Women in Texas aren’t getting the contraception they want

Lauren Thaxton may be one of the last doctors in Texas to legally perform an elective abortion. As a provider at Whole Woman's Health, she was at the frontlines last fall when state leaders enacted Senate Bill 8, the six-week abortion ban that slashed access for 7 million women of reproductive age. And she is there now, after the Supreme Court has overturned Roe v. Wade.

Thaxton sees all types of patients, but many of the most financially disadvantaged have a common story: they were hindered from taking proactive steps toward family planning.

"Every day I see someone who can't access the contraceptive method that they want, like an IUD, an implant or sterilization," she said.

Texas has struggled for years to meet demand for the most effective forms of family planning, known as long-acting reversible contraceptive devices, or LARCs. Three years ago, the state's health agency committed to improving those outcomes by 10%, through a host of public-private initiatives including mobile clinics, outreach to physicians and a proposed partnership with the Texas Department of Criminal Justice.    

But the pilot program never gained traction, and soon health officials were overwhelmed by the COVID-19 pandemic. Doctors who treat women of reproductive age today say access remains difficult and unequal, especially for patients from low-income communities, many of whom are uninsured.

The many barriers that women and pregnant people across Texas face in accessing LARCs follows a dearth of funding and policies to bolster widely supported family planning methods, even as the state’s leaders pour time and money into stripping abortion access.

State elected officials began cutting funding for women's health care and family planning a decade ago in an attack on Planned Parenthood, and within a few years more than a quarter of family planning clinics in Texas had closed, most of them not affiliated with the national provider. Some later reopened, but access to contraception and other non-abortion related care, including cancer screenings and STD testing, remains limited. 

With federal abortion protections now overturned, disparities in LARC access are likely to be more pronounced. Research from 2017 found gaping divides among Texas hospitals in the availability of LARCs and sterilization for uninsured women and those on Medicaid who had recently given birth. 

Overall, more than 60% of women said they wanted access to contraception or sterilization, but just under 40% were actually using such methods after six months. Those who received their preferred method of birth control were more likely to be born in the U.S., over 30 years of age and have had a public prenatal care provider.

"Limited use of long-acting and permanent contraceptive methods after delivery is associated with indicators of provider and system-level barriers," the study's authors wrote.

This project for the 2022 National Fellowship aims to build off that research, using statewide data and interviews to show where gaps in access to reproductive health care are greatest and ways in which doctors and elected officials can reduce them. It will also look at other states and counties that have more effectively expanded access.

Tracking these disparities is critical not just for Texas, but states across the South and Midwest where legal abortion access has disappeared. The loss of abortion clinics across these regions will hit hardest on Black, Latino and Indigenous women, many of whom have dealt with generations of social and economic discrimination.

While contraception is no replacement for abortion, equal access to it is imperative for women when abortion is no longer legal, according to providers.

I spoke to Emily Briggs, a family physician who has chaired the Texas Medical Association’s Committee on Reproductive, Women’s, and Perinatal Health, before Roe had been overturned. 

"Especially if Roe v. Wade is overturned, we need to focus on the other service lines in public health, including pregnancy spacing, contraception and education, foster care — all of these other things that are so important if we're not allowing something that's been legal for 50 years," she told me.

Briggs works north of San Antonio and treats a high number of Medicaid patients. Like other physicians, she has to specially order IUDs and similarly costly contraception methods, a process that can take up to a month to complete. That kind of delay reduces the likelihood that the patient will return to actually receive the device, she said.

"I literally can't afford to purchase LARCs and have them just on the shelf for when a patient decides that she wants one and comes into my office to have it," Briggs said.

Cost is a key hurdle for patients as well. Texas has not expanded Medicaid under the Affordable Care Act and has long had the highest uninsured rate and largest number of uninsured people of any state. It also has among the highest rates of teen pregnancy and the highest rate of repeat teen births — teens having more than one child before their 18th birthday. 

Low-income women also lose Medicaid coverage for new moms sooner in Texas than in several other states.

This reporting hopes to shed light on some of the underlying causes of these trends and the ways in which lawmakers and local officials can ensure greater access to reproductive health care and equity for all Texans.