This is the second edition of the State of Choice. In the first edition, we identified several alarming trends in health outcomes in our state, including many disparities in health outcomes between racial groups. This updated edition finds similarly concerning trends. Although in some cases overall outcomes are showing improvement, a closer look reveals that these improvements often do not include all Ohioans. Specifically, improvements in health outcomes routinely leave behind many Black and brown Ohioans. Although the content of this report uncovers many alarming trends and reveals a severe dearth of current data at the state level, we hope it inspires readers to create and implement change. It will take a dedicated group of researchers, advocates, constituents, and policymakers to reverse the current state of choice, but the work can and must be done. We hope that this report serves as a comprehensive guide to the current state of affairs, provides a baseline to track issues, and is useful in the identification of necessary policy changes.
What follows on this page is our Executive Summary. Download the full report. (.pdf)
The State of Abortion Access
Access to abortion has been under attack in Ohio since Governor Kasich took office in 2011. During his time in office, Kasich signed 23 attacks on abortion and other forms of reproductive health care, but it wasn’t until Governor Mike DeWine took office in 2019 that anti-abortion advocates and their allies in the legislature finally accomplished what they had been working toward since 2011: the signing into law of a six-week abortion ban (aka the ‘heartbeat’ bill). On April 11th, 2019, surrounded by his anti-abortion allies, Governor DeWine signed Senate Bill 23 into law. Like others before it, Senate Bill 23 has been blocked by the courts and is not being enforced. But the constant attacks have taken their toll.
Half of Ohio’s abortion clinics have closed since 2011, making access more difficult for patients who need care. The 2016 State of Choice report described how clinic closures may have delayed access to abortion care. In 2014 and 2015, we saw the proportion of abortions performed before nine weeks gestation decrease, while the proportion of abortions performed between nine and 18 weeks rose, meaning more individuals were getting abortions later in their pregnancies. This trend began to reverse in 2016 and 2017, and in 2017 the proportion of abortions before nine weeks were fairly similar to those from 2013.
A contributing factor to the reversal of this trend is the Food Drug Administration’s change to the protocol for medication abortion in 2016. Before 2016, Ohio medical professionals were required to continue using the full FDA protocol, which was more expensive and less effective than the evidence-based standard. After the FDA changed its protocol to the evidence-based standard and approved the use of medication abortion through the first nine weeks of pregnancy, medication abortion became less expensive and more accessible in Ohio. The use of mifepristone increased in Ohio by 48% between 2016 and 2017. This could account for the greater proportions of abortions occurring earlier in pregnancy.
Age and race affect access to reproductive health care and sex education, and this affects abortion rates in Ohio. An overwhelming majority of abortion patients are legal adults (aged 18 and older). The abortion rate for those 17 and younger has been decreasing which corresponds with the decrease in teen pregnancy rates. Statewide, the Black/African American population accounts for 13% of the overall population, but 44% of abortion patients report Black/African American as their racial identity. Further research clarifying how the social determinants of health contribute to the over-representation of Black Ohioans in abortion rates is needed. However, it is safe to say that inequitable access to contraception, comprehensive sex education, and health services exist as a barrier for people of color in Ohio and contribute to disparities in abortion rates.
Currently, the only economic indicator that Ohio tracks with abortion rates is educational level. The vast majority of abortion patients have at least a high school diploma or GED. All too often, anti-abortion activists paint a picture of uneducated individuals making uninformed decisions when it comes to choosing abortion care. These data clearly show that associating abortion with a lack of education is an unfounded stereotype. The reality is that abortion patients are knowledgeable and fully capable of assessing what is best for their reproductive life plan.
Reproductive Choice Funding
State governments demonstrate their priorities and biases through the programs and services they choose fund and defund. This certainly holds true for reproductive health care programs across Ohio.
Since 2013, Ohio has had a direct funding stream for crisis pregnancy centers (CPCs). The state government pulls the funds for CPCs from the Temporary Assistance for Needy Families (TANF) Block Grant. The TANF block grant is meant to provide crucial financial assistance to families in need. Instead, Ohio funnels a portion of TANF funds to CPCs. Crisis pregnancy centers claim to provide impartial counseling and information, but in reality, they give clients misleading, incomplete, and factually inaccurate information about pregnancy and abortion. Yet the state of Ohio has increased funding for CPCs for 2020-2021.
In July 2019, Governor Mike DeWine signed the Fiscal Year 2020-2021 state budget, boosting funding for CPCs from $500,000 per year to $3,750,000 a year – a 750% increase in funding from previous years. As funding for CPCs increased by $3.25 million a year, Ohio lawmakers eliminated $2.5 million for a Medicaid-based program supporting better access to long-acting, reversible contraception (LARCs). Moving $2.5 million in funding for real health care services to non-medical services provided by crisis pregnancy centers shows exactly how little the Ohio government prioritizes Ohioans’ sexual and reproductive health. The majority of Ohio lawmakers would rather fund misinformation and coercion than actual health care services.
Changes in regulations for federal funding such as the Affordable Care Act, Title X, and other national-level programs can affect Ohioans’ access to reproductive health care. In 2011, the Affordable Care Act provisions requiring coverage of contraception with no cost-sharing (co-pays or other out-of-pocket expenses) went into effect. These provisions ensured that at least one method from each of the 18 categories of birth control would be covered without any additional cost to the consumer. Although these provisions are not perfect, they have certainly increased access to contraception for millions of people in Ohio and across the country. The U.S. Supreme Court restricted this provision’s reach in the Burwell v Hobby Lobby case by allowing the limited religious exemption included in the ACA to apply to for-profit organizations. In 2017, the Trump administration attempted to expand this exemption again by allowing any employer, whether non-profit or for-profit, to exclude some or all contraceptive methods and services from the health plans it sponsors if the employer has religious objections. For now, enforcement of these regulations has been blocked by the courts.
The only federal program specifically devoted to family planning is Title X, which provides grant funding to local public health departments, family planning clinics, and nonprofits. With this funding, these agencies can offer reproductive health services such as STI testing, Pap smears, breast and cervical cancer screenings, and a broad range of family planning services including contraception. The Guttmacher Institute reported that 55% of Ohio women ages 13-44 needed contraceptive services and supplies in 2014. More than half (56%) of these women needed publicly-supported contraceptive services and supplies, meaning they needed financial help to pay for these services either because they were under the age of 20 or had incomes below 250% of the federal poverty line. Despite the clear need for publicly-funded contraceptive services and supplies, only 14% of those in need of publicly-funded providers and services had their needs met in 2014. In 2014, a total of 65,220 women in Ohio received Title X-supported contraceptive services, a 33% decrease from 2010.
Publicly-funded clinics are especially important to meeting adolescents’ reproductive health care needs. In Ohio, 21,460 teens were served at publicly-funded clinics in 2014, which resulted in 11% of teens’ need for services met and the aversion of 5,200 pregnancies, 2,600 births and 1,700 abortions. In 2019, the Trump administration finalized new regulations — the domestic gag rule — that makes it even harder for young and economically-disadvantaged people to get reproductive health care. This new regulation prohibits Title X funded programs from giving referrals for abortion care, which led to Planned Parenthood pulling out of the program. Planned Parenthood is the largest provider of services in the Title X program here in Ohio and across the nation. It is not fully known yet how this will impact access to care, but the rule change has already led to the closure of two Planned Parenthood centers in southwest Ohio.
Misplaced and biased priorities in funding are apparent in the funding for sex education programs in Ohio. Ohio has some of the highest rates of sexually-transmitted infections (STIs) in the nation. Compared to other states, Ohio had the ninth highest rate of reported chlamydia cases among people ages 15-19, the sixth highest rate of reported cases of gonorrhea, and the 23rd highest rate of reported cases of primary and secondary syphilis in the nation in 2016. The risk of sexually-transmitted infections and unintended pregnancies can be reduced through comprehensive sex education that teaches young people about safe and consensual sex. Data collected in Ohio high schools during the 2013 Youth Risk Behavior Survey (YRBS) suggests that comprehensive sex education is needed in Ohio’s schools. In 2013, the YRBS found 53.7% of female students and 44% of male students reported not using a condom during their last sexual intercourse; 12.8% of female students and 11% of male students reported not using any method to prevent pregnancy during their last sexual intercourse; 11.2% of female students and 4.3% of male students reported being physically forced to have sexual intercourse; and 13.4% of female students and 6.1% of male high school students reported experiencing sexual dating violence in the previous year.
The CDC has identified 19 critical sexual education topics as crucial to young people’s sexual health and necessary for sexual education curricula. The SIECUS State Profiles Report for Fiscal Year 2018 found that only 10.8 % of Ohio secondary schools taught students all 19 critical sexual education topics in grades six, seven or eight, and 35.6 % of Ohio secondary schools taught students all 19 critical sexual health education topics in grades 9, 10, 11 or 12. Many Ohio students do not get the information they need to make healthy decisions when it comes to their sexual health.
In Ohio, the funding levels for abstinence-only programs far exceed funding for comprehensive sex education programs. In 2018, the state gave $3,729,208 to abstinence-only sex education programs, compared to $498,160 for comprehensive sex education programs. These totals do not reflect additional funding that the state may have received from the Personal Responsibility Education Program Innovation Strategies grant, which funds state programs supporting “research and demonstration projects that implement innovative strategies to prevent pregnancy.” Funding levels for this program were not available for 2018.
Ohio is one of only nine states that has a child welfare program that is state-supervised but county-administered. The largest portion of funding for child welfare programs comes from local sources. Local government funding accounts for 48.1% of funding for these programs and federal funding for the remaining 41.5%. Ohio ranks last in the nation for the amount of state revenues spent on child protection funding. Ohio contributes only 10%, or 10 cents of every dollar spent, to child welfare programs in the state. The national average for state contributions to child welfare programs is 42 cents of every dollar spent. This clearly illustrates that Ohio’s state government does not adequately support children and families in crisis. With the ongoing opioid crisis, our child welfare agencies have to manage ever-growing caseloads. Our state must start investing in these programs.
In addition to the lack of adequate funding for health care and child welfare in Ohio and nationally, the United States is the only affluent country that does not offer paid parental leave. The lack of funding for these necessities shows just how far our nation and our state need to go to support the health and well-being of its children and families. Because of inaction at the federal level, a handful of states and local governments have taken initiative and enacted paid family and medical leave policies. As of 2018, six Ohio municipalities have enacted local ordinances requiring paid family and medical leave. Columbus is a national leader in taking such action. Paid family leave legislation has been introduced in both the Ohio House and Senate, but it has not yet gained significant traction. In order to truly support parents and families, we must create paid leave programs that give parents the paid time off they need.
Racial Disparities in Health
According to the Centers for Disease Control and Prevention (CDC), health disparities are “preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations. … Health disparities are inequitable and are directly related to the historical and current unequal distribution of social, political, economic, and environmental resources.” This report shows how health disparities are fueled by racial, gender and economic injustice. But health disparities do not impact all non-white racial groups in the same ways. Overall among non-white racial groups, Asian American women do better than their Black, Latina and Native American counterparts. Another challenge in addressing racial disparities in health is the fact that in Ohio and nationally, most data is collected with just two racial categories, Black and white. Without comprehensive data on more racial and ethnic groups we cannot fully understand the impact of racial health disparities on communities of color. Yet even with this lack of data, efforts can be made to effectively dismantle the structures that create inequality.
The majority of data available to write this report paints an alarming picture. Black Ohioans suffer worse health outcomes than people of any other racial and ethnic identity. This pattern of racially-inequitable health outcomes is seen in rates of abortion, preterm births, low birth weight, prenatal care, infant mortality, STIs and teen pregnancy. Nationwide, Black women are three to four times more likely than white women to experience a pregnancy-related death, have higher rates of unintended pregnancies than any other racial group — partially due to inequitable access to contraceptive care and counseling — and bear the burden of abortion restrictions which increase time and money needed to access care.
Income and educational attainment can improve reproductive health outcomes for whites and some non-white ethic groups. However, these are not protective factors for Black women, who continue to experience more problems with pregnancy, healthy delivery, and a healthy first year of baby’s life. Nonetheless, it is important to closely examine the economic reality of Black Ohioans, since income status gives insight into people’s quality of life. For all Ohioans, the median household income is $54,000, but the median household income for Black Ohioans is just 59% of that amount, at $32,163. Beyond income inequality, historical policies such as redlining have a direct impact on present-day health disparities. Historically redlined districts in Cuyahoga County overlap with neighborhoods that currently have high rates of infant mortality, an issue that disproportionately impacts Black Ohioans. Income inequalities engender health disparities, and historical discriminatory policies have set the foundation for disparities to continue.
Latinx Ohioans typically have better reproductive health outcomes in comparison to Ohioans from other racial and ethnic groups. Two highlights are that STI rates are fairly low within the Latinx community, and the majority of Latinx women report getting routine mammograms. However, there are a few alarming trends in maternal health that deserve more attention, research, and funding to determine the root cause. Specifically, 11% of all births to Latinx people in Ohio were preterm births, in comparison to 9% of births to white Ohioans and 14.5% births to Black Ohioans. The percentage of Latinx babies who died before their first birthday remained the same from 2016 to 2017. Most alarming is that Latinx Ohioans had the highest rate of severe maternal morbidity; an average of 215 per 10,000 Latinx women experienced life-threatening health problems within a year of giving birth.
Xenophobia and racism play a significant role in shaping the social environment Latinx Ohioans must navigate to get reproductive health care. Since 2016, Trump’s campaign and presidency has intensified public discourse around immigration reform and furthered narratives that paint Latinx immigrants in a negative light. This sort of public discourse harms the Latinx community as a whole, regardless of immigration history and/or citizenship status, because it treats Latinx people as “outsiders” who do not belong in the US and does not honor the rich legacy and contributions of Latinx people living in America.
It is difficult to fully ascertain the state of health disparities for Asian and Pacific Islander women who reside in Ohio, because the state does not collect as much data on this population’s health outcomes as it does other ethnic groups. Asian Americans accounted for 4% of abortions in 2017. The 2015 teen birth rate for Asian and Pacific Islanders was 7 per 1,000 females age 15-19, far below the statewide rate of 23 per 1,000, and the lowest of all five racial groups reported. Although the past nine years have shown a slight increase in reported cases of chlamydia, gonorrhea and syphilis, prevalence of these STIs is still relatively low among Asian Americans compared to other Ohioans. About 8% of Asian and Pacific Islander babies born in Ohio in 2015 had a low birth weight, which was close to the statewide average of 8.5%, and is perhaps the only health indicator in which Asian Americans fare close to the overall population.
It is particularly difficult to determine the state of health disparities for American Indian women who reside in Ohio because the state collects limited data on this population’s health outcomes. American Indians accounted for 0.3% of abortions in 2017. In 2015, 9.1% of American Indian babies born in Ohio had a low birth weight, the second highest percentage after African Americans and higher than the statewide average of 8.5%.
Three conclusions can be drawn after assessing the widespread reproductive health disparities in Ohio:
First, both the gender and racial wage gaps play key roles in compounding barriers to quality health care and diminishing choice, especially for women who are also racial or ethnic minorities. Almost two-thirds of Ohio’s households are dependent on a woman’s income, yet women from every racial and ethnic group have lower incomes than men from the same group. The median income of Latinx and Black households is significantly lower than the median income of white and Asian households. For Ohio to achieve a society in which everyone has real choices when it comes to their health and having children, there must be employment opportunities that pay a living wage so that Ohioans can afford the childcare, housing, and other costs associated with supporting a family.
Second, a significant investment in Ohio’s public health infrastructure must be made to increase access to critical preventative care such as routine women’s wellness visits, STI testing and treatment, prenatal and maternity care, and gender-affirming treatment and therapy.
Third, health inequity can be attributed to the racism and discrimination present in the medical care system. We describe the problem in Ohio, but research shows that racial bias in medical care provision is a problem all across America.
The legal right to bodily autonomy is meaningless without the ability to make choices that affect a person’s reproductive health outcomes. Based on the findings in this report, we offer three recommendations for improving the state of choice in Ohio.
The state of Ohio must adopt a data-driven approach to state reproductive health care policies. Ohio has positioned itself as a national frontrunner for passing restrictive abortion policies, having abominable infant mortality rates, woefully inadequate funding for the child welfare system, and incarcerating women at a rate higher than the national average. Instead of basing policy decisions on data and research, Ohio legislators advance biased policies that placate their political base. Data-driven policy would be a step in creating an Ohio in which reproductive health disparities are addressed and eradicated, policy-making is transparent and comprehensive, and state funding is used responsibly towards solving problems and creating real-time solutions.
The state of Ohio must invest in research to clarify the relationship between dollars spent and changes in health outcomes in the state. It is difficult to measure the true impact of reproductive health policy without adequate data collection procedures in place. For several topics, data was not collected for every race and ethnicity, or data was voluntarily submitted, or datasets were completely restructured from year to year, which makes comparing and drawing conclusions extremely difficult, if not totally impossible. Because public health outcomes are so closely tied to public spending, there must be in-depth research conducted on the relationship between dollars spent and changes in health outcomes in the state. This is necessary to better understand how government funding has both contributed to the current state of choice, and is also necessary to forge funding streams that improve reproductive health outcomes for all Ohioans.
Finally, the state of Ohio must honor the reproductive autonomy of every Ohioan. Restrictive anti-choice legislation that closes clinics, censors medical providers and incites abortion stigma creates a climate in which accessing abortion is unnecessarily difficult, costly and stressful. Everybody deserves the right to the medical treatment they deem best for their body. Medical decisions should be informed by the recipient and their chosen provider, not by policymakers far removed from the lived reality of their constituents. Ohioans deserve to live in a state that honors their reproductive autonomy.