The most common Essential Services related to abortion were Monitor Health Status (EPHS1), Enforce Laws (EPHS6), and Evaluate Effectiveness, Accessibility, and Quality (EPHS9). EPHS1 documents (Monitor Health Status, 98% of states) related to abortion surveillance. The level of detail of reporting varied across states but typically included abortion data by demographic characteristics, county, procedural type, and gestational age. Documents were primarily surveillance reports, as well as the presentation of data in other health department materials. EPHS6 documents (Enforce Laws, 92%) commonly presented as the full text of state laws pertaining to abortion regulation, as well other materials that cited those laws as the reason for their creation. These documents reflected the range of abortion laws that the health department must enforce, including requirements for data collection, state-mandated informed consent and counseling, parental involvement for minor's access, facility licensing, and prohibitions of abortion referrals. EPHS9 documents (Evaluate Effectiveness, 76%) primarily reported numbers of procedural complications, types of abortion procedures used, and cost of services. Few described quality improvement activities.
A second group of less widespread, but still common, Essential Services included Develop Policies (EPHS5), Link to Services (EPHS7), and Inform and Educate (EPHS3). EPHS5 documents (Develop Policies, 69%) commonly described policies related to the regulation of abortion facilities, including licensing and inspection. Other documents reflected policies restricting or allowing state funding for abortion, complying with federal restrictions on funding for abortion, requiring that counseling for pregnant women include referrals to abortion (if not provided), detailing eligibility for services for pregnant women, and other policies. There were no documents including abortion within state health improvement plans. EPHS7 documents (Link to Services, 65%) typically presented as resource directories, often required as part of state-mandated informed consent and counseling (“Women's Right to Know”) legislation. These included contact information for clinics providing abortion, organizations promoting alternatives to abortion (ie, crisis pregnancy centers), or—most commonly—both. All EPHS3 documents (Inform and Educate, 47%) implement state-mandated informed consent and counseling legislation.
The remaining Essential Services were less common. EPHS2 documents (Diagnose and Investigate, 29%) suggested abortion as a risk factor for various outcomes, including infections, low birth weight, and maternal mortality. A few documents proposed abortion clinics as useful monitoring sites for other health issues (eg, intimate partner violence). EPHS8 documents (Assure Competent Workforce, 29%) included descriptions of trainings for health care providers to understand state abortion laws, trainings for abortion providers about nonabortion health issues (eg, intimate partner violence screening), and licensure and certification of individual clinicians providing abortion. The few EPHS4 documents (Mobilize Community Partnerships, 4%) described one health department's facilitation of an abortion access workgroup, as well as another's effort to engage a broad range of stakeholders to develop reasonable abortion facility regulations. As noted earlier, there were no state documents reflecting EPHS10 (Innovative Research, 0%).
The additional non-EPHS code was identified in 19 states (37%). These documents included reports and materials that described the prevention of abortion as an explicit goal of state family planning or teen pregnancy prevention programs.
Essential Services by state and region
On average, individual states had documents reflecting activities across 5.1 Essential Services, with a range from 1 (Colorado) to 8 (Texas). There were regional trends in the number of Essential Services performed. There was a non-significant effect of region on the total number of Essential Services (P = .07), with a greater average number of Essential Services in the Midwest (5.67) and South (5.53) than in the Northeast (4.22) and West (4.62). Region was a significant predictor of EPHS3 (Inform and Educate, P < .01) and EPHS7 (Link to Services, P < .01) activities. For each, states in the Midwest and South regions were more likely to engage in these activities than states in the Northeast and West. Region and governance structure were correlated (P = .005), as expected; however, the association between the number of Essential Services in a state and its governance structure was not statistically significant.
Local health department results
The majority of large local health departments either did not have Web sites or did not have documents related to abortion on their Web sites. We found Web sites for 117 (of 136) large local health departments and identified 671 documents that referenced abortion on the Web sites of 73 departments. During the coding process, we determined that 217 documents (32%) were not relevant. We excluded these documents, for a total of 454 relevant documents from 63 local health departments in 24 states.
We found at least 1 local health department engaging in each of the Essential Services, with the exception of EPHS4 (Mobilize Community Partnerships). About a quarter of the local health departments engaged in EPHS1 (Monitor Health Status, 27% of 117) and EPHS6 (Enforce Laws, 24%), and about one-fifth engaged in EPHS7 (Link to Services, 18%). Fewer engaged in EPHS2 (Diagnose and Investigate, 12%), EPHS5 (Develop Policies, 12%), EPHS9 (Evaluate Effectiveness, 8%), EPHS8 (Assure Competent Workforce, 5%), EPHS 10 (Innovative Research, 3%), and EPHS3 (Inform and Educate, 2%). (See Figure 2) In addition, the non-EPHS code—indicating that abortion prevention was an explicit goal of family planning or teen pregnancy prevention programs—was identified in 15 local health departments (13%).
Many local health department documents were similar to those presented by states, including vital statistics reports (EPHS1), county codes for abortion facilities (EPHS6), and trainings for providers (EPHS8). In contrast to the state analysis, local health department documents showed evidence of activities that were not mandated by law. For example, EPHS3 and EPHS7 documents were developed for health promotion rather than informed consent purposes, listing abortion among other local reproductive health and social services and offering targeted information to subgroups of women. Evidence of research activities (EPHS10) included a qualitative study of women's experiences with abortion, as well as coordination with academic researchers.
Regional differences in the number of Essential Services were noted. Local health departments in the West averaged more EPHS activities (1.80) than those in the Northeast (1.10), Midwest (0.87), and South (0.75). Local health departments in the West were more likely than departments in other regions to engage in EPHS7 (Link to Services, P < .001)—that is, the opposite trend of the state results—and EPHS8 (Competent Workforce, P < .01) activities.
Through this Web site content analysis, we found that most state health departments engage in activities related to abortion but conclude that this involvement largely reflects what the departments are legally required to do. This is evidenced by (1) the commonness of mandated EPHS6 (Enforce Laws) and EPHS1 (Monitor Health Status) activities across states; (2) the bulk of EPHS3 (Inform and Educate) and EPHS7 (Link to Services) documents being developed for “Women's Right to Know” legislation rather than broader health promotion efforts; and (3) the fact that states that are known to more heavily regulate abortion (ie, the South and Midwest20) engage in more Essential Services, particularly those specifically required by law. Our sensitivity analysis lends further support to this last point, indicating that state differences are not due to the governance structure of health departments but rather the greater regulation of abortion in some regions of the country. We found little evidence of innovation in either research or practice at state health departments. One notable exception was an example from Maryland, where the health department brought together a broad coalition to create reasonable abortion facility standards; this example was unique enough to have been written up in the New York Times. 25 We found that few local health departments engage in activities related to abortion, but those that do appeared to have unique approaches. Some large local health departments—particularly in the West—are involved with a range of abortion-related activities.
Despite these examples, the vast majority of health department activities related to abortion appear almost entirely to reflect what is legally required and not a comprehensive set of activities undertaken by governmental public health agencies meeting the Essential Services framework. Our non-EPHS code provides an additional example of this point. Health departments make large and diverse investments in reproductive health for women, men, and adolescents. It is telling that, in 19 states, we identified documents that emphasized the prevention of abortion as a goal of family planning and teen pregnancy prevention programs rather than the inclusion of abortion within the broader context of preventive health services that aim to reduce unintended pregnancy and improve birth outcomes.
We made the analytic decision to assess the breadth of abortion-related activities using the Essential Services framework but not evaluate whether a given activity reflected a quality public health approach. That is, we did not assess whether a state's approach was based on the best available evidence, protected public health, or facilitated care for the most vulnerable members of communities. The results of this decision are likely apparent in a range of codes, especially EPHS3, EPHS6, and EPHS7. Certainly, the provision of information (EPHS3) that contradicts the best available evidence26 does not conform to professional values related to health education. Enforcing laws (EPHS6) that have a good likelihood of harming rather than helping women's health27 , 28 does not conform to the standards of use of evidence in public health decision making. Providing referral information (EPHS7) to crisis pregnancy centers with misleading or false information about abortion29 or that do not provide prenatal care to women who want to continue their pregnancies contradicts basic public health values related to facilitating use of health services. Our decision to sidestep these questions and instead code according to the Essential Services framework was a deliberate one, as the results reflect the full range of abortion-related activities that health departments are conducting using the public health infrastructure. Efforts to describe whether these activities conform to high-quality public health practices are needed.
This study has limitations worth noting. First, we are unaware of research assessing health department Web sites as an indicator of practice. In particular, we may have missed abortion-related activities that health departments do not publicize on their Web sites or use nonstandardized language to describe. In states where abortion is more controversial, this could have biased our findings toward documents that reflected the political climate in the state. To examine the extent to which our data source may have affected our findings, we conducted 2 validity checks using external resources. States with EPHS1 (Monitor Health Status) codes were checked against known abortion surveillance reporting to the Centers for Disease Control and Prevention (CDC).30 States with EPHS3 (Inform and Educate) codes were checked against known mandatory counseling legislation, tracked by the Guttmacher Institute.31 Together, these checks suggested that abortion-related activities appear to be represented on state health department Web sites. We note, though, that we are unlikely to have false-positives, that is, activities that are reflected in documents on the health department Web sites that have not actually occurred. The use of Web sites as our data source may be a particular limitation for the local health department analysis. Many do not maintain Web sites, and we were unaware of external sources to use for validity checks. This decision may affect our understanding of the role of local health departments in providing or linking to health services, which may vary by the size of the population served.34
Second, we did not examine the timing of the activities. It is possible that some states have not removed old documents from their Web sites and thus we characterize health departments as engaging in an activity in which they no longer engage. This could have led us to suggest that health departments are currently conducting more abortion-related activities than they actually are. Third, the 10 Essential Services framework was not developed as a research tool, and there is no gold standard that guides how to apply the framework for research purposes.
This study also has strengths. First, following in the footsteps of public health colleagues,2 , 7 we apply an accepted public health framework to a controversial topic. This allows for a noncontroversial approach so that ideological disagreements and discussion can focus on the content of the results rather than the framework. Second, we used systematic methods that included reviewing all relevant documents from health department Web sites, as well as multiple steps and quality controls to ensure interrater reliability and validity of the codebook.
In this study, we examined how state and local health departments are currently engaged in activities related to abortion. In a recent commentary,32 we describe a vision of how health departments might engage with abortion if abortion were treated like other health issues and guided by core principles of public health. Relying again on the Essential Services framework, we argue that it is the role and responsibility of governmental public health agencies to facilitate women's ability to obtain abortion services, research barriers to abortion care, and promote the use of scientific evidence in policy making and law enforcement about abortion. This positive vision—a vision that requires ensuring the availability and accessibility of abortion care, as well as the quality and safety of these services—differs greatly from what health departments appear to be currently doing about abortion.
Yet, we believe strongly that this vision is not out-of-touch. It fits soundly within the public health accreditation efforts that have operationalized the EPHS into standards for state and local health departments to assess their capacity to improve public health across varied areas of health care.15 , 16 It also brings to the forefront the work that local health departments, such as the New York City Department of Health and Mental Hygiene and the federal government (through the CDC's Joint Program for the Safety of Abortion), were doing for decades from the 1970s through the 1990s, of which some local health departments engage today.17 , 19 It does, however, involve reframing our work. It reflects a view of governmental public health agencies as institutions that work for social justice rather than solely as technical experts serving as defenders of the state and public health bureaucracies.33 It is time for the public health community to embark on a dialogue about how health departments should be engaging with abortion and take the next steps to realize this vision.
Implications for Policy & Practice
- As state legislatures continue to enact regulations on abortion, governmental health agencies at the state and local levels are being tasked with new roles and responsibilities.
- Through an analysis of heath department Web sites, this study finds that the abortion-related activities of these agencies largely reflect what the law requires rather than the full range of core public health activities.
- These findings have important implications for public health agencies and professionals, who need to engage in dialogue about how to define and implement a vision of how health departments should be engaging with abortion, based in evidence and guided by social justice.
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Keywords:Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
abortion; government agencies; health policy; health systems agencies