The United Nations Population Fund defines sexual and reproductive health as “a state of complete physical, mental, and social well-being in all matters relating to the reproductive system. It implies that people are able to have a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so.” There is a clear connection between reproductive health and the well-being of individuals, their families, and populations across generations. Reproductive rights worldwide are inextricable from gender equality and human rights, particularly the human rights of women.
There has been substantial and dramatic progress on reproductive health worldwide over the past few decades. For example, globally, the number of women who died in pregnancy or childbirth decreased by almost half over the past 25 years. In the US, the teenage pregnancy rate in 2013 reached a record low, recording a 10 percent drop over the previous year, attributable in no small part to birth control used by sexually active teens throughout the country.
This progress, however, does not obviate the unmet sexual and reproductive health needs in many parts of the world. For example, complications related to pregnancy and childbirth, a large proportion of which are preventable, remain worldwide the second most common cause of death for women of reproductive age, killing almost 300,000 women worldwide, most in low-income countries.
The provision of safe, effective abortions is a core reproductive right that remains sadly elusive for women in many countries in the world, not the least of which in the US. It has been estimated that 13 percent of maternal mortality worldwide is due to unsafe abortions, resulting in the deaths of some 47,000 women. On the occasion of the 43rd anniversary of a momentous Supreme Court decision that paved the way for widely available medical abortions in the US, a few thoughts on the past, present, and future of abortion as a core reproductive right in this country.
On January 22, 1973, Roe v. Wade transformed reproductive health in the US, ruling unconstitutional a state law that banned abortions outside of saving the life of the mother. The decision declared that states were only allowed to regulate abortions after the first trimester of pregnancy, and only in cases explicitly related to maternal health or in laws protecting the lives of fetuses during the third semester. The lawsuit was brought on by a pregnant woman in Dallas, “Jane Roe,” whose lawyers argued that the Texas ban on abortions was violating her constitutional rights. The Court’s 7-2 decision was written by Justice Harry Blackmun and argued that contraception and childbirth are covered in constitutional “zones of privacy” and are therefore protected in the First, Fourth, Ninth, and Fourteenth Amendments. The decision of a companion case, Doe v. Bolton, was released on the same day, overturning the Georgia abortion law that required a licensed physician to perform an abortion only under his “best clinical judgment,” among many other statutes surrounding the practice.
Although Roe v. Wade was transformative in the US, the provision of abortion care remains challenging, and frequently challenged. The Hyde Amendment, which was originally passed in 1976 and has been updated since, bans the use of federal funds for abortion services in all but extreme circumstances such as rape, incest, or life endangerment. Many states defied the decision of Roe v. Wade outright by passing new laws that prohibited abortions, while others put logistical hurdles in place for women seeking abortions. For example, in 1982, Pennsylvania passed the Abortion Control Act, which required women to give informed consent, and minors to get informed consent from their parents (except in cases of “hardship”), and placed a 24-hour waiting period on abortions while women were given information about the procedure. The act also required that a wife must inform her husband of her plans to abort, except in medical emergencies, and that all Pennsylvania abortion clinics report themselves to the state. In 1992, Planned Parenthood v. Casey affirmed Roe v. Wade’s basic ruling, and kept states from placing unnecessary burdens or obstacles on women seeking abortions. However, it also said that states may outlaw abortions of “viable” fetuses, and ruled that most of Pennsylvania’s laws were in fact constitutional.
Perhaps one state that makes the challenge faced by women looking for safe medical abortion most vivid is Texas. Texas is the second most populous state in the nation. It is also the state with the most restrictions in place that make it difficult for a woman to get an abortion. The average county in Texas is currently 111 miles from the nearest clinic that will perform abortions, and there are currently only 17 abortion clinics, almost all in major urban areas, down from 41 in 2012 (see Figure 1). This makes it very difficult for rural, low-income women to receive the service. The Texas Policy Evaluation Project estimates that 1.7 percent of women aged 18 to 49 in the state reported having attempted to end a pregnancy on their own without medical assistance.
Testament to US success in promoting overall reproductive health, abortion uptake is decreasing overall in the US. Abortion rates decreased from 2002 to 2011 for women in all age groups except for those younger than 15 years old, for whom they increased. Still, about half of all pregnancies in the US each year are unplanned, and almost one-third of women will have an abortion in their lifetime. Highlighting perhaps the importance of ready access to safe abortion, adolescents 15 to 19 years of age accounted for 13.5 percent of all abortions in 2011, 58% percent of women who have abortions are in their 20s, and 69 percent are economically disadvantaged. In 2011, there were 1,720 abortion providers in the United States, down slightly from 1,787 in 2008.
Roe v. Wade came at a time when most states had strict abortion policies and bans making obtaining an abortion difficult for all, and impossible for many. This made the freedoms for which Roe v. Wade paved room a critical part of a population reproductive health armamentarium. As important perhaps was the Title X Family Planning program, enacted in 1970 as part of the Public Health Service Act (Public Law 91-572, Population Research and Voluntary Family Planning Programs). Title X is a grant program aiming to provide comprehensive family planning, prioritizing low-income individuals and those not eligible for Medicaid or otherwise uninsured even as Title X funds, by statute, cannot be used to pay for abortions. Title X continues to this day to offer a range of counseling, contraceptive methods, cancer screening, pregnancy testing, HIV testing, and screening and treatment for sexually transmitted infections. These services are overseen by the U.S. Department of Health and Human Services’ Office of Population Affairs and serve about 4.5 million clients a year. Services include state, county, and local health departments; community health centers; Planned Parenthood centers; and hospital-based, school-based, faith-based, and other private nonprofit organizations. Public expenditures for family planning services in the US overall totaled $2.37 billion in 2010, with Medicaid accounting for 75 percent of total expenditures, state appropriations for 12 percent, and Title X for 10 percent.
Two straightforward pieces of evidence readily highlight the contribution to population health made by Title X. First, women using Title X reproductive services in general are young, minority, and poor—populations that need access to safe, effective reproductive health services and are not likely to have such access absent government services. Among the 20 million women in need of publicly funded contraceptive care, 77 percent are considered low-income. Among women in need of publicly funded services from 2000 to 2010, the proportion of Hispanic women increased by 47 percent, the proportion of black women increased by 17 percent, and the proportion of white women increased by 4 percent. Second, it is estimated that every public dollar spent on contraceptive services in 2008 resulted in about $3.74 in savings that would have been spent on Medicaid costs related to pregnancy care and delivery, or to infants in their first year of life.
As we enter 2016, many reproductive rights remain challenged throughout the country. Abortion in particular remains divisive and contentious, even as a clear majority of Americans favor abortion rights. In 2015, tensions around the issue reached new heights with a shooting at a Planned Parenthood in Colorado after an anti-abortion organization released a series of edited videos claiming that Planned Parenthood was illegally selling body parts of aborted fetuses.
It is with some hope that one looks to the new year as a year when we can perhaps enter a new era of reproductive rights and reproductive heath in this country, owing in part to shifts in the political and legal landscapes. In particular, Whole Woman’s Health v. Cole, No. 15-274 is the Supreme Court’s first major abortion case since 2007, providing the opportunity for the removal of unreasonable barriers to access to abortion in Texas, with implications for the whole country. One would rather not contemplate the implications of a regressive Supreme Court ruling for the health of the US population, but the threat certainly clarifies the mind about the need for a resolute public health voice agitating for action by all three branches of government that promote reproductive health across the country.
This past week, on January 20, we were joined by Wendy Davis for our monthly Dean’s Seminar. Davis has been at the forefront of the reproductive rights discussion in this country over the past years. It was an honor having her visit us.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
Acknowledgement: I am grateful for the contributions of Laura Sampson and Catherine Ettman to this Dean’s Note.
Previous Dean’s Notes are archived at: https://www.bu.edu/sph/category/news/deans-notes/