In Oklahoma, Native American women struggle to access emergency contraception

TULSA, Okla. — When Apollonia Piña, a citizen of the Muscogee Nation of Oklahoma, needed Plan B four years ago, she turned to the Indian Health Care Resource Center of Tulsa, where she received her primary care. But the pharmacist there told her they didn’t carry emergency contraception.

“I was like, ‘Oh, why not?’ And she goes, ‘Because we’ve just decided not to carry it, and we will never carry it,’” Piña said. “She was kind of gloating about it.”

Piña also tried calling a health clinic run by her tribe, but they didn’t have it either. Ultimately, she had to make a 60-mile round trip to the federally-run Claremore Indian Hospital to get Plan B.

The federal government promises free health care for Native Americans, which it provides through both federally-operated clinics and funding for Native American tribes and private organizations to run their own clinics. The federal government requires its own clinics to provide emergency contraception, but many tribally-run clinics do not. 

An investigation by Medill News Service determined that around half of the Native American health care facilities in Oklahoma don’t provide Plan B, a medication that can prevent pregnancy if taken within 72 hours of unprotected sex or birth control failure. The state is home to 38 federally-recognized tribes and has one of the highest concentrations of Native Americans in the country. It also has one of the strictest abortion bans in the nation, with no exception for rape or  incest.

In a climate where women across the country confront uncertainty regarding access to reproductive health care, some Native American women feel that the failure of these clinics to provide emergency contraception echoes a painful history of the U.S. government denying them and their ancestors control over their own bodies. This includes forced sterilizations of Native American women at federal health clinics in the 1960s and 1970s.

“Access to Plan B is a Native woman's right to self-determination,” Piña said. “(It) allows her to have autonomy and governance over her own body and decision-making without interference from others.”

Dr. Jesicah Gilmore, the medical director of the Indian Health Care Resource Center of Tulsa, where Piña first sought Plan B, said in an email that the clinic started providing the generic form of Plan B in July 2022. Before this, Gilmore said the clinic didn’t provide emergency contraception due to lack of patient demand and because it was accessible through other avenues like the Claremore Indian Hospital.

“In 2022, we experienced a sharp rise in the number of patients who were asking about its availability, so we reexamined the issue and voted to add it,” Gilmore said.

The clinic is run by a nonprofit, but it receives funding from the Indian Health Service, the federal agency that provides free health care for Native Americans.

In an email, the agency’s public affairs office said that emergency contraception “has been widely available without barriers at all federal IHS facilities since 2012.” Plan B One-Step is on the agency’s national core formulary, a list of medications that all Indian Health Service facilities are required to provide. However, the public affairs office said only facilities directly run by the agency are required to follow the formulary.

There are nine federally-run Indian Health Service facilities in Oklahoma and 48 clinics run by tribes. There are also two urban Indian health centers, which are privately-operated clinics that provide medical care to Native Americans living in urban areas.

“Implementation of the IHS (national core formulary) is encouraged but not required at tribal and urban Indian organization facilities,” the public affairs office said in an email. “As such, it is possible that patients seeking care at these latter sites may not have access to (national core formulary) medications.”

A phone survey of each of the 59 Native American health care facilities in Oklahoma found that about half either don’t provide Plan B or only provide it as part of sexual assault exams. While all the federally-run facilities that answered said they provide Plan B, many of the tribal facilities said they do not. Each tribe sets its own policy regarding emergency contraception. For example, all Cherokee and Absentee Shawnee health centers offer Plan B, but Muscogee and Chickasaw health centers do not, according to interviews with pharmacists and tribal leaders.

Half of Oklahoma Native American health clinics don’t provide Plan B

Even when tribes do provide Plan B, they sometimes add restrictions. For instance, Cherokee Nation Communications Executive Director Julie Hubbard said a patient has to be at least 17 to get the drug through the nation’s health system, even though there are no age requirements for Plan B at Indian Health Service facilities or retail pharmacies.

Medill News Service reached out to each of the tribes in Oklahoma that don’t provide Plan B to ask why that is, but most did not respond or declined to comment.

Choctaw Chief Gary Batton did say he feels women should have the choice to use Plan B. But Choctaw Nation Public Relations Director Randy Sachs said in an email that the tribe’s clinics only provide Plan B as part of sexual assault exams.

In a follow-up email, Batton said the nation decides what medications to provide based on cost, the needs of its members and “shared community beliefs.”

Batton also said he doesn’t think Plan B should be provided in all situations.

“There are other better proven methods of birth control,” he said. “That is why it is called Plan B.”

Native American Women’s Health Education Resource Center co-founder Charon Asetoyer spent years fighting for equal access to Plan B. In 2010, the center launched a campaign to raise awareness about inconsistent access to the drug through the Indian Health Service. It wasn’t until 2015 that the agency had a formal written policy requiring its facilities to provide Plan B without prescription or age requirements. This was two years after the Food and Drug Administration approved over-the-counter Plan B for all ages.

Despite the policy, however, many Native American health centers still either don’t provide Plan B or place restrictions on it. A 2017 survey by the Native American Women’s Health Education found that, while nearly all clinics run by the Indian Health Service were following the Plan B policy, only 40 percent of tribal and urban clinics surveyed provided Plan B over the counter without any age requirements. Of the nearly one-third of tribal and urban clinics that didn’t provide Plan B at all, 91 percent were located in Oklahoma. 

Asetoyer, a citizen of the Comanche Nation of Oklahoma who lives in South Dakota, said clinics that don’t provide Plan B “ought to be ashamed of themselves.”

“They are denying women access to a contraceptive that every other woman in this country has access to,” she said.

She said Native women should be able to get free Plan B, which can cost around $50 at retail pharmacies.

“We don't pay for our health care, and there are reasons for it,” she said.

Those reasons are based on the historical relationship between the U.S. government and Indigenous nations. During the seizure of Native lands in the 19th and 20th centuries, the U.S. government often promised to provide health care for tribes as part of treaty negotiations. To honor these treaty obligations, the federal government passed legislation to provide free health care to all Native Americans who are part of federally recognized tribes.

Some Native American women also may not be able to afford to buy Plan B at a retail pharmacy. Native Americans face some of the highest poverty rates in the country. Nearly one in four American Indians and Alaska Natives lives in poverty, Census Bureau data shows.

“We have women that don't even have automobiles, let alone the money to get gas (or) to hire someone to take them to the nearest (retail pharmacy),” Asetoyer said.

Asetoyer was surprised to hear that the Indian Health Service said tribal and urban clinics aren’t required to provide Plan B. She disagreed with the agency’s interpretation of its policy that exempts those clinics.

“Why isn't the Indian Health Service making them follow federal policy?” she questioned.

While Asetoyer feels all Native health clinics should have to provide Plan B, Piña wants her tribe to decide on its own to provide it for women. Piña said having the federal government require it would be a violation of tribal sovereignty, the legal principle that Native tribes should be free to govern their own affairs.

Like many Native Americans, Piña has a complicated relationship with the Indian Health Service. Now an ER nurse, she did her emergency room rotations at the Claremore Indian Hospital. Decades prior, that same hospital sterilized Native American women without their consent as part of mass sterilizations by the Indian Health Service.

“It was a bizarre and kind of surreal experience,” she said. “I have to compartmentalize my feelings about the hospital.”

This dark history makes reproductive rights a touchy subject in Indian Country.

Piña said she and many other Native Americans view reproductive health care and abortion as issues of “body sovereignty,” the idea that a person should be able to make decisions about their own body.

However, because of historical trauma, other Native Americans view abortion differently, Piña said.

“They see it as like, you're trying to kill Native children,” Piña said. “And see, this is where it gets a little bit complicated, talking about these things with Native people, because of this intergenerational trauma, because of the history of a white government trying to, well, eradicate us off the face of the earth.”

Sarah Adams, a citizen of the Choctaw Nation of Oklahoma, said Plan B is often caught up in disputes about abortion, even though it's actually a form of contraception used to prevent pregnancy by stopping the ovaries from releasing an egg.

“I think that a lot of people have no idea what it does, or they have political or religious leanings that have misled them to believe something that just isn't true about it,” she said.

Adams is a co-founder of Matriarch, a female-led group dedicated to empowering Native American women. She said discussions of sexual health can be somewhat taboo in Native communities. This stems in part from historical trauma from the 19th and 20th centuries, when the federal government forced many Native children into boarding schools to assimilate them into white culture. Physical and sexual abuse were common at such schools.

“Those boarding school kids … were really heavily influenced by Christianity and a really judgmental look on sex and bodies and the sexualization of those bodies,” Adams said.

Adams also pointed out that only one of the 12 members of the Choctaw Tribal Council is a woman, which she said is counter to her nation’s roots.

“If you don’t have women in leadership in those spaces to help make those decisions, this is what’s going to happen,” she said.

Adams said colonization caused Native American women to be disempowered and also led to an increase in violence against women.

Native American women experience violence at a much higher rate than other races. A 2013 report by the National Congress of American Indians found that more than one in three American Indian and Alaska Native women will be raped in their lifetime.

In the rural town of Antlers, Oklahoma, members of the Choctaw Nation gathered on a stormy May morning for a race to raise awareness about the  crisis of missing and murdered Indigenous women.

As she took shelter from the rain underneath a tent after the race, Linda Goodwin, senior director of victim services for the Choctaw Nation, talked about the services the tribe provides to victims of domestic violence, such as counseling, life skills training and transitional housing. The Choctaw also have trained sexual assault nurse examiners who can perform rape kits for sexual assault victims, including offering them emergency contraception.

But outside of sexual assault situations, Choctaw clinics don’t provide Plan B.

When asked for her thoughts, Goodwin, a grandmother who calls herself “more liberal than a lot of people,” said she thinks emergency contraception should be more easily accessible for Native women. She connected a lack of reproductive choices to the history of the government seeking to control Native women’s bodies.

“Historically, we were not given choices,” she said. “That goes back to when the powers that be felt they had control over our lives.”

Adams also felt this way.

“There’s never been a point in time in our history where we weren’t being oppressed or being told what to do with our bodies,” she said. 

To help fill the gaps in access to Plan B, Adams said Matriarch has taken it upon itself to start distributing emergency contraception kits to anyone who needs them.

“We don't need more people telling us when and if we need care,” she said. “We know when we need care.”

Medill News Service publishes stories reported, written and produced by Northwestern University graduate journalism students.