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The Elephant in the Womb: Reproductive Healthcare Accessibility for Low-Income Women

Access to affordable reproductive healthcare is an issue of vital importance to women across the United States today.  The cost of such services is clearly prohibitive for many women:  it is estimated that approximately half of all sexually-active women in the US are in need of publicly-funded services, and only half of those women currently obtain the desired services through existing providers.  Race and income also contribute to the barriers many women face in accessing reproductive healthcare: both women of low socio-economic status and minority women are disproportionately uninsured in the United States, resulting in a 30% decrease in the use of prescription contraception among these population subsets (Dehlendorf, 2010).  The Omaha metropolitan area is no exception to these trends, particularly given its diversity in both race and income.  Douglas County faces the additional challenge of STI rates consistently above the national average (KETV, 2015).  Consequently, it is difficult to overstate the importance of access to affordable reproductive healthcare for Omaha’s economically- and racially-diverse female population.  This study undertook an examination of the true availability of reproductive healthcare options for lower-income women in the Omaha metro area.  Multiple factors influencing the availability of these services were examined, including location, income, racial factors, and community issues.  Additionally, specific reproductive healthcare clinic types were identified and their divergent service offerings were examined as they pertained to abortion services.  Finally, an examination of reproductive health services for LGBTQ individuals was undertaken.

Methodology

In examining the availability of reproductive healthcare for low-income women in the Omaha metro area, the criteria for available reproductive health clinics was first determined.  Eligible clinics were required to be independent (not affiliated with a hospital system), provide general reproductive services, STI testing, and/or contraceptive services, and have flexible service cost options (no-cost services, sliding scale fees, etc.)  It was determined that 17 clinics met these requirements:  Planned Parenthood, Assure Women’s Center (2 locations), Essential Pregnancy Services (3 locations), One World Community Health Centers (5 locations), Charles Drew Health Centers (5 locations), and Bellevue Health Clinic.

Through web and phone research, each eligible clinic was then surveyed for the availability of 30 different reproductive health services.  These services were divided into the categories of general health services (ie. pelvic exams, cervical cancer screenings), abortion services, STI testing and treatment, a comprehensive list of contraceptive services (including emergency contraception), and specific LGBTQ service availability.

Each eligible clinic was also surveyed for its service cost options:  acceptance of Medicaid, acceptance of private or public insurance, a sliding fee scale, an established fee for services, and no-cost services.

The Omaha metro area was divided geographically by zip codes.  The divisions included West Omaha, North Omaha, Central Omaha, South Omaha, and Bellevue.  Utilizing Zip Atlas, these geographic divisions were then examined by median household income.

All geographic divisions were also analyzed for their racial composition, again utilizing Zip Atlas.  The available divisions included White, Asian, Black, and Other.  A separate designation for Hispanic or Latino inhabitants was unavailable, and individuals meeting that designation had been categorized as Other.

Findings & Analysis

Location-Based Factors

A survey of clinics providing reproductive health services in the Omaha area revealed that most of the city’s low-income population is reasonably served by clinic access.  In the zip codes comprising North Omaha, a remarkable eight clinic locations were found.  In the zip codes comprising South Omaha, three clinic locations were found serve the area.  However, in the designated Central Omaha zip code locations, a single clinic was found to offer services.  That clinic offered services exclusively to the homeless population associated with the Siena/Francis House shelter and not to low-income area women generally.  (In the higher-income areas of West Omaha and Bellevue, two and three clinics were found to offer services, respectively.)

It was determined that the three providers offering the most comprehensive health services, including reproductive health services, were the Charles Drew Health Centers (centered in North Omaha), the One World Community Health Centers (centered in South Omaha), and Planned Parenthood (a single clinic located in North Omaha).

The obvious question raised by the above clinic availability numbers involves why North Omaha was so well-served by clinics offering reproductive health services, and why Central Omaha, the area reporting the lowest median income, was so underserved.  While many factors may have influenced this discrepancy, two are considered here.

First is an issue impacting North Omaha’s ample clinic services.  North Omaha houses the Charles Drew Health Center (CDHC), an organization providing comprehensive health services at multiple locations.  Three of North Omaha’s clinics are offered by Charles Drew, and the CDHC’s origins offer insight into their significant presence in the North Omaha neighborhood.  When a decrease in affordable and available healthcare for the community of North Omaha was observed in the 1970’s, the CDHC was founded to offer assistance, primarily to women and children, through facilitation of the WIC (Women, Infants, and Children) program.  The CDHC has grown to offer comprehensive health care through multiple locations, including some of the most thorough STD screening and treatment and contraception methods available in the metro.  Today, the majority of both the center’s Executive Board and its active practitioners are African-American, indicating a continued emphasis by the African-American leadership of the organization to continue service to North Omaha’s African-American community.  (Similar healthcare needs, observed in the Latino and Native American populations of South Omaha during the 1970’s, prompted the inception of what eventually became the One World Community Health Centers.)

Second are issues potentially impacting Central Omaha’s comparative lack of services.  The area appears underserved by its single clinic attached to the Siena/Francis House homeless shelter.  A potential factor in this lack of available services may simply be the central location of low-income women in the area:  living in a centrally-located area, women have options to utilize available clinics in surrounding North or South Omaha neighborhoods.  Another factor may involve the majority racial composition of the area. (Central Omaha is majority Caucasian.)  Research has demonstrated that ethnic minority clients may feel more comfortable or make a more immediate connection with clinic staff members who look similarly or who speak the same language, resulting in the desirability of clinic presence in those minority areas (Vu, 2008).  Conversely, majority- race women residing in Central Omaha, enjoying the well-documented privileges inherent in majority- race status, may feel no such limitations and may exhibit greater comfort in visiting clinics primarily serving minority races.  Majority-race women may therefore be more likely to visit available clinics in North or South Omaha, rather than demonstrating a need for more exclusively Caucasian-staffed clinics in their area.  Conversely, minority women may prefer visiting clinics geared toward their language and culture and may be more hesitant to visit a clinic outside of their neighborhood area, necessitating the observed presence of clinics found in their neighborhoods.

Income-Based Factors

An examination of median household income in specific areas of the Omaha metro area served by clinics revealed that the lowest-income areas were concentrated in North, South, and Central Omaha, while the highest-income areas were located in Bellevue and West Omaha.  The city appears to exhibit demonstrable segregation by income.  For the purpose of this analysis, the lower-income areas were considered.  North Omaha reported an annual median household income of $39,278, while South Omaha households reported an annual median income of $38,628.  The lowest household income was reported by Central Omaha, with an annual median of $35,875.

Income Location

In surveying the clinics that offered services in all of these low-income areas, it was determined that various methods of financial assistance were available.   With the exceptions of the religiously-based, single-issue centers (who offered their limited services free of charge), every clinic offering services in these areas accepted Medicaid and both public and private insurance.  Each of these clinics offered sliding-fee scales for service fees.

An important service provided to low-income women by the three most comprehensive health centers (CDHD, One World, and Planned Parenthood) involved that of assisting patients with the process of determining their eligibility for Medicaid or various public and private health care insurance plans, including those offered through the Affordable Care Act insurance exchanges.  Women seeking financial support through these clinics were also offered assistance in enrolling in programs for which they were eligible, as well as provided assistance in determining their specific service coverage.  While more low-income women in the United States are uninsured versus their higher-income counterparts, the uninsured rates of African-American and Hispanic women show an even greater disparity than those of Caucasian women (Pollock, 2005).  Determining eligibility for Medicaid and public insurance programs is often a daunting and confusing experience, and previous research has indicated the correlation between a delay in seeking treatment and the perceived difficulty of determining eligibility for service coverage (Dennis, 2013).  The financial assistance eligibility services offered at these three clinics are a critical factor in allowing low-income women access to needed reproductive health care.

Race- and Community-Based Factors

White Location

Omaha is blatantly segregated by race, although not by law. West Omaha is overwhelmingly white as 93% of its inhabitants report to be Caucasian. This number rises to 95% if Boys Town is not included in West Omaha. Only 5% claim to be black. Asian and other sits at 2% each. Again, if Boys Town is removed these numbers change to 2% black, 2% Asian, and 1% other. North Omaha has the most obvious containment of one race. Around 70% of Omaha’s black population resides in North Omaha. Of its inhabitants, 30% are Black, 64% White, 2% are Asian, and 2% are Other. South and Central Omaha both contained some diversity, but South Omaha had a significant amount of other races and is known for its high Latinx population. Meanwhile Central Omaha had more black people than South Omaha with 9% compared to 4%. It also had a higher percentage of Asian inhabitants than any other area in Omaha.

Black Location

When looking at the websites of clinics in these areas, it was clear that some were made for a certain community. Charles Drew, in North Omaha, places an emphasis on family, community, and diversity. Its history appears to be inclusive and they provide translators for fifteen different languages. Within its history, it mentions how it began from WIC and that it has connections with Fathers for Life. Due to high rates of single motherhood in the black community, these are important programs to have access to. Within the African American community, there is a strongly maternal family that tends not to follow the nuclear family dynamic. This is likely due in part to a high death rate for young black men and to the higher incarceration rates they face due to racial biases. In the 2014 National Research Council’s report, “Growth of Incarceration in the United States: Exploring Causes and Consequences,” it was found that “the prevalence of drug use is only slightly higher among blacks than whites for some illicit drugs and slightly lower for others; the difference is not substantial. There is also little evidence, when all drug types are considered, that blacks sell drugs more often than whites.” (60-61). Yet according to politifact.com, based off of numbers from both the Bureau of Justice Statistics and the United States Sentencing Commission, black males were imprisoned for drug use nearly six times more often than white males. This helps to explain why there is a prevalence of single mother families in African American communities. It is also worth noting that North Omaha had the lowest number of inhabitants per clinic, which is probably due to their maternally based fluid family structure and the belief that abortion should remain legal. According to Pew it was found that, between whites, African Americans, and Latinos, 68% of African Americans felt that abortion should remain legal, which was the highest percentage for that viewpoint. Cultures that have a maternally based families and/or a high rate of single mothers must value women’s health more than most cultures with paternal based families and those with two parents present, because it is necessary for them to be in good health to manage caring for their families.

Other Location

One World, a South Omaha clinic, had an obvious display of Latino culture. The websites homepage advertised a countdown to Cinco de Mayo, beginning on May 2nd  in 2017. Their website had a majority of providers listed as bilingual and bicultural, an important need for the Latinx community in South Omaha. On their history page it can be seen that they started out as Indian-Chicano Health Center to help support those communities when the meat packing plants moved out of Omaha and men in the community were left jobless. Although these terms would not be used today, due to their negative connotation, Indian was synonymous with Native American and Chicano was a term used for those who had immigrated to the United States from Mexico back in those days when the clinic first began. They also advertised a strong community and family involvement. This is a prevalent part of Latinx culture. Family and blood are strong themes within that culture and a nuclear family dynamic is the social norm. According to Interexchange’s article “Latino/Hispanic Culture in the US” Latinxs have “a strong value on family. Hispanics and Latin Americans tend to have large, close-knit families. It is not uncommon for three generations to live in the same household or nearby each other” (Latino). One world also claimed to offer “culturally sensitive care”. This may be due to the low approval of abortion within Latinx communities and a strongly paternalistic society. According to the same article from Pew “Hispanics” are almost evenly split on the issue, with 48% saying that it should be legal in all or most cases and 49% saying that it should be illegal in all or most cases. This goes back to the strong nuclear family and importance of blood within the Latinx community. Children are an important part of the family and to not desire to have more of your own bloodline is abnormal in the culture. There is also a large number of Catholics in many Latinx populations. These factors likely also play a role in why the inhabitant to clinic number is more than double that number in North Omaha.

Due to racial and income segregation in Omaha, in is especially important that minority and low income communities are served in culturally relevant ways. According to Pollock and Ranier in an article in the Georgetown Journal of Gender and the Law, “racial and ethnic minorities received a lower quality of healthcare from providers, even when access related factors… were controlled.” (830)  They suggested that this was due to a racial bias, whether or not the providers were aware that they were discriminating. This is why racial minorities need low cost health care that is diverse and culturally relevant and inclusive. The same barriers do not appear as an issue for white people seeking healthcare. It is likely a reason why there is only one clinic in Central Omaha that is only available to homeless women, as the area’s composition is whiter than North and South Omaha. White people in Central Omaha are able to travel to any clinic without the concern of being discriminated against based on race. Thankfully is seems apparent that the minority segregated areas of Omaha have worked within their communities to provide culturally relevant care for racial minorities.

Availability of Services and Single-Issue Clinics

In surveying the available reproductive health services offered throughout the lowest-income areas of the Omaha metro, it was revealed that these areas were well-served in many important areas of women’s reproductive healthcare needs.  Regarding basic reproductive healthcare, each low-income area identified was served by one or more clinics providing such essential services as pelvic exams, clinical breast exams, cervical cancer screenings, and mammograms.  Regarding STI testing, each low-income area identified was again served by one or more clinics offering screens and (in most cases) treatment for HIV, chlamydia, gonorrhea, herpes, syphilis, and trichomoniasis.  Regarding contraception, a wide variety of contraceptive options were available, usually through multiple locations of a single provider.  Barrier methods, hormonal methods, long-acting reversible contraceptive (LARC) methods, and other methods were widely available in the areas surveyed.  In addition, emergency contraception was offered with the same wide availability in the identified areas.  These clinics, comprising the majority of those surveyed, provide comprehensive reproductive healthcare services for women.

Two exceptions were discovered to the otherwise comprehensive array of services provided by most clinics surveyed, and these exceptions related to the uniquely divisive issue of abortion.  Women’s access to safe and affordable abortion services is a source of intense controversy in the United States, and these observed clinic outliers uniquely illustrate the divisiveness of the issue.  One of these outlying categories of clinics surveyed (called “women’s centers” and “pregnancy services”) provided very limited services and, based on these services, the counseling and parenting options advertised, the religious funding of the clinics, and other observable factors, clearly operated from an anti-abortion paradigm.  It was observed that the aim of the clinic services involved a clear focus on confirming and illustrating the life or potential life involved in a patient’s condition of pregnancy, and offering pregnant women options that did not include abortion, such as adoption assistance, parenting classes, and other supports.  The clinics did not offer any other stand-alone reproductive-related health services of any kind.  The second outlying category of clinic surveyed was a location offering almost exclusively abortion services, up to the maximum gestation period allowed by state law.  This clinic clearly operated from a pro-choice paradigm, with its website explicitly stating, “Abortion is our business.”  It was observed that the aim of the clinic was to unapologetically provide all available abortion services (both medication and surgical) allowed by law.  While this clinic did offer some contraceptive services, particularly LARC methods that may be implanted concurrently with an abortion procedure, the clinic’s primary offering was abortion services and it did not provide other reproductive-related health services.

The existence of these two unique clinic categories speaks to the divisive nature of accessible and affordable abortion services in the US.  While most clinics surveyed provided a wide array of comprehensive reproductive health service offerings, the very presence of these two outliers, and the clear aims of the services offered by each, starkly illustrates the opposing paradigms with which the United States views both the procedure of abortion and the rights of women in their own healthcare decision-making.  (In contrast, one can scarcely imagine such single-issue clinics, manifesting such opposing beliefs, existing reasonably for any other reproductive health service, such as STI testing or clinical breast exams.)

While the Planned Parenthood clinic also offered both medication and surgical abortion services, it provided them for a more limited gestation period.  It also offered the comprehensive reproductive health services found in other clinics surveyed and was therefore not considered an outlier.

LGBTQ Services

In the clinics of Omaha there is a clear lack of services for LGBT women. When assessing them, we looked for 3 factors; if there was a page dedicated to LGBT people, issues or services, if they offered STD prevention for women having sex with women such as female condoms, and if they offered any other LGBT services. Planned Parenthood was the only clinic to offer all three. They have two pages of their website dedicated to LGBT, offer services for those transitioning between sexes, provide information on and to the LGBT community, and offer female condoms. The only other clinics to offer female condoms were the Bellevue Abortion Clinic and clinics associated with Charles Drew. This included the Charles Drew Health Center, the Charles Drew Public Housing Health Center, the Charles Drew Public Housing Health Center Jackson Tower, and Siena/Francis House, but excluding their location in Northwest High School. Nothing else was specifically offered for the LGBT community at any other clinics, although it is worth noting that Charles Drew does offer counseling for depression and other mood related problems, which are often associated with the LGBT community. Although the affordable services offered for LGBT women in Omaha are very minimal, there is hope for the younger poor LGBT population. Omaha very recently introduced a new sex education program that was of much controversy, because it included extensive information on LGBT identity, protection, sex, and other factors. (Omaha World Herald) This means that poor teenage students in public high schools throughout Omaha will be able to access information about safe sex for LGBT persons and other health factors, such as mental health and transitioning.

Conclusion

In this survey of affordable reproductive healthcare options for women in the Omaha metro area, it was observed that the lowest-income areas of the city were reasonably well-served, with the exception of Central Omaha.  This underservice may have been due to geographic factors, racial preferences, or other issues.  A sliding fee scale option was determined at the overwhelming majority of clinic locations, aiding in the affordability of services, and assistance in obtaining public or private insurance, as well as determining potential Medicaid availability, was also offered by most providers.  Some disparities in service access were observed between communities with different racial minority concentrations.  These disparities may be influenced by multiple social factors, ranging from disparate incarceration rates to the cultural value of various family structures.  While the majority of clinics surveyed provided comprehensive reproductive healthcare services, two outlying clinic types were observed, illustrating the divisiveness of the issue of abortion services.  Finally, it was observed that limited reproductive healthcare options existed for members of the LGBTQ community.

Bibliography

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