Recommendations for Pregnancy Counseling and Abortion Referrals

Abstract

Access to abortion care is essential to the well-being of pregnant people and their families. While the Supreme Court decision in Roe v. Wade in 1973 protects pregnant people’s decision to terminate their pregnancy, several state and federal regulations have chipped away at equitable access to abortion. Some of these laws regulate pregnancy counseling and block providers from engaging in non-directive counseling, thereby banning providers from referring patients to abortion care. These regulations harm patients by interfering with the patient-provider relationship and keeping patients from seeking abortion care in a timely manner. These effects may be disproportionately felt by low-income people and people of color, who may be more likely to seek pregnancy counseling in settings funded by state and federal programs subject to regulations on counseling. This policy statement recommends that APHA members, public health workers, and medical providers work to repeal regulations that prohibit providers from presenting patients with non-directive pregnancy counseling; calls for the end of government funding for crisis pregnancy centers; and supports the right of all individuals to receive comprehensive reproductive health care, including abortion and abortion referrals.

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 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 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

Problem Statement

Since its implementation, the United States Title X national family planning program has been dedicated to advancing high-quality family planning services, especially for low-income communities that tend to face barriers in accessing such care. In 2018, the Title X program operated 3,954 sites and served 3.9 million people; 22% of clients identified as Black/African American, one third identified as Hispanic or Latino, two thirds were younger than 30 years, and 65% had family incomes at or below the federal poverty level.[1] Its recipient health centers are required to offer “neutral, factual information and nondirective counseling” on all pregnancy options, including abortion, as well as “referral upon request.”[2] The number of abortion referrals provided annually by Title X clinics is not publicly available.

In 2019, the United States Department of Health and Human Services (DHHS) issued a final rule to revise the Title X program consistent with previous attempts to implement a domestic gag rule. Its key changes on counseling, abortion care, and abortion referrals include the following:

• “Requiring clear financial and physical separation between Title X funded projects and programs or facilities where abortion is a method of family planning.”
• “Prohibiting referral for abortion as a method of family planning. The final rule does not bar nondirective counseling on abortion but eliminates the requirement that Title X providers offer abortion counseling and referral. It protects Title X health care providers so that they are not required to choose between participating in the program and violating their own consciences by providing abortion counseling and referral.”[3]

According to the DHHS, Title X providers “may provide a list of comprehensive health care providers (including prenatal care providers), including some (but not the majority) who perform abortion as part of a comprehensive health care practice. However, this list cannot serve as a referral for, nor identify those who provide abortion—and Title X providers cannot indicate those on the list who provide abortion.”[4]

This rule change compels Title X recipients to no longer adhere to the medical ethics of informed consent and nondirective counseling.[5] Regardless of pregnant patients’ preferences, intentions, and needs, they may receive inaccurate information from their provider or incomplete information about where to access the services they need and request. Mandating that clinicians deny their patients comprehensive information and referral options interferes with the patient-provider relationship and erodes patients’ trust in their providers and the health care system. This is particularly detrimental for Black and Indigenous patients and people of color (BIPOC), as well as lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities.

BIPOC have historically experienced and continue to experience coercive health care practices, especially with respect to reproductive and maternal health care.[6,7] Between 1970 and 1976 alone, an estimated 25% to 50% of all Indigenous women in the United States were sterilized by the Indian Health Service against their knowledge and consent.[8] In the 1990s, some states required women accused of crimes to accept contraceptive implant insertion as a condition for receiving a reduced sentence.[9] Young Black and Hispanic women report experiencing biased contraceptive counseling, with health care providers pushing long-acting reversible contraceptive methods rather than counseling on all options or honoring patient preferences for removal.[10,11] These are a few examples of scores of past and current reproductive coercion, uninformed consent, and systems of discriminatory health care policies. This legacy of deliberate misinformation and directive counseling influences these communities’ distrust of the health care system.[12] The Title X rule change institutionalizes a disregard for medical ethics and exacerbates a legacy of reproductive coercion. This may further erode the already tenuous relationships between BIPOC patients and providers, potentially contributing to more patients avoiding seeking reproductive health care, and health care generally, out of distrust of the entire system.

LGBTQ people have experienced a long history of discrimination, disrespect, and refusal from receiving health care services due to stigma arising from uninformed beliefs around sex, gender roles, and reproduction.[13] A 2015 national survey of transgender people revealed that 23% did not see a clinician for health care due to fear of mistreatment or discrimination.[14] According to a 2018 survey, one in five LGBTQ people (including 31% of transgender people) would find it nearly impossible to obtain the health care they need if turned away from their current source of care.[15] Experiences and fears of discrimination in health care result in myriad consequences, including poor access to high-quality care and increased risks of unwanted pregnancies, psychological distress, and multiple chronic conditions.[13,16,17] LGBTQ people need access to family planning services, abortion, and abortion referrals. They need gender-affirming care that supports their bodily autonomy and dignity,[18] not care that reinforces stigma, misgenders patients, and harms people. Title X clinics have become important settings for providing nonjudgmental services. However, the rule change would violate LGBTQ patients’ abilities to receive unbiased care, information, and counseling. This may especially affect those with low incomes and those who live in rural communities as a result of the limited social support and resources available to find new providers.[19] Withholding referrals and information from LGBTQ patients may further erode the fragile trust that has grown between reproductive health providers and LBGTQ populations, deterring many from seeking health care at all and perpetuating existing disparities.

Incarcerated pregnant people may be particularly vulnerable to negative reproductive health experiences and outcomes due to the Title X rule change. An estimated 2,500 pregnant people are admitted into state and federal prisons each year. Ninety-two percent of pregnancies result in live births and 1% in abortions.[20] Although pregnant people in jail retain their legal right to an abortion, their experiences in attempting to obtain an abortion vary widely by state and facility.[21] In a 2009 survey of correctional health officials, 68% indicated that women in their prisons were allowed to have an abortion, but only 54% helped arrange appointments.[22] Some clinics at women’s correctional facilities receive Title X funding.[23] Studies have not demonstrated the extent to which directive counseling on pregnancy options affects incarcerated pregnant women in facilities with or without Title X funding. However, they do experience widespread abusive and discriminatory practices that affect health outcomes and overall well-being. Examples include solitary confinement, physical and sexual violence, insufficient access to birth control, shackling and neglect during labor and delivery, and rapid separation from their newborns after delivery.[24]

Denying pregnant people complete information about pregnancy options and services reduces their ability to access care in a timely manner.[25] As a pregnancy progresses, navigating financial and logistical barriers becomes more difficult, especially with limited social support.[26] Arranging transportation, child care, accommodations, and time off from work in the absence of accurate information about where to obtain abortion care requires significant time and money.[26] This can be detrimental for low-income people, who already have little in savings or lack access to social and financial support. These compounding barriers may result in further delays, which may push pregnant people into receiving second-trimester abortions. For example, after Texas implemented House Bill 2 in 2014, which resulted in the closing of nearly half of the state’s abortion clinics, the number of second-trimester abortions in the state increased by 13%, even though the total number of abortions declined by 18%.[27] Women who lived between 50 and 99 miles from an abortion clinic, lived in regions with fewer clinics, and/or waited more than 3 days due to the state-mandated waiting period were more likely to have a second-trimester abortion.[27] These abortions are more costly and involve slightly higher medical complications than first-trimester abortions, and procedure options are limited.[28] Because the Title X program was designed to serve low-income populations, they will be most disadvantaged by inadequate, biased counseling and a lack of referral to abortion services. Timely access to information and services for wealthier patients with private insurance, funds, and social support will largely remain unchanged.

Research from the Turnaway Study, a longitudinal study of patients who sought abortions and either were able to obtain them or were “turned away” (due to having passed the state’s gestational limits for abortion), revealed detrimental consequences of being denied a wanted abortion. Those who were denied an abortion and carried their pregnancy to term were more likely to live below the federal poverty level, experience serious complications, stay in contact with abusive partners, and suffer short-term anxiety and loss of self-esteem and less likely to have aspirational life plans for the coming year.[29] As of 2020, studies have not specifically examined the immediate and long-term consequences of not referring patients to abortion services. However, as incomplete, biased information can delay patients from obtaining care, some patients may not receive abortion care within the gestational limit of their state or neighboring states and be “turned away.”

When abortion is inaccessible or legally restricted, pregnant people look outside of the formal medical setting to end unwanted pregnancies.[30] As the Title X rule change perpetuates an environment of reduced abortion access and mistrust of the health care system, this may lead some patients to self-manage their abortion. As of 2020, research has not been conducted to assess the association between lack of abortion referrals and self-managed abortion. However, studies have shown that the demand for self-managed medication abortion is higher overall in states with hostile abortion policy climates.[31] Self-managed abortion is not inherently unsafe. More people are self-managing with the pills mifepristone and misoprostol (or misoprostol alone), which are more safe and effective than older, invasive techniques.[32] A 2016–2017 study on the quality of mifepristone and misoprostol pills obtained online for self-managed abortions in the United States demonstrated that the pills were safe.[33] Given accurate information and access to clinical consultation, self-managed medication abortion is as safe as clinic-based care.[32]

Beyond the Title X rule change and ongoing efforts to implement a widespread domestic gag rule, anti-abortion policymakers have long attempted to undermine fundamental ethical concepts of informed consent, unbiased counseling, and respect for patient preferences. State legislators have enacted a multitude of regulations (lacking foundations in scientific evidence) that interfere with the patient-provider relationship and contribute to misinformation, delays, and stigma.[34] Examples include limiting reasons for seeking an abortion, requiring medically inaccurate preabortion counseling (e.g., information on “reversing” a medication abortion), and mandating that the abortion provider perform an ultrasound and requiring patients to view it.[35] These regulations embolden clinicians who object to abortion and uplift their personal beliefs over duties to engage in ethical, unbiased care as medical providers, as well as undermining the abilities of clinicians who want to provide unbiased, nondirective counseling, referrals, and care to their patients.

Various professional medical organizations oppose the Title X rule change due to the aforementioned implications around biased counseling and referrals, misinformation, and patient harms. For example, the American College of Obstetricians and Gynecologists (ACOG) “opposes efforts that seek to regulate the way in which Title X providers talk to their patients and that prevent Title X providers from sharing complete and accurate medical information necessary to ensure that their patients are able to make timely, fully informed medical decisions.”[36] This restriction of medically accurate information will only lead to further health inequities, including increased “rates of unplanned pregnancy, pregnancy complications, and undiagnosed medical conditions.” Similarly, the American Academy of Family Physicians (AAFP) notes that “by dictating what medical information family physicians can and cannot provide to patients, this rule amounts to an unconscionable level of intrusion with the practice of medicine…. When our government restricts the information that can be given to women, women will receive substandard medical care and their health will suffer.”[37]

Nurses offer a similar perspective and emphasize their commitment to centering the needs of patients and to living their values of honesty, ethics, and evidence-based reproductive health care. The American College of Nurse-Midwives strongly opposes the rule change, as it “puts providers in the untenable, unethical position of having to be deceitful or give incomplete information to patients, undermining patient-provider relationships and putting patient health and safety in jeopardy.”[38] According to the American Nurses Association, “nurses must guard against any erosive policy that hinders patients from making meaningful, informed decisions about their own health, or that blocks access to care.”[39]

The rule change has led many organizations and governors to reject Title X funding. As of June 2019, 1,041 Title X clinics had either withdrawn from the program or were no longer using Title X funds, a loss of 23%.[40] All Planned Parenthood direct grantees and subgrantees have withdrawn. States where state departments of health are the only Title X grantee (e.g., Oregon, Washington, Hawaii, and Vermont) will no longer use Title X funds.[41] The loss of funding for these sites is already affecting access to care. For example, some Planned Parenthood centers have closed. Other clinics have decided to make up lost revenue by charging patients additional fees and limiting clinic hours.[41] These clinic closures, reductions in services, and additional costs can be harmful for BIPOC, LGBTQ, low-income, and rural populations. For many, Title X health centers may be the only providers of comprehensive reproductive health care, as well as primary care, specialist referrals, and preventive screenings. Federally qualified health centers are crucial in providing health care to all, but they do not have the capacity to fill the gaps in family planning coverage left by former Title X clinics.[42] As more former Title X clinics close, reduce services, or increase costs, millions of people dependent on affordable reproductive health care will be left without access.[43]

The rule change has allowed some organizations called crisis pregnancy centers (CPCs) to qualify for federal funding under Title X, despite their not providing highly effective, evidence-based contraceptive options such as hormonal birth control.[44] CPCs engage in practices to manipulate and deceive pregnant people seeking abortion care. Research has documented a number of these practices, including naming facilities to sound like legitimate family planning clinics, locating facilities nearby legitimate abortion or family planning clinics, advertising services under “abortion” or “medical” categories online and in the Yellow Pages, and misleading clients by offering free services such as pregnancy testing, ultrasounds, and biased counseling to deter abortion.[45,46] Some of that biased counseling includes falsely informing clients of supposed negative consequences of abortion: infertility, breast cancer, and long-term psychological distress. As of 2020, there are 2,527 operating CPCs in U.S. states, primarily in the South and Midwest.[47]

The Obria Group, which operates a network of CPCs, was awarded $1.7 million in 2019 under Title X. Its application for funding in Texas stated that Obria’s subrecipients would provide a “broad range of family planning methods”; however, the organization contacted its supporters via e-mail and asserted that “Obria’s clinic model is committed to never provide hormonal contraception nor abortions.”[48] Its Web site claims to offer evidence-based information regarding abortion to help pregnant people make an informed decision yet provides medically incorrect information about and services for abortion reversal.[49] A 2015 study conducted in southern Louisiana showed that 6% of abortion patients and 5% of prenatal patients visited a CPC for their pregnancy.[50] Most went for free pregnancy tests and reported receiving inaccurate information about abortion from CPC staff. Several patients reported that this misinformation influenced their pregnancy plans.[50] To date, no national data are available on the number and characteristics of pregnant people who visit CPCs; thus, the scope of people affected by their harmful tactics is unknown. However, as more reproductive health clinics pull out of Title X, more CPCs may be awarded federal funding and have further opportunities to misdirect and misinform patients. This can result in further misinformation, stigma, and delays in accessing needed health care services.[51]

The primary focus of this policy is a human rights issue. International human rights laws and policies affirm the right to access abortion care and stipulate that regulations on abortion must not interfere with the ability to access the service or cause harm.[52] International human rights laws also affirm the right to timely access to health services and nondiscriminatory services; in addition, health services must be “scientifically and medically appropriate and of good quality.”[53] This policy statement aligns with these human rights principles, as it seeks to ensure that people have scientifically accurate information to make informed decisions about their pregnancy and to remove barriers to accessing abortion.

Evidence-Based Strategies to Address the Problem

Mandating and implementing nondirective pregnancy counseling that includes abortion in family planning clinics receiving federal dollars can ensure that patients have access to unbiased pregnancy counseling and would prevent CPCs that discourage abortion from receiving federal dollars. In addition, reversing the recent Title X rule change may encourage clinics that recently departed the Title X network to return to the program.

There is no evidence quantifying the impact of receiving nondirective versus directive pregnancy counseling. The current Title X rules have not been in place long enough to evaluate their direct impact on access to abortion. However, there is evidence that patient-centered, nondirective pregnancy counseling can have positive emotional and psychological effects on people who are seeking or have had an abortion.[54,55] Shared decision making, in which all options are presented to the patient, is an example of nondirective pregnancy counseling. This approach centers the patient’s desires, and the provider and patient work together to achieve the patient’s goals.[56,57] Patient-centered approaches such as shared decision making can positively affect communication[56] between patient and provider and improve patient satisfaction.[54,55,58] Patients’ satisfaction with their decision is associated with more shared decision making with a provider.[54,55,58] Counseling that prioritizes patients’ values is also important for positive psychological outcomes.[55]

Withholding information about abortion during pregnancy counseling violates medical ethics. Professional medical associations such as ACOG,[36] AAFP,[37] the American College of Nurse-Midwives,[38] the American Nurses Association,[39] and the American Medical Association (AMA)[59] have spoken out against the recent Title X regulations and have historically supported ethical norms that affirm the right to nondirective pregnancy counseling and patient-centered care. For example, the AMA has written in its Code of Ethics that “truthful and open communication between physician and patient is essential for trust in the relationship and for respect for autonomy” and that “withholding pertinent medical information from patients in the belief that disclosure is medically contraindicated creates a conflict between the physician’s obligations to promote patient welfare and to respect patient autonomy.”[60] The AMA Code of Ethics also states that a physician’s decision to refer a patient for health care services should be based on the “patient’s medical needs.”[61]

Withholding referrals for abortion may also act as an additional barrier to accessing abortion in a timely manner. Several studies indicate the consequences of delays in receiving abortion care for a variety of reasons, including lack of referrals or information about where to seek abortion services.[62] The availability of abortion decreases as gestational age increases: 13 states have successfully enacted bans on abortion after 22 weeks from the start of the pregnant person’s last period.[62] The out-of-pocket cost for an abortion also increases with gestational age.[62] If patients are delayed in seeking their abortion due to lack of information or support from a provider, they may struggle to be able to obtain or afford an abortion. This is especially true for patients with low incomes.

Opposing Arguments/Evidence

The public health and medical communities are aligned around rigorous evidence supporting referral for abortion care. APHA Policy Statement 20152 (Restricted Access to Abortion Violates Human Rights, Precludes Reproductive Justice, and Demands Public Health Intervention) clearly states the association’s commitment to abortion access rooted in data and scientific evidence.[63] Proponents of restrictions on abortion care, including referral, base their policy efforts on religious and moral beliefs. Quality public health research supporting the opposition’s claims is rare, and much of the research cited in opposition arguments has been found to be deeply flawed and has subsequently been debunked.[64]

With this in mind, the most common opposition arguments to referral for abortion include the following: a right to conscientious objection (and obstruction of the right to conscientious provision), a right to limit the uses of state and federal funds related to abortion (and the right to fund religiously affiliated facilities that do not provide abortions), and a belief in the efficacy of biased and directive counseling (and the ability of CPCs and other facilities that do not provide abortions to offer adequate care for pregnant people).

Conscience: Opponents of abortion care and referral argue that they are protected by a right to conscientious refusal.[65] However, support for conscientious refusal is rooted in moral and religious arguments, not scientific evidence. In a medical setting (e.g., abortion care), arguments of conscience should not take precedence over the obligation of providers to ensure patient care, whether it be provided by them directly or through referral. ACOG explores the concept of conscientious refusal in its committee opinion 385 (The Limits of Conscientious Refusal in Reproductive Medicine).[66] Refusal to refer is based on an individual provider’s concept of moral integrity, but the public health impact falls squarely on the patient. To ensure that providers meet their responsibility to patients, ACOG recommends that “providers with moral or religious objections…either practice in proximity to individuals who do not share their views or ensure that referral processes are in place.”[66]

Proponents of laws that protect provider conscience by refusal fail to extend the concept to provision of abortion care. Many providers of abortion care consider it their moral and ethical obligation to provide the care their patients are seeking or to help them access it.[67] However, laws that mandate non-evidence-based restrictions and limitations on provider actions regularly make conscientious provision of abortion care more difficult for both the provider and the patient.[68]

Funding: Opponents of abortion care argue that federal taxpayer funds should not be used to provide or refer for abortion care on moral and religious grounds. This argument has been used to pass discriminatory policies and appropriations since the legalization of abortion in the United States.[69] Despite the documented harm to patients, federal funding for abortion has been restricted by the Hyde Amendment since 1976, and Title X has never been able to fund abortion care. Restrictions on Title X services (including referrals) reduce the pool of providers and disproportionately affect family planning services for low-income patients.[70] APHA Policy Statement 20152 rejects restrictions on federal and state funding for abortion care and affirms the public health value that abortion care is health care and, as such, should be publicly funded.[63]

Opponents of funding for abortion care and referral do, however, advocate for government funding of facilities that do not provide abortions, many of which have religious affiliations. They argue that these facilities adequately provide information and options for patients.[71] However, as discussed previously, many CPCs are clear in their intentions to not offer comprehensive information about abortion or contraception.[48] In reality, the facilities that have retained Title X funding have very limited capacity to provide comprehensive care, religiously affiliated or otherwise.[41] Arguments that taking funding away from CPCs would be a violation of religious or moral beliefs are a diversion, as the founding intention of Title X was to provide a range of effective family planning care to every person who needed such care. By virtue of their religious beliefs, CPCs do not offer comprehensive contraceptive care and do not contribute toward the public health intention of the Title X program.

Biased counseling: Finally, opponents of referral claim that people seeking abortions are persuaded to change their minds when provided with alternative options. Legislation mandating biased counseling and delays before care relies on data from studies that have been widely debunked by major medical and public health organizations.[72] Recent research has shown that CPCs do not achieve their stated goal of changing the minds of people who have made the decision to have an abortion.[73] The decisional certainty of women seeking an abortion has been found to be as high as (if not higher than) the decisional certainty of both men and women regarding other common health care procedures.[47] The risks to pregnant people who are given misinformation and forced to delay legitimate medical care are in stark contrast to the values of the public health community.[74]

Alternative Strategies

There are no evidence-based counterpoints to our knowledge.

Action Steps

1. APHA calls on members, medical organizations, public health officials, and elected officials to work to repeal prohibitions on comprehensive and evidence-based counseling on pregnancy options under the Title X program.
2. APHA calls on elected officials to discontinue state and federal funding of crisis pregnancy centers that interpret religious beliefs to deny abortions to individuals seeking comprehensive reproductive health counseling, including abortion referrals.
3. APHA calls on on elected officials to discontinue state and federal funding of crisis pregnancy centers that do not provide comprehensive, evidence-based pregnancy counseling and that employ deceptive techniques and promote anti-scientific and debunked information about abortion.
4. APHA calls on regulatory bodies to deny relevant medical licenses to clinics that offer family planning services but do not provide comprehensive, nondirective reproductive health counseling. Clinics eligible for funding must offer pregnancy counseling that incorporates all options, including abortion, and offer referrals for abortion and other reproductive health services not offered on site. Pregnancy counseling will be based on standard medical practice and available scientific evidence. An example of a federal regulatory body would be the DHHS Office of Population Affairs, which would deny Title X grants to clinics that do not provide comprehensive pregnancy counseling and refer for abortions under this policy recommendation. States could make crisis pregnancy centers ineligible for state Medicaid reimbursement.
5. APHA calls on public health agencies, health care professional organizations, and providers to engage in continuous education and dialogue about medical and ethical obligations to provide comprehensive reproductive health care, including obligations to be able to competently explain reproductive health options without coercing patients.
6. APHA encourages public health professionals to promote outreach and campaigns to inform communities of reproductive rights and how to identify crisis pregnancy centers that may not offer all of the services community members seek.

References

1. Fowler CI, Gable J, Wang J, Lasater B, Wilson E. Title X family planning annual report: 2018 national summary. Available at: https://www.hhs.gov/opa/sites/default/files/title-x-fpar-2018-national-summary.pdf. Accessed July 17, 2020.
2. U.S. Department of Health and Human Services. Rules and regulations, part 59—grants for family planning services. Available at: https://www.hhs.gov/opa/sites/default/files/42-cfr-59-b_1.pdf. Accessed February 7, 2020.
3. U.S. Department of Health and Human Services. HHS releases final Title X rule detailing family planning grant program. Available at: https://www.hhs.gov/about/news/2019/02/22/hhs-releases-final-title-x-rule-detailing-family-planning-grant-program.html. Accessed January 31, 2020.
4. U.S. Department of Health and Human Services. Title X final rule compliance and enforcement: myth vs. fact. Available at: https://www.hhs.gov/opa/title-x-family-planning/about-title-x-grants/statutes-and-regulations/compliance-with-statutory-program-integrity-requirements/myth-vs-fact/index.html. Accessed January 31, 2020.
5. Hasstedt K. Unbiased information on and referral for all pregnancy options are essential to informed consent in reproductive health care. Available at: https://www.guttmacher.org/gpr/2018/01/unbiased-information-and-referral-all-pregnancy-options-are-essential-informed-consent. Accessed January 31, 2020.
6. Roberts DE. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York, NY: Pantheon Books; 1997.
7. Center for Reproductive Rights. Reproductive injustice: racial and gender discrimination in U.S. health care. Available at: https://reproductiverights.org/document/reproductive-injustice-racial-and-gender-discrimination-in-us-health-care. Accessed January 31, 2020.
8. Lawrence J. The Indian Health Service and the sterilization of Native American women. Am Indian Q. 2000;24(3):400–419.
9. Gold RB. Guarding against coercion while ensuring access: a delicate balance. Available at: https://www.guttmacher.org/gpr/2014/09/guarding-against-coercion-while-ensuring-access-delicate-balance. Accessed January 31, 2020.
10. Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: perceptions of young adult women. Am J Public Health. 2016;106(11):1932–1937.
11. Gubrium AC, Mann ES, Borrero A, et al. Realizing reproductive health equity needs more than long-acting reversible contraception (LARC). Am J Public Health. 2016;106(1):18–19.
12. Prather C, Fuller TR, Jeffries WL, et al. Racism, African American women, and their sexual and reproductive health: a review of historical and contemporary evidence and implications for health equity. Health Equity. 2018;2(1):249–259.10. Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: perceptions of young adult women. Am J Public Health. 2016;106(11):1932–1937. 11. Gubrium AC, Mann ES, Borrero A, et al. Realizing reproductive health equity needs more than long-acting reversible contraception (LARC). Am J Public Health. 2016;106(1):18–19. 12. Prather C, Fuller TR, Jeffries WL, et al. Racism, African American women, and their sexual and reproductive health: a review of historical and contemporary evidence and implications for health equity. Health Equity. 2018;2(1):249–259.
13. Thoreson R. “You don’t want second best”: anti-LGBT discrimination in US health care. Available at: https://www.hrw.org/report/2018/07/23/you-dont-want-second-best/anti-lgbt-discrimination-us-health-care. Accessed January 31, 2020.
14. James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. The Report of the 2015 US Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016.
15. Mirza SA, Rooney C. Discrimination prevents LGBTQ people from accessing health care. Available at: https://www.americanprogress.org/issues/lgbtq-rights/news/2018/01/18/445130/discrimination-prevents-lgbtq-people-accessing-health-care/. Accessed January 31, 2020.
16. Hsieh N, Ruther M. Despite increased insurance coverage, nonwhite sexual minorities still experience disparities in access to care. Health Aff (Millwood). 2017;36(10):1786–1794.
17. Everett BG, McCabe KF, Hughes TL. Sexual orientation disparities in mistimed and unwanted pregnancy among adult women. Perspect Sex Reprod Health. 2017;49(3):157–165.
18. Wagner J, Sackett-Taylor AC, Hodax JK, Forcier M, Rafferty J. Psychosocial overview of gender-affirmative care. J Pediatr Adolesc Gynecol. 2019;32(6):567–573. 19. GLBTQ Legal Advocates & Defenders. Brief for National Center for Lesbian Rights et al. as amici curiae supporting respondents. Available at: http://www.glad.org/wp-content/uploads/2019/08/TITLE-X-NCLRetal.pdf. Accessed January 31, 2020.
20. Sufrin C, Beal L, Clarke J, Jones R, Mosher WD. Pregnancy outcomes in US prisons, 2016–2017. Am J Public Health. 2019;109(5):799–805.
21. Kasdan D. Abortion access for incarcerated women: are correctional health practices in conflict with constitutional standards? Perspect Sex Reprod Health. 2009;41(1):59–62.
22. Sufrin CB, Creinin MD, Chang JC. Incarcerated women and abortion provision: a survey of correctional health providers. Perspect Sex Reprod Health. 2009;41(1):6–11. 23. Office of Population Affairs. Title X family planning directory. Available at: https://www.hhs.gov/opa/sites/default/files/Title-X-Family-Planning-Directory-June2020.pdf. Accessed January 31, 2020. 24. Sufrin C, Kolbi-Molinas A, Roth R. Reproductive justice, health disparities and incarcerated women in the United States. Perspect Sex Reprod Health. 2015;47(4):213–219. 25. Sobel L, Salganicoff A, Frederiksen B. New Title X regulations: implications for women and family planning providers. Available at: https://www.kff.org/womens-health-policy/issue-brief/new-title-x-regulations-implications-for-women-and-family-planning-providers/. Accessed January 31, 2020.
26. Jerman J, Frohwirth LF, Kavanaugh ML, Blades N. Barriers to abortion care and their consequences for patients traveling for services: qualitative findings from two states. Perspect Sex Reprod Health. 2017;49(2):95–102.
27. White K, Baum S, Hopkins K, Potter J, Grossman D. Change in second-trimester abortion after implementation of a restrictive state law. Obstet Gynecol. 2019;133(4):771–779.
28. Upadhyay UD, Desai S, Zlidar V, Weitz TA, Grossman D, Anderson P, et al. Incidence of emergency department visits and complications after abortion. Obstet Gynecol. 2015;125(1):175–183.
29. University of California, San Francisco. Turnaway Study annotated bibliography: advancing new standards in reproductive health. Available at: https://www.ansirh.org/sites/default/files/publications/files/turnawaystudyannotatedbibliography.pdf. Accessed January 31, 2020.
30. Harris LH, Grossman D. Complications of unsafe and self-managed abortion. N Engl J Med. 2020;382:1029–1040.
31. Aiken ARA, Starling JE, Van der Wal A, et al. Demand for self-managed medication abortion through an online telemedicine service in the United States. Am J Public Health. 2020;110(1):90–97.
32. Aiken ARA, Digol I, Trussell J, Gomperts R. Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland. BMJ. 2017;357:j2011.
33. Murtagh C, Wells E, Raymond EG, Coeytaux F, Winikoff B. Exploring the feasibility of obtaining mifepristone and misoprostol from the internet. Contraception. 2018;97(4):287–291.
34. Gold RB, Nash E. Flouting the facts: state abortion restrictions flying in the face of science. Available at: https://www.guttmacher.org/gpr/2017/05/flouting-facts-state-abortion-restrictions-flying-face-science. Accessed January 31, 2020.
35. Guttmacher Institute. An overview of abortion laws. Available at: https://www.guttmacher.org/state-policy/explore/overview-abortion-laws. Accessed January 31, 2020. 36. American College of Obstetricians and Gynecologists. The importance of preserving access to care through the federal Title X program. Available at: https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2018/the-importance-of-preserving-access-to-care-through-the-federal-title-x-program. Accessed August 13, 2020.
37. Cullen, J. AAFP calls on HHS to rescind Title X rule: stay out of patient-physician relationships and protect women’s health. Available at: https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/women/ST-TitleX-022519.pdf. Accessed January 31, 2020.
38. American College of Nurse-Midwives. ACNM statement in opposition of Title X “domestic gag” final rule. Available at: https://www.midwife.org/acnm-opposes-new-title-x-funding-and-eligibility-rules. Accessed August 13, 2020.
39. American Nurses Association. ANA condemns Title X funding cuts proposed by the Trump administration. Available at: https://www.nursingworld.org/news/news-releases/2018/ANA-condemns-title-x-funding-cuts--proposed-by-the-trump-administration/. Accessed August 13, 2020.
40. Kaiser Family Foundation. The status of participation in the Title X federal family planning program. Available at: https://www.kff.org/interactive/the-status-of-participation-in-the-title-x-federal-family-planning-program/. Accessed February 7, 2020.
41. Frederiksen B, Salganicoff A, Gomez I, Sobel L. Data note: impact of new Title X regulations on network participation. Available at: https://www.kff.org/womens-health-policy/issue-brief/data-note-impact-of-new-title-x-regulations-on-network-participation/. Accessed August 13, 2020.
42. Hasstedt K. Federally qualified health centers: vital sources of care, no substitute for the family planning safety net. Available at: https://www.guttmacher.org/gpr/2017/05/federally-qualified-health-centers-vital-sources-care-no-substitute-family-planning. Accessed January 31, 2020.
43. Fredriksen B, Gomez I, Salganicoff A. Data note: is the supplemental Title X funding awarded by HHS filling in the gaps in the program? Available at: https://www.kff.org/womens-health-policy/issue-brief/data-note-is-the-supplemental-title-x-funding-awarded-by-hhs-filling-in-the-gaps-in-the-program/. Accessed February 7, 2020.
44. Bryant AG, Swartz JJ. Why crisis pregnancy centers are legal but unethical. AMA J Ethics. 2018;20(3):269–277.
45. Bryant AG, Narasimhan S, Bryant-Comstock K, Levi EE. Crisis pregnancy center websites: information, misinformation and disinformation. Contraception. 2014;90(6):601–605.
46. Bryant AG, Levi EE. Abortion misinformation from crisis pregnancy centers in North Carolina. Contraception. 2012;86(6):752–756.
47. Swartzendruber A, Lambert DN. A Web-based geolocated directory of crisis pregnancy centers (CPCs) in the United States: description of CPC map methods and design features and analysis of baseline data. JMIR Public Health Surveill. 2020;6(1):e16726.
48. Campaign for Accountability. Trolling for Title X funds. Available at: https://campaignforaccountability.org/work/trolling-for-title-x-funds/. Accessed January 31, 2020.
49. Obria Medical Clinics. Regret taking the abortion pill? Call now…we can help! Available at: https://www.obria.org/services/abortion-pill-reversal/#toggle-id-14. Accessed January 31, 2020.
50. Kimport K, Kriz R, Roberts SCM. The prevalence and impacts of crisis pregnancy center visits among a population of pregnant women. Contraception. 2018;98(1):69–73. 51. Rosen JD. The public health risks of crisis pregnancy centers. Perspect Sex Reprod Health. 2012;44(3):201–205.
52. Office of the United Nations High Commissioner for Human Rights. General comment no. 36 on article 6 of the International Covenant on Civil and Political Rights, on the right to life. Available at: https://www.ohchr.org/Documents/HRBodies/CCPR/CCPR_C_GC_36.pdf. Accessed January 31, 2020.
53. Office of the United Nations High Commissioner for Human Rights, World Health Organization. The right to health. Available at: https://www.ohchr.org/Documents/Publications/Factsheet31.pdf. Accessed January 31, 2020.
54. Kerns JL, Mengesha B, McNamara BC, Cassiady A, Pearlson G, Kuppermann M. Effect of counseling quality on anxiety, grief, and coping after second-trimester abortion for pregnancy complications. Contraception. 2017;97:520–523.
55. Kerns JL, Light A, Daltgon V, McNamara B, Steinauer J, Kuppermann M. Decision satisfaction among women choosing a method of pregnancy termination in the setting of fetal anomalies and other pregnancy complications: a qualitative study. Patient Educ Counseling. 2018;101(10):1859–1864.
56. Stacey D, Bennet CL, Barry MJ, et al. Decision aids for people facing health treatment or screening decisions. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001431.pub3/full. Accessed January 31, 2020.
57. Elwyn G, Frosch D, Thomson R, et al. Shared decision making: a model for clinical practice. J Gen Intern Med. 2012;27(10):1361–1367.
58. Shay LA, Lafata JE. Where is the evidence? A systematic review of shared decision making and patient outcomes. Med Decis Making. 2015;35(1):114–131. 59. Harris PA. AMA statement on ninth circuit Title X decision. Available at: https://www.ama-assn.org/press-center/ama-statements/ama-statement-ninth-circuit-title-x-decision. Accessed January 31, 2020.
60. American Medical Association. Code of Medical Ethics opinion 2.1.3: withholding information from patients. Available at: https://www.ama-assn.org/delivering-care/ethics/withholding-information-patients. Accessed January 31, 2020.
61. American Medical Association. Code of Medical Ethics opinion 1.2.3: consultation, referral, and second opinions. Available at: https://www.ama-assn.org/delivering-care/ethics/consultation-referral-second-opinions. Accessed January 31, 2020.
62. Jerman J, Jones RK. Secondary measures of access to abortion services in the United States, 2011 and 2012: gestational age limits, cost, and harassment. Womens Health Issues. 2014;24(4):e419–e424.
63. American Public Health Association. Policy Statement 20152: restricted access to abortion violates human rights, precludes reproductive justice, and demands public health intervention. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2016/01/04/11/24/restricted-access-to-abortion-violates-human-rights. Accessed January 31, 2020.
64. National Academies of Sciences, Engineering, and Medicine. The safety and quality of abortion care in the United States. Available at: http://www.nationalacademies.org/hmd/Reports/2018/the-safety-and-quality-of-abortion-care-in-the-united-states.aspx. Accessed January 31, 2020.
65. Sonfield A. In bad faith: how conservatives are weaponizing “religious liberty” to allow institutions to discriminate. Available at: https://www.guttmacher.org/sites/default/files/article_files/gpr2102318.pdf. Accessed January 31, 2020.
66. American College of Obstetricians and Gynecologists, Committee on Ethics. Committee opinion no. 385: the limits of conscientious refusal in reproductive medicine. Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Ethics/The-Limits-of-Conscientious-Refusal-in-Reproductive-Medicine?IsMobileSet=false. Accessed January 31, 2020.
67. Harris L. Recognizing conscience in abortion provision. N Engl J Med. 2012;367:981–983.
68. Buchbinder M, Lassiter D, Mercier R, Bryant A, Lyerly AD. Reframing conscientious care: providing abortion care when law and conscience collide. Hastings Center Rep. 2016;46(2):22–30.
69. American College of Obstetricians and Gynecologists, Committee on Health Care for Underserved Women. Committee opinion no. 613: increased access to abortion. Available at: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Increasing-Access-to-Abortion. Accessed January 31, 2020.
70. Gold R. The role of family planning centers as gateways to health coverage and care. Available at: https://www.guttmacher.org/sites/default/files/article_files/gpr140215.pdf. Accessed January 31, 2020.10. Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: perceptions of young adult women. Am J Public Health. 2016;106(11):1932–1937.
71. Eunjung Cha A. New federally funded clinics emphasize abstinence, natural family planning. Available at: https://www.washingtonpost.com/health/2019/07/22/new-federally-funded-clinics-california-emphasize-abstinence-natural-family-planning/. Accessed January 31, 2020.
72. Guttmacher Institute. Mandatory counseling for abortion. Available at: https://www.guttmacher.org/evidence-you-can-use/mandatory-counseling-abortion. Accessed January 31, 2020.
73. Ralph L, Foster DG, Kimport K, Turok DK, Roberts SCM. Measuring decisional certainty among women seeking abortion. Contraception. 2017;95(3):269–278.
74. Eunice Kennedy Shriver National Institute of Child Health and Human Development. What are some factors that make a pregnancy high risk? Available at: https://www.nichd.nih.gov/health/topics/high-risk/conditioninfo/factors. Accessed January 31, 2020.