Social Work in Public Health, 29:132–140, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1937-1918 print/1937-190X online DOI: 10.1080/19371918.2013.775872
Reproductive Health Policy Affecting Low-Income Women: Historical Precedents and Current Need for Social Work Action Jessica Averitt Taylor College of Education and Human Services, Northern Kentucky University, Highland Heights, Kentucky, USA
This article provides an overview of the historical arguments surrounding reproductive health policy and current policy initiatives. Because reproductive policy itself is a vast subject matter with sometimes blurry boundaries, the struggle concerning the advent of birth control is used to illustrate the historic complexities of policy affecting such a wide array of individuals. The battle over introduction of the birth control pill is pertinent because the very same arguments are used today in debates over reproductive health policy. Keywords: Reproductive health, policy, low-income, social work, health policy
Reproductive policy is especially pertinent for those women at the lower end of the income spectrum, as such women are less able to access alternative resources outside of the official social service delivery system. The reproductive health of lower income women in particular evidences unsettling disparities. It is the responsibility of social workers to incorporate reproductive health into existing policy, practice, and research concerning human rights. The moral basis used to ground debates concerning reproductive health policy and the historic reproductive health disparities according to income show that though the particular focus may change, time has done little to alter the broader framework of reproductive health policy. Given the existence of such reproductive health disparities, this article concludes with a brief summary of currently pertinent reproductive health policy issues as outlined by familiar, morally based frameworks.
BACKGROUND Reproductive health is an essential cornerstone of overall well-being, particularly among women. Although this assertion, and countless others along similar lines, certainly carries a defined weight, one would be not entirely remiss to further examine what is contained in such a statement. There is no universally accepted definition for reproductive health. However, reproductive health was officially defined in the Report of the International Conference on Population and Development Address correspondence to Jessica Averitt Taylor, PhD, MSW, Department of Counseling, Social Work, and Leadership, College of Education and Human Services, Northern Kentucky University, MEP 222, One Nunn Drive, Highland Heights, KY 41099, USA. E-mail: [email protected]
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(1994). The World Health Organization (n.d.) currently employs the same definition: “Reproductive health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (para. 1). Furthermore, the very phrase reproductive health seems to automatically outline stark contrasts in personal philosophies and societal standards. It is quite common to find significant overlap between the phrase reproductive health and the phrase reproductive rights. Reproductive rights are more often a legal or political assertion of reproductive health matters. It has been asserted that social work has thus far not prioritized the alleviation of inequalities in reproductive health (Blythe, 2008). Nevertheless, it is the responsibility of social workers to incorporate reproductive health into existing policy, practice, and research concerning human rights. Regardless of particular professional focus, many social workers will eventually encounter issues related to reproductive health, as this area affects numerous clients across spectrums of diversity (Alzate, 2009). Many social workers will encounter various intervention and advocacy opportunities in the field of reproductive health and reproductive health inequalities. Examples of opportunities for social workers in this area include provision of condoms in strategically placed locations (such as women’s restrooms in public facilities), lobbying efforts to extend public transportation routes and hours of operation, and negotiations for extended clinical hours for health care services. The area of reproductive health is continually under debate, with compromise negotiated anew according to the currently reigning mores. Indeed, reproductive health policy may be described as a specific morality policy. It is worth noting, however, that it is the framing of an issue rather than the content that leads to classification or exclusion as a morality policy (Mooney & Schuldt, 2008). For instance, reproductive health policy is typically framed in terms of health and morality, rather than a matter of only health. Those involved in reproductive health policy consistently struggle to influence the actual framing of the issue. The historic birth control debate and modern-day reproductive health policy issues illustrate this struggle. It is incredibly difficult to separate points of fact in such a heated topic of discussion, and this is made even more difficult by the lifetime integration of morality into personal psyche. “In every society, people have their own moral, religious and ethnic doctrines that have not only reinforced their social fabrics but, due to prolonged observance in the community, have also pervaded the psychosocial environment of the individual” (Sarkar, 2008, p. 115). Such integration occurs across boundaries of social class, but may combine with differential access to resources to create quite an imposing barrier to reproductive health for those on the lower end of the economic spectrum. Reproductive policy has long been a source of contestation, especially pertaining to the rights and abilities of women and precise groups of women. In this view, underlying politics heavily influence reproductive decision making. Reproductive Health and Poverty Specific segments of the population have historically been unable to attain common standards of reproductive health. The gap in reproductive health between poor and affluent women in the United States has been growing for almost 20 years (Tanne, 2006). It has long been asserted that one half of all pregnancies in the United States are unintended (Kulczycki, 2007; Sable & Galambos, 2006). However, this rate of unintended pregnancy varies by income (Sable & Galambos, 2006). In 2001, women living below the poverty line were 4 times as likely to have an unplanned pregnancy, 5 times as likely to have an unplanned birth, and 3 times as likely to have an abortion as women whose income was more than twice that at the poverty line (Boonstra et al., 2006; Sable & Galambos, 2006). This disparity is not a new phenomenon; the reproductive health of women in poverty has been a separate issue altogether for some time now. According to Sable and Galambos (2006), unintended pregnancies occur disproportionately among women who are
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“young, unmarried, African American, and have low income” (p. 163). This illustrates a disparity in reproductive choice between women of differing economic positions. For the sake of simplicity, this article employs the standard demarcations of poverty as outlined by the federal government. Current federal guidelines define poverty as an annual income of: $11,490 for an individual, $15,510 for a family of two individuals, and $23,550 for a family of four individuals (Office of the Assistant Secretary for Planning and Education, 2013). In the United States, 13% of all women fall below the poverty line (Myers & Gill, 2004). More than one half (57%) of the 34.5 million people living in poverty are women (Rice, 2001). Furthermore, about 20% of women in the United States are either below or perilously near the poverty line (Myers & Gill, 2004). These percentages are particularly relevant to the discussion of reproductive health among low-income women. Such women are not a tiny sliver of the population; a discussion of reproductive health among low-income women necessarily references many, many people. As noted, the issue of poverty is central to any exploration of the well-being of women. Women face significant challenges regarding income-status gender discrepancies (Myers & Gill, 2004). On average, women in the United States earn 74 cents for every dollar earned by men (Rice, 2001). Although this wage gap does vary by state and level of education, the wages of men and women remain essentially unequal at every level of employment (Rice, 2001). A female bluecollar worker will typically earn less than her male counterparts, just as a female executive will typically earn less than her male peers. Women have a greater likelihood of falling into poverty as compared to men. Women also tend to have greater difficulty getting out of poverty (Fitzpatrick & Gomez, 1997). This gendered vulnerability stems from a variety of systemic sources. Both social and economic conditions contribute to the continued povertization of women (Fitzpatrick & Gomez, 1997). Women in poverty are affected by social factors such as stigma and stereotypes (Myers & Gill, 2004). Some of the stereotypes originate with the certain stigma associated with poverty, thus causing social difficulties for women who seek to move above the poverty threshold (Myers & Gill, 2004). Poverty trajectories are also longer for women than for men (Ruspini, 2001). This is because “female poverty is closely linked to critical family events, whereas male poverty depends on labor market-related risks” (Ruspini, 2001, p. 113). A man might find himself living in poverty due to a recession in his chosen field, or a risky investment decision. However, a woman is more likely to become impoverished after a family event such as the birth of a child. This is an especially relevant point in light of the common characterization of women as primary caregivers. The relationship between poverty and reproductive rights is fraught with morality-infused arguments based on an ever-shifting array of societal norms. Historical debates concerning reproductive rights tended to focus on particular populations, most notably either the hallmark poverty-stricken family or upper class society in general (for examples, begin with Reed, 1978; Rowland, 2004; Sanger, 1918). A closer examination of the common frameworks reveals the often tenuous links forged among popular notions of citizenship, economy, power, and womanhood. Differential access to power and resources places low-income women in a more vulnerable position with regards to reproductive health policy. The debate over birth control is a fine example of a moral framework as applied to reproductive health policy, and modern policy evidences many of the very same arguments. Closer examination of the underlying assumptions behind reproductive health policy is necessary to alleviate the disparities that exist in the reproductive health status of women across the income spectrum. The current reigning political view of reproductive health needs, especially related to fertility control, remains primarily a matter of perception. As illustrated by the historical overview presented below, reproductive health has been characterized as a purely private matter and as a public concern related to common welfare. Reproductive health policy encompasses many different points. The birth control debate is outlined to provide a frame for the common moral arguments presented in many debates about reproductive health policy. The historic debate about birth control
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has, in a sense, continued to this very day, as modern reproductive health policy debates have relied upon the very same arguments. This ambivalent and shifting characterization is also evidenced in current legislation. Historical Review The history of reproductive rights and contraception in the United States is replete with debate. The previous century has witnessed a spate of new developments in these areas, most of which were vehemently opposed and passionately supported (Tone, 2002). In 1873, antivice crusader Anthony Comstock successfully lobbied Congress to pass an antiobscenity statute (Tone, 2002). The resulting federal law forbade use of the mail to distribute any obscene material. This definition of obscene material included information concerning abortion and contraception (Biesel & Kay, 2004). Comstock quite deliberately founded his argument in terms of morality, a common tactic in the realm of reproductive health. Reproductive health policy may wisely be described as a morality policy at the core. “Morality policies frequently address social relationships, but their primary concern is the legitimacy of values: which values are accepted by the state and which are considered unacceptable” (McFarlane & Meier, 2001, p. 3). Most often, debates concerning reproductive health have actually been founded in clashes over accepted morality. This is the perspective from which much legislation has been debated. The historic national debate over birth control centered to some extent on the controversial figure of Margaret Sanger and her advocacy for access to birth control as a basic foundation for female independence. Sanger argued that birth control had the potential to offer economic freedom to the lower classes, whereas opponents asserted that widespread use of birth control would inevitably result in a catastrophic decline in population and morality (Abruzzo, 2009a; Benjamin, 1938; Browne, 1917; Buekle, 2008; Chesler, 1992; Dublin, 1918; Fite, 1916; Goldstein, 1918; Gordon, 2002; Holmes, 1932; Kosmack, 1937; Lake, 1932; McCann, 1994; Reed, 1978; Reynolds, 1994; Sanger, 1918, 1938; Tone, 2002). Current State The frameworks outlined in the historic birth control debates are still quite commonly used even today. Modern reproductive health policy may be perceived as a matter of personal privacy and as a matter intricately related to societal good. Current legislation is a reflection of the same underlying moral frameworks. There are numerous court cases that constitute the modern legal battle over reproductive rights in the United States. In 1970, federal family planning sources initiated the option of contraceptive sterilization (Keown, 2006). The 1973 Roe v. Wade case established an implied constitutional right to privacy which encompassed a woman’s right to terminate her pregnancy (Keown, 2006). The Hathaway v. Worchester City Hall suit of 1973 required public hospitals to cancel arbitrary restrictions on sterilization (Kluchin, 2007). Since 1975, four federal statutes (Titles V, X, XIX, and XX) have comprised nearly all federal support for family planning services (McFarlane & Meier, 2001, p. 54). Specific discretions are allowed to states in the administration of this funding, including mandating eligibility levels and “determining the range of services that constitute family planning” (McFarlane & Meier, 2001, p. 80). The Hyde amendment of 1977 presently extends Medicaid abortion funding only to pregnant women whose lives are endangered by the pregnancy or who conceived as a result of rape or incest (McFarlane & Meier, 2001; Sable & Galambos, 2006). This is a critical point for women
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in poverty, as it was earlier noted that such women have higher rates of unintended pregnancies. Low-income women have lower rates of contraceptive and higher rates of unintended pregnancy. Young, poor, and unmarried women have lower rates of contraceptive use than other women (Boonstra et al., 2006). These lower rates of contraceptive use can have lifelong effects. Early pregnancy and childbearing, which are both linked to poverty, also serve to perpetuate the cycle of poverty through the creation of additional challenges in such arenas as continued education, employment, and suitable childcare (Myers & Gill, 2004). Based on these two assertions, it is evident that women in poverty have a greater likelihood of unplanned pregnancy and fewer financial resources to abort an unwanted pregnancy if so desired. But there exist many additional barriers to equally accessible reproductive health services for low-income women. Structural barriers that may inhibit the ability of a woman to obtain contraception include time of available services, geographic access, transportation, child care, and expense (Sable & Libbus, 1998, p. 263). A women’s health clinic that is open only during typical weekday hours may prove inaccessible to women who work. In addition, dismal public transportation services, particularly in rural (and poor) areas may further isolate women with fewer resources. The entire structure of the health care system denies women in poverty the means to define their own existence, with or without reproduction. The historic Gonzales v. Carhart ruling of 2007 further restricted access to abortion services by outlawing intact dilation and extraction techniques, otherwise colloquially known as partialbirth abortions. This ruling was notable because it included no exceptions for cases in which the pregnant woman’s life was determined to be endangered by the pregnancy (Kulczycki, 2007). Again, such legislation is most likely to have the greatest impact on poorer women who necessarily have fewer resources with which to access safe care outside of the system if needed. Modern reproductive health policy in the United States is perhaps best described as a patchwork of federal and state legislation. “Much of the funding for family planning in the United States is the result of federal legislation. States, however, have a great deal of discretion in this policy area” (McFarlane & Meier, 2001, p. 2). For example, individual states may impose restrictive qualification criteria for particular methods of fertility control, or refuse to fund a method altogether. A restrictive qualification criterion might involve mandatory viewing of an ultrasound scan before an abortion, or a mandatory waiting period for an abortion. States may deny funding of abortions for low-income women or offer only partial coverage (McFarlane & Meier, 2001). A denial of public funding, or availability of only partial funding, serves as an effective economic deterrent to such services altogether for low-income women. Abortion is used in the above examples only because it tends to be a hotly contested area of reproductive health. Although many other aspects of reproductive health are also consistently on the legislative forefront (think of the recent widespread use of standardized hormone therapy for postmenopausal women, abstinence-only education efforts, and even contraceptive access in rural areas), abortion provides a ready reference point due to its continual polarizing popularity as a poignant topic. Modern Framework Public discussions regarding reproductive health issues tend to heavily draw on moral perception rather than lived fact: “When pertinent topics are discussed in the public arena, politicians tend to echo American ideals about sexuality rather than discuss how most people actually behave” (McFarlane & Meier, 2001, p. 13). Because ideals and actual behavior might not exactly be one and the same, discussions need to address lived fact as well as utopian ideals. Furthermore, reproductive health policy does not actively involve women of all classes. As noted by Few (1997), “The self-esteem of women should be a concern of all health care professionals working in the area of sexual health: : : : Women, particularly young women, need to be empowered
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to make choices and decisions about sexual relationships” (p. 623). Empowerment may be realized through such choices, however personal and discrete. “The voice that emerges echoes the master discourse, but this echo nevertheless establishes that there is a voice, that some articulatory power has not been obliterated” (Butler, 2004, p. 201). There is a recognized need for improvement of gendered/sexed power relations in health care settings: Although the pathways between gender inequality and health are not clear, interventions to improve gender equity in health service provision and planning may increase contraceptive use. Such interventions may include training of health care providers as well as improving women’s participation in decision-making about health at various levels including individual, community and government levels. (Bentley & Kavanagh, 2008, p. 77)
Aspects of reproductive health policy remain a subject of continued debate, marked by impassioned personal testimony and legislative compromise. Those who oppose introductions of lenient reproductive health policy frequently cite possible negative effects on women’s health. Thus, opponents of the over the counter morning-after pill claim that it will surely lead to widespread promiscuity, whereas those who oppose abortion assert that the procedure can lead to such horrors as “post-abortion stress disorder,” and social conservatives declare that condoms raise doubts about marital fidelity (Kulczycki, 2007, pp. 339–340). Differential Participation This moral framework divide is also gender specific. Women have historically been challenged by commonly applied double binds (Jamieson, 1995). One such double bind is the womb/brain divide, which asserts that men are able to think and thus make rational decisions, whereas women base decisions on emotions and feelings (Jamieson, 1995, p. 53). This womb/brain double bind insists that “true” women are unable to make decisions based on logic. Rather, only women who have denied their natural instincts and destinies can behave as men, and madness surely awaits women who have chosen such denial (Jamieson, 1995). The double bind is readily applied to reproductive health policy debates, in which women may be characterized as either independent and capable decision makers, or in need of legislative guidance to avoid negative repercussions from their own lack of decision-making prowess. The argument has long been advanced that woman is defined by her biology. As stated by de Beauvoir (1953), “Woman has ovaries, a uterus; these peculiarities imprison her in her subjectivity, circumscribe her within the limits of her own nature. It is often said that she thinks with her glands” (p. xxvii). This argument casts woman as an emotional, largely irrational being. Such a role automatically excludes her from full participation in public life, including policy decisions that ultimately affect her own well-being. According to de Beauvoir (1953), man’s privileged position results from his ability to override, or at least occasionally deny, his biological reproductive drives. However, woman is unable (supposedly) to ignore her biology, and the reproductive drive of the species serves to overwhelm woman and deny her individuality, at least in prior (and perhaps present) popular understanding. Whether this is true is not precisely the issue; it is largely believed to be true, even if in an implicit rather than explicitly stated manner. Therefore, the argument does hold merit, at least to some people, and manages to affect even those women to whom the argument is archaic and ridiculous. de Beauvoir (1953) provided a comprehensive outline of woman’s condition, stating that “The individuality of the female is opposed by the interest of the species, it is as if she were possessed by foreign forces—alienated” (p. 25). This appears to be less a reflection of immediate inherent truth than a summary of the belief systems that surround female existence. Of course, woman is no
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more “possessed” by foreign forces (such as estrogen) is man (after all, he, too, has documented hormonal drives). The factual truth of the statement is less important than the accepted truth. Advancements in perception of woman cannot be made upon the basis of mere scientific evidence. Public opinion must change, so that societal mores may begin to reflect objective reality instead of highly subjective beliefs.
CONCLUSION The Washington Times lamented that much has been written about the changing characteristics of American families: : : : Researchers have attributed the enormous changes in America’s family formation to the introduction of the birth-control pill, which permitted sex without pregnancy; the en masse entry of women into the workforce; and the growing belief that couples should postpone marriage until they get a college degree, a steady job or a mortgage. (Wetzstein, 2006, p. A01)
In the above quote, widespread changing mores are subtly linked to social and scientific forces. Thus, the introduction of the birth control pill separated pleasure from procreation and thereby led to alterations in “America’s family formation.” It is never blatantly noted, but this piece is a prime example of the combination of scientific and moral arguments. From a different perspective, a rather scathing summary of reproductive health policy under the Bush administration was offered by Kulczycki (2007): Within the United States, pharmacists and other health-care providers, institutions, and insurers have been both directly and indirectly encouraged to refuse to cover contraceptive services. The administration has promoted federally funded abstinence-only education and, in the process, prohibited teachers from discussing contraception except in the context of failure rates. Legal access to abortion, which remains the country’s most contentious social issue, has also been undermined by the Bush administration. Such developments mean that American women, particularly the poor and the young, have lost ground in achieving reproductive health. (p. 333)
Implicit in the commentary offered by Kulczycki (2007) is the assumption that reproductive health itself is best defined in a very specific framework of personal choice. The author does not need to baldly state this; it is an obvious foundation of the presented argument. Sable and Galambos (2006) argued that reproductive health policy should grant ultimate decision-making power to women and families. This is a cornerstone of policy arguments surrounding reproductive health: those in favor of lenient legislation and generous funding claim that women are quite capable of making their own decisions and should have the right to do so, whereas those in favor of restrictive legislation and limited funding claim that the government or society at large has the right to make decisions for women. The opposing sides have relied on these same foundational perspectives for over a century now. Although societal norms dictate that politically correct persons openly profess a belief in equal opportunity, tangible actions do not reflect intentions to make opportunities available for disadvantaged populations, particularly women in poverty. Butler (2004) offered reflections regarding this discrepancy: We say something, and mean something by what we say, but we also do something with our speech, and what we do, how we act upon another with our language, is not the same as the meaning we consciously convey. It is in this sense that the significations of the body exceed the intentions of the subject. (p. 199)
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Each side stringently asserts that their claim is based in fact rather than passion, and that the other side is based primarily on an emotional foundation. This is evident in the following statement by Kulczycki (2007), “Good sexual and reproductive health services rest on scientifically sound and accepted, ethically based, and politically pragmatic policy” (p. 344). However, both sides offer their own opinions regarding what constitutes scientifically sound, pragmatic, ethically based policy. Kulczycki, and others of the same opinions, would likely naturally assume that scientifically sound and accepted policy is that which most strengthens their own position. But science may be interpreted in many different ways, and those with opposing points of view may both rely on science to support their own claims. However, one would be mistaken to assume that there is a ready solution to disparities in reproductive health among women, or even that the problem itself is easily defined or universally acknowledged. Diane Sollee, director of the Coalition for Marriage, Family and Couples Education, asserted that current U.S. policies “are based on acceptance of family breakdown and are focused on dealing with the aftermath and fallout” (Wetzstein, 2006, p. A01). Arguing from a different perspective, Sable and Galambos (2006) claimed that meager allocations for federal assistance programs like Temporary Assistance for Needy Families prove the reluctance of our society to properly support women and children: “Morality cannot feed a hungry child: : : : It is time for us to deeply consider the consequences of our collective actions” (p. 165). Regardless of privately held convictions, the politics of reproductive health exist within a publicly debated moral framework.
REFERENCES Abruzzo, M. (2009a, February 12). Lecture notes. Presented at a history 500 lecture at The University of Alabama, Tuscaloosa, AL. Abruzzo, M. (2009b, February 17). Lecture notes. Presented at a history 500 lecture at The University of Alabama, Tuscaloosa, AL. Alzate, M. M. (2009). The role of sexual and reproductive rights in social work practice. Affilia Journal of Women and Social Work, 24(2), 108–119. Benjamin, H. C. (1938). Lobbying for birth control. Public Opinion Quarterly, 2(1), 48–60. Bentley, R., & Kavanagh, A. M. (2008). Gender equity and women’s contraception use. Australian Journal of Social Issues, 43(1), 65–80. Biesel, N., & Kay, T. (2004). Abortion, race, and gender in nineteenth-century America. American Sociological Review, 69, 498–518. Blythe, E. (2008). Inequalities in reproductive health: What is the challenge for social work and how can it respond? Journal of Social Work, 8, 213–232. Boonstra, H. D., Gold, R. B., Richards, C. L., & Finer, L. B. (2006). Abortion in women’s lives. Guttmacher Institute. Retrieved from http://www.guttmacher.org. Browne, S. F. W. (1917). Some problems of sex. International Journal of Ethics, 27(4), 464–471. Buerkle, C. W. (2008). From women’s liberation to their obligation: The tensions between sexuality and maternity in early birth control rhetoric. Women and Language, 31(1), 27–34. Butler, J. (2004). The end of sexual difference? In J. Butler (Ed.), Undoing gender (pp. 174–259). New York, NY: Routledge. Chesler, E. (1992). Woman of valor: Margaret Sanger and the birth control movement in America. New York, NY: Simon & Schuster. de Beauvoir, S. (1953). The second sex. New York: Knoff. Dublin, L. I. (1918). The significance of the declining birth rate. Science, New Series, 47, 201–210. Few, C. (1997). The politics of sex research and constructions of female sexuality: What relevance to sexual health work with young women? Journal of Advanced Nursing, 25, 615–625. Fite, W. (1916). Birth-control and biological ethics. International Journal of Ethics, 27(1), 50–66. Fitzpatrick, J. A., & Gomez, T. R. (1997). Still caught in a trap: The continued povertization of women. Affilia Journal of Women and Social Work, 12(3), 318–342. Goldstein, N. W. (1918). Birth control as a socio-economic panacea. International Journal of Ethics, 28(4), 515–520.
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Gordon, L. (2002). The moral property of women: A history of birth control politics in America. Chicago, IL: University of Illinois Press. Holmes, S. J. (1932). Will birth control lead to extinction? Scientific Monthly, 34(3), 247–251. Jamieson, K. H. (1995). Beyond the double bind: Women and leadership. New York, NY: Oxford University Press. Keown, J. (2006). Back to the future of abortion law: Roe’s rejection of America’s history and traditions. Issues in Law and Medicine, 22(1), 3–37. Kluchin, R. M. (2007). Locating the voices of the sterilized. Public Historian, 29(3), 131–144. Kosmak, G. W. (1937). The sanity and insanity of birth control. Vital Speeches of the Day, 3(6), 175–178. Kulczycki, A. (2007). Ethics, ideology, and reproductive health policy in the United States. Studies in Family Planning, 38(4), 333–351. Lake, G. B. (1932). The spiritual aspect of birth control. The Nation, 134, 110–111. McCann, C. R. (1994). Birth control politics in the United States, 1916–1945. Ithaca, NY: Cornell University Press. McFarlane, D. R., & Meier, K. J. (2001). The politics of fertility control. New York, NY: Seven Bridges Press. Mooney, C. Z., & Schuldt, R. G. (2008). Does morality policy exist? Testing a basic assumption. Policy Studies Journal, 36(2), 199–134. Myers, J. E., & Gill, C. S. (2004). Poor, rural, and female: Under-studied, under-counseled, more at-risk. Journal of Mental Health Counseling, 26(3), 225–242. Office of the Assistant Secretary for Planning and Evaluation. (2013). 2013 poverty guidelines. Retrieved from http://aspe. hhs.gov/poverty/13poverty.cfm Reed, J. (1978). The birth control movement and American Society: From private vice to public virtue. Princeton, NJ: Princeton University Press. Reynolds, M. D. (1994). Women advocates of reproductive rights: Eleven who led the struggle in the United States and Great Britain. Jefferson, NC: McFarland & Company. Rice, J. K. (2001). Poverty, welfare, and patriarchy: How macro-level changes in social policy can help low-income women. Journal of Social Issues, 57(2), 355–374. Rowland, D. (2004). The boundaries of her body: The troubling history of women’s rights in America. Naperville, IL: Sphinx Publishing. Ruspini, E. (2001). The study of women’s deprivation: How to reveal the gender dimension of poverty. International Journal of Social Research Methodology, 4(2), 101–118. Sable, M. R., & Galambos, C. M. (2006). Prevention and women’s reproductive health: A matter of concern. Health & Social Work, 31(3), 163–166. Sable, M. R., & Libbus, M. K. (1998). Beliefs concerning contraceptive acquisition and use among low-income women. Journal of Health Care for the Poor and Underserved, 9(3), 262–275. Sanger, M. (1918). Morality and birth control. Birth Control Review, 2(2), 11–14. Sanger, M. (1938). Margaret Sanger: An autobiography. New York: W. W. Norton & Company. Sarkar, N. N. (2008). Barriers to condom use. European Journal of Contraception and Reproductive Health Care, 13(2), 114–122. Tanne, J. H. (2006). Gap in contraceptive use between rich and poor is growing in US. British Medical Journal, 332(7551), 1170. Tone, A. (2002). Historical influences on women’s sexual and reproductive health. In G. M. Wingood & R. J. DiClemente (Eds.), Handbook of women’s sexual and reproductive health (pp. 7–19). New York: Springer. Wetzstein, C. (2006, December 26). U.S. out of love with marriage? Forces eroding foundation of American family meet resistance. The Washington Times, p. A01. World Health Organization. (n.d.). Health topics: Reproductive health. Retrieved from www.who.in
Reproductive Health Policy Affecting Low-Income Women: Historical Precedents and Current Need for Social Work Action Jessica Averitt Taylor College of Education and Human Services, Northern Kentucky University, Highland Heights, Kentucky, USA
This article provides an overview of the historical arguments surrounding reproductive health policy and current policy initiatives. Because reproductive policy itself is a vast subject matter with sometimes blurry boundaries, the struggle concerning the advent of birth control is used to illustrate the historic complexities of policy affecting such a wide array of individuals. The battle over introduction of the birth control pill is pertinent because the very same arguments are used today in debates over reproductive health policy. Keywords: Reproductive health, policy, low-income, social work, health policy
Reproductive policy is especially pertinent for those women at the lower end of the income spectrum, as such women are less able to access alternative resources outside of the official social service delivery system. The reproductive health of lower income women in particular evidences unsettling disparities. It is the responsibility of social workers to incorporate reproductive health into existing policy, practice, and research concerning human rights. The moral basis used to ground debates concerning reproductive health policy and the historic reproductive health disparities according to income show that though the particular focus may change, time has done little to alter the broader framework of reproductive health policy. Given the existence of such reproductive health disparities, this article concludes with a brief summary of currently pertinent reproductive health policy issues as outlined by familiar, morally based frameworks.
BACKGROUND Reproductive health is an essential cornerstone of overall well-being, particularly among women. Although this assertion, and countless others along similar lines, certainly carries a defined weight, one would be not entirely remiss to further examine what is contained in such a statement. There is no universally accepted definition for reproductive health. However, reproductive health was officially defined in the Report of the International Conference on Population and Development Address correspondence to Jessica Averitt Taylor, PhD, MSW, Department of Counseling, Social Work, and Leadership, College of Education and Human Services, Northern Kentucky University, MEP 222, One Nunn Drive, Highland Heights, KY 41099, USA. E-mail: [email protected]
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(1994). The World Health Organization (n.d.) currently employs the same definition: “Reproductive health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (para. 1). Furthermore, the very phrase reproductive health seems to automatically outline stark contrasts in personal philosophies and societal standards. It is quite common to find significant overlap between the phrase reproductive health and the phrase reproductive rights. Reproductive rights are more often a legal or political assertion of reproductive health matters. It has been asserted that social work has thus far not prioritized the alleviation of inequalities in reproductive health (Blythe, 2008). Nevertheless, it is the responsibility of social workers to incorporate reproductive health into existing policy, practice, and research concerning human rights. Regardless of particular professional focus, many social workers will eventually encounter issues related to reproductive health, as this area affects numerous clients across spectrums of diversity (Alzate, 2009). Many social workers will encounter various intervention and advocacy opportunities in the field of reproductive health and reproductive health inequalities. Examples of opportunities for social workers in this area include provision of condoms in strategically placed locations (such as women’s restrooms in public facilities), lobbying efforts to extend public transportation routes and hours of operation, and negotiations for extended clinical hours for health care services. The area of reproductive health is continually under debate, with compromise negotiated anew according to the currently reigning mores. Indeed, reproductive health policy may be described as a specific morality policy. It is worth noting, however, that it is the framing of an issue rather than the content that leads to classification or exclusion as a morality policy (Mooney & Schuldt, 2008). For instance, reproductive health policy is typically framed in terms of health and morality, rather than a matter of only health. Those involved in reproductive health policy consistently struggle to influence the actual framing of the issue. The historic birth control debate and modern-day reproductive health policy issues illustrate this struggle. It is incredibly difficult to separate points of fact in such a heated topic of discussion, and this is made even more difficult by the lifetime integration of morality into personal psyche. “In every society, people have their own moral, religious and ethnic doctrines that have not only reinforced their social fabrics but, due to prolonged observance in the community, have also pervaded the psychosocial environment of the individual” (Sarkar, 2008, p. 115). Such integration occurs across boundaries of social class, but may combine with differential access to resources to create quite an imposing barrier to reproductive health for those on the lower end of the economic spectrum. Reproductive policy has long been a source of contestation, especially pertaining to the rights and abilities of women and precise groups of women. In this view, underlying politics heavily influence reproductive decision making. Reproductive Health and Poverty Specific segments of the population have historically been unable to attain common standards of reproductive health. The gap in reproductive health between poor and affluent women in the United States has been growing for almost 20 years (Tanne, 2006). It has long been asserted that one half of all pregnancies in the United States are unintended (Kulczycki, 2007; Sable & Galambos, 2006). However, this rate of unintended pregnancy varies by income (Sable & Galambos, 2006). In 2001, women living below the poverty line were 4 times as likely to have an unplanned pregnancy, 5 times as likely to have an unplanned birth, and 3 times as likely to have an abortion as women whose income was more than twice that at the poverty line (Boonstra et al., 2006; Sable & Galambos, 2006). This disparity is not a new phenomenon; the reproductive health of women in poverty has been a separate issue altogether for some time now. According to Sable and Galambos (2006), unintended pregnancies occur disproportionately among women who are
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“young, unmarried, African American, and have low income” (p. 163). This illustrates a disparity in reproductive choice between women of differing economic positions. For the sake of simplicity, this article employs the standard demarcations of poverty as outlined by the federal government. Current federal guidelines define poverty as an annual income of: $11,490 for an individual, $15,510 for a family of two individuals, and $23,550 for a family of four individuals (Office of the Assistant Secretary for Planning and Education, 2013). In the United States, 13% of all women fall below the poverty line (Myers & Gill, 2004). More than one half (57%) of the 34.5 million people living in poverty are women (Rice, 2001). Furthermore, about 20% of women in the United States are either below or perilously near the poverty line (Myers & Gill, 2004). These percentages are particularly relevant to the discussion of reproductive health among low-income women. Such women are not a tiny sliver of the population; a discussion of reproductive health among low-income women necessarily references many, many people. As noted, the issue of poverty is central to any exploration of the well-being of women. Women face significant challenges regarding income-status gender discrepancies (Myers & Gill, 2004). On average, women in the United States earn 74 cents for every dollar earned by men (Rice, 2001). Although this wage gap does vary by state and level of education, the wages of men and women remain essentially unequal at every level of employment (Rice, 2001). A female bluecollar worker will typically earn less than her male counterparts, just as a female executive will typically earn less than her male peers. Women have a greater likelihood of falling into poverty as compared to men. Women also tend to have greater difficulty getting out of poverty (Fitzpatrick & Gomez, 1997). This gendered vulnerability stems from a variety of systemic sources. Both social and economic conditions contribute to the continued povertization of women (Fitzpatrick & Gomez, 1997). Women in poverty are affected by social factors such as stigma and stereotypes (Myers & Gill, 2004). Some of the stereotypes originate with the certain stigma associated with poverty, thus causing social difficulties for women who seek to move above the poverty threshold (Myers & Gill, 2004). Poverty trajectories are also longer for women than for men (Ruspini, 2001). This is because “female poverty is closely linked to critical family events, whereas male poverty depends on labor market-related risks” (Ruspini, 2001, p. 113). A man might find himself living in poverty due to a recession in his chosen field, or a risky investment decision. However, a woman is more likely to become impoverished after a family event such as the birth of a child. This is an especially relevant point in light of the common characterization of women as primary caregivers. The relationship between poverty and reproductive rights is fraught with morality-infused arguments based on an ever-shifting array of societal norms. Historical debates concerning reproductive rights tended to focus on particular populations, most notably either the hallmark poverty-stricken family or upper class society in general (for examples, begin with Reed, 1978; Rowland, 2004; Sanger, 1918). A closer examination of the common frameworks reveals the often tenuous links forged among popular notions of citizenship, economy, power, and womanhood. Differential access to power and resources places low-income women in a more vulnerable position with regards to reproductive health policy. The debate over birth control is a fine example of a moral framework as applied to reproductive health policy, and modern policy evidences many of the very same arguments. Closer examination of the underlying assumptions behind reproductive health policy is necessary to alleviate the disparities that exist in the reproductive health status of women across the income spectrum. The current reigning political view of reproductive health needs, especially related to fertility control, remains primarily a matter of perception. As illustrated by the historical overview presented below, reproductive health has been characterized as a purely private matter and as a public concern related to common welfare. Reproductive health policy encompasses many different points. The birth control debate is outlined to provide a frame for the common moral arguments presented in many debates about reproductive health policy. The historic debate about birth control
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has, in a sense, continued to this very day, as modern reproductive health policy debates have relied upon the very same arguments. This ambivalent and shifting characterization is also evidenced in current legislation. Historical Review The history of reproductive rights and contraception in the United States is replete with debate. The previous century has witnessed a spate of new developments in these areas, most of which were vehemently opposed and passionately supported (Tone, 2002). In 1873, antivice crusader Anthony Comstock successfully lobbied Congress to pass an antiobscenity statute (Tone, 2002). The resulting federal law forbade use of the mail to distribute any obscene material. This definition of obscene material included information concerning abortion and contraception (Biesel & Kay, 2004). Comstock quite deliberately founded his argument in terms of morality, a common tactic in the realm of reproductive health. Reproductive health policy may wisely be described as a morality policy at the core. “Morality policies frequently address social relationships, but their primary concern is the legitimacy of values: which values are accepted by the state and which are considered unacceptable” (McFarlane & Meier, 2001, p. 3). Most often, debates concerning reproductive health have actually been founded in clashes over accepted morality. This is the perspective from which much legislation has been debated. The historic national debate over birth control centered to some extent on the controversial figure of Margaret Sanger and her advocacy for access to birth control as a basic foundation for female independence. Sanger argued that birth control had the potential to offer economic freedom to the lower classes, whereas opponents asserted that widespread use of birth control would inevitably result in a catastrophic decline in population and morality (Abruzzo, 2009a; Benjamin, 1938; Browne, 1917; Buekle, 2008; Chesler, 1992; Dublin, 1918; Fite, 1916; Goldstein, 1918; Gordon, 2002; Holmes, 1932; Kosmack, 1937; Lake, 1932; McCann, 1994; Reed, 1978; Reynolds, 1994; Sanger, 1918, 1938; Tone, 2002). Current State The frameworks outlined in the historic birth control debates are still quite commonly used even today. Modern reproductive health policy may be perceived as a matter of personal privacy and as a matter intricately related to societal good. Current legislation is a reflection of the same underlying moral frameworks. There are numerous court cases that constitute the modern legal battle over reproductive rights in the United States. In 1970, federal family planning sources initiated the option of contraceptive sterilization (Keown, 2006). The 1973 Roe v. Wade case established an implied constitutional right to privacy which encompassed a woman’s right to terminate her pregnancy (Keown, 2006). The Hathaway v. Worchester City Hall suit of 1973 required public hospitals to cancel arbitrary restrictions on sterilization (Kluchin, 2007). Since 1975, four federal statutes (Titles V, X, XIX, and XX) have comprised nearly all federal support for family planning services (McFarlane & Meier, 2001, p. 54). Specific discretions are allowed to states in the administration of this funding, including mandating eligibility levels and “determining the range of services that constitute family planning” (McFarlane & Meier, 2001, p. 80). The Hyde amendment of 1977 presently extends Medicaid abortion funding only to pregnant women whose lives are endangered by the pregnancy or who conceived as a result of rape or incest (McFarlane & Meier, 2001; Sable & Galambos, 2006). This is a critical point for women
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in poverty, as it was earlier noted that such women have higher rates of unintended pregnancies. Low-income women have lower rates of contraceptive and higher rates of unintended pregnancy. Young, poor, and unmarried women have lower rates of contraceptive use than other women (Boonstra et al., 2006). These lower rates of contraceptive use can have lifelong effects. Early pregnancy and childbearing, which are both linked to poverty, also serve to perpetuate the cycle of poverty through the creation of additional challenges in such arenas as continued education, employment, and suitable childcare (Myers & Gill, 2004). Based on these two assertions, it is evident that women in poverty have a greater likelihood of unplanned pregnancy and fewer financial resources to abort an unwanted pregnancy if so desired. But there exist many additional barriers to equally accessible reproductive health services for low-income women. Structural barriers that may inhibit the ability of a woman to obtain contraception include time of available services, geographic access, transportation, child care, and expense (Sable & Libbus, 1998, p. 263). A women’s health clinic that is open only during typical weekday hours may prove inaccessible to women who work. In addition, dismal public transportation services, particularly in rural (and poor) areas may further isolate women with fewer resources. The entire structure of the health care system denies women in poverty the means to define their own existence, with or without reproduction. The historic Gonzales v. Carhart ruling of 2007 further restricted access to abortion services by outlawing intact dilation and extraction techniques, otherwise colloquially known as partialbirth abortions. This ruling was notable because it included no exceptions for cases in which the pregnant woman’s life was determined to be endangered by the pregnancy (Kulczycki, 2007). Again, such legislation is most likely to have the greatest impact on poorer women who necessarily have fewer resources with which to access safe care outside of the system if needed. Modern reproductive health policy in the United States is perhaps best described as a patchwork of federal and state legislation. “Much of the funding for family planning in the United States is the result of federal legislation. States, however, have a great deal of discretion in this policy area” (McFarlane & Meier, 2001, p. 2). For example, individual states may impose restrictive qualification criteria for particular methods of fertility control, or refuse to fund a method altogether. A restrictive qualification criterion might involve mandatory viewing of an ultrasound scan before an abortion, or a mandatory waiting period for an abortion. States may deny funding of abortions for low-income women or offer only partial coverage (McFarlane & Meier, 2001). A denial of public funding, or availability of only partial funding, serves as an effective economic deterrent to such services altogether for low-income women. Abortion is used in the above examples only because it tends to be a hotly contested area of reproductive health. Although many other aspects of reproductive health are also consistently on the legislative forefront (think of the recent widespread use of standardized hormone therapy for postmenopausal women, abstinence-only education efforts, and even contraceptive access in rural areas), abortion provides a ready reference point due to its continual polarizing popularity as a poignant topic. Modern Framework Public discussions regarding reproductive health issues tend to heavily draw on moral perception rather than lived fact: “When pertinent topics are discussed in the public arena, politicians tend to echo American ideals about sexuality rather than discuss how most people actually behave” (McFarlane & Meier, 2001, p. 13). Because ideals and actual behavior might not exactly be one and the same, discussions need to address lived fact as well as utopian ideals. Furthermore, reproductive health policy does not actively involve women of all classes. As noted by Few (1997), “The self-esteem of women should be a concern of all health care professionals working in the area of sexual health: : : : Women, particularly young women, need to be empowered
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to make choices and decisions about sexual relationships” (p. 623). Empowerment may be realized through such choices, however personal and discrete. “The voice that emerges echoes the master discourse, but this echo nevertheless establishes that there is a voice, that some articulatory power has not been obliterated” (Butler, 2004, p. 201). There is a recognized need for improvement of gendered/sexed power relations in health care settings: Although the pathways between gender inequality and health are not clear, interventions to improve gender equity in health service provision and planning may increase contraceptive use. Such interventions may include training of health care providers as well as improving women’s participation in decision-making about health at various levels including individual, community and government levels. (Bentley & Kavanagh, 2008, p. 77)
Aspects of reproductive health policy remain a subject of continued debate, marked by impassioned personal testimony and legislative compromise. Those who oppose introductions of lenient reproductive health policy frequently cite possible negative effects on women’s health. Thus, opponents of the over the counter morning-after pill claim that it will surely lead to widespread promiscuity, whereas those who oppose abortion assert that the procedure can lead to such horrors as “post-abortion stress disorder,” and social conservatives declare that condoms raise doubts about marital fidelity (Kulczycki, 2007, pp. 339–340). Differential Participation This moral framework divide is also gender specific. Women have historically been challenged by commonly applied double binds (Jamieson, 1995). One such double bind is the womb/brain divide, which asserts that men are able to think and thus make rational decisions, whereas women base decisions on emotions and feelings (Jamieson, 1995, p. 53). This womb/brain double bind insists that “true” women are unable to make decisions based on logic. Rather, only women who have denied their natural instincts and destinies can behave as men, and madness surely awaits women who have chosen such denial (Jamieson, 1995). The double bind is readily applied to reproductive health policy debates, in which women may be characterized as either independent and capable decision makers, or in need of legislative guidance to avoid negative repercussions from their own lack of decision-making prowess. The argument has long been advanced that woman is defined by her biology. As stated by de Beauvoir (1953), “Woman has ovaries, a uterus; these peculiarities imprison her in her subjectivity, circumscribe her within the limits of her own nature. It is often said that she thinks with her glands” (p. xxvii). This argument casts woman as an emotional, largely irrational being. Such a role automatically excludes her from full participation in public life, including policy decisions that ultimately affect her own well-being. According to de Beauvoir (1953), man’s privileged position results from his ability to override, or at least occasionally deny, his biological reproductive drives. However, woman is unable (supposedly) to ignore her biology, and the reproductive drive of the species serves to overwhelm woman and deny her individuality, at least in prior (and perhaps present) popular understanding. Whether this is true is not precisely the issue; it is largely believed to be true, even if in an implicit rather than explicitly stated manner. Therefore, the argument does hold merit, at least to some people, and manages to affect even those women to whom the argument is archaic and ridiculous. de Beauvoir (1953) provided a comprehensive outline of woman’s condition, stating that “The individuality of the female is opposed by the interest of the species, it is as if she were possessed by foreign forces—alienated” (p. 25). This appears to be less a reflection of immediate inherent truth than a summary of the belief systems that surround female existence. Of course, woman is no
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more “possessed” by foreign forces (such as estrogen) is man (after all, he, too, has documented hormonal drives). The factual truth of the statement is less important than the accepted truth. Advancements in perception of woman cannot be made upon the basis of mere scientific evidence. Public opinion must change, so that societal mores may begin to reflect objective reality instead of highly subjective beliefs.
CONCLUSION The Washington Times lamented that much has been written about the changing characteristics of American families: : : : Researchers have attributed the enormous changes in America’s family formation to the introduction of the birth-control pill, which permitted sex without pregnancy; the en masse entry of women into the workforce; and the growing belief that couples should postpone marriage until they get a college degree, a steady job or a mortgage. (Wetzstein, 2006, p. A01)
In the above quote, widespread changing mores are subtly linked to social and scientific forces. Thus, the introduction of the birth control pill separated pleasure from procreation and thereby led to alterations in “America’s family formation.” It is never blatantly noted, but this piece is a prime example of the combination of scientific and moral arguments. From a different perspective, a rather scathing summary of reproductive health policy under the Bush administration was offered by Kulczycki (2007): Within the United States, pharmacists and other health-care providers, institutions, and insurers have been both directly and indirectly encouraged to refuse to cover contraceptive services. The administration has promoted federally funded abstinence-only education and, in the process, prohibited teachers from discussing contraception except in the context of failure rates. Legal access to abortion, which remains the country’s most contentious social issue, has also been undermined by the Bush administration. Such developments mean that American women, particularly the poor and the young, have lost ground in achieving reproductive health. (p. 333)
Implicit in the commentary offered by Kulczycki (2007) is the assumption that reproductive health itself is best defined in a very specific framework of personal choice. The author does not need to baldly state this; it is an obvious foundation of the presented argument. Sable and Galambos (2006) argued that reproductive health policy should grant ultimate decision-making power to women and families. This is a cornerstone of policy arguments surrounding reproductive health: those in favor of lenient legislation and generous funding claim that women are quite capable of making their own decisions and should have the right to do so, whereas those in favor of restrictive legislation and limited funding claim that the government or society at large has the right to make decisions for women. The opposing sides have relied on these same foundational perspectives for over a century now. Although societal norms dictate that politically correct persons openly profess a belief in equal opportunity, tangible actions do not reflect intentions to make opportunities available for disadvantaged populations, particularly women in poverty. Butler (2004) offered reflections regarding this discrepancy: We say something, and mean something by what we say, but we also do something with our speech, and what we do, how we act upon another with our language, is not the same as the meaning we consciously convey. It is in this sense that the significations of the body exceed the intentions of the subject. (p. 199)
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Each side stringently asserts that their claim is based in fact rather than passion, and that the other side is based primarily on an emotional foundation. This is evident in the following statement by Kulczycki (2007), “Good sexual and reproductive health services rest on scientifically sound and accepted, ethically based, and politically pragmatic policy” (p. 344). However, both sides offer their own opinions regarding what constitutes scientifically sound, pragmatic, ethically based policy. Kulczycki, and others of the same opinions, would likely naturally assume that scientifically sound and accepted policy is that which most strengthens their own position. But science may be interpreted in many different ways, and those with opposing points of view may both rely on science to support their own claims. However, one would be mistaken to assume that there is a ready solution to disparities in reproductive health among women, or even that the problem itself is easily defined or universally acknowledged. Diane Sollee, director of the Coalition for Marriage, Family and Couples Education, asserted that current U.S. policies “are based on acceptance of family breakdown and are focused on dealing with the aftermath and fallout” (Wetzstein, 2006, p. A01). Arguing from a different perspective, Sable and Galambos (2006) claimed that meager allocations for federal assistance programs like Temporary Assistance for Needy Families prove the reluctance of our society to properly support women and children: “Morality cannot feed a hungry child: : : : It is time for us to deeply consider the consequences of our collective actions” (p. 165). Regardless of privately held convictions, the politics of reproductive health exist within a publicly debated moral framework.
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