Contraceptive access remains an uphill battle in Alabama amid near-total abortion ban

In a state like Alabama, with a near-total abortion ban, access to contraception is critical for young women.

But getting it can be difficult, and without the right resources, nearly impossible.

A Centers for Disease Control and Prevention report found nearly 75% of Alabama women aged 18 to 24 in 2019 needed contraceptive services. 60% of women aged 25 to 34 needed those services, and 49.2% of women aged 35 to 44 needed them.

But according to the National Conference of State Legislatures, Alabama does not pursue policies making contraception easier to obtain, such as requiring insurers to pay for contraception, allowing pharmacists to dispense it or making some contraceptives available over the counter.

“Certainly folks who could afford it, who can afford private insurance and those sorts of things are going to have access to other ways of getting their contraception,” said Christina Okarmus, executive director of the Alabama Campaign for Adolescent Sexual Health.

That means uninsured and low-income women have very few options if they can’t afford contraception at retail price. They can go to a community health department, where they may face long waits for an appointment, or they could find a reproductive health organization that can provide birth control at a low-cost.

But these organizations are struggling. Long-acting reversible contraception (LARC) is nearly impossible to provide because of the price tag.

This method, which includes an intrauterine device (IUD) and the birth control implant, are deemed the most effective form of reversible birth control available, according to the American College of Obstetricians and Gynecologists, and can be removed any time a person wants get pregnant or stop using them.

The West Alabama Women’s Center in Tuscaloosa, one of the few organizations that provided abortions before Alabama’s near-total ban went into effect last year, now provides various reproductive services, like birth control, to patients who may not be able to afford these services otherwise.

But the organization can’t buy contraception through a program at a discounted price, like similar organizations that provide reproductive health services and receive Title X funding – federal funds for family planning and preventative care – in other states.

With Title X funds, the organizations would be eligible for a discounted pharmacy program under the federal government.

In most states, community and nonprofit organizations that provide reproductive health services can apply for these funds.  Prescriptions are administered through the 340B Drug Pricing Program, where manufacturers provide outpatient drugs to eligible health care organizations and covered entities at significantly reduced prices. These organizations typically serve uninsured and low-income patients.

“For instance, I have a patient that wants to get a Paragard IUD. That patient comes in, does not have insurance, and we would need to purchase the Paragard, which would cost us about $1,200. If we were able to access it from a 340B pharmacy, that same one would cost us $250. Meanwhile, this patient has $100 to be able to pay for the IUD because that’s all the money that they have,” said Robin Marty, operations director at the West Alabama Women’s Center.

At West Alabama Women’s Center, there is an OB-GYN on staff five days a week, which means they have the capacity to serve a significant portion of the uninsured population. Unlike county health departments, patients don’t need an appointment and pay what they can afford for the services. The catch, Marty said, is that without access to the federal drug pricing program, serving more people means they will close their doors faster.

“We will run out of money that much faster,” she said. “Whereas not seeing patients helps us because it allows us to stay open longer.”

In Alabama, Title X funds only go to local public health departments.

But it’s not required that Title X be administered by a government agency, such as the Alabama Department of Public Health (ADPH), said Dr. Wes Stubblefield, the department’s district medical officer. Other states implement these funds outside of a government agency.

“Although some other agencies in Alabama have expressed interest in applying for the grant, none have done so or were not meeting Title X requirements to be a subrecipient,” he said.

Stubblefield said the state does not have a policy to only give money to community health departments. The local health departments, Stubblefield said, are meeting the current need for family planning services, with 80 sites across the state, including in every county health departments.

Okarmus said negative effects could be reduced if the state took a more active role, such as making contraception more accessible and investing in comprehensive sex education. She also said the state’s administration of Title X funds contribute to obstacles in accessing contraception, particularly for young people.

“Yes, we have contraception in the state. Yes, people can access it, in theory,” she said. “In practice, especially for young people, that they have to go to the county health department to get their birth control, it’s just – it’s not happening.”

Higher risk

The data shows that more Alabama high schoolers are not using any form of protection during sex, compared to rates across the country. The rates of unprotected sex in Alabama, higher than the nation across the board, suggest that young people are not accessing birth control, Okarmus said.

According to Youth Risk Behavior Surveillance System (YRBS) statistics, a comprehensive health survey conducted biennially by the Centers for Disease Control and Protection (CDC) and its state partners, including the Alabama State Department of Education, 24% of Alabama high school students (grades 9-12) admitted to not using any form of contraception before their last sexual encounter, compared to 13.7% nationally. 51.6% said they did not use a condom, compared to 48.2% in the United States.

Despite the increased risk due to unprotected sex, only 6% have been tested for sexually transmitted infections (STIs), 8% for HIV. The state also ranks among the highest for teen births.

Factors such as poor access to sexual education and divestment from communities contribute to unwanted pregnancies. According to the Guttmacher Institute, an organization focused on sexual and reproductive rights, the rate of unwanted pregnancies is more than five times higher among women with earnings below the federal poverty line ($14,580 a year for an individual; $24,860 for a household of three) than among those with incomes at or above 200% of the poverty line.

Women with incomes less than 200% of poverty had six times the abortion rate as women with incomes more than 200% above poverty.

Marty said the community health departments, while they do offer reproductive health services, also see people for a variety of other health issues. Appointments are often booked months in advance, and it may take several calls to reach a human. She said that there’s no reason for a person to have to go through a complicated health care system, such as going to urgent care or trying to get an appointment in a health department to get services that could be done in a few minutes.

She said that’s why reproductive health clinics are so important. 

“A person doesn’t really need to have an appointment to go in and get a refill on your birth control prescription,” she said. “A person can go in and get a Depo shot with it being super quick. These are things that people can do that are very quick, that you can cycle through.”