EARLY CHILDHOOD STARTS LONG BEFORE CHILDHOOD
Joanna L. Grossman*
The image of newborn babies wrapped in identical blankets, lying side by side in hospital bassinets, one indistinguishable from the next, is both familiar and pervasive. The irresistible inference is that those babies leave life’s starting line together. Each is safe, clean, nurtured, and swaddled, under the watchful eye of a mother, perhaps a father, and an array medical providers. But the reality is quite different. And while focusing on early childhood, those crucial years from zero to five, is necessary and long overdue, we need to train our lens to earlier points in time as well in order to understand the inequality, racism, and poverty that cements different life trajectories for children before they even start kindergarten. Even the hospital nursery is not a level playing field.
Pre-birth inequalities are not natural or inevitable. Rather, we create and cement them policy choices that reduce access to adult healthcare, restrict accessible contraception, impede access to abortion, and deny prenatal care. Together, these choices mean that we maintain very high rates of unwanted pregnancy and increasingly high rates of maternal mortality and morbidity, burdens that fall disproportionately on women of color and women of lower socioeconomic status. Equality demands that we address these disproportionate burdens.
I. CONTRACEPTION, FUNDING, AND THE BATTLE FOR ACCESS
After decades of watching the expansion of access to contraception, we have entered an era of increasing restriction due to ideological battles over reproductive rights and increased power granted to individuals and corporations to interfere with the reproductive healthcare of others ostensibly because of religious beliefs.
The birth control pill was first approved for use in 1960, and the number of women relying on it for contraception greatly increased with the passage in 1970 of Title X, a law that led to the creation of federally-supported family planning clinics. That greatly increased access to contraception for poor women. The Supreme Court’s 1965 decision in Griswold v. Connecticut, in which it ruled unconstitutional a state law criminalizing the sale of contraceptives even to married couples, removed remaining formal obstacles to contraceptive access. After 1970, the battles over contraception revolved largely around funding and the issue of “contraceptive equity”. One of the flashpoints in this battle has been over coverage by employer-based health insurance plans. Although the number of plans that covered prescription contraceptives (which are used only by women) increased from 3 in 10 in 2000 to 9 in 10 in 2010 due largely to state laws mandating coverage, many of those plans charged co-payments or deductibles that made contraception unaffordable. After the Affordable Care Act took effect, the Department of Health and Human Services issued regulations that require employer-based health plans to cover prescription contraceptives at no cost to the patient. This 2011 mandate was based on a comprehensive study of health care needs and access in the United States, conducted by the non-partisan, Congressionally chartered group, the Institute of Medicine (IOM). IOM determined that contraception is an essential health benefit and that the primary barrier to access to effective birth control is cost. The relevant agency thus promulgated Women’s Preventive Services Guidelines that required “coverage, without cost sharing” for FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling. The medical profession is in agreement: access to contraception is a necessity for women’s health. The impact of the contraceptive mandate was significant. Within just a few years, the percentage of American women paying for prescription oral contraceptives dropped from more than twenty percent to under four percent. More than fifty-five million women have access to free birth control because of the mandate. In addition to expanding women’s workplace opportunities, greater access to contraception contributes to fewer unintended pregnancies, fewer abortions, and fewer maternal deaths.
Though abortion has been consistently controversial, the right to use contraception established in Griswold was, until very recently considered sacrosanct. Federal funding of family planning for poor women was also a consensus position. It was indeed hard to find people, regardless of their place on the political spectrum, who would admit to believing that the government should be able to block access to contraception or that it should find ways to make it more difficult to access. This reflects in large part the popularity of contraception—99% of the women who have ever had sex have used at least one contraceptive method other than natural family planning (including 98% of Catholic women, despite the Church’s denunciation of all such methods). Before the recent controversy over contraceptive coverage under the Affordable Care Act, it was hard to find people, regardless of their place on the political spectrum, who would admit to believing that the government should be able to block access to contraception. As just one illustration of this point, recall that Judge Robert Bork’s open opposition to the Griswold ruling cost him a seat on the Supreme Court in 1987. But in just the last decade, religious and moral opposition to contraception have re-emerged with gusto.
One successful attack from this perspective has been on the scope of the religious exemption to the contraception mandate. An exemption was built into the original regulations, but it was dramatically expanded by the Supreme Court’s ruling in Burwell v. Hobby Lobby Stores, Inc., in which the Court held both that closely held corporations that are not religious in nature can have religious beliefs and that they could demand an exemption from the mandate based on those ostensible beliefs. Then, after Donald Trump became President, greater incursions on contraceptive access took hold. His administration announced a further rollback of the mandate, permitting any employer to be exempted based on either “sincerely held religious beliefs” or “moral convictions.” The apparent justification for the rollback—that contraceptive access promotes risky sexual behavior among teens and adults—has no scientific support; indeed, all evidence is to the contrary. An administration that wanted to curtail teen pregnancy or STD rates would follow Colorado’s lead in providing long-acting contraceptives (LARCs) such as IUDs completely free to teenagers and poor women for the last six years. After implementation of that program, the teen birth rate fell forty percent in just four years, and the rate of abortion fell forty-two percent. Instead, however, the federal government is following the example of Texas, which, after significantly curtailing family planning funding and access based on ideology, has seen a doubling of its maternal mortality rate, a slower decline in the teen pregnancy rate than in the rest of the country, the highest teen birth rate in the country, and one of the highest teen rates for sexually transmitted infections.
Where a scientist or public health expert would see a cautionary tale, the Trump Administration sees a roadmap. The Trump Administration has taken several other measures that have the purpose or effect of restricting access to contraception or other components of reproductive health care. He appointed Neil Gorsuch to the Supreme Court, at least in part because he believes Gorsuch will vote to overturn Roe v. Wade, but Justice Gorsuch was also the author of a deeply conservative opinion on contraceptive access at the federal appellate level. He has nominated Brett Kavanaugh to fill a second vacancy on the Court, another candidate pre-approved by the Heritage Foundation for his commitment to overturning reproductive rights. Trump also reinstated the Mexico City Policy, also known as the Global Gag Rule, that prohibits foreign non-governmental organizations from receiving U.S. aid if they perform abortions, even if funded with non-US money, or provide any information about abortion to patients or clients. While this rule is always reinstated by Republican Presidents (and then withdrawn by Democratic ones), Trump’s version is worded in a way that increases the scope of the gag rule more than tenfold and does not exempt organizations working to provide HIV/AIDS relief. This rule, which has operated for enough years to have been well-studied, seems to increase rather than reduce the number of abortions because the cuts in funding cause family planning clinics to close or curtail services in ways that increase the rate of unintended pregnancy. Trump has taken the additional, unprecedented step of proposing a domestic gag rule that would apply to family planning clinics in the United States as well as abroad.
The recent shifts in favor of “religious liberty” (or simply conservative ideology) over women’s health are not costless, at least not for many women. Justice Ginsburg dissented in Hobby Lobby, writing powerfully about the direct tie between control over reproduction and women’s ability “to participate equally in the economic and social life of the Nation. . . .” She quoted this language from the Supreme Court’s 1992 ruling in Planned Parenthood v. Casey, in which it reformulated by reaffirmed the central holding of Roe v. Wade and protected the right of women to terminate a pregnancy without undue burden from the government.
The economic security of all women is threatened when access to contraception is reduced, but women of low socioeconomic status are disproportionately burdened. Currently, low-income women are overrepresented among those who do not wish to be become pregnant but are not using contraception. A report by the Kaiser Family Foundation concluded, for example, that the proposed domestic gag rule would leave many women “with far fewer options to obtain affordable, comprehensive, and high quality family planning care,” at the same time more women are becoming uninsured due to the weakening of coverage under the Affordable Care Act. Millions of low-income women have relied on public programs and providers for everything from contraception to cancer screenings to STI treatment. These programs are funded by a combination of sources, including Title X and Medicaid. Cuts to either or both of those programs will have real and potentially devastating effects on poor women’s access to care.
Federal efforts to curtail funding for family planning are mirrored at the state level, at least in some states. Texas, for example, significantly cut its family planning program in 2011, reducing the total pool of money significantly and restricting participation in the program. As a result, one-quarter of family planning clinics in the state closed. Within just a few years, less than half as many women were receiving services from state-funded providers, and many providers reduced the range of services available. Among the changes implemented in 2011 was a ban on Planned Parenthood affiliates’ receiving any state funds. This change “was associated with adverse changes in the provision of contraception,” including a reduction in the number of women continuing to use injectable contraceptives and an increase in the number of births covered by Medicaid. In other words, this study concluded, the ban reduced access to one of the most effective types of contraception and likely increased the number of unplanned births. Another study found that the exclusion of Planned Parenthood caused twenty percent of patients to miss a dose of injectable contraception due to the difficulty of finding a provider, with the burdens falling most heavily on women in rural areas of the state. Poor women are the losers in this battle.
II. RESTRICTIONS ON ABORTION
Across the country, taxpayers are paying to defending a seemingly never-ending barrage of new abortion restrictions, passed by conservative legislatures as part of the current anti-abortion strategy. This strategy, which gained momentum in the 1990s, was to impose burdens on abortion providers that would make it difficult, if not impossible, to remain in operation. So-called TRAP laws—targeted regulation of abortion providers—were designed as an end run around the protections of Roe and Casey. Dozens and dozens of abortion restrictions—92 in just the year 2011—made their way into state laws that made it practically more difficult for doctors to provide abortions, and for women to obtain them. These laws imposed waiting periods, ultrasound requirements, and requirements for clinic architecture; they also banned particular abortions based on timing or method; and they prohibited coverage of abortion care by private insurance policies.
The strategy was initially a great success—it drove abortion clinics out of business in droves. It left a handful of states with only a single operating clinic. The Supreme Court drove a nail into this strategy in 2016, when it decided in Whole Woman’s Health v. Hellerstedt that two of Texas’s TRAP laws were unconstitutional because they imposed too significant a burden on women’s access to abortion without any sufficient medical benefits to justify the incursion. While this decision throws the constitutionality of many other state restrictions into question, it does nothing to bring back the clinics that were forced to close in Texas or elsewhere because of these laws. Indeed, one of the undue burdens identified by the Court was women’s impeded access to abortion because so many clinics were forced to close. Moreover, the attacks on abortion access have resulted in reductions in access to other kinds of care, including family planning, prenatal, and primary care. TRAP laws represent just one type of attack on abortion access, and significant others remain. It should surprise no one that virtually all barriers to access are disproportionately adverse for lower-income women.
III. HEALTHY BABIES AND DEAD MOTHERS
Maternal mortality rates are rising in the United States, even as they fall in other countries. Defined as the death of a woman during childbirth or within one year of giving birth in the absence of another known cause, maternal mortality is measured as a ratio of maternal deaths per 100,000 live births. The maternal mortality ratio (MMR) allows for comparisons across different populations. Reducing the MMR has been a goal of governments, NGOs, and other organizations for many decades. Overall, the MMR has declined significantly since 1990. The Center for Disease Control (CDC) in the United States started tracking data nationally on maternal death in 1986 in order to compile better data on its causes. On a global scale, efforts to reduce the risk of maternal death have met with great success. According to the World Health Organization, the global rate of maternal death decreased 44 percent between 1990 and 2015. In some regions with particularly high rates, the decreases have been even more substantial. In the United States, however, the rate has actually increased steadily over the last twenty years.
The CDC tracks maternal death using the Pregnancy Mortality Surveillance System, established in 1986, which shows that the rate has, “steadily increased from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.” The rates are not even across the nation—with some states showing vastly higher numbers than others. During that same period, rates in other developed nations have fallen. In Germany, for example, the rate per 100,000 live births fell from 20 to just under 10.
What’s behind the numbers is more complicated. Some of the increase might be due to increased reporting or changes in the way deaths are recorded, both of which might inflate the rate without reflecting an increase in actual risk or deaths. But other information suggests that pregnancy and childbirth are, indeed, getting riskier rather than safer in the United States. We have seen, for example, an increase in chronic health conditions like diabetes and high blood pressure, both of which aggravate pregnancy risk.
According to a recent study, among women who give birth each year, 50,000 are severely injured, and 700 die. Reporters sought to understand those alarming statistics by reviewing hospital records from dozens of hospitals in three states. The reporters documented widespread failures in the medical management of childbirth. For example, a leading cause of maternal mortality and injury is high blood pressure. Yet, experts estimate 60 percent of deaths related to hypertension could be prevented. Since 2011, the American College of Obstetricians and Gynecologists since 2011 has been warning that high blood pressure can cause maternal death—and it has given hospitals and doctors detailed instructions in how and when to treat the condition. Three years later, a coalition of leading medical societies developed another program, called AIM, which categorizes risk into “safety bundles,” each of which provides the tools and instructions necessary to counteract or treat a particular maternal risk. Despite these forms of assistance—and the evidence-based recommendations they reflect—hospitals are failing to implement the protocols in a huge percentage of cases. That appears to be true even at hospitals that function as the primary birthing center for a metropolitan area.
As with virtually every other aspect of sexual and reproductive health, harm is not evenly distributed across the population. Pregnancy-related risk is not even across geographical regions, racial groups, or socioeconomic status. For 2011–2014, for example, 40 black women died for every 100,000 who gave birth, compared with only 12.4 white women. The maternal mortality rate also varies considerably state-to-state, with the highest rates in states like Louisiana (58.1), Georgia (48.4), and Indiana (43.6).
Several states have convened commissions to study maternal mortality in recent years. When lawmakers follow the recommendations of such commissions, they can be a useful vehicle for reducing preventable maternal deaths. California, for example, put substantial resources into a study of pregnancy-related deaths. The state uses a painstaking process to accurately count pregnancy-related deaths, to understand their likely causes, and to identify potential remedies for future cases. Since undertaking this process, the state has been able to reduce its maternal mortality rate from 14.6 per 100,000 live births in 2003 to 7.3 in 2013. It did this by focusing on specific, evidence-based reforms. Even simple reforms, like making sure hospitals had a hemorrhage cart with all the appropriate medication and devices to stop sudden, uncontrolled bleeding, can save lives. The California reforms also focused on increasing the frequency and quality of prenatal care. Other state committees and commissions have done similar work and, typically to a lesser degree, instituted relevant reforms. Alabama has managed to reduce its maternal mortality rate by instituting reforms to reduce infant mortality—chief among them by expanding access to prenatal care—and those reforms had the indirect effect of also helping mothers. Texas, in contrast, has studied the problem, but instituted no reforms the evidence might justify.
Maternal death is not an isolated problem. It is a moment in time—potentially a catastrophic one—that is preceded and followed by other aspects of the reproductive cycle. And while hospitals play a significant role in the safety of childbirth, so do lawmakers. As discussed in this essay, there are so many different points at which we can do right, or not do right, by women and their babies. Unfortunately, at many of those points, we have adopted policy preferences that minimize the chance of healthy pregnancy, birth, and childhood. Instead, we should be making choices that do just the opposite. Lawmakers are driven by ideology rather than evidence, and they often prefer short-term cost-savings over expenditures that will reap savings in the long term. These decisions impose burdens on many women, but especially women of color and low-income women.
Conclusion
Our healthcare system does not dispense care or good outcomes equally. Quite the contrary. As summarized in a recent brief of the U.S. Department of Health and Human Services, “[m]inority populations, in particular, continue to lag behind whites in a number of areas, including quality of care, access to care, timeliness, and outcomes.” Overall, the Affordable Care Act reduced gaps in healthcare access between rich and poor, white and non-white, and men and women. Substantial inequalities remain, and attacks on the ACA threaten to return to the previously larger disparities. And these general disparities in access to healthcare are exacerbated by attacks on sexual and reproductive health care. There are racial disparities in every aspect of sexual and reproductive health care. Women of color are “less likely to have access to reproductive health care, including medically appropriate contraceptives, annual gynecological exams, and prenatal care.” Black women have higher rates of unintended pregnancy, particularly for teenagers; these disparities would disappear with the removal of barriers to “cost, access, and knowledge.” Abstinence-only education, proven not to work yet clung to by many states, disproportionately harms non-white teenagers.
Let’s return to the image of those side-by-side newborn babies in the hospital. Perhaps they look indistinguishable, but the paths that led to that nursery might have been very different—and ensure that the days, weeks, and years after that nursery stay are different as well. That one might have a dead mother is just one of many inequalities that may distinguish one baby from the next. A system that prioritized maternal and infant health would include comprehensive sex education from an early age to give women the information necessary to make informed choices about sex, reproduction, and healthcare. It would ensure access to contraception so women could avoid unwanted or unsafe pregnancy. It would make abortion accessible so women could choose whether to continue an unwanted or unsafe pregnancy to term. It would ensure that pregnant women had access to prenatal care from the first trimester, a proven contributor to safe and healthy pregnancy and birth. It would ensure that pregnant women had access to hospitals within a reasonable distance for childbirth. It would provide access to the health care and social services necessary to recover from childbirth and provide assistance with postpartum depression and any other health condition associated with pregnancy. It would ensure access to infant medical care. And the government should facilitate these goals because they are proven to increase the well-being of its mothers and children. Increasingly, however, we make policy preferences that undermine women’s health—and sometimes actively sabotage it. Children, particularly those from disadvantaged backgrounds, will pay the price.