A new Texas Policy Evaluation Project (TxPEP) study on Texas organizations receiving family planning funds finds that proposed federal guidelines restricting abortion counseling and referrals for Title X providers may adversely impact the health care of pregnant women.

The study, published in Contraception, compares pregnancy options counseling and referral practices at state-funded and federal Title X-funded family planning organizations in Texas after the state enforced a policy in 2013 restricting abortion referrals for providers participating in state-funded programs. Pregnancy options counseling consists of providing information on parenting, adoption and abortion. Referrals can include handing out a list of providers, connecting patients to programs for financial assistance and making an appointment for the patient.

Proposed changes to the Title X guidelines prohibit organizations from receiving funds if they provide comprehensive abortion referrals. This new ‘gag rule,’ similar to a policy implemented in Texas in 2013, states that organizations and providers receiving family planning funds must not “provide or promote elective abortions.” The changes would severely limit providers’ abilities to provide medically appropriate information about abortion to the nearly 4 million clients who rely on Title X-funded services nationwide.

The study found a major discrepancy between abortion referrals and referrals for other pregnancy-related care. At both Title X and state-only funded organizations, if providers did offer patients information about abortion services at all, they typically only gave patients a list of facilities that provided abortion, which was not always up to date. In contrast, providers were more willing to offer additional information and referrals for prenatal appointments.

At the time of the study, Title X providers were required to provide abortion referrals upon request, but the new guidelines do not require organizations to provide abortion referrals at all. Even in the case that organizations choose to offer a list of women’s health providers to someone explicitly seeking information about abortion, organizations may not distinguish between those that offer abortion services and those that offer only prenatal care.

“None of the organizations in our study provided abortions, but the people we interviewed were worried that they could lose their family planning funding just by sharing information about abortion. They feared this might be seen as ‘promoting’ abortion, which would violate state policy,” said Kari White, Ph.D., lead author of the study and investigator at TxPEP, part of the Population Research Center at The University of Texas at Austin. “What we saw in Texas is likely to happen on a national level under the proposed Title X guidelines that include similar restrictions.”

The study also found that all Title X-funded organizations offered pregnancy options counseling while less than half of the state-funded organizations did. “Our study shows that if the policy does not require providers to counsel patients about all their pregnancy options, including abortion, providers often don’t,” said Kristine Hopkins, Ph.D., TxPEP investigator and an author on the study. “This policy is inconsistent with best practices for patient-centered care for pregnant women. When providers cannot even discuss abortion as an option with women experiencing unplanned pregnancies, it may not be seen as a valid choice–this intensifies abortion stigma.”

The study took place between November 2014 and February 2015. The conclusions are based on interviews with administrators, medical directors, clinical services directors, and clinicians from 15 Title X-funded organizations and 22 state-funded organizations.

Major medical associations, such as the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, recommend that women receive options counseling and referrals to appropriate sources of care. Restricting options counseling and referrals can pose ethical dilemmas for medical practitioners who seek to follow medical best practices for pregnant patients.