How California's approach to women's health just got 100% better—and how country girls stand to benefit

Disclaimer: Sorry, y’all. I’mma get political up in here about rural health. Check back in later for coverage about nitro coffee if women's health issues that impact country girls ain't your jam. 

A just-released AP survey found that abortions are down in almost all states since 2010—including states with strict abortion laws and states where regulations are looser. Specifically, abortions have dropped 12 percent nationwide and experts are pointing to the decline in teen pregnancies, which in 2010 reached its lowest level in decades, as a major contributing factor for the drop.

The thing about this AP study is that it looked at the data on a state level, not a county level. So while it’s a really useful barometer in assessing the impact of access to abortion, it doesn’t take into account the impact of more granular data—like whether people live in a rural or an urban area. And when it comes to teen pregnancies—supposedly such an important driver here—rural counties lag way behind.

According to a 2010 study (the most recent analysis available), the birth rate for girls ages 15 to 19 in urban areas was 33 per 1,000. In rural counties, it was 43 out of 1,000, a rate nearly a third higher. Rural counties actually accounted for one in five teen births, even though only 16 percent of teen girls live in rural counties.

And according to that same study, things aren’t improving in the country as quickly as they are improving in urban areas. Between 1990 and 2010, the birth rate among teens in major urban centers dropped by almost 50 percent. In rural counties, it declined by only 32 percent.

Why country girls are having more babies

One of the the biggest differences between rural and urban life is access to health-care services—in this case, contraception. Julia De Clerque, a research fellow and investigator at the University of North Carolina Sheps Center for Health Services Research, told USA TODAY that birth control availability in rural areas  "lags far behind availability for teens living in urban and metro areas.”

Last year, I drove to a two-bed critical access hospital in Mountain City, Tennessee for a story that at the time, I wanted to call “You Can’t Have a Baby Here" (a lot of rural providers don't have the bandwidth to offer obstetrics, so women have to travel to deliver). 

To get the hospital, I had to drive switchback roads, keeping a healthy distance between me and the long-haul truckers riding their jake brakes through the mountains (not recommended). There was no bus or subway—just a two-lane through the pines.

About 17 percent of the U.S. population lives in a rural county, where it can be tough for rural teens to get to a provider of birth control—whether because the nearest clinic is too far away or because the cost of travel is too great (about 17 percent of rural residents lived below the poverty line in 2012, compared to about 15 percent nationally). Not to mention recruiting a sufficient number of providers to an isolated area like Mountain City, Tennessee is a huge challenge—not every physician wants to live in a place where a traffic jam is a low-moving tractor (although personally, I don't see why not).

NB here: I’m going to assume you all know that abstinence-only education does not work and I’m not going to waste your time belaboring the obvious connection between teen births and access to contraception. If you do need evidence, take a look at how Colorado averted $5.85 in spending for every dollar it did spend providing free IUDs in health clinics—and lowered its teen birth rate 40 percent from 2009.

There’s more than just distance and a paucity of providers keeping country teens from contraception. There is also evidence that the simple presence of a health-care provider (e.g., a clinic) isn’t enough to improve access to contraception. From that same study

There is some evidence that publicly funded clinics—at least those run by local health departments— are less likely to offer family planning services in rural areas. Also, some research suggests that rural providers on average are less comfortable raising the issue of contraception with teens and are less familiar with the latest information on contraception, particularly the most highly effective methods—long-acting, reversible contraceptives (or LARC), including the implant and the intrauterine device (or IUD). This may be related to the fact that, compared to metropolitan patients, rural patients are more likely to see family doctors instead of specialists, and family doctors on average have a higher degree of discomfort or lack of confidence in providing care to adolescents on topics related to sexuality than obstetrician/gynecologists. It may also reflect the fact that the providers who are most comfortable offering contraceptive care and most familiar with LARC insertion tend to be younger and female—also less common among rural providers.

Another factor may be cultural:

"For many rural families, teen pregnancy and parenting are cultural norms, repeated generation after generation," Josie Weiss, an associate professor at the Christine E. Lynn College of Nursing at Florida Atlantic University in Boca Raton, told USA TODAY.

I don't doubt this is true, but I'm less convinced this is a key driver of the disparity. One read of Adrian Nicole Leblanc’s tour de force Random Family ought to convince you that cycle is not necessarily unique to the country—although perhaps the rural cycle is more driven by religiosity than in urban areas? This is just a speculation.

How OTC contraception could help and hurt

Why teen pregnancies are higher in rural areas is such a complex issue—it’s not just transportation barriers, provider education, sex ed. Solutions aren’t going to be simple either, but states are trying different things that might help. Recent California legislation will allow pharmacists to prescribe birth control pills, patches and rings—although the law stops short of legalizing over-the-counter contraception.

There is some political wrangling going on in Congress at the minute that would result in that kind of unfettered access: Colorado Republican Cory Gardner is working on legislation that would streamline the federal approval process for OTC birth control by creating a pathway for expedited review by the FDA and waiving the filing fee for transitioning drugs. That sounds great for access, but it creates another problem: Many plans don't cover OTC medicines without a prescription and Gardner's legislation wouldn't require them to cover OTC birth control, either. Without insurance, birth control can be exorbitant:  To give you an idea of price: I used to be on Loestrin, a low-estrogen daily that costs between $48 and $116 a month without insurance.

Planned Parenthood and the national OBGYN organization aren’t in favor of Gardner's legislation for this very reason (although they are in favor of OTC birth control generally). They argue that making birth control OTC without accounting for adjusting coverage requirements would shift the cost of birth control on to women, something that the Affordable Care Act tried to eliminate by requiring insurers to fully cover contraception. Making birth control OTC without the complementary controls on insurers would essentially negate the benefits of the provision of the law that makes contraception accessible and affordable without achieving that same benefit some other way. 

(Here's why you should try to set aside how you feel about whether or not women have a right to birth control when thinking about this part: Reducing unwanted pregnancies makes things cheaper for everyone, by a country mile—a 2013 analysis found that maternal and newborn care makes up the most expensive category of hospital payouts for private plans and state Medicaid programs. Your premiums and/or tax-payer dollars pay for that.)

In reality, there’s evidence that not all plans are complying with the birth control coverage mandate, so some women are up shit creek without the proverbial paddle anyway. But I like California’s approach because it aligns with the intent of the mandate—which I believe will be increasingly enforced—while simultaneously boosting the number of providers who are able to prescribe contraception. In other words, insurance still covers birth control as an essential benefit—and insurance continues to be required under the health law—but actually getting ahold of birth control is that much easier for women in areas with not a lot of providers.

Is an OTC option that is covered by issuers the ideal? Of course—as Dr. Nancy Stanwood, an associate professor of Obstetrics and Gynecology at the Yale School of Medicine said: "It's just a matter of taking away the traditional barriers. Maybe a woman can’t get to a doctor’s appointment, but she can get to a Walgreen’s."

But right now, I'll take what I can get. 

Shameless self-promotion: I'm a health-care journo in my real life. I write primarily for hospital execs, which why this piece is appearing here as opposed to on Healthcare Dive, but a lot of what I write about rural health is equally important for you non-health-care wonks out there. Check out this piece I wrote on quality of care in rural hospitals and this piece about how two rural hospitals are bucking the rural health crisis