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© 2001 American Public Health Association
EDITORIAL |
Wendy Chavkin is with the Heilbrun Center for Population and Family Health, Mailman School of Public Health, Columbia University.
Correspondence: Requests for reprints should be sent to Wendy Chavkin, MD, MPH, Heilbrun Center for Population and Family Health, Mailman School of Public Health, 60 Haven Ave, B-3, New York, NY 10032.
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INTRODUCTION |
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 TOP INTRODUCTION References |
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In this issue of the Journal, Radha Jagannathan has provided us with a methodologically elegant assessment of the degree to which low-income New Jersey women underreported abortions.1 By comparing self-report with Medicaid claims, she is able to compare rates of underreporting by race/ethnicity and other social and behavioral characteristics. Such an analysis is of great help to those of us who seek to characterize various populations' behaviors so that we can design public health interventions.
The accuracy of self-report is always a matter of concern to public health researchers, as we recognize that memory, misunderstanding, and a host of other factors affect respondents' answers. A body of literature addresses the degree to which people are particularly hesitant to report behaviors considered "socially undesirable." To understand why so many New Jersey women did not report abortions, we have to locate Jagannathan's study in its context. This context comprises a wide-ranging effort to denigrate sexual activity outside of marriage and to constrict access to reproductive health information and services.
As we are all too well aware, abortion has been at the heart of a political and cultural storm for the 3 decades it has been legally available in the United States—a particularly deadly, ugly storm at that. It has left dead in its wake Dr David Gunn, Dr John Bayard Britton, Dr Bernard Slepian, James Barrett, Shannon Lowney, and Leanne Nichols. At least 6 other people have been shot and seriously wounded.2 Dr George Tiller now wears a bulletproof vest to work. Many women seeking abortions have also faced harassment, interference, and intimidation at abortion clinics. Since 1977, there have been more than 45 000 reported cases of picketing, 400 cases of stalking, 150 cases of arson, and 40 bombings.2
All of this is old news. The New Jersey story, however, gives us a lens through which to view recent twists in this anti–reproductive choice maelstrom. Dr Jagannathan's work took place as part of an evaluation of the New Jersey Family Cap program. This program, called the Family Development Program, began in 1993 when New Jersey received a waiver from the federal government to try "innovative" approaches with its welfare program, on condition that the program be set up in an experimental design and formally evaluated. One component of New Jersey's Family Development Program that was evaluated was the Family Cap policy that was intended to reduce births to welfare recipients by denying a stipend to any subsequently born child (quaintly referred to as an "afterborn" child). Importantly, legislators sought to achieve this reduction in births without an increase in abortion. The evaluation in New Jersey demonstrated a decline in births and an increase in family planning utilization but also an increase in abortion, especially for those recently enrolled.
The Family Cap was one of a series of measures that states were allowed to impose (either by waiver prior to 1996 or without waiver after the 1996 passage of the Personal Responsibility and Work Opportunity Reconciliation Act, known as "welfare reform") that were intended to control and constrain the sexual activity and fertility of poor women, goals articulated explicitly in the preamble to the bill.3 Other notable state provisions include conditioning receipt of cash benefits on identification of the child's father and attendance at family planning counseling and requiring women who have had "capped" children to return to work earlier after delivery than is required of mothers of "noncapped" children. Two components of the federal bill are directed at the general population and not exclusively at welfare recipients: block grants to the states for abstinence-only education programs, which must advocate sexual abstinence outside marriage and must delineate the harm to society, the mother, and the child allegedly caused by out-of-wedlock births; and annual bonus funds to the 5 states whose out-of-wedlock birth rates declined the most without increased abortion rates.
Since George W. Bush assumed the presidency, the storm has intensified. One of his first acts was to reimpose the Global Gag Rule, which restricts foreign nongovernmental organizations that receive US family planning funds from using their own, non-US funds for providing legal abortion services, lobbying for abortion law reform, or providing accurate medical counseling or referrals regarding abortion.4 The Bush administration has opposed coverage of contraceptive care for federal employees, has recently decided to refuse waivers to states wishing to extend Medicaid coverage for family planning, has endorsed the Unborn Victims of Violence Act, and has proposed to extend Child Health Plus Program (CHIP) coverage for prenatal care on behalf of the fetus, rather than to the pregnant woman as proposed in a competing bill.5 Pro-choice advocates believe these last 2 acts are backdoor efforts to establish fetal personhood under the law. In concert with the promulgation of abstinence education, there has been an effort to depict condoms as ineffective in protecting against sexually transmitted diseases (STDs). This disinformation campaign has included demands that warning labels be put on condoms, that the director of the Centers for Disease Control and Prevention (CDC) resign because of the CDC's promotion of safe-sex programs, and that federal funds be withdrawn from supporting all such programs. Although a recent report by the Department of Health and Human Services concluded that condoms have been proven effective at preventing transmission of HIV and gonorrhea but that data were insufficient regarding other pathogens, there are indeed data demonstrating that condoms offer significant protection against chlamydia, herpes, and human papillomavirus as well.6,7
There are many vantage points from which to disagree with these measures; those people concerned with poverty and equity, with women's rights and human rights, and with the separation of church and state have all expressed grave concern.8,9 These measures also have adverse consequences for public health. They lead to increased morbidity and mortality, to attacks on providers, to reduced access to care, and to silence instead of informed discussion. Elsewhere, I and my colleagues have reviewed evaluations of the welfare-associated policies listed above and concluded that evidence of efficacy is lacking.10 The Campaign to Prevent Teen Pregnancy has scrutinized programs attempting to reduce teen pregnancy and concluded that the most successful such program is comprehensive in nature—including sex education, provision of contraception, and job and skill development—and that, to date, the evidence does not support the abstinence-only approach.11
Others have critiqued the gag rule and pointed to the public health damage wreaked by impeding access to family planning for women in countries in which maternal mortality and severe morbidity and infant mortality are serious risks.12 Efforts to disparage condoms bring the disinformation campaign and its harm to public health back home. Not only does the United States have one of the highest rates of unintended pregnancy in the developed world, but we also have a recurrent and persistent problem with STDs.13 Importantly, we have seen a rise in condom use by young people in the last decade, attributed in part to fear of HIV infection. Since young women, particularly young Black women, are at increasing and disproportionate risk of heterosexually acquired HIV infection, it seems the height of public health irresponsibility to disparage and discourage an important means of self-protection.14
The attempt to provide health insurance for prenatal care to the fetus and not the woman not only reveals overt hostility to her as a human being of worth and dignity, but also cannot attain its purported goal of advancing fetal and infant health. Fetuses reside within women and neonates depend on them. Women's health problems, if not treated, can have long-term trajectories, affecting the ability to conceive, carry to term, and care for infants as well as the well-being of the women. Only a handful of studies have addressed this interaction, but these have demonstrated the obvious: just as maternal problems can be a marker of risk of infant problems, neonatal ill health can be a marker of risk of maternal problems. Efforts to limit care to the prenatal period alone have not been successful in preventing preterm delivery, the major current contributor to infant mortality and serious morbidity in the United States. Women whose health problems (hypertension, glucose intolerance, etc.) go untreated continue to suffer from these conditions and thus have recurrent problem pregnancies as well as worsening health conditions.15
The violence surrounding abortion not only has made women reluctant to report having them but also has affected the number of clinicians willing to provide them. This, together with denial of Medicaid reimbursement by most states, has seriously reduced access. Information and access are further curtailed by abstinence-only education. Twenty-nine of 46 jurisdictions (44 states, the District of Columbia, and Puerto Rico) report prohibiting the provision of information regarding contraception, even in response to a direct question, and 10 prohibit information about providers of STD and HIV services.16
How can one make sense of policies designed to curtail births, abortions, contraception, and sex information? These varied policies have in common the single-minded belief that sex should be only for procreation within legal marriage. This notion conflicts with the post–World War II reality that fertility has declined dramatically, age at marriage and first birth has risen, and divorce and out-of-wedlock childbearing have increased. These patterns appeared first in the developed world, but many developing countries show similar profiles.9 The fact that the train has left the station, so to speak, regarding this yearning for an idealized nuclear marital family does not of course mean that its proponents will give up their efforts. It does, however, add an additional line of argument for those of us who believe that these policies cannot be efficacious and actually aggravate important public health problems and obstruct efforts to remedy them.
It is important for public health researchers and program planners to understand why people are hesitant to acknowledge their own actions. Underreporting happens in a context. In the case of Jagannathan's study, the context is both that of New Jersey's Family Cap and, simultaneously, the nationwide controversies about sex and reproduction. Public health advocates must refuse disinformation and the imposition of silence. The health of the public requires information and discussion.
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Acknowledgments |
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I gratefully acknowledge the thoughtful input of Diana Romero, Barbara Pastrana, and Naomi Lince.
Accepted for publication August 14, 2001.
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References |
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TOPINTRODUCTIONReferences |
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1. Jagannathan R. Relying on surveys to understand abortion behavior: some cautionary evidence. Am J Public Health.2001;91:1825–1831.
2. National Abortion Federation. Chronological history of violence. May 22, 2001. Available at: http://www.prochoice.org/default7.htm. Accessed July 25, 2001.
3. Personal Responsibility and Work Opportunity Reconciliation Act of 1996. Pub L No. 104-193, 110 Stat 2105-2355, 1996.
4. Center for Reproductive Law and Policy. House retains Bush Global Gag Rule. May 16, 2001. Available at: www.crlp.org/pr_01_0516ggrvote.html. Accessed July 25, 2001.
5. Center for Reproductive Law and Policy. Bush administration denies states the opportunity to help women, creates rights for fetuses. Available at: www.crlp.org/pr_01_0720bush.html. Accessed July 25, 2001.
6. Judson F, Bodin G, Levin M, Ehret J, Masters H. In vitro tests demonstrate condoms provide an effective barrier against Chlamydia trachomatis and herpes simplex virus. Paper presented at: 5th Meeting of the International Society for STD Research; August 1–3, 1983; Seattle, Wash.
7. Juarez-Figueroa LA, Wheeler CM, Uribe-Salas FJ, et al. Human papillomavirus: a highly prevalent sexually transmitted disease agent among female sex workers from Mexico City. Sex Transm Dis.2001;28:125–130.[Medline]
8. Levin-Epstein J. Open questions: New Jersey's Family Cap evaluation, February 1999. Available at: http://www.clasp.org/pubs/teens/OpenQuestions.htm. Accessed July 25, 2001.
9.
Albisa C. Welfare reform as a human rights issue. Am J Public Health.1999;89:1476–1478.
10. Chavkin W, Draut T, Romero D, Wise PH. Sex, reproduction and welfare reform. Georgetown J Poverty Law Policy. 2000;7(2):1–11.
11. Kirby D. Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. Washington, DC: National Campaign to Prevent Teen Pregnancy; May 2001.
12. Center for Reproductive Law and Policy. Bush Global Gag Rule: endangering women's health, free speech and democracy. Available at: www.crlp.org/pub_fac_ggrbush.html. Accessed July 25, 2001.
13. Centers for Disease Control and Prevention. Tracking the hidden epidemics: trends in STDs in the United States 2000. Available at: http://www.cdc.gov/nchstp/dstd/Stats_Trends/Trends2000.pdf. Accessed July 25, 2001.
14. Lee ML, Fleming PL. Trends in human immunodeficiency virus diagnoses among women in the United States, 1994–1998. J Am Med Womens Assoc.2001;56:94–99.
15.
Mandl K, Tronick E, Brennan TA, Alpert HR, Homer CJ. Infant health care use and maternal depression. Arch Pediatr Adolesc Med.1999;153:808–813.
16. Sonfield A, Gold RB. States' implementation of the Section 510 abstinence education program, FY 1999. Fam Plann Perspect. 2001;33:166–171.[Medline]
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