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Friday, April 12, 2019

Women's Health-The Attack on Reproductive Health


Women’s Health Revisited-Reproductive Health and Violence Towards Women

State healthcare laws impact women and should be considered by anyone thinking of relocating within the USA. Primary measures of women’s health and well-being include: access to reproductive services, availability of birth control options, maternal death rates, proportion of women covered by medical insurance, and violence against women. In order to keep this a blog-sized article, this analysis reviews; reproductive services, sex education mandates, and reported rates of rape, murder, and aggravated assault, which includes domestic violence. A subsequent issue will explore other components of women’s health.
Access to Abortion
Roe-v-Wade, the Supreme Court ruling which made abortions legal in the United States was enacted in 1973. The majority of the national population felt that abortion should be legally available to women then and still do today.  A 1979 study conducted by the Gallup Organization found 80% of the population believed abortion should be legal and 70% thought it should be available to women on Medicaid. (Public Perception on Abortion) It should be noted, the survey was commissioned by Redbook Magazine, which would have targeted a largely female population, so this acceptance of abortion rights may reflect the feminine viewpoint. A Harris Group poll at the time found 60% of Americans thought abortion should be legal in all cases. Fast forward to 2018 and Pew Research found that 58% of Americans still think abortion should be legal and only 15% were willing to say that abortion should be illegal in all cases, including rape, incest, and when the woman’s life is endangered. (Public Opinion on Abortion, 2019) The latter must view women as a host body rather than as emancipated individuals.
Table of Abortion Laws
Most Restrictive
Moderately Restrictive
Least Restrictive
Bans at 0-12 weeks gestation, which is during the first trimester of pregnancy
Allows abortion during the second trimester of pregnancy; 12-24 weeks gestation
States which permit abortion to-24-weeks and into the third trimester; depending on the circumstances
6 weeks-Louisiana* Senate Bill 184 proposes banning abortion at fetal heartbeat detection, which is during the embryonic stage (Clark, 2019)
Louisiana current law permits abortion to 15 weeks, which is 2 weeks past the 1st trimester
States permitting abortion to 24 weeks; CA, CT, DE, HI, ID, IL, MD, ME, MI, MN, MO, MT, NY, TN, WY
6 weeks fetal heartbeat law was voted unconstitutional by the North Dakota Supreme Court in 2016. ND has since voted to outlaw dilation and evacuation procedures, criminalizing doctors who perform them (Lam, 2019)

North Dakota current law permits abortion to 22 weeks
Massachusetts law allows abortion up to 27 weeks past the last period
18 weeks-Arkansas abortion ban was signed by Governor Hutchinson in March 2019. (Arkansas Governor Signs 18 Week Abortion Ban Into Law, 2019)
Arkansas current law allows abortion within the 2nd trimester
Virginia permits abortion at 25 weeks
6 weeks-Mississippi Governor Bryant signed a bill in March 2019 banning abortion at fetal heartbeat or 6 weeks past-last-period (Blinder, 2019)

Mississippi- current law permits abortion to 20 weeks, but restriction to 15 weeks is under litigation
These states permit abortion for lethal fetal anomaly: MS, GA, LA, SC, TX, DE, MD
6 weeks-Florida has a bill pending to restrict abortion once there is a fetal heartbeat, which is during the embryonic stage, so 6 weeks or less of pregnancy; and to make doctors performing abortions felons (Weiss, 2019)
Current Florida law permits abortion to 24 weeks
These states permit abortion to viability w/o restriction, leaving the decision to the clinician and patient: AK, CO,DC, NH, NJ, NM, OR, VT
Bans partial birth abortion; NH
House Bill 28 would outlaw abortion after 13 weeks in North Carolina (Cross, 2019)
North Carolina- current law allows abortion to 20 weeks
Michigan permits post viability abortion if a woman’s health is endangered
Senate Bill 1867 was signed by Arizona Governor Ducey, would require doctors to give life-saving treatment to aborted fetuses (Rau, 2019)
Arizona-has passed a law mandating a rollback to 20 weeks which is under litigation
Arizona currently allows abortion to 25 weeks
Ohio’s fetal heartbeat bill passed the legislature but was vetoed by Governor Kasich
Ohio current law allows abortion to 22 weeks
Permits abortion to viability for rape and incest: MI
Similar efforts to restrict abortion to 6 weeks also include:  Kentucky, South Carolina,Tennessee, and Texas. A Texas bill failed in April 2019 and would have included the death penalty for women who have abortions for any reason and for clinicians who perform them.
AL, AR, GA, ID, IND, IO, KS, KT, LA, NB, OK, SC, SD, TX, WV, WI all permit abortion up to 22 weeks
States permitting abortion to viability  if woman's life is endangered: RI, MI

States permitting abortion to viability for fetal abnormality: MD, DE
Utah has an 18 week ban on abortion in their 2019 legislative agenda
FL, MA, RI, NV, and PA permit abortion to 24 weeks
Utah permits abortion to viability for-rape, incest, and lethal fetal anomaly
Notes-
*All first trimester bans are under review by the courts and are not currently allowed. The now conservative US Supreme Court is expected to hear some of these cases this year. Several states are trying to limit abortion from the point of fertilization or at the embryonic stage, which occurs within two weeks of the sperm penetrating the egg during intercourse, and before a woman would know she is pregnant. These folks must have skipped biology class as a fertilized egg is not a baby.

Availability of Contraceptive Services
Catholic hospitals have repeatedly been found not to comply with state laws regarding the availability of emergency contraception for women whom have been sexually assaulted. A California study found only 66% compliance among Catholic hospitals. (National Women's Law Center, 2019)
Table of Laws Governing Access to Birth Control Options
Criteria
Most Restrictive for Sexual Activity
Least Restrictive for Sexual Activity
Access to Abortion Clinics (Citizen Access.org, 2019)

States with the fewest number of abortion clinics for the eligible population of females, each with only 1 clinic: MS, MO, KT, ND, SD, WV
Other states with a dearth of facilities: AL, SC, LA, WI, UT, TX
These states may have adequate abortion facilities, based on population but they are not geographically dispersed: MN, IA, ID, WY, NE, KS, OK, AR, TN, DE, RI, HI
States considered to have acceptable access to abortion clinics: CA, OR, WA, CO, MT, GA, AK, NC, VI, MD, NJ, PA, NY, NH, VT, ME, CT
Availability of Morning After Pill
This is commonly known as Plan B was approved by the FDA in 2011 (Princeton University, 2019) Because this is emergency contraception it must be administered within 120 hours of sperm exposure.
States which do not mandate information on emergency contraception even in the event of rape: MS, MO, GA, NC, LA, ND, SD (NCSL.org, 2019)
States permitting pharmacists to prescribe emergency contraception to women of any age: AK, WA, CA, HI, NH, NM, VT, ME, MA
States with reporting mechanisms for hospitals that do not comply with emergency contraception notification for rape victims: HI, MN, NJ, NM, IL OR, UT, WA, and WI (Washington Women's Law Center, 2019)
Birth control RX is mandated coverage for private insurance; although self-insured plans under ERISA are exempt as are religious entities (Laurie Sobel, 2019)
No mandate to cover RX contraceptives on government plans in: TX, TN, VI, OH
All other states mandate RX contraceptive coverage on private insurance plans
Birth control RX is mandated coverage for state agencies



Abortion covered by insurance
(Guttmacher Institute, 2019)
No mandate to cover RX contraceptives on government plans in: TX, TN, VI, OH


States with limited insurance mandates to cover abortion: AZ, ID, IN, KS, KY, MI, MO, NE, ND, OK, UT
These states will not allow any exemptions for state or private agencies: CO, GA, IA, MT, NH, NV, VT, WA, WI (Laurie Sobel, 2019)
Medically necessary abortions must be covered by insurance: WA, OR, NJ, NM, NY, IL, HI, CT, CA, AZ, AK
Mandated sex education in public schools (Guttmacher Institute.org, 2019)
These states have no mandate for sex education in public schools: AZ, CO, FL ID, MA, VI, TX, LA,
States requiring sex education to be medically accurate and also provide education on sexually transmitted diseases: CA, DE, DOC, GA, HI, IA, KT, MN, MD, MS, MT, NV, NJ, NM, NC, ND, RI, SC, TN, UT, VT, WI
Nonprescription birth control measures (condoms) widely available at retail outlets

Some states like TX, AR, and DE have laws requiring condoms to be distributed by MD’s or Pharmacists-These laws are typically not enforced. (McDevitt, 2016)
Metropolitan areas throughout the US have condoms in grocery, drug, and convenience stores. Individuals can have condoms delivered to their home from Amazon or the Condom Super Store.com
Adequate supply of OBGYN and primary care providers (Citizen Access.org, 2019)
Inadequate supply of primary care for women in: ND, SD, MO, IO, IND, WI, KT, WV, UT, MS, TX, GA, LA
Adequate supply of primary care for women: WA, OR, CA, NY, MA, MI, IL, PA, NJ, NC, VI, MD, FL

Assault and Violence-A Statewide Analysis
Using the Federal Bureau of Investigation Crime Statistics for 2017 I analyzed rape, murder, and aggravated assault, which includes domestic violence statewide. The tables below show the safest and most dangerous states for women to live. Scores compare the variance between the national average and each state’s metrics including the Washington DC area. A negative score means these states had fewer incidents than the national average and conversely a positive score means the state had greater incidents of violence. These data are combined male and female rates, but 79% of all violent crimes were committed by men and women were victims 48% of the time. However, 93% of rapists were male and 89% of their victims were female. Likewise, for murder,78% were men and 24% of the victims were women.  (Federal Bureau of Investigation, 2019)
Safest Places
The safest places to live in the USA are the northeastern states of Maine or Vermont or the eastern seaboard states of Connecticut or Virginia. These states all tend to have good education systems and fairly high taxation. If you are a woman living in Maine you are 3 times less likely to be raped, nearly 5 times less likely to be murdered and 3 times less likely to be assaulted than for a woman in Alaska.

Table of Safest Places in the United States

Health Metrics
For Violence
Statewide



Measures based on 2017 FBI data
National Incidence Rate per 100,000 people
Maine
Connecticut
Vermont
Virginia
 Rape
41.7
35.4
23.3
35
33.8
Score

-6.3
-18
-6.7
-7.9
Murder
5.3
17.
2.8
2.2
5.3
Score

-3.6
-2.5
-3.1
0
Aggravated Assault
284.9
65.3
123
114
118
Score

-220
-162
-171
-167
Combined Score

-230
-182
-181
-175


 Most Violent Places
In terms of this ranking methodology, the goal is to have fewer events than the national average for acts of violence but as you can see, these states have high rates of aggravated assault, rape, and murder, compared to the national incidence rate. It is difficult to draw conclusions from this grouping as they are so varied. Most worrisome is the rape statistic for Alaska, which I triple checked and represents 32 out of 39 agencies reporting their data for 2017.  Alaskans have 386 more incidents of these violent crimes per 100,000 people than the national average, due largely to the rape metric.  However, the assault rate was high in Alaska as well.  The highest murder rate in the nation was in Washington DC, with more than twice as many murders than the national average for 2017. The rate of assaults in DC is similar to Alaska. About the only things that Alaska and New Mexico have in common are large tribal populations, which may explain some of the violence. But Montana also has significant tribal populations and their violence metric was much lower as was North Dakota's, where the Pine Ridge Reservation is located.

 Table of Most Violent Places In the United States

Health Metrics
For Violence
Statewide



Measures based on 2017 FBI data
National Incidence Rate per 100,000 people
Alaska
Washington, District of Columbia
New Mexico
Tennessee
Rape
41.7
116.7
64
60.3
43.7
Score

75
22.3
18.6
2
Murder
5.3
8.4
16.7
7.1
7.8
Score

3.1
11.4
1.8
2.5
Aggravated Assault
284.9
575.4
546.3
537.8
483
Score

290.5
261.4
252.9
198.1
Combined Score

386.6
295.1
273.3
202.6


 Conclusion
In my 15 hours of research for this article, I decided the issue of female autonomy and reproductive rights is too complicated for one article. This analysis has attempted to show the level of vitriol lobbed against women’s constitutional rights at this moment, during the Trump Administration. Though the anti-abortionists have been relentless in their assaults on state laws governing women’s health and the clinicians whom provide these services, they have only managed to change public perception by 2%. According to a recent Pew Research poll only 2% fewer Americans believe abortion should be outlawed.  All of the harassment, personal injury, and even deaths caused by the irrational cabal of personhood-fetus-promoters has barely managed to move the dial. One can only hope that doctor patient privilege and privacy will be protected by the courts. But with the statewide and more recent federal court appointments hueing conservative, we can anticipate an increase in the rate of incarceration for women whom are merely trying to make informed decisions for their lives. At the Supreme Court we can count on newly minted Justice Kavanaugh, who doesn’t hate all women, just the ones who disagree with him, to vote against women’s autonomy at every turn. (Congressional Record, 2018) (AP, CNN, 2018)  

And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when entering an inpatient facility. Do stipulate that for which you agree and for which you decline.

This article was written by Roberta E. Winter, MHA, MPA a freelance journalist and is not subject to approval of any corporate or government agency. Winter is the author of Unraveling US Healthcare-A Personal Guide, published by Rowman and Littlefield in 2013. Research for this article will inform an update to her healthcare guide. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References


80% of Americans Believe Abortion Should Be Legal-70% Approve Medicaid Funding. (n.d.). Retrieved April 6, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/383496
AP, CNN. (2018, September 28). Key Moments from the Ford and Kavanaugh Hearings Video. Retrieved from The Guardian: https://www.theguardian.com/global/video/2018/sep/28/key-moments-from-the-ford-and-kavanaugh-hearings-video
APnews.com. (2019, April 6). Retrieved from Associated Press News: https://www.apnews.com/e41973cb7e7c4441b77d90e852568401
Arkansas Governor Signs 18 Week Abortion Ban Into Law. (2019, March 15). Associated Press. Retrieved April 11, 2019, from https://www.apnews.com/b0e1e6fb69c6414e89ecadb0f4dd8178
Blinder, T. W. (2019, March 21). The New York Times. Retrieved April 11, 2019, from https://www.nytimes.com/2019/03/21/us/abortion-laws-states.html
Citizen Access.org. (2019, April 7). Data shows unequal access to abortion clinics nationwide. Retrieved from CU-Citizen access.org: https://www.cu-citizenaccess.org/2019/02/08/data-shows-unequal-access-to-abortion-clinics-nationwide/
Clark, M. (2019, April 8). Law Banning Abortion After A Fetal Heartbeat is Detected Is Set for Consideration by Louisiana Legislature. Times Picayune. Retrieved April 11, 2019, from https://www.nola.com/news/2019/04/law-banning-abortion-after-a-detectable-fetal-heartbeat-is-set-for-consideration-by-louisiana-legislature.html
Congressional Record. (2018, September 27). Supreme Court Hearing Sexual Assualt Hearing. Retrieved from C-Span: https://www.c-span.org/video/?451895-2/supreme-court-nominee-brett-kavanaugh-sexual-assault-hearing-judge-kavanaugh-testimony
Cross, J. (2019, February 11). The Daily Tarheel. Abortions After 12 Weeks Could Be Ilegal In North Carolina If New Bill Passes. Retrieved April 11, 2019, from https://www.dailytarheel.com/article/2019/02/nc-abortion-ban-0211
Federal Bureau of Investigation. (2019, April 11). United States Crime Statistics 2007-20017. Retrieved from Federal Bureau of Investigation Crime Data Explorer: https://crime-data-explorer.fr.cloud.gov/explorer/national/united-states/crime/2007/2017
Guttmacher Institute. (2019, April 7). State Policy-Insurance Coverage for Contraceptives. Retrieved from Guttmacher.org: https://www.guttmacher.org/state-policy/explore/insurance-coverage-contraceptives
Guttmacher Institute.org. (2019, April 7). State Policy Sex and HIV Education. Retrieved from Guttmacher.org: https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education
Lam, K. (2019, April 11). North Dakota Becomes Third State to Ban Dialation and Evacuation Procedure. USA Today. Retrieved April 11, 2019, from https://www.usatoday.com/story/news/nation/2019/04/10/north-dakota-abortion-procedure-dilation-evacuation/3429483002/
Laurie Sobel, A. S. (2019, April 7). Kaiser Family Foundation State and Federal Contraceptive Coverage Requirements. Retrieved from KFF.org: https://www.kff.org/womens-health-policy/issue-brief/state-and-federal-contraceptive-coverage-requirements-implications-for-women-and-employers/
McDevitt, D. J. (2016, July 22). Condom Laws. Retrieved April 7, 2019, from RipnRoll.com sex education blog: https://www.ripnroll.com/blogs/sexual-education/condom-laws
NCSL.org. (2019, April 7). Emergency Contraception State Laws. Retrieved from National Center for State Legislation: http://www.ncsl.org/research/health/emergency-contraception-state-laws.aspx
Princeton University. (2019, April 7). Emergency Contraception. Retrieved from Princeton.edu: https://ec.princeton.edu/questions/state-pharmacy-access-list.html
Public Opinion on Abortion. (2019, April 6). Retrieved from Pew Forum.org: https://www.pewforum.org/fact-sheet/public-opinion-on-abortion/
Rau, A. B. (2019, March 14). What Arizona's Latest Abortion Law Really Does. The Republic, p. 2017. Retrieved April 11, 2019, from https://www.azcentral.com/story/news/politics/legislature/2017/03/14/what-arizonas-latest-abortion-bill-really-does/98606122/
National Women's Law Center. (2019, April 7). Providing Emergency Contraception to Sexual Assualt Victims. Retrieved from Washington Womens Law Center.org: https://nwlc.org/wp-content/uploads/2015/08/providing_ec_to_sexual_assault_survivors_factsheet_6-28-13.pdf
Weiss, J. (2019, January 20). What is the Future of Abortion Restrictions in Florida. WLRN. Retrieved April 11, 2019, from https://www.wlrn.org/post/what-future-abortion-restrictions-florida




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