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Intended cuts

When Colorado lawmakers rejected a bill to help fund the Colorado Family Planning Initiative in April, they halted the most successful teen pregnancy prevention program in the nation. The CFPI will run out of funding June 30 and local health clinics, including the Pueblo City-County Health Department, are scrambling to find a way to keep the program going.

Colorado saw a 39 percent drop in its rate for teen mothers ages 15 to 19 from 2007 to 2012, making it the most dramatic decrease in the nation, according to an August 2014 Centers for Disease Control and Prevention report. The teen abortion rate during the time period dropped by 35 percent.

The CFPI, which provides the state with funding for long-acting reversible contraception products, has been largely responsible for the dramatic decrease since its creation in 2009.

The overall decrease in teen pregnancy for the United States during the same time period was 29 percent.

“Through the Colorado Family Planning Initiative, we were able to purchase those products and then give them to our clients for free, so we were able to increase our access to care and decrease their barriers, which is huge when it comes to decreasing pregnancy rates,” said Stacy Herrera, clinic program manager at the Pueblo City-County Health Department.

Now that the funding has been slashed from the state budget, the department will have to rely on its existing stock of products either until they run out or find a new source of funding.

“We’re not going to have access to purchase those products because they are super expensive. Each product is about $1,000 apiece,” Herrera said.

Six years ago the initiative was introduced after the Susan Thompson Buffett Foundation, an organization headed by Warren Buffett, provided the state of Colorado with a $23 million private grant. At the time, the donation was anonymous.

“Youth born to teen moms are highly likely to become teen mothers themselves. We’ve seen the cyclical action in Pueblo several times.” – Stacy Herrera, Pueblo City-County Health Department

The recently rejected bill would have provided the initiative with $5 million worth of public funds. Supporters of the funding said it was a good investment. For every dollar invested into the program it saved Colorado $5.85 in Medicaid dollars.

“It was a proven program in Pueblo County,” said Rep. Daneya Esgar, D-Pueblo. “We fought very hard and it was hard to watch it fall to partisan politics.”

The funding died in a senate committee on a 3-2 party line vote.

Sen. Larry Crowder, R-Alamosa, told the Denver Post he didn’t support funding the program because the Affordable Care Act should cover the contraceptives.

“I do believe we have to safeguard the taxpayer’s purse on this,” he told the Post.

Ironically, the day before the vote the state received an award for the program from the National Family Planning and Reproductive Health Association for being among the best public health access programs in the country.

Since the initiative began, around 30,000 intrauterine devices have been provided to Colorado women.

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A highly controversial form of birth control, IUDs work by releasing hormones to prevent sperm from fertilizing an egg. They can last from three to 12 years and are more effective than traditional forms of birth control largely because once inserted, women don’t have to think about the device again until they want to replace or remove it.

Opponents argue that this form of contraception is abortion. In the rare event that sperm still fertilizes an egg, IUDs prevent it from implanting on the uterine wall.

But regardless of the debate behind them, IUDs and other forms of long-acting reversible contraception products, like the Nexplanon hormonal implant, have been instrumental in reducing the teen pregnancy rate in Colorado.

Teen pregnancy and Pueblo

For years, Pueblo has had one of the highest teen pregnancy rates in Colorado. Herrera accounts for the county’s high rate through a combination of cultural messages and a lack of proper sexual health education among Pueblo teens.

“Youth born to teen moms are highly likely to become teen mothers themselves. We’ve seen the cyclical action in Pueblo several times,” Herrera said.

Occasionally, Herrera sees grandparents in their 30s, the result of a cycle in which the children of teenage parents also get pregnant in their teens.

“Sometimes some of the parents, not real often but I’ve heard it, will say, ‘I want to be a grandma.’ They’re 32 and 35 and they’re saying, ‘I don’t have any grandkids yet,’” she said.

Because of efforts like the CFPI and the community health improvement plan, Pueblo has seen a 40 percent decrease in its teen pregnancy rate. It has also been making strides in education and changing cultural messages about sex in the community.

Introduced in 2013, the community health improvement plan intends to lower the obesity and teen pregnancy rates in Pueblo. The plan’s two main objectives are based on the results of a state-mandated community health assessment.

“In Pueblo County alone, between 2009 and 2013, our teen pregnancy rates for 15 to 19-year-olds dropped 40 percent. During those years, we had a decrease of 391 births,” Herrera said.

Now that the Family Planning Initiative is without a source of funding Herrera said she thinks the teen pregnancy rate will increase again in Pueblo.

“That was one of our fears. We were hoping for a downward trend with receiving that $5 million from the state to hopefully get it as close to zero as we could’ve. Unfortunately, with decreased access to the LARC products, we probably will see another increase again,” she said.

The department will continue to offer free birth control to Pueblo women, but it will be limited to more traditional forms, like the pill and the Depo-Provera birth control shot, which are generally less effective at preventing pregnancy.

On a national basis, the failure rate for IUDs is 0.8 percent, according to the CDC. The pill, on the other hand, has a failure rate of 9 percent and the Depo-Provera shot has a failure rate of 6 percent. Condoms have a failure rate of 18 percent.

“We still have birth control pills and the Depo shot available, which are good methods. But they are methods that have a huge rate of human error factored into that,” Herrera said. “Teens who use traditional birth control methods, such as the pill or the Depo shot are 20 times more likely to become pregnant than a girl on LARC in the same age group.”

Methods like the pill and the Depo-Provera birth control shot require women to consistently take action to ensure their birth control is working. The pill requires daily use and the Depo-Provera shot requires women to visit their clinic every 12 weeks for administration in order to be effective.

Herrera said IUDs and other long-acting forms of birth control are more realistic.

“Unfortunately, with decreased access to the LARC products, we probably will see another increase again.” – Stacy Herrera

“Once you put it in, it makes sense. Once you put it into your arm, you’re done thinking about it for three to five to 10 years, depending on what device you received,” she said.  “You know, we as women, have busy lifestyles. We work, we go to school, we have social gatherings, we have social events and life just happens. That human error factor is just really high sometimes.”

The health department has an onsite pharmacy, where it stores immunizations and birth control.

“I currently have long-acting reversible products available for about five to six months and so we’ll continue to offer those products,” Herrera said. “We are currently looking for more funding to purchase more products but unfortunately, there’s just not a lot of grants or monies to be had surrounding those specific types of birth control.

“So, we’re going to work vigorously along with the CDP and the state health department, to continue to look for monies and for further funding.”

In the meantime, the department plans to continue with its sexual health education efforts in the community.

Lowering the rate

Recently, a major focus of the department has been to normalize the conversation about sex by encouraging parents to be “askable” adults. After conducting research, the department discovered that nine out of 10 teens would prefer to get information about sex from their parents.

pregnancy3“We understand that it’s a difficult conversation and we know it’s difficult to bring that up, but we’ll give them some tips on how to talk to their parents because we want those conversations to go on. What we’re trying to do is normalize the conversation,” Herrera said.

“So, talking about sexual reproductive health is no different from what most parents feel is a safe conversation. You know, I talk to my kids about vegetables and driving and wearing a helmet when they ride a bike and wearing a seatbelt. It’s the same thing.”

The department’s biggest educational focus, though, is on the teens themselves. Before teens make an appointment at the clinic, they can ask nurses questions about reproductive health, which has been an effort to increase access to care.

The clinic navigator, for example, is available to answer questions via telephone prior to making an appointment. The clinic also has a texting service called Go Ask Tara, which allows teens to ask reproductive health questions anonymously.

“So when people get a little bit skittish about asking those sexual reproductive health questions, it’s nice to kind of be able to have that access,” Herrera said.

The department also encourages teens to plan for their future.

“We’ll ask youth, ‘what do you want to do in life?’” Herrera said, “and sometimes they’ll say, ‘I’ve never been asked that. I have no clue. I just thought about tomorrow.’”

“We’re able to start that fire and set that spark in their mind and help them start visualizing and thinking about the future and how their decisions today will affect them in years and generations to come,” she said.

The health department also offers services like immunizations, so patients are not necessarily only there for birth control. In the clinic, there is a sign that lists the multiple services provided by the department, an effort that helps de-stigmatize the environment.

In 2014, the department received a grant from the state to renovate its clinic rooms to make visits more comfortable. After conducting a focus group, the department decided to redecorate the rooms based on teen opinions.

“We applied for the extra grant monies with the state and we were one of the only two clinics statewide to do the improvements so we are very excited,” Herrera said.

The loss of a clinic

Recently, the clinic has seen a slight increase in appointments. Pueblo’s only Planned Parenthood closed in February after the landlord of the building it was located in declined to renew its lease. Those patients were directed to other clinics around Pueblo and in Colorado Springs.

“We would love to have those patients. We currently have the capability to accept new patients and so if someone wants to come in and join our clinic, we would love to have them,” Herrera said.

Pueblo’s A Caring Pregnancy Center, which offers services to women with unintended pregnancies, has not seen a dramatic increase in patients since Planned Parenthood closed.

Sen. Larry Crowder, R-Alamosa, told the Denver Post he didn’t support funding the program because the Affordable Care Act should cover the contraceptives.

“We’ve noticed an increase in calls and we’re fully booked,” said executive director Tamra Axwothy, but the clinic is not sure whether they are receiving those calls as a result of Planned Parenthood’s closing.

Because ACPC’s clinic is so small, they do not offer birth control. Instead, their emphasis is on offering services to women who are already pregnant. Twenty percent of their clients are teens.

ACPC offers counseling for women who have unplanned pregnancies, specifically those who are considering having an abortion. While the clinic does not necessarily discourage women from having abortions, they place an emphasis on the pregnancy and parenting classes they offer.

Axworthy said ACPC does not plan to change any of their services to accommodate for Planned Parenthood’s closing.

“We’re not changing who we are or what we do as a result of their closing,” she said.

Many low-income Pueblo women looking for birth control options may be turning to the health department.

The Pueblo health department is a Title X clinic, which means it receives money from the state to offer services on a sliding fee scale.

“Based on income, that means that services are free to low cost. For 19-year-olds and under, services are always free. That includes breast exams, gonorrhea and chlamydia testing, birth control, everything,” Herrera said. pregnancy1

But as more clients turn to the health department, they will have to rely on a limited supply of the most effective forms of birth control until more funding is found.

“Here at the clinic, once those products run out, unfortunately if I can’t get any more, we’ll continue to offer the traditional birth control,” Herrera said. “We’ll continue to look for more funding. Hopefully we’ll find something.”

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