abortion. By overturning Roe v. Wade, the Dobbs v. Jackson Women’s Health Organization decision gives states the power to determine the legality—and potential criminalization—of people providing and seeking abortions.
People living in rural areas struggle to access reproductive health care due to a lack of providers, long travel distances, and high health care costs. In the last ten years, conservative lawmakers and anti-abortion activists have attacked contraception—specifically long-acting methods of contraception (LARCs)—as part of their agenda to restrict reproductive autonomy, despite recent claims by some that access to contraception and family planning are part of their “pro-life” agenda post-Roe. Due to the popularity of contraception, these attacks have been widely unsuccessful. However, some lawmakers have indicated that they plan to double down on their efforts now that Roe has been overturned. Limiting access to highly effective methods of contraception will disproportionately affect rural Americans, who already struggle to access comprehensive reproductive health care.
People Living in Rural Areas Face Worse Reproductive Health Outcomes
People living in rural communities often face worse reproductive health outcomes because they are more likely to experience poor health outcomes, less education, lower-paying jobs, and lower rates of being insured. These outcomes are the consequences of structural barriers which impede access to wealth and resources. Due to hospital closures and physician shortages, people living in rural areas are expected to drive long distances to access health care. This is not feasible for all people, because not everyone has access to a car nor are they able to take off from work. The ongoing COVID-19 pandemic has only made matters worse. Beyond these factors, rural communities are experiencing a dearth in obstetric-gynecologic services. A 2008 study found that only 6.4 percent of obstetric-gynecologists practice in rural areas. With limited access to obstetricians (OB/GYNs), many people living in rural areas report relying on their primary care providers for family planning services. Unfortunately, the number of physicians trained in obstetrics is also in decline. People living in rural areas face another complication in receiving reproductive health care: many rural OB/GYNs and physicians are not trained in intrauterine device (IUD) or implant placement.
Rural communities have less access to reproductive health care, and thus they stand to benefit the most from these services. Teenagers living in rural areas are more likely to experience pregnancy, and they are more likely to start having sex at a younger age than people living in urban areas. Yet, rural teenagers are less likely to have access to comprehensive sex education, family planning resources, and abortion and maternity care. A lack of access to resources and support will undoubtedly result in adverse health outcomes. Evidence suggests women and pregnant people in rural areas face low birth weight, preterm births, and infant and maternal mortality at higher rates than people living in urban areas.
Women of color living in rural areas experience negative health outcomes two-fold, because they also face systemic racism and implicit bias from health care providers. In the United States, Black women are three to four times more likely to die from pregnancy-related causes than white women. The cause of this disparity can be attributed to racism and not race. Black women are also more likely to seek an abortion and they are more likely to live in contraception deserts. Ultimately, the Black maternal health crisis is a rural health crisis: 83.3 percent of people of color live outside of urban communities.
The Emergence of LARCs in Rural Reproductive Health
In recent years, researchers have supported the use of long-acting reversible contraceptive methods (LARCs) as a way to decrease the total number of unintended pregnancies in rural areas. LARCs can be an attractive option for people living in rural communities because the long-acting nature of these methods decreases the need to take multiple trips to the doctor or pharmacy. After efforts to improve access, people in rural areas are more likely to use LARCs than people living in urban areas. However, it is important to recognize that despite their relative safety and efficacy, some people will choose to forgo these highly effective methods of birth control. They are not necessarily wrong to do so: birth control is not a “one size fits all” type of medical provision. Many people have expressed concerns about IUDs or implants because they are unable to remove their birth control device at will. When discussing birth control options, physicians should adopt a patient-centered approach, meaning engaging with their patients in a collaborative process to create a health plan best suited for the patient’s needs. Increasing access to LARCs is helpful, but it cannot be the only solution to improve rural reproductive health outcomes. More importantly, people should have access to all birth control methods, and they should not feel pressured to pick any one method.
In 2001, less than 1 percent of people living in rural areas relied on LARCs to protect against pregnancy. A lack of training and education also results in providers holding misconceptions about LARCs. One study found that physicians not trained in IUD placement were more likely to not tell their patients about IUDs and others reported feeling hesitant. Some physicians have gone as far as to spread misinformation about IUDs, stating that LARCs are associated with higher rates of STIs and can affect fertility. Both of these claims are unfounded.
Women of color living in rural areas experience negative health outcomes two-fold, because they also face systemic racism and implicit bias from health care providers.
Contraceptive choices are also shaped by systemic racism, discrimination, and socioeconomic factors. The United States has a long, painful history of subjecting Black and Brown women to coercive contraceptive practices and sterilization. Generational trauma and structural barriers can have lasting effects on a community’s health behaviors. For example, evidence suggests that Black women are less likely to use contraception than other races or ethnicities. Rural America is an extremely heterogeneous population with different backgrounds and experiences; again, it is important that providers take their patients’ experiences and concerns into consideration when engaging in conversations about contraception.
The Dobbs Decision Has Implications for Contraceptive Access
The recent Supreme Court decision on abortion will have far-reaching implications that touch upon all aspects of reproductive health care, and beyond. The Dobbs decision is a dangerous attack on bodily autonomy, but it is important to recognize that many people in this country were already essentially living in a post-Roe world. In 2017, people living in rural Montana, Texas, Wyoming, North Dakota, South Dakota, Nebraska, and Kansas had to travel more than 180 miles to access abortion care. States that have enacted abortion bans worked to chip away at abortion access for years by instituting targeted regulation of abortion providers (TRAP) laws and other medically unnecessary restrictions. TRAP laws are designed to shut down abortion clinics by implementing medically unecessary standards. The high cost of abortion care, which sits at an average of $500 per procedure, also disproportionately burdens people living in rural areas because they are more likely to be low-income, uninsured, and enrolled in Medicaid. Federal restrictions prohibit insurance coverage of abortion through publicly funded health programs, but sixteen states currently use state funds to cover abortion though Medicaid. Medicaid enrollees from the remaining thirty-four states have to pay for abortion care out-of-pocket, except in the limited cases of rape, threat to the life of the pregnant person, and incest. Although the Dobbs decision will make it harder for people to access abortion, many people were already living without access.
The Dobbs decision has caused significant concern among reproductive rights advocates who believe that contraception may be the next right to go. In his concurring opinion, Justice Clarence Thomas writes that the court should review the decisions made in Lawrence v. Texas, Obergefell v. Hodges, and Griswold v. Connecticut. The Griswold case legalized contraception for married couples in 1965, and in 1972, the court legalized contraception for all people regardless of marital status. Although no other justices signed onto Justice Thomas’s opinion, there is enough evidence to suggest that contraception will be the next big fight over reproductive autonomy.
In March, Senator Marsha Blackburn (R-TN) received criticism on twitter after she called the Griswold decision “constitutionally unsound.” In Missouri, anti-abortion lawmakers introduced a bill that banned Medicaid funds from being used to pay for IUDs and emergency contraception. Fortunately, this bill did not pass; but Missouri lawmakers have indicated that they plan to re-up their efforts now that Roe has been overturned. Again, this law will disproportionately affect people living in rural areas, because they are more likely to be enrolled in Medicaid and they are more likely to use LARCs such as IUDs.
It is important that providers take their patients’ experiences and concerns into consideration when engaging in conversations about contraception.
Anti-abortion advocates are also circulating false information about IUDs and emergency contraception. They are calling IUDs “abortifacients” and saying that emergency contraception (EC) is a chemically induced abortion. Both statements are scientifically inaccurate. Emergency contraception is a form of birth control that delays or prevents ovulation. It does not end pregnancy but like all other methods of contraception, it does prevent pregnancy. Access to emergency contraception is already scarce in states like Arkansas, Georgia, Mississippi, and South Dakota, where pharmacies can deny EC based on moral or religious objections. Additionally, there is no evidence that supports the claim that IUDs end pregnancies. By labeling these drugs as life-ending drugs, lawmakers and activists are able to expand their attack on reproductive freedoms to contraception.
What Can States and the Federal Government Do?
Rural reproductive health outcomes will only worsen if states and the federal government do not act to protect the right to contraception. Contraception is not a replacement for abortion care, but it is an integral part of reproductive health care as a whole. Improving reproductive health outcomes also means addressing issues of systemic racism and structural barriers that affect access and quality of care. The following proposals are just some of the actions that should be taken to improve contraceptive access and reproductive health care in rural communities.
- Congress needs to pass a law that codifies the right to contraception.
- Congress should pass the Affordability is Access Act. This bill protects the ACA birth control mandate and provides coverage for birth control without cost-sharing.
- Congress should pass Senator Joe Manchin (D-WV)’s Protecting Rural Health Telehealth Access Act. This bill would protect and expand telehealth services created during the COVID-19 pandemic.
- States need to institute programs that provide financial incentives for physicians and OB/GYNs to practice in rural areas.
- States should bolster their telemedicine technologies and data infrastructure by applying for grants through CMS or HHS.
Rural reproductive health outcomes will not improve if reproductive rights are under attack. Contraception is an essential element of health care and it needs to be protected.