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

This project was designed and carried out by staff of KFF and HMA. Major components of the project were the selection of sites, review of documents about state and local policies, structured interviews with providers and organizations in each community, focus groups with women in each community, analysis, and preparation of reports.

Overall design: Site visits by 4-person teams from KFF and HMA including in-depth, semi-structured interviews with local clinicians and representatives from health and social sector organizations caring for low-income, reproductive age women, and focus groups in five communities: Dallas County (Selma), Alabama; Tulare County, California; St. Louis, Missouri; Crow Tribal Reservation, Montana; and Erie County, Pennsylvania.

Site selection criteria: Based on variation in state Medicaid expansion, presence of state-funded family planning program, state laws governing abortion, geographic region in US, racial/ethnic makeup, presence of religiously-affiliated providers and CPCs (Table 1).

Document and policy reviews: Included but not limited to Medicaid eligibility and covered services, state family planning programs and restrictions on use of public funds, sex education, abortion, community health needs assessments, and provider shortage areas.

Structured interviews: The research team, comprised of staff from KFF and HMA, conducted interviews in-person or by phone with key reproductive health safety net clinicians and clinic directors, social service and community-based organizations, researchers, and health care advocates. Qualitative interview guides (master guide available upon request) were developed and included questions and probes regarding policies, access, facilitators and barriers related to contraception/family planning, sex education, STIs, obstetrical care, and abortion services. The interviews were tailored to individual regions and interviewee roles. After obtaining verbal consent, interviews were recorded and typically lasted 60-75 minutes. Interviewees who are quoted by name in this report gave approval for their attribution. Notably, not all individuals who were contacted agreed to be interviewed, and the research team was not able to speak to all providers in the community. Interview responses are self-reported, based largely on perception and experience not verifiable by investigators.

Focus groups: A focus group in each region was conducted with low-income women ages 18-40, with race and language reflecting the community/regions. The number of women in the groups ranged from 9 to 12. Recruitment and facilitation was provided by Perry Undem Research/Communication using a KFF staff-developed moderator guide with questions about their access to and use of family planning, obstetrical, and abortion services. The groups were comprised of a mix of women who were uninsured, on Medicaid, and covered by private insurance. All of the groups were conducted in English, except for Tulare County, which was conducted in Spanish. While the focus groups were audio recorded for preparation of this report, all participants were guaranteed anonymity. Thus, none of the participants are identified in this report. Each woman was paid $200 for her time and participation.

Analysis: Included but not limited to reviews of relevant policies, statistics and background information; qualitative review of interview notes and recordings; development of comparative grid summarizing, comparing and contrasting interviewee responses; focus group transcripts and moderator outlines of key themes; development of individual site case study reports.

Table 1: Key Characteristics of Study Communities
  Midwest Northeast West South
  St. Louis, MO Erie County, PA Crow Tribal Reservation, MT Tulare County, CA Dallas County (Selma), AL
Urban X
Rural X
Urban-rural mix X X X
Served by Indian Health Service X
Medically underserved and health professional shortage area X X X X X
Declining number of family planning providers X X X X X
Large faith-based provider presence X
State has not expanded Medicaid X X
Medicaid-funded family planning program X X X X
State-only funded family planning program X
High rates of teen pregnancy X X X X
Erie County, PA