One expected benefit of implementation of the Affordable Care Act was that publicly funded family planning providers would be seeing fewer uninsured patients and therefore would be able to obtain reimbursement for more of the services they render. Indeed, the proportion of patients at Title X–funded sites who have some kind of health insurance has grown since the act went into effect. Yet, Leah E. Masselink and colleagues report in this issue of Perspectives on Sexual and Reproductive Health that facilities are not always able to bill patients' insurance plans for covered services (page 51). Focus group discussions conducted in 2015 with staff members of Title X–funded health centers and state program administrators revealed barriers stemming from concerns about confidentiality (one of the cornerstones of the Title X program); confusion among both patients and providers about plan features; changes in state Medicaid family planning waiver coverage; administrative burdens; and patients' reluctance to use their insurance for a variety of reasons.

Among other things, the findings underscore the importance of ensuring that both patients and providers are well informed about how various types of insurance work. Furthermore, the authors conclude, it seems clear that Title X–funded centers will need to continue relying on their public funding even while serving patients who have insurance. And given current political debates about both the Title X program and the Affordable Care Act, these centers “will likely face continuing—and perhaps escalating—challenges to their provision of family planning…services.”

Also in This Issue

  • Child marriage, defined as marriage before age 18, is widely considered a human rights violation; the Sustainable Development Goals call for its elimination by the year 2030. It remains legal throughout the United States, but its prevalence in recent years has been unclear. To obtain nationwide and state‐level estimates, Alissa Koski and Jody Heymann examined data on the marital status of all persons aged 15 and older who were included in the 2010–2014 rounds of the American Community Survey (page 59). They estimated that 6.2 of every 1,000 children—or more than 78,000 children nationwide—had ever been married. State‐level estimates ranged from less than four to more than 10 per 1,000. The estimated prevalence appears to be greater for girls than for boys, and particularly high among immigrants and certain racial and ethnic groups. Koski and Heymann call for research into the social forces that perpetuate child marriage so that appropriate policies and mechanisms can be developed to prevent it “and its deleterious effects.”
  • According to the evidence‐based U.S. Medical Eligibility Criteria for Contraceptive Use, issued by the Centers for Disease Control and Prevention (CDC) in 2010 and updated in 2016, IUD use is safe for most women with HIV. However, HIV‐positive women rely on this method less than HIV‐negative women do. To assess whether provider misperceptions of IUD safety contribute to the disparity, in 2013–2014 (after the initial guidance, but before the update), Katharine B. Simmons and coauthors surveyed a nationwide sample of family planning providers. They report (page 67) that seven in 10 providers considered IUDs safe for HIV‐positive women; the remainder disagreed or were unsure. Although misperception about safety was equally common among public‐sector providers and office‐based physicians, its correlates differed somewhat. Notably, however, within each group, those who did not use the CDC guidance had elevated odds of misperception. The authors observe that greater use of evidence‐based guidance may correct providers' misperceptions about IUD safety and thus help expand contraceptive options for women with HIV.
  • Some abortion providers limit or bar men's involvement in their partners' abortion care, thinking that it may adversely affect women's autonomy or other aspects of the experience. However, in a mixed methods study described by Brian T. Nguyen and colleagues (page 75), men accompanying their partners to two abortion clinics in 2015–2016 were overwhelmingly supportive. Survey respondents nearly universally expressed the desire to support their partner, even if they would not have chosen for her to terminate the pregnancy. In‐depth interview participants talked about how much they valued being involved, seldom brought up their own preferences regarding the abortion and described a range of ways in which they supported their partner. While the authors acknowledge that their study omits women's own perspectives, they report that nothing in the data suggests negative effects of male partners' involvement. Rather, it appears that men who accompany their partner for an abortion may be important “allies,” who may help improve women's abortion experience and, more generally, promote their reproductive health.
  • In 2009, just months after the murder of Dr. George Tiller, one of the few U.S. providers of third‐trimester abortions, Carole Joffe interviewed seven members of his clinic staff about what it had been like to work with a man she characterized as “one of the most polarizing symbols of the U.S. abortion conflict.” A special report based on those interviews appeared in Perspectives in 2011, and this year, as part of our 50th‐year retrospective, we asked Joffe to revisit the experience of talking with Tiller's coworkers. The ensuing interview was originally posted on our anniversary blog, [email protected] (https://www.guttmacher.org/perspectives50), and is presented in this issue (page 85). In it, Joffe explains why she had felt the need to “document what had happened there” and why the experience was unlike any other in her decades of conducting sociological research.

The Editors