For years after it opened in the late 1990s, Passage Charter School in western Colorado’s Montrose County had a waiting list for the 24 spots it offered teen parents. Last year the school had only two students and closed at the end of the term.
Louis Winkler, a Montrose doctor who was a member of the Passage board, gives much of the credit to a state program that made the most effective birth control methods widely and affordably available across Colorado.
Teen pregnancy rates have been falling nationwide, but more sharply in Colorado. Nationally, the birthrate for women aged 15 to 19 dropped from 41.5 per 1,000 in 2007 to 24.2 in 2014. In Colorado, the drop was from 40.2 to 19.4.
Nationally and historically the teen birthrate in rural counties such as Montrose has been higher than in cities and suburbs, and falling more slowly. Colorado’s success in addressing teen pregnancy has included strides in rural counties. Only Colorado and Connecticut saw decreases of 50 percent or more in rural teen birthrates between 2007 and 2015, according to the Centers for Disease Control and Prevention.
The State of Rural Health Care
“There are a lot of preconceived beliefs and notions about what happens in rural areas as opposed to more urban areas,” says Bill Albert, chief innovation officer at Power to Decide. His national think tank, which was not involved in Colorado’s birth control project, works to prevent unplanned pregnancies and ensure young people can get good information about sexual health and a full range of contraceptive methods.
Are rural parents less likely to talk to their teens about birth control? Are people marrying and having children earlier in the country? Power to Decide researchers set out to test such assumptions. In a 2015 report based on a review of county-by-county birthrates and other statistics, they found that the same issues contributed to teenagers having babies in rural and urban areas – chiefly lack of economic opportunity and of hospitals and clinics and the nurses and doctors to staff them. It’s not that the people or the culture differed radically. It’s that poverty, joblessness, poor education prospects and inadequate health care are more prevalent outside cities.
Power to Decide concluded the higher rates of unprotected sex and childbearing among rural teens are “predominantly a function of the everyday difficulties that communities face in making services and opportunities available to young people.”
In Montrose, Winkler said that in addition to ensuring teens with children got their diplomas, a dedicated school staff helped them get scholarships for cosmetology, dental and other vocational programs and saw some go to college. One graduate became a teacher, and another became a police officer. Winkler says the schools’ founders reasoned if they could help young mothers succeed, “we could maybe break the cycle of poverty and pregnancy.”
Studies have shown having babies early hurts the health of the mothers and the children, and keeps young women from achieving personal, educational and professional goals.
In 2008, a $27 million, multiyear grant from the Susan Thompson Buffett Foundation allowed the Colorado Department of Public Health & Environment to distribute intrauterine devices and hormonal implants at little or no cost. The state used a network of publicly funded family health clinics that largely served low-income women to distribute the devices known as long-acting reversible contraceptives, or LARCs, which provide no-fuss contraception for years after insertion. LARCs are more effective than pills or condoms and have higher up-front costs.
“It was just about making LARC devices available,” says Jody Camp, who manages the state health department’s Family Planning Unit. “Put them on the shelf and women choose them.”
After the national private grant ran out in 2015, a dozen Colorado foundations provided bridge funding and in 2016 the state legislature voted to increase family planning spending. The 2010 Affordable Care Act and subsequent Medicaid expansion in Colorado also helped more women obtain LARCs and put clinics on firmer financial footing.
Kinsey Hasstedt, senior policy manager at the Guttmacher Institute, is as admiring of Colorado’s achievements as she is anxious about the future for it and other states. Hasstedt, whose 50-year-old Washington, D.C.-based think tank focuses on population issues, said the Trump administration has targeted not only the Affordable Care Act but the federal Title X program, which since 1970 has funded family planning clinics like the ones on which the Colorado program depended for its success.
“Anything that seeks to undermine women’s access to a full range of (contraceptive) options is unacceptable,” Hasstedt says, adding the extent of any threat would only be clear once the budget process in Washington yields details.
Along with providing the contraceptive devices, which more than 36,000 women had received under the project by 2015, Colorado stepped up health care workers’ training on LARC insertion and removal and on how to talk about family planning. A public awareness campaign included a Web site and social media advertising – Power to Decide researchers had found rural teens were just as digitally connected as their city cousins – designed to get Coloradans talking about reproductive health and choices ranging from abstinence to IUDs.
In southwestern Huerfano County, clinic manager Debbie Channel says the campaign prompted her neighbors to speak more openly about their concerns for the future of teens who have kids.
“They started having the conversation in public and that I think helped,” she says. “Especially in small rural communities, we need to watch out for each other’s children.”
In the early days, the initiative’s two coordinators traveled the state. They learned of wait lists for expensive contraceptive devices in rural areas like Huerfano as well as at urban clinics, evidence of a pent-up demand regardless of geography. Coordinator Ellen Marshall and her partner also found rural health care providers ready to take the lead in potentially controversial areas such as providing contraceptive services in school-based clinics.
Health workers at school clinics, the only clinics in some rural areas, “understood the ‘this is basic health care’ argument earlier,” Marshall says.
Public health nurse Megan Coatney was born, raised and now works in Morgan County in the wheat, corn and cattle country of the eastern Colorado plains. She is still in touch with a friend who had a baby in middle school and another who had one in high school.
“There’s just so much that they didn’t know,” she says. “They have both struggled.”
When Coatney started work in 2011, the nurse who trained her pointed to a half dozen IUDs in a cabinet, all the clinic budget would allow. When Coatney spoke in a recent interview, she had a stock of more than 100 LARCs.
Coatney talks to young people about LARC and other options at a round table in a clinic office.
“I don’t want them to feel they’re in a doctor’s office being lectured to. We just talk,” she says. “I want to give them the education to help them take charge.”
Tags: Colorado, pregnancy, teen pregnancy, birth rate, birth control, economy, health care, health care reform, Medicaid, education.