Reproductive care in underserved communities:

women's health after the Affordable Care Act

For five years, a women-led study team at OCHIN examined the essential role community health centers (health centers) in the United States play in connecting women to quality reproductive health care. They also studied the impact of the Affordable Care Act (ACA) on access to comprehensive preventive, contraceptive, and pregnancy-related care, comparing Medicaid expansion states to non-expansion states across the country.

Through quantitative analyses using ADVANCE electronic health records and community data, and qualitative interviews with patients and providers, OCHIN and Oregon Health & Science University (OHSU) researchers produced six peer-reviewed articles within the EVERYWOMAN project. In summary, their work found that policies that fund health centers and expand coverage for reproductive health services in primary care settings are effective ways to ensure ongoing access to equitable reproductive health care. This is especially critical for health center patients who already face economic and systemic barriers to care.

Read more about the EVERYWOMAN study below, or contact Project Director Anna Templeton to learn more: templetona@ochin.org.

RESOURCES

DOWNLOAD VISUAL ABSTRACT

DOWNLOAD STUDY FLYER

DOWNLOAD STUDY SUMMARY

CARE CHALLENGE

Women from underrepresented racial and ethnic groups and/or living in poverty are less likely to receive reproductive health care, often due to cost and lack of health insurance.

STUDY GOAL

To understand the impact of the ACA and state- level reproductive health policies, across the full spectrum of women’s care in health centers.

RESEARCH METHODS

Quantitative electronic health record and community data was used to analyze policy impacts and social determinants associated with preventive, contraceptive, and pregnancy related care.

Qualitative interviews with patients and providers helped explain how women access and use available care.

KEY FINDINGS

ACA/Medicaid expansion improves access and utilization of reproductive services.

After the Affordable Care Act and Medicaid expansion, women seeking care in health centers got more preventive care and had increased access to the most effective forms of contraception.

Prenatal care and pregnancy intention screening in primary care helps drive health equity.

Health centers provide pregnancy planning and prenatal care that drives health equity by improving outcomes for pregnant people with higher risk of complications, including people of color, people with low incomes, and people with multiple health conditions.

Funding community health centers is an effective way to close disparities in reproductive health.

Health centers are an important access point for effective contraception among adolescents and young women. Health centers that receive supplemental contraceptive and sexual health care funding through Title X provide more contraception than health centers that do not receive Title X funding.

OCHIN members provide equitable and comprehensive reproductive care to the people they serve.

OCHIN health centers provide comprehensive reproductive care with no measurable disparities between patients, regardless of their zip code.

“Most women don’t receive all of the preventive care that they need … and the reasons for this are complex. As a family doctor who provides this type of care every day, I recognize how important it is to understand the ways these complex systems—from state and national policies, to health systems, to patients and communities—support people in getting the care that they need. Studies like this help me to advocate for my patients’ needs beyond the exam room and make sure that we’re finding and building systems that work.”

— Brigit Hatch, MD, PhD, Co-Investigator and Site PI, Oregon Health & Science University

Over 40%

of health centers provide
primary care-based prenatal care

44%

of women who gained Medicaid coverage in expansion states during pregnancy kept Medicaid after childbirth, vs. 12% in non-expansion states

IMPLICATIONS FOR POLICY, PRACTICE, and FUTURE RESEARCH

Health centers and policies that expand health care coverage are essential for providing access to effective, equitable reproductive care.

Health Care Policy

Policies that expand access to health care coverage and community-based health services are critical for reproductive health equity.

Clinical Practice

Health centers provide effective, high-quality preventive, contraceptive, and pregnancy-related care in community-based primary care settings.

Health Care Research

Electronic health record data from OCHIN and ADVANCE are a uniquely valuable tool to measure and understand the real-time impacts of policy in community health center settings.

“It is vitally important that women have access to comprehensive reproductive care. In essence, that is some of the best preventive care that we can provide. Having access to reproductive care enables women to make choices about their reproductive trajectories, and choices about their childbearing and their futures.”

– Erika Cottrell, PhD, MPP, Principal Investigator, OCHIN

MEET THE RESEARCH TEAM

Meet the women-led research team at OCHIN that spent five years and published six peer-reviewed articles, in partnership with OHSU, demonstrating the importance of the Affordable Care Act for reducing reproductive health disparities among female adolescents and women in the national OCHIN and ADVANCE networks.

OCHIN Researchers

Erika Cottrell, PhD, MPP

Principal Investigator, OCHIN

Anna Templeton, DNP, RN

Co-Investigator, OCHIN

Jee Oakley, MPH

Project Manager, OCHIN

Megan Hoopes, MPH

Co-Investigator, OCHIN

Teresa Schmidt, PhD, MS

Co-Investigator, OCHIN

Fran Biel, MPH

Research Analyst, OCHIN

Joanna Georgescu, PhD

Research Analyst, OCHIN

OHSU Researchers

Brigit Hatch, MD, PhD

Co-investigator and Site PI, Oregon Health & Science University

Blair Darney, PhD, MPH

Co-investigator, Oregon Health & Science University

Maria Rodriguez, MD, MPH

Co-Investigator, Oregon Health & Science University

Miguel Marino, PhD

Co-investigator, Oregon Health & Science University

ADVANCE Researchers

Jennifer Potter, MD

Co-investigator and Site PI, Fenway Health

Katherine Chung-Bridges, MD

Co-investigator, Health Choice Network

Matteo Peretti

Project Manager, Fenway Health

“The significance for me of having a women-led team to lead and undertake EVERYWOMAN is twofold. On the one hand, I think as women engaged in this work, we all feel a deep personal commitment to ensuring access to equitable health care for low-income women in the U.S. On the other hand, I also think increasing the number of women who are leading large projects … improves the quality of our science nationwide. In addition to being women-led, EVERYWOMAN is also multidisciplinary … we are each able to bring our strengths and our points of view to bear on the research questions, which I always feel results in a much more nuanced and deep interpretation of the data we’re seeing.”

— Blair Darney, PhD, Co-Investigator, Oregon Health & Science University

PEER-REVIEWED PUBLICATIONS

Access peer-reviewed publications resulting from the EVERWOMAN study via the citations below.

Cottrell, E., Darney, B. G., Marino, M. Templeton, A. R., Jacob, L., Hoopes, M., Rodriguez, M., & Hatch, B. (2019). Study protocol: a mixed-methods study of women’s healthcare in the safety net after Affordable Care Act implementation – EVERYWOMAN. Health Res Policy Sys 17(58). https://doi.org/10.1186/s12961-019-0445-y
Darney, B., Biel, F., Hoopes, M., Rodriguez, M., Hatch, B., Marino, M., Templeton, A., Oakley, J., Schmidt, T., & Cottrell, E. (2022). Title X improved access to most and moderately effective contraception in US safety net clinics, 2016-2018. Health Affairs, 41(4). https://doi.org/10.1377/hlthaff.2021.01483
Darney, B., Biel, F., Oakley, J., Rodriguez, M. & Cottrell, E. (2022). US “safety net” clinics provide access to effective contraception for adolescents and young women, 2017-2019. American Journal of Public Health, 112(55). S555-S562. https://doi.org/10.2105/AJPH.2022.306913
Darney, B., Biel, F. M., Rodriguez, M. I., Jacob, R. L., Cottrell, E. K., DeVOe, J. E. (2020). Payment for contraceptive services in safety net clinics: Roles of Affordable Care Act, Title X, and state programs. Medical Care, 58(5), 453-460. https://doi.org/10.1097/MLR.0000000000001309
Darney, B. G., Biel, F. M., Oakley, J., Coleman-Minahan, K., & Cottrell, E. K. (2023). Contraceptive Method Switching and Long-Acting Reversible Contraception Removal in U.S. Safety Net Clinics, 2016–2021. Obstetrics & Gynecology, 142(3), 669. https://doi.org/10.1097/AOG.0000000000005277
Darney B. G., Jacob, R. L., Hoopes, M., Rodriguez, M. I., Hatch, B., Marino, M., Templeton, A., Oakley, J., & Cottrell, E. K. (2020). Evaluation of Medicaid Expansion under the Affordable Care Act (ACA) and contraceptive care in US community Health centers. Journal of the American Medical Association Network Open, 3(6). https://doi.org/10.1001/jamanetworkopen.2020.6874
Goodman, J. M., Colon, M., Cottrell, E. K., & Guise, J.-M. (2023). Work as a social risk factor in pregnancy: A systematic review of screening practices related to working conditions and family leave among pregnant adults. Birth, 50(1), 32–43. https://doi.org/10.1111/birt.12695
Hatch, B., Hoopes, M., Darney, B. G., Marino, M., Templeton, A. R., Schmidt, T., & Cottrell, E. (2020). Impacts of the Affordable Care Act on receipt of women’s preventive services in Community Health Centers in Medicaid expansion and non-expansion states. Women’s Health Issues, 31(1). 9-16. https://doi.org/10.1016/j.whi.2020.08.011
Hatch, B., Schmidt, T., Davis, E., Templeton, A., Hoopes, M., Darney, B., & Cottrell, E. (2021). Clinic factors associated with utilization of a pregnancy intention screening tool in community health centers. Contraception, 103(5). 336-341. https://doi.org/10.1016/j.contraception.2021.02.003
Putnam, K. E., Biel, F. M., Hoopes, M., Templeton, A. R., Cottrell, E. K., Darney, B. G., & Hatch, B. A. (2023). Landscape of Pregnancy Care in US Community Health Centers. The Journal of the American Board of Family Medicine, 36(4), 574–582. https://doi.org/10.3122/jabfm.2023.230025R1

Funding and Partner Acknowledgements

This study is funded by the Agency for Healthcare Research and Quality award 1R01HS025155-01. This work was conducted with the Accelerating Data Value Across a National Community Health Center Network (ADVANCE) Clinical Research Network (CRN). ADVANCE is a CRN in PCORnet®, the National Patient Centered Outcomes Research Network. ADVANCE is led by OCHIN in partnership with Fenway Health, Health Choice Network (HCN) and Oregon Health & Science University (OHSU). ADVANCE’s participation in PCORnet® is funded through the Patient-Centered Outcomes Research Institute (PCORI), contract number RI-OCHIN-01-MC.

The ADVANCE Clinical Research Network (CRN) is led by OCHIN in partnership with Fenway Health, Health Choice Network (HCN), and Oregon Health & Science University (OHSU). The goal of ADVANCE is to build and maintain a network of Federally Qualified Health Centers (FQHCs)- community-based health care organizations- to strengthen inclusion of populations that have been systemically underserved and underrepresented in research. ADVANCE adds value to health equity initiatives and health equity research by curating data sets for researchers.

Reproductive care in underserved communities:

women's health after the Affordable Care Act

RESOURCES

CARE CHALLENGE

STUDY GOAL

RESEARCH METHODS

KEY FINDINGS

ACA/Medicaid expansion improves access and utilization of reproductive services.

Prenatal care and pregnancy intention screening in primary care helps drive health equity.

Funding community health centers is an effective way to close disparities in reproductive health.

OCHIN members provide equitable and comprehensive reproductive care to the people they serve.

— Brigit Hatch, MD, PhD, Co-Investigator and Site PI, Oregon Health & Science University

Over 40%

of health centers provide primary care-based prenatal care

44%

of women who gained Medicaid coverage in expansion states during pregnancy kept Medicaid after childbirth, vs. 12% in non-expansion states

IMPLICATIONS FOR POLICY, PRACTICE, and FUTURE RESEARCH

Health Care Policy

Clinical Practice

Health Care Research

– Erika Cottrell, PhD, MPP, Principal Investigator, OCHIN

MEET THE RESEARCH TEAM

OCHIN Researchers

Erika Cottrell, PhD, MPP

Anna Templeton, DNP, RN

Jee Oakley, MPH

Megan Hoopes, MPH

Teresa Schmidt, PhD, MS

Fran Biel, MPH

Joanna Georgescu, PhD

OHSU Researchers

Brigit Hatch, MD, PhD

Blair Darney, PhD, MPH

Maria Rodriguez, MD, MPH

Miguel Marino, PhD

ADVANCE Researchers

Jennifer Potter, MD

Katherine Chung-Bridges, MD

Matteo Peretti

— Blair Darney, PhD, Co-Investigator, Oregon Health & Science University

PEER-REVIEWED PUBLICATIONS

Funding and Partner Acknowledgements

Popular Resources

Grand Rounds – October 24 2024

of health centers provide
primary care-based prenatal care