Improving the Role of Health Departments in Activities Related to Abortion

Abstract
Abundant evidence demonstrates that abortion in the U.S. legal context is common and safe and does not have long-term negative effects on physical or mental health. Yet considerable barriers to abortion care exist, and these barriers can result in adverse health consequences. Some barriers are caused by state-level abortion policies that are not based on scientific evidence and restrict the availability or provision of abortion. Many health departments are tasked with implementing and enforcing policies that are inconsistent with public health values and, as a result, may be harming — rather than improving — the health of pregnant people and their families. Research shows that implementing and enforcing legally mandated policies account for the bulk of health department activities related to abortion. Few departments engage in activities that facilitate people’s ability to obtain abortion care in their communities, even though health departments play a critical role in the provision of other sexual and reproductive health services. This policy statement argues that health department activities related to abortion should be consistent with public health values and frameworks. Because abortion is politically controversial, health departments need encouragement and support to guide their activities related to abortion. Policy change, funding, workforce development, and knowledge transfer activities can support health departments in making this shift. APHA should support these strategies and advocate for health departments to base their activities related to abortion in public health values and frameworks.

Relationship to Existing APHA Policy Statements

• APHA Policy Statement 20083: Need for State Legislation Protecting and Enhancing Women’s Ability to Obtain Safe, Legal Abortion Services Without Delay or Government Interference
• APHA Policy Statement 20103: Protecting Abortion Coverage in Health Reform
• APHA Policy Statement 20112: Provision of Abortion Care by Advanced Practice Nurses and Physician Assistants
• APHA Policy Statement 20113: Regulating Disclosure of Services and Sponsorship of Crisis Pregnancy Centers
• APHA Policy Statement 20115: Ensuring Minors’ Access to Confidential Abortion Services
• APHA Policy Statement 20151: Opposition to Requirements for Hospital Admitting Privileges and Transfer Agreements for Abortion Providers
• APHA Policy Statement 20152: Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, and Demands Public Health Intervention
• APHA Policy Statement 20153: Universal Access to Contraception 
• APHA Policy Statement 20199: Preventing and Reducing the Harm of the Protecting Life in Global Health Assistance Policy in Global Public Health
• APHA Policy Statement 20201: Recommendations for Pregnancy Counseling and Abortion Referral

Problem Statement
Abortion and public health: Since 2011, states have enacted more than 500 laws restricting abortion services.[1] These laws are often enacted with the stated goal of protecting the health and safety of pregnant people, although there is no evidence they do so.[2] Instead, these laws contribute to closure of abortion clinics, increases in wait times and travel distances for abortions, and, in some cases, reductions in numbers of people able to obtain abortions.[3] A robust body of evidence has shown that being unable to obtain a wanted abortion has adverse consequences for the health and well-being of women, children, and families. Specifically, the Turnaway Study, a longitudinal investigation of the impact of receiving versus being denied a wanted abortion, indicates that women unable to obtain abortions have worse physical health outcomes, experience more violence from the man involved in the pregnancy, and face more economic insecurity subsequent to the abortion than women who obtain abortions.[4–7]

Abortion is a critical component of comprehensive reproductive health care and is essential to ensuring the health and well-being of pregnant people and their families. Safe, legal, and accessible abortion is key to reproductive autonomy and fundamental to human rights. Yet, abortion is not available to many people in the United States. Nearly 90% of counties do not have a facility that provides abortions.[8] In the case of residents of 27 major U.S. cities—so-called “abortion deserts”—the closest abortion provider is more than 100 miles away.[9] A reduced number of abortion clinics, coupled with onerous, restrictive abortion policies, may result in increased logistical and financial burdens on people with lower incomes, people of color, and people in rural areas.[10–13] The inability to use Medicaid to cover abortion disproportionately affects people with lower incomes and people of color, who are more likely to have Medicaid.[14] Patients cite cost as a reason for delaying or preventing them from obtaining abortions; costs are exacerbated when patients have to travel long distances, pay for lodging, or pay for caregiving.[10,15] Pregnant people who are incarcerated, the majority of whom are of color,[16] also face notable barriers to obtaining abortions.[18] Prisons and jails have inconsistent policies and practices related to abortion,[17] and the distance between abortion clinics and prisons, which are often in rural, isolated areas, increases the many barriers to obtaining abortions faced by incarcerated people.[18]

History of health departments (HDs) and abortion: HDs in the United States play a critical role in ensuring the provision of sexual and reproductive health services in many communities, particularly those that face barriers to quality care. However, the involvement of HDs in abortion is highly politicized, and, as a result, HDs have been unable to play a similar role in abortion care. HDs have been engaged in some activities related to abortion since the Roe v. Wade Supreme Court decision in 1973, but little attention has been paid to defining the roles of HDs in relation to abortion. Attending to this question is timely and important due to the drastic increase in restrictive abortion laws that increase barriers to abortion, many of which are implemented by HDs.[1,2,19] Such laws are not evidence based because an extensive body of research indicates that abortion is very safe[2] and that people’s ability to obtain abortions is important for their health and well-being[4–7]; moreover, rigorous research has not revealed long-term negative physical or mental health effects of having an abortion.[2,4,7,20] While some people do have mental health symptoms after having an abortion, research does not indicate that these symptoms are caused by the abortion. Instead, they are typically a continuation of mental health symptoms that existed before the person sought an abortion,[21] and in the case of posttraumatic stress disorder they are most commonly attributable to stressful life events such as sexual, physical, or emotional abuse or violence.[22]

The earliest HD efforts related to abortion included data surveillance, clinical quality improvement, and research syntheses, some of which (e.g., data surveillance) continue today.[23–26] Also, the federal Title X Family Planning Program has required HDs to engage in activities related to abortion since the 1970s. Title X grantees, which include some state and local HDs,[27] distribute funds to local clinics to provide access to contraception, test for and treat sexually transmitted infections, and provide other preventive services such as human papillomavirus vaccination and breast and cervical cancer screening. For decades, federal regulations have restricted Title X funds from paying for abortion services; previous to a regulation change in 2019,[28] however, they had required that pregnant people be offered specific nondirective information and counseling about their pregnancy options (including abortion) and be given referrals upon request, which APHA has a policy (20201) to support.[27,29] Title X grantees are responsible for ensuring that federal regulations are followed; thus, many HDs have engaged with abortion as part of their Title X activities for years. However, because these regulatory activities have been a primary role of HDs in relation to abortion for decades, HD professionals’ thinking about broader sets of public health activities related to abortion in their community may be constrained.

As the number of restrictive abortion policies increased in the 2010s, HDs were required to take on new roles in relation to abortion.[1,19] In some cases, HDs have been tasked with defending, implementing, and enforcing non-evidence-based laws that are contrary to public health values of honesty, transparency, protection of health and safety, self-determination, and privacy.[30] For example, some laws require HDs to implement regulations that single out abortion-providing facilities with requirements that are not mandated for facilities offering other procedures of equivalent risk.[31] These targeted regulation of abortion provider laws (which APHA policy 20151 opposes) are not evidence based[2,3] and have resulted in facility closures that limit people’s ability to obtain abortions.[3] Other laws require HDs to produce and distribute informational materials to abortion patients that include inaccurate information, such as disproven links between abortion and breast cancer, mental health, and infertility.[1] Implementing and enforcing these policies is inconsistent with public health values and can harm, rather than improve, the health of pregnant people and their families.

Health department activities related to abortion: The most well-known activity related to abortion that HDs conduct is data surveillance.[26] State abortion surveillance reports are often modeled after a national template designed by the Centers for Disease Control and Prevention (CDC) that collects basic public health information, including identification of the facility, patients’ basic demographic characteristics, patients’ residence, date of the abortion, gestational age, and type of abortion provided. States with restrictive abortion policies may require HDs to go beyond the CDC template and collect policy enforcement data, such as whether state-mandated counseling was provided or whether clinics documented patients’ reasons for having an abortion.[32] Beyond surveillance, very little is known about which HDs engage in activities related to abortion, which activities they engage in, and why they do (or do not) engage in particular activities. Two studies published since 2017 begin to answer these questions. The activities analyzed in the studies encompass activities that are and are not evidence informed and those that facilitate or restrict people’s ability to obtain abortions.

In one study, researchers used the 10 Essential Public Health Services framework to conduct a content analysis of the public-facing Web sites of all 50 state and many large local HDs as a means of describing their activities related to abortion.[19] The study showed that all state HDs engage in some activities related to abortion. Nearly all state HDs (98%) conduct data surveillance, and most (92%) enforce laws related to abortion. About half conduct activities to provide information to abortion patients (47%) and linkages to services (65%). These activities focus almost exclusively on implementing state-mandated legislation related to information about abortion (“Women’s Right to Know” laws) and preparing materials that commonly include contact information for organizations promoting alternatives to abortion (e.g., crisis pregnancy centers [CPCs]) but rarely include contact information for abortion clinics. Both Women’s Right to Know laws and CPCs provide scientifically inaccurate information about abortion and reproductive health[33]; APHA policy 20113 opposes CPCs. Few local HDs engage in activities related to abortion; the few that do engage in a broader range of activities.

In a second study, researchers interviewed maternal and child health and family planning professionals in 22 state and local HDs across the United States to understand how HDs approach their work on abortion and to examine facilitators of and barriers to implementing activities related to abortion.[34] The researchers identified three approaches to abortion-related work in HDs. First, consistent with Web site study findings, many, particularly those in state HDs, described engaging in activities related to abortion only when required to do so by law and only in ways the law prescribed. On the other end, some (almost exclusively those in local HDs) described engaging in activities related to abortion prompted by needs they identified in their communities. Notably, the study identified a third scenario — a middle ground — in which some professionals in state HDs in a range of political climates found flexibility as they implemented mandated activities. In these cases, HDs met legal requirements and also incorporated common public health values, such as scientific accuracy, clinical expert engagement, presentation of unbiased and neutral information, and promotion of access to care, into the ways they implemented activities.

Barriers to health department engagement with abortion: In the same study,[34] public health professionals described barriers that affected whether and how their HDs engaged in activities related to abortion. Many noted effects of federal and state funding requirements. For some, fear of losing funding led to trepidation about engaging in activities related to abortion. Respondents also believed that individual leadership within their department could push the department toward or away from bringing a public health approach to activities related to abortion. Respondents viewed departmental leadership that was opposed to abortion or concerned about avoiding controversy as a formidable barrier, even in states with less restrictive abortion policy environments. Finally, many discussed the political climate. Even in the absence of specific laws mandating HDs to engage with abortion in particular ways, respondents were very aware of the political environment in which they operated and expressed concerns about possible political backlash if they engaged more proactively.

The political responses to the COVID-19 pandemic have clearly demonstrated the limitations on public health professionals to follow through on politically controversial evidence-informed policies without facing personal or financial harm. Dozens of public health officials have resigned during the pandemic after experiencing burnout or being threatened with violence after enforcing coronavirus mitigation strategies.[35] Others have been fired or had their authority diminished due to political backlash.[36] Given the highly politicized rhetoric about both abortion and the pandemic, public health professionals in communities with significant organized opposition to abortion may not be able to engage in public health activities that would otherwise be well within their scope without risking harm to their jobs and possibly their safety.

Evidence-Based Strategies to Address the Problem
The trends described above raise questions about use of government public health infrastructure for the political purpose of impeding people’s ability to obtain health care. Ideally, whether and how HDs engage in activities related to abortion would be determined by community needs and the potential for improving community health. From a public health perspective, policies and the organization of the abortion care delivery system should neither delay nor prevent people from obtaining abortions. If HD activities were consistent with public health frameworks and guided by public health values, it would be easier for people to obtain abortions, which would support the health and well-being of pregnant people and their families.[4–7] In addition to not implementing policies that make it more difficult for people to obtain abortions, HDs can facilitate people’s ability to obtain abortions through engaging in activities related to abortion consistent with public health values and frameworks.

While some HDs already engage in activities related to abortion that are consistent with accepted public health values and frameworks,[34,37] most do not.[19,34] Thus, strategies to encourage and support HDs in shifting practices are necessary. There is now sufficient work describing what HD activities related to abortion would look like if they were aligned with public health values and frameworks (as described below). However, there is no published research demonstrating the impact of HDs engaging in activities related to abortion that are consistent with public health frameworks, nor is there specific evidence on how best to encourage HDs to change their activities related to abortion. Thus, this policy statement draws on the broader literature about evidence-informed strategies to make changes in HD practices.

Relevant public health values and frameworks: As HD roles have shifted over time, public health professionals have used established frameworks to define their roles in emerging health topics. The 10 Essential Public Health Services framework is widely accepted and guides practices in many HDs.[38] The APHA Code of Ethics establishes professional standards and expectations intended for public health practitioners, specifically naming core values such as honesty, transparency, protection of health and safety, self-determination, and privacy.[30] Public health practitioners have named values relevant to abortion: basing decisions on the best available scientific evidence, relying on clinical and professional expertise, respecting autonomy, promoting access to care, and promoting racial, gender, and social justice.[34,39]

Between 2017 and 2020, two efforts described activities related to abortion consistent with the 10 Essential Services. The first listed activities related to abortion that HDs might engage in if they were guided by public health values and the 10 Essential Services.[40] The commentary argued that HDs “should be facilitating women’s ability to obtain an abortion in the state and county where they reside, researching barriers to abortion care in their states and counties, and promoting the use of a scientific evidence base in abortion-related laws, policies, regulations, and implementation of essential services.” In the second, public health professionals from seven state and nine local HDs in all U.S. regions engaged in a consensus process to develop a “menu of activities related to abortion that are appropriate for health departments.”[39] This menu was categorized by the 2020 revision of the 10 Essential Services, which actively promotes policies, systems, and overall community conditions that enable optimal health and seeks to remove systemic and structural barriers that result in health inequities.[41] As such, many activities in the menu align with HDs’ overarching efforts to address systemic and structural barriers to optimal health and reduce health inequities. These activities include providing evidence-based information on abortion to the public, including public health impacts of being unable to obtain an abortion; working on policy changes to expand Medicaid coverage for abortion to broader groups; overseeing abortion facility licensing using the same practices and protocols as other facilities that provide similar health care; engaging with the community directly, especially people of color and immigrants, to learn about their experiences obtaining abortions; researching barriers to abortion care in the community; including organizations that provide abortion or support people seeking abortion as speakers at or cosponsors of conferences and other events; and preparing briefs, reports, and talking points about the scientific evidence related to abortion to inform and respond to policy proposals.

Evidence-informed strategies to change health department practices: Most HD activities related to abortion are legally required, and some states have been able to implement legally mandated activities in manners consistent with public health values.[19,34] This indicates an opportunity to use policy levers to encourage HDs to engage in activities related to abortion. Policies are needed to support activities consistent with public health values and frameworks. Such policies can come with funding, which is necessary to support activities that facilitate people’s ability to obtain abortions and meet community needs.[34] For example, encouragement for Title V needs assessments to review local accessibility of abortion care could support this work.[39] Such assessments would include availability of both clinic-based and, for the very small number of people who need it, hospital-based abortion care,[8] particularly after hospital mergers that impose religious restrictions on the availability of hospital-based abortion services.[42] Local policy levers (e.g., requests from boards of supervisors or city councils) and federal policies, especially those with funding, can change HD practices.[43,44] Public health accreditation can also support changes in HD practices.[45] HD quality improvement actions for accreditation could include activities related to abortion consistent with public health values and frameworks, which could result in changes in HD activities related to abortion.

Another strategy involves workforce development for HD leadership, managers, and front-line staff. Such activities are especially important in the context of abortion, as few schools of public health include training about abortion in their curriculum.[46] The broader research literature indicates the necessity of building the capacity of HD leadership to engage in creative strategies that support change making[47,48]; research specific to abortion suggests that having the support of leadership appears necessary for HD professionals to implement activities related to abortion consistent with public health values and frameworks.[34]

Learning communities are an accepted approach to implementing evidence-based public health initiatives on broader scales.[49] Such communities consist of members or teams across geographies that concurrently implement system changes related to a specific public health topic. Learning communities have been used successfully in a range of content areas, such as heart health[50] and immediate postpartum long-acting reversible contraception placement,[51] as well as with more politically controversial issues such as strategies to reduce racial inequities in adverse birth outcomes.[52]

HD workforce development often includes training and requirements for continuing education. Ensuring that training follows implementation science principles is key,[53] as is having committed and competent trainers, organizational incentives, leadership support, funding, and infrastructure to support training.[54] Training efforts related to abortion could draw on existing strategies for training other health professionals about abortion[55] while adapting them for a public health rather than clinical workforce. Training HD professionals on how to assess and use evidence in decision making has also been found to increase evidence-based public health practices.[56,57] For HD professionals who may be putting their jobs at risk when engaging in activities related to abortion consistent with public health values and frameworks, training is critical. Training could build their capacity to avoid partisanship, present evidence fairly, choose the correct messenger, and sharpen policy-relevant analytic skills.[58] It could also include training in how to select activities that are likely to be more (politically) feasible in their context.

HDs can promote use of evidence in decision making by seeking, analyzing, synthesizing, and applying the best available scientific evidence on abortion safety, availability, provision, and community needs. Yet, requiring individual HDs to do this does not make sense from a resource allocation perspective. Knowledge translation research has shown that external bodies can support evidence-based decision making among HD professionals by synthesizing relevant scientific knowledge and communicating it in easy-to-use formats for HD practitioners.[59,60] Studies have also identified a need for trusted external partners to assess the quality and credibility of research and index it for easy access and use by HDs.[61] Thus, partnerships between HDs and academic centers that conduct rigorous research on abortion may be useful, with universities able to play a vital role in gathering, assessing, and synthesizing evidence about abortion.[62]

Opposing Arguments/Evidence
Funding: Some HD professionals are concerned about HD involvement in activities related to abortion because of funding-related reasons. HD professionals report that they do not have dedicated funding to support this work[34] and worry that engaging in such activities will lead to a loss of funding due to explicit and implied restrictions on engaging in activities related to abortion.[34] Engaging in activities related to abortion could jeopardize funding that supports other essential HD activities.

However, the idea that lack of funding, as well as politicized funding restrictions already opposed by APHA (i.e., APHA policies 20152, 20199, and 20201), should dictate the scope of activities related to abortion is inconsistent with public health values that prioritize using scientific evidence rather than politics to make decisions. Changing policies that limit activities related to abortion in which HDs are (or perceive themselves as being) allowed to engage can help address this concern. While some activities might require significant funding, others may require only limited funding or can be engaged in within the scope of existing jobs (e.g., disseminating information about abortion services in a jurisdiction and providing analyses of the programmatic, fiscal, and health effects of abortion-related bills and policies to HD leadership). Most state HDs already engage in activities related to abortion; thus, funding is already expended. The issue is that current activities are not typically consistent with public health values and frameworks and are rarely guided by scientific evidence or community needs. Also, if HDs no longer need to devote financial and human resources to implementing and enforcing non-evidence-based activities related to abortion, this would free up funding to focus on activities related to abortion consistent with public health values and frameworks and other essential services.

Politics: Because HDs are government agencies, they need to attend to the political environment in which they are located. Some HDs are required to implement politically motivated restrictive abortion policies.[19,34] Even in the absence of specific laws mandating whether and how HDs should engage with abortion, a politically conservative climate may limit HDs from initiating a broader range of public health activities related to abortion.[34] Engaging in such activities in unsupportive political contexts may lead HDs to rightfully fear not being able to implement other public health activities because they have lost the support of other government officials or the broader public. The COVID-19 pandemic also demonstrated that HD professionals could be personally harmed financially (e.g., complete job loss, having to move) and physically (e.g., threats to themselves and family members) for implementing evidence-informed policies.[36,63] Pushing public health professionals to engage in more activities related to abortion — especially more public-facing activities — may result in job losses in the short term and an inability to fill key public health jobs in the future.

Effectively navigating political climates is necessary for successful public health practice. Clearly, not all activities related to abortion consistent with public health values and frameworks are feasible in all political environments, and decisions about which of the menu of activities are feasible in different political environments should be informed by the local context. In political contexts that are more heavily politically opposed to abortion, public-facing activities related to abortion may be less feasible, while other activities (e.g., collecting data regarding use of abortion services in ways that ensure patient privacy, protect the safety of providers, and do not include more than the minimum information necessary; convening a sexual and reproductive health/justice workgroup; and providing evidence-based education to health department leadership on abortion-related topics) may be more feasible. Furthermore, basing policies and practices on the best scientific evidence regardless of political climate is a core public health value.[30] HDs engage in other politically contentious topics in manners consistent with public health values and frameworks, including vaccination, racism, and cannabis regulation.[64–66] Also, even in political climates opposed to abortion, some HDs have ensured that legally mandated activities are based on scientific evidence.[34]

Personal opposition to abortion/conscience refusal: For some people in HDs, engaging in activities related to abortion may go against personal beliefs and be uncomfortable. Such conscientious refusal is common in clinical reproductive health care, in which there are deep divisions regarding the moral acceptability of abortion. There is no reason to believe that HDs will differ.

The American College of Obstetricians and Gynecologists stated in a 2007 committee opinion that “[a]lthough respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients, negatively affect a patient’s health, are based on scientific misinformation, or create or reinforce racial or socioeconomic inequalities.”[67] Institutions also need to respect the personal beliefs and consciences of public health workers whose moral and religious convictions require that reproductive care include options for available and safe abortion services. While few HD staff are likely to be directly involved in direct clinical provision of abortion, they still have obligations as public health practitioners. Public health professionals “are expected to put the public interest and the public trust ahead of their personal interests.”[30] As with other stigmatized and politically controversial topics, workforce development activities can help people distinguish personal views from professional obligations and clarify values.

Skepticism of government public health: Many people are skeptical of government public health activities, particularly when engaging with politicized topics. For example, people may have significant privacy concerns, especially if HD activities related to abortion involve provision of direct services to people seeking abortion (e.g., facilitating transportation) or gathering of information about barriers to or experiences with obtaining abortion care among marginalized communities.

As with other politically controversial public health topics, support and training to build trust between HDs and the general public, as well as with specific communities that have been historically mistreated by government institutions, are essential. HDs also need to acknowledge that mistrust exists and work to build and rebuild trust with their communities, particularly marginalized members. In relation to abortion, this might be in the form of participating in community-led efforts to address shame and stigma related to abortion, particularly where there is mistrust.[39]

Action Steps

1. APHA calls on federal, state, and local policymakers to create policies that support HDs in engaging in activities related to abortion that are consistent with public health values and frameworks.
2. APHA calls on federal policymakers to remove explicit and implied restrictions on HDs engaging in activities related to abortion when receiving federal funding.
3. APHA calls on state and local governments to allow HDs to use existing resources to engage in activities related to abortion that are consistent with public health values and frameworks, particularly those that meet local community needs.
4. APHA calls on state and local HDs to contribute current scientific evidence to legislative consideration of laws and to establish regulations consistent with that scientific evidence. 
5. APHA calls on state and local HDs to engage in activities related to abortion consistent with public health values and frameworks, including collecting data related to abortion in community needs assessments, providing evidence-based information on abortion to the public and policymakers, and convening working groups to reduce barriers to obtaining abortions for people in their jurisdictions.
6. APHA calls on state and local HDs to work with correctional facilities to understand and address barriers jails and prisons face in ensuring that pregnant people in their facilities can access abortion services.
7. APHA calls on state and local HD leaders to inform and educate policymakers and the public about policies inconsistent with scientific evidence, such as those mandating that abortion providers have hospital admitting privileges or limiting insurance coverage for abortion. 
8. APHA calls on state and local HD leaders to implement legally mandated activities using public health values, such as ensuring that activities are based on scientific evidence, facilitating access to health care, and respecting autonomy.
9. APHA calls on private, nonprofit, and governmental funders to support development activities for the public health workforce to support abortion-related activities that are consistent with public health values and frameworks.
10. APHA calls on schools of public health to include training about abortion in their curricula to prepare future professionals in state and local HDs to develop and implement activities related to abortion that are consistent with public health values and frameworks.
11. APHA calls on HDs and academic research centers to form collaborative partnerships to gather, assess, and synthesize rigorous scientific evidence on abortion.
12. APHA calls on members, affiliates, and schools of public health to be voices for the importance of abortion in the well-being of pregnant people, children, and families and for an accurate research record about abortion, especially in political environments where HDs’ engagement in activities related to abortion is constrained. 

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