Beyond the Numbers: Access to Reproductive Health Care for Low-Income Women in Five Communities

Erie County, PA

KFF: Usha Ranji, Michelle Long, and Alina Salganicoff
Health Management Associates: Diana Rodin, Carrie Rosenzweig, and Sharon Silow-Carroll

Introduction

Located in northwestern Pennsylvania on the shore of Lake Erie, Erie County has a large city (Erie), where 80% of the population lives, several smaller communities, and a large swath of rural area. Although the state expanded Medicaid under the Affordable Care Act, the county is federally designated as medically underserved and as a health professional shortage area (Figure 1). However, the city of Erie has a relatively strong health care safety net that includes family planning services, and the local health care system is working to meet the needs of a relatively large population of refugees and immigrants. As a whole, Erie County is more politically conservative than the city of Erie, and the Roman Catholic Diocese of Erie and the large Catholic population in the region influence both the health care and educational systems. The conservative culture plays a role in reproductive health care access in the region, particularly as it affects the availability of abortion services.

This case study examines access to reproductive health services for low-income women in Erie County, Pennsylvania. It is based on semi-structured interviews conducted by staff of KFF and Health Management Associates (HMA) with safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates (“interviewees”), as well as a focus group with low-income women in April 2019. Interviewees were asked about a wide range of topics that shape access to and use of reproductive health care services in their community, including availability of family planning and obstetrical care, provider supply and distribution, scope of sex education, abortion restrictions, and the impact of state and federal health financing and coverage policies locally. An Executive Summary and detailed project methodology are available at https://www.kff.org/womens-health-policy/report/beyond-the-numbers-access-to-reproductive-health-care-for-low-income-women-in-five-communities.

Key Findings from Case Study Interviews and Focus Group of Low-income Women
  • Access to contraception – Overall, a range of family planning services for low-income residents are available in the city of Erie, though access can be a challenge in rural parts of the county and for uninsured women.
  • Refugee communities – Reproductive health and family planning preferences vary widely among Erie’s large refugee community with its diverse religious and cultural beliefs. While many refugees face language barriers when seeking care, case managers, dedicated service agencies, and a Federally Qualified Health Center focused on providing culturally appropriate care support access to preferred methods of family planning.
  • Cost and coverage – Pennsylvania expanded Medicaid, improving access to coverage for thousands of Pennsylvanians. However, low-income uninsured women who are not eligible for refugee support services face barriers to family planning and other health care including high cost sharing, logistical barriers such as lack of transportation, and the need for multiple appointments to obtain long-acting reversible contraception or postpartum tubal ligation.
  • Ob-Gyn practice consolidation – Ob-Gyn practice consolidation has reduced options for women in the Erie area who are seeking perinatal care. One large practice dominates the Ob-Gyn provider landscape.
  • Abortion – There are no abortion providers within 90 miles of Erie, which makes it difficult for women to get to abortion providers and compounds cost barriers for women seeking abortion services. The region’s conservative and religious culture limits discussion of reproductive and sexual health topics, particularly abortion, which carries significant stigma.

Figure 1: Demographic Characteristics of Reproductive Age Women in Erie County, PA, 2017

Contraceptive Provision, Access, and Use

Family planning providers offer a wide range of contraceptive choices including long-acting reversible contraceptives (LARCs), but barriers persist for some patients and for same-day access among some providers.

Erie County’s Title X clinic is the only provider offering same-day access to long-acting reversible contraceptives (LARCs), including IUDs and implants. Adagio Health, the most comprehensive provider of family planning services in the county, has a clinic in the city of Erie and one in nearby Edinboro. These clinics are supported by funds from the federal Title X program and are reportedly the only providers offering same-day access to most contraceptive methods including LARCs. Interviewees noted that the need for multiple appointments at other providers can be a barrier to LARC access. A clinician commented that more immigrant and refugee patients were requesting LARCs recently because they feared access to services would soon be restricted under federal policy changes related to immigrants. Federally Qualified Health Centers (FQHCs) in the region offer far fewer contraceptive methods, typically the pill. Interviewees perceived primary care providers as similarly limited in their provision of family planning services, particularly in that they do not provide LARC. One interviewee noted that referral loops between the large Ob-Gyn group and FQHCs are not always closed, leaving clinicians uncertain whether their patient made their appointment or received services. However, these entities are working to improve their coordination.

With the new [Trump] administration, immigrant and refugee patients saw an upswing in LARC because people were afraid they wouldn’t be able to get services because of their status.”
–Susan Scriven, Nurse Practitioner, Adagio Health

Challenges getting patient-centered, respectful care are widespread. While many focus group participants had been able to access family planning services they needed, many also had negative experiences with reproductive services over the course of their lives. Focus group participants described: pressure from providers to use or not use contraception based on the providers’ own preferences and attitudes about ideal family size, the age of the patient, or the provider’s own religious beliefs; traumatic birth experiences or obstetric care; and racial and socioeconomic discrimination in the health care system. Interviewees and focus group participants reported that women who are uninsured or covered by Medicaid are not always treated with respect by private providers and have limited alternatives to switch providers if they have a negative experience.

“Well with my OBs, [contraception has] always been kind of pushed on me. I think with having more children, with having a bigger family, since like baby number three, it’s like automatically they’re like pushing me into using contraception.”
–Focus group participant

“I just went to the gynecologist in January… I’m… trying to conceive, and when I brought that up I kind of got brushed off.”
–Focus group participant

Sex Education Policy and Provision

Interviewees described variation among school districts in their willingness to provide sex education and their use of evidence-based programs. The student parenting program associated with Erie City School District recently implemented the evidence-based, comprehensive FLASH curriculum.1 At the same time, there is a significant presence of crisis pregnancy centers (CPCs) in schools from elementary through high school that provide more limited “character education.” A stakeholder reported that the CPCs, which usually promote abstinence, receive state, federal, and private funding which enables them to conduct more outreach and programs than the more comprehensive reproductive health care providers. Focus group participants perceived availability of sex education as inconsistent across schools and not necessarily adequate for high school-aged students.

“We worked really hard to get FLASH implemented. Prior to that, [sex ed] was the most ignored curriculum in the district. [Students] only get this program [FLASH] when they get that health class, and we are in a block schedule, so they are not getting this information every year regularly.”
–Interviewee

Initiative: Supporting Erie’s pregnant and parenting students
The Erie Student Parenting Program, ELECT, assists pregnant and/or parenting middle and high school students in the Erie City School District, charter and prep schools, and other educational programs in Erie, to attain their high school diploma or GED while learning to be parents of healthy babies. Roughly 90 students are enrolled in the program, which provides a wide range of services including: case management; prenatal, family planning, and parenting education; individual and group counseling; and linkages to social services including childcare, transportation, job readiness training, and continuing education. ELECT also has an initiative to promote breastfeeding among teen parents, a doula program to accompany teens to appointments and during the delivery, and a home visiting program to establish individual goals with each student. During the 2017-2018 school year, about 5.4% of the program’s participants had repeat pregnancies, down from 8% in 2015-2016. Average excused absences also decreased from 48% to 30%. In addition, ELECT’s participant graduation rate was 91% in 2016-2017, up from 85% the prior year.

Religious and Cultural Factors

Erie County, including the city, has a large Roman Catholic population, and the church’s policies on family planning and abortion have influenced the health care and educational systems. The Catholic Diocese of Erie includes 12 northwestern Pennsylvania counties in addition to Erie, and claims 202,000 members, almost half of whom are in Erie County. Although Erie County’s formerly-Catholic hospital, St. Vincent, no longer has a religious affiliation,2 some interviewees and focus group participants were unsure whether all faith-based restrictions on care, such as limits on sterilization, have been eliminated. More broadly, Catholic and Evangelical Christian opposition to abortion is reflected in the community, with focus group participants stating that people are “closed off” and reticent to discuss abortion, and to some degree, contraception and other reproductive health issues.

Members of the extremely diverse refugee and immigrant communities in Erie have a wide variety of religious affiliations and beliefs, with varied preferences related to reproductive health care. The health center that provides culturally competent care predominantly to refugees provides referrals to the full range of reproductive health care, including family planning and abortion services. Staff noted that it was rare for patients to seek abortion services, but they had provided referrals when asked.

Specialized Services for Erie’s Refugee Communities

The local health care system is focused on meeting the health and family planning needs of a significant refugee population.

Erie is home to one of the largest refugee resettlement populations in Pennsylvania, and refugee resettlement agencies as well as a refugee-focused health center, the Multi-Cultural Health Evaluation Delivery System (MHEDS), are focused on meeting their health needs including family planning services. According to one interviewee, from 2012 through 2016, Erie settled almost 3,500 refugees from countries including Bhutan, Nepal, the Democratic Republic of Congo, Russia, Somalia, South Sudan, Syria, and Ukraine. Some interviewees mentioned that there has been a significant reduction in the number of refugees seeking services in Erie, which they attribute to the current national political climate. The State Department’s Refugee Processing Center reports that refugee arrivals to Erie has plummeted since 2016.3 Women who are part of those communities have varying preferences and use of family planning services, and the local health care system is building capacity to better meet their needs. MHEDS is an FQHC “look-alike” health center and the sole provider in Erie for the refugee resettlement program, with which it contracts to complete health screenings for newly arrived refugees. MHEDS, along with the Title X program, also provides services to migrant agricultural workers and Amish and Mennonite communities in Erie County.

MHEDS has tailored its services and staffing to address the particular concerns of Erie’s refugee communities and to provide culturally competent care. The health center has medical interpreters from many refugee communities in Erie to address language and cultural barriers. Some women have experienced genital mutilation, and MHEDS is focused on improving provider capacity in Erie to address the associated physical and mental health consequences and competently care for these women. They plan to add well women visits to further develop their onsite women’s health services. Refugees also have varied views of the highly medicalized American model of prenatal care. Some women are not accustomed to the frequent prenatal appointments or standard testing, which can lead to tension with providers. Refugees have Medicaid coverage and are assigned case managers for their first five years in the United States, which helps support access to health care services. However, outside MHEDS, women who need services in languages other than English often face barriers, particularly when providers do not follow requirements to offer interpretation services.

“Language is a barrier – for all languages. We have an interpreting program they can access that is fee-for-service. Providers contract with the interpretation services through our agency. We have a broad range of languages available. We can cover the need, it’s just whether the provider wants to use it. It’s their responsibility. Some providers are very proactive about providing language services, and others bend the rules to get around the standards.”
–Interviewee

Cost and Coverage

Access to contraceptives is shaped by state policies that have expanded Medicaid and promoted availability of all family planning methods, but on the local level, providers are concentrated in the population centers, limiting access for women in the rural parts of the county. Cost is a barrier to contraception for some uninsured women, even at publicly-funded health centers or Title X clinics using sliding fee scales.

Table 1: Pennsylvania Medicaid Eligibility Policies and Income Limits
Medicaid Expansion Yes
Medicaid Family Planning Program Eligibility 220% FPL
Medicaid Income Eligibility for Adults Without Children, 2019 138% FPL
Medicaid Income Eligibility for Pregnant Women, 2019 220% FPL
Medicaid Income Eligibility for Parents, 2019 138% FPL
NOTE: The federal poverty level for a family of three in 2019 is $21,330.
SOURCE: KFF State Health Facts, Medicaid and CHIP Indicators.

Medicaid expansion has supported increased access to health care broadly and to family planning services in recent years. Pennsylvania’s Democratic governor presided over Medicaid expansion in 2015.4 Between 2010 and 2017, Pennsylvania’s uninsured rate decreased from 10.2% to 5.5%. As of early 2019, nearly 700,000 Pennsylvanians were enrolled in the Medicaid expansion. Pennsylvania also has a family planning program established through a Medicaid State Plan Amendment that covers comprehensive family planning services for eligible men and women with incomes up to 220% FPL (Table 1).

“No one is turned away. As long as people know about us [they can get access] – we do sometimes hear from patients, ‘Oh, I just found out about you.’ Ten to twenty percent are uninsured and get services through Title X. That number went down as a result of Medicaid expansion.”
–Susan Scriven, Nurse Practitioner, Adagio Health

Erie County’s Title X grantee, Adagio Health, is the key provider of comprehensive family planning services to low-income women, though access to all health care services is limited in rural areas. While Medicaid expansion has increased the number of providers in Pennsylvania, interviewees reported that it remains difficult to recruit and retain clinicians and staff in Erie County, resulting in provider shortages. As a result of competing demands on patients’ time, many providers struggle with high no-show rates which lead to scheduling difficulties. Transportation is a barrier to all health care services. Unreliable buses and lack of access to cars limit low-income women’s ability to travel, particularly in rural areas, but also within the city of Erie where severe winter weather can compound travel challenges.

According to an interviewee, between 10% and 20% of patients served by Adagio Health are uninsured. Because Title X patients pay for care based on a sliding scale, some can face fees up to 50% of the cost of the family planning method, which can be as much as $250 for an IUD. Emergency contraception is available at pharmacies or from a doctor, but focus group participants found it expensive to buy over the counter and hard to get a prescription; one participant described a provider refusing to dispense emergency contraception because of their own religious beliefs.

“The Plan B you can buy…over the counter, but it’s 50, 60 bucks, otherwise you have to get a prescription and it is hard as hell to get a prescription for it.”
–Focus group participant

“Because so many different doctors have their own beliefs—and I think that’s part of that problem in women’s care—their personal beliefs will overcrowd what they need to do medically for their patient…”
–Focus group participant

Initiative: Connecting patients to transportation
Because the majority of their patients do not drive, the Primary Health Network (PHN), a local school-based FQHC, provides transportation for patients to and from medical appointments at the clinic at no cost using ride-share applications such as Uber and Lyft. The PHN transportation department receives charitable donations to cover the cost.

Provider Distribution and Ob-Gyn Consolidation

Rural areas of Erie County have less access to health care. The Title X grantee is the primary family planning provider for low-income women, while one Ob-Gyn practice dominates the perinatal care landscape.

Maternity Care

Provider consolidation has resulted in fewer options for maternity care in the county. There are no longer any maternity facilities outside of the city of Erie, so most deliveries take place at one of the three major hospitals in the city. Nearly all perinatal care is provided by a single physician group, with two locations in the city of Erie and two satellite offices in Corry and Union City, smaller towns in Erie County. Interviewees highlighted that there is little competition or alternative to this large provider group. The Title X grantee, Adagio Health, also provides prenatal care to some low-risk women, working with physicians in the large Ob-Gyn practice who track their charts weekly and provide delivery and postpartum services. Many interviewees and focus group participants raised concerns that having only one major Ob-Gyn practice could result in lower quality of care and noted they had heard or directly experienced that some of the practice’s providers do not treat patients with Medicaid coverage with respect. Focus group participants also expressed preferences for greater continuity of care than offered by this practice where patients may see a different prenatal provider during each visit and at delivery. Several focus group participants had used midwifery or doula services, but this was not reported to be the dominant model.

“Ob/Gyn Associates is the go-to, but if there were more options it would be easier for patients. If they have a bad experience with one doctor, they don’t want to go to that practice again, even to another doctor. And there is nowhere else close by, or they don’t accept Medicaid.
–Interviewee

Provider practices around postpartum care and related family planning services vary and often lack continuity. Some providers discuss postpartum resources including family planning during prenatal visits, while others do so after delivery. One interviewee noted that some women do not know where to go for postpartum services; and some return to their prior source of care, only to be directed back to the Ob-Gyn for their postpartum follow-up visits. Most providers refer low-income women to the Title X provider for family planning after their pregnancy Medicaid ends; however, women seeking sterilization are referred to the hospitals in the city of Erie.

“I think we could all suffer from a bit of PTSD with our [reproductive health care] experiences…”
–Focus group participant

“I think almost every woman has had a bad experience [seeking reproductive health care] …”
–Focus group participant

Other Reproductive Health and Social Service Providers

The Erie County Department of Health (DOH) operates a sexually transmitted infection (STI) clinic providing testing and treatment, infectious disease surveillance, education, and robust HIV follow-up care. The STI clinic provides free testing and treatment two days per week or by appointment, with a particular focus on pregnant women and their partners. DOH recently identified an increase in syphilis among infants in Erie, reinforcing the need to screen all pregnant women. DOH collaborates with partners including the Title X grantee, which also provides free HIV testing and treatment services. The department also conducts rapid HIV screening, counseling, pre-exposure prophylaxis (PrEP), and ongoing follow-up with each person who tests positive for HIV to ensure that they are connected with and maintain access to treatment, including home visits if needed. Multiple interviewees and focus group participants stated that there is a lack of knowledge about STIs among youth in the community. Stigma continues to be a barrier to STI testing and treatment, but DOH conducts community-based education programs as funding allows.

Initiative: Sexual health promotion and outreach
The Erie Department of Health (DOH) operates a health promotion program in which they conduct educational outreach at community events and promote their services via bus advertisements and billboards. The DOH also distributes condoms in high-risk areas to 26 non-clinical sites such as barbershops. To promote their services, the DOH includes a flyer that identifies where free condoms and STI/HIV testing and care are available. In addition, the DOH attends a state LGBTQ health disparities convention annually and participates in state training on cultural competency and humility. The DOH implements targeted interventions for the LGBTQ population such as testing and providing education about PrEP at events like gay pride and local conventions.

The Erie County Women Infants and Children (WIC) program and the Nurse Family Partnership provide social and medical services and referrals for family planning. The WIC program is well-established, long-standing, co-located with community centers in the city of Erie, and serves a “unique and diverse” caseload of about 7,500 people annually with a wide variety of community-based programs for parents and infants. Two of its centers are located close to Erie’s largest public housing facilities. Enrollment in WIC services has been declining due to fears among the large immigrant population about use of public programs creating risks to immigration status (“public charge”). The Nurse Family Partnership program, based at the DOH, provides evidence-based nurse home visiting services free of charge to low-income women who are pregnant with or parenting their first child, up to the age of two. The program serves an average of 95 women per year, with the goals of improving pregnancy outcomes, child health and development, and economic self-sufficiency.

“People [think] that if they seek benefits they may be deported. This [perception intensified] recently. We see it and have conversations throughout the state. If anything is going to affect a person being here, or benefits, they will shy away. We know through word of mouth in the community people may not be coming [for services] because of that.”
–Debora Jamison, Director, Erie County WIC

Access to mental health care is very limited in Erie County. There is a lack of access to treatment for postpartum depression and to mental health services more broadly. Focus group participants highlighted stigma, concerns about child welfare involvement, and a shortage of mental health services in the city and county as the key barriers.

Access to Abortion Counseling and Services

The lack of abortion providers in Erie County and the anti-abortion climate make it difficult to access abortion counseling and services.

There are no clinics providing abortion services in Erie County, and residents seeking abortion care must travel at least 100 miles away to Pittsburgh, New York, or Ohio. Travel time, transportation, and the cost of the procedure are barriers to abortion access for Erie County residents. Compounding the challenges for low-income women, Pennsylvania Medicaid does not cover most abortions, and the 24-hour waiting period in Pennsylvania (and Ohio) results in women having to make two trips. Furthermore, earlier in 2019, Ohio passed a bill that could prohibit any abortions in the state as early as six weeks of gestation. While the law is currently blocked under judicial order, if implemented, it would further diminish options for abortion services for women in western Pennsylvania. One focus group participant recounted an experience in which she and her husband could not save enough money for the transportation to the clinic, which ultimately prevented her from having the procedure she sought. Several interviewees and focus group participants mentioned that there used to be a local abortion provider, but the clinic closed several years ago. Many interviewees were unfamiliar with the state’s policies and restrictions on abortion, and some focus group participants and more than one interviewee believed, incorrectly, that abortion is not legal in the area.

“When I called [an abortion provider two hours away], one of the first things they asked me was how was I [going to] pay for it because it wasn’t free. They did let me know that there [were] funding options available, which would cover a portion. And they did notify me that certain insurances do cover them, depending on what insurance you have. Mine, since mine is state funded, it did not cover it.…The difference in what they said I had to come up with was $400.”
–Focus group participant

Many providers said they provide women with information on where to obtain an abortion if they ask. It is often hard for women to get information about abortion, or to know which providers can make a referral to services. Some providers discussed looking up information for women who needed abortion counseling or services, and some said they would refer to the Title X program, which could provide abortion referrals. At the time of the interviews, most providers did not view the new Title X regulation that prohibits grantees from making referrals for abortion as having a significant impact in the area because they felt that the number of referrals is already low. (These interviews took place before the new rule took effect.) Subsequent follow up conversations with Title X providers have found that this requirement has in fact been challenging as they have not been able to offer referrals, and this has eroded trust between the providers and the women who seek abortion care.

“There may not be any [abortion] providers in western Pennsylvania at all – not a welcoming atmosphere for an abortion clinic. It’s been the reality here for so long, so most people don’t think about it unless you are in that situation. It’s a very Catholic area. Less so now, but those cultural norms have stayed.”
–Interviewee

Crisis pregnancy centers (CPCs) have a large presence in the community, and many providers refer to CPCs without knowing what services they do and do not offer. CPCs typically offer limited medical services and all discourage women from seeking abortion services. In Erie County, the largest CPC offers pregnancy tests, STI screening, ultrasounds, referrals to prenatal care, adoption counseling, smoking cessation services, and classes on topics such as breastfeeding and childbirth, all at no cost to clients as they receive state and federal funding. Some interviewees suggested that the CPCs provide biased information, and that many providers refer women to the largest CPC in Erie without understanding its limited scope or anti-abortion mission. The major CPC in Erie County reported that they counsel women on all their options; however, this appears to be at odds with its mission, the priorities of its funders, and the typical policies of CPCs. A focus group participant reported feeling pressured by CPC staff to adhere to its faith-based principles, which include opposition to abortion. Focus group participants were aware of the CPCs in the area and knew these organizations provide adoption counseling and pregnancy tests (a few had gone for pregnancy tests in the past) and do not offer abortion services.

Conclusion

Family planning services are generally available in the city of Erie, but access is more limited in the rural parts of the county and for uninsured women. Medicaid expansion, a Medicaid-funded state family planning program, and targeted programs to serve the refugee communities in Erie County facilitate access to contraception for most low-income people. However, lack of integration between primary care and reproductive health services, gaps in referral follow-up, heavy reliance on the area’s sole Title X provider, and language barriers are ongoing challenges to the provision of comprehensive reproductive health services. Further, with no abortion providers in Erie County, a conservative political and cultural environment, and no abortion coverage through Medicaid, low-income women seeking abortion services face cost and transportation barriers as well as stigma.

Acknowledgements

The authors thank all of the interviewees that participated in the structured interviews for their insights, time, and helpful comments. All interviewees who agreed to be identified are listed below. The authors also thank the focus group participants, who were guaranteed anonymity and thus are not identified by name.

Laura Beckes, CHES, HIV Disease Intervention Specialist, Erie County Department of Health

Amanda Cox, Medical Advocate, Safe Journey

Kathy Dahlkemper, Erie County Executive

Heather Goodwin, Medical Assistant, Primary Health Network

Dylanna Grasinger, Director, USCRI-International Institute

Toni Gromacki, Medical Coordinator, Community Health Net

Debora Jamison, Director, Erie County WIC

Chris Kain, Nurse Practitioner, Community Health Net

Juliette Mannino, Nurse Practitioner, Independent Consultant

Wendy Neilsen, RN, Nurse Family Partnership/Immunization Supervisor, Erie County Department of Health

Myrna Otero, Practice Manager, Primary Health Network

Susan Scriven, Nurse Practitioner, Adagio Health

Patricia Stubber, CEO, Multi-Cultural Health Evaluation Delivery System (MHEDS) (and team)

Lisa Szymanski, BSN, RN, Public Health Nurse, HIV/AIDS Surveillance and Partner Services, Erie County Department of Health

Crow Tribal Reservation, MT Methodology