Advancing Sexual and Reproductive Health and Rights
 
The Guttmacher Report on Public Policy
December 2001, Volume 4, Number 6
 
Issues and Implications

Reproductive Health and Rights: Keys to Development and Democracy at Home and Abroad

By Susan A. Cohen

In recent years, debates over reproductive health and rights—both at the federal and state levels and involving both domestic and international policies—have become so politicized that the underlying principles and values have become obscured. Family planning, and programs that support contraceptive services, are now discussed almost exclusively in terms of the extent to which they reduce (or, some would argue, increase) the number of abortions that may later occur. The political argument over abortion seems frozen in an irreconcilable clash between the legal right of women to bodily integrity and self-determination and the putative right of a developing human fetus to be born. Certainly, these are important and legitimate policy debates; it is just that they largely bypass the practical realities of why abortion and contraception are issues in women's lives.

Outside the realm of politics, the reason women the world over seek to control their fertility—by using contraception if it is socially supported and available to them and by having abortions, legal or illegal, if it is not—is their simple but overwhelming desire, at a specific time and in specific life circumstances, not to have a child. This has been the case since time immemorial, and it is increasingly so now, given the strong and virtually worldwide desire among women and couples to have smaller families.

There is a growing recognition that having fewer children, and at times and in circumstances when they best can be cared for, constitute both an individual and a social good, because doing so takes a lesser toll on the health of the mother, improves the health prospects of her children and makes it easier to ensure that each child thrives. Having the ability to time and space their pregnancies also allows women to become educated, establish themselves in the workforce and at least begin to take their rightful place alongside men in community life. In both developed and developing countries, fertility control and the maintenance of reproductive health are not luxuries; they are essential to women's lives and by extension, to the well-being of their partners and children and to the future of the societies in which they live.

Fertility control and the maintenance of reproductive health are not luxuries; they are essential to women's lives.

In this post-September 11 world, amidst war and economic recession and a host of competing priorities (see related story), it is clear that a compelling case will need to be made for government support for reproductive health programs and reproductive rights issues. The values and principles underlying that case may be most obvious in an international context, though the parallels to the U.S. domestic situation lie not far beneath the surface.

ICPD Globally

In a recent radio address to the nation, First Lady Laura Bush said the worldwide fight against terrorism is "also a fight for the rights and dignity of women." Indeed, a side effect of the war has been heightened public consciousness about the brutal repression of Afghan women and girls under the Taliban. As the reconstruction phase begins, Secretary of State Colin L. Powell declared, women and girls must "become full participants in the future of their country." In truth, this is not just a humanitarian goal but also an inescapable fact of economic, social and political development.

Family planning assistance to poorer countries is now widely accepted as a primary development strategy, and, at least in theory, it originated as such. At the first United Nations-sponsored World Population Conference in Bucharest in 1974, the Plan of Action endorsed by all 130 participating countries—with only the Vatican dissenting—declared that population policies and programs are an integral part of economic and social development. Even at that time, the central role of women in development was beginning to be recognized. The Plan called for the full participation of women in the educational, economic, social and political life of their countries on an equal basis with men. It also stated explicitly that the ability to decide freely and responsibly the timing and spacing of one's children is a basic human right, and that governments have an obligation to facilitate access to the information and services necessary to realizing this right.

Notwithstanding these rhetorical goals, the early years of the worldwide population stabilization effort—or population control effort, as it was generally called—were clearly driven very largely by macro-demographic concerns. The 1994 United Nations-sponsored Cairo conference, however, marked a major shift in direction and emphasis. The name of the meeting was changed to the International Conference on Population and Development (ICPD), but the real breakthrough was that the so-called Cairo consensus propelled the role and status of women in society to the top of the development agenda. Having the knowledge, ability and means to control their fertility was acknowledged as not just a population stabilization strategy but as a central and necessary step toward women's achieving full empowerment, itself now finally recognized both as important to women as individuals and as central to economic, social and political development efforts around the world.

"When women's influence increases," explained Barbara Crossette in a November New York Times article, "...it strengthens the moderate center, bolstering economic stability and democratic order." Increased levels of education, nutrition and family income, along with longer life expectancy and lower birthrates, are all associated with increased status of women—and are all key measures of successful development. "Everything the world has learned in the last decade about why some countries develop and others stay mired in poverty," adds Crossette, "shows that women can make all the difference."

ICPD at Home

The U.S. population assistance program, administered primarily by the U.S. Agency for International Development (USAID), began in 1968 with a priority on slowing population growth rates; stimulating demand for and access to family planning services was largely a means to that end. By 1994, though, under the leadership of the Clinton administration, the United States was playing a major role in shaping the Cairo agenda generally and in elevating the notion of women's rights in particular.

In contrast, the U.S. domestic family planning program legitimately can be seen as a "post-Cairo" program from its very beginnings. In recognition of the relationship between the ability to control one's fertility and the ability to attain economic self-sufficiency, the domestic family planning program emerged as a part of the national antipoverty campaign of the 1960s. In the second half of that decade, Congress went further to incorporate a more explicit public health approach, mandating that family planning services be made available as a part of the federal maternal and child health program and shortly thereafter under the newly created Medicaid program as well.

In recognition of the relationship between the ability to control one's fertility and the ability to attain economic self-sufficiency, the domestic family planning program emerged as a part of the national antipoverty campaign of the 1960s.

Congress combined both the public health and antipoverty approaches when it created the Title X program in 1970, which remains to this day the centerpiece of the national family planning effort and the only federal program designed exclusively to enhance access to contraceptive and related reproductive health services for low-income women and teenagers. Then as now, cornerstones of the program include voluntary participation, confidentiality of services, the offer of a broad range of methods to ensure individual choice and the provision of contraceptive services in the context of broader preventive health care.

Many civil rights leaders regarded equalizing access to family planning services as an issue of social justice, particularly beneficial to minority Americans who faced the most significant obstacles to care. Martin Luther King, Jr., suggested that improved access to family planning offered black Americans "a fair opportunity to develop and advance as all other people in our society," enriching their lives and helping to guarantee them "the right to exist in freedom and dignity."

Meanwhile, a rights-based approach to voluntary fertility control was evolving in state legislatures and in the courts. The landmark U.S. Supreme Court decision in Griswold v. Connecticut in 1965 established that a married woman's right to use birth control is constitutionally protected. Soon thereafter, this right was extended to unmarried women. At around the same time, states began passing laws legalizing the right to abortion, beginning in Colorado in 1967. By 1973, when the U.S. Supreme Court decided in Roe v. Wade that the right to abortion is grounded in the fundamental right to privacy, abortion already was legal in 17 states.

The primary rationale for reforming abortion laws at the time was to protect and enhance the public health, and indeed, legalization had an immediate and salutary effect on reducing maternal mortality and injury. But its ramifications reached far beyond, relating directly to women's ability to have greater control over their lives and their destinies. In 1992, Roe's primary value was described in exactly this way by Justice Sandra Day O'Connor in her majority opinion in Planned Parenthood of Southeastern Pennsylvania v. Casey. The central holdings of Roe had to be reaffirmed, she wrote, because in the 20 years since it had originally been decided, people "have organized intimate relationships and made choices that define their views of themselves and their places in society, in reliance on the availability of abortion in the event that contraception should fail. The ability of women to participate equally in the economic and social life of the Nation has been facilitated by their ability to control their reproductive lives."

Looking Ahead

When Congress reconvenes in 2002, it will continue to be consumed with national security—both overseas and on the home front—and with revitalizing the American economy. In that complicated and uncertain political environment, attention to the needs of women—including their reproductive health needs and their reproductive rights—must be given high priority.

At least in terms of overseas aid, there does seem to be a growing appreciation of the importance of women to development efforts and democracy, and to achieving and maintaining "human" security as well national security.

During Senate consideration of the FY 2002 foreign aid appropriations bill, Subcommittee Chairman Patrick Leahy (D-VT) called it "our moral responsibility" to "lead the world in combating poverty and supporting the development of democracy and preserving what is left of the world's natural environment." Sen. Dianne Feinstein (D-CA) argued for tripling the foreign assistance budget of the United States because "as America undertakes a war on terrorism, we must declare war on poverty as well."

Consistent with these goals, Congress this year did take steps to increase the development assistance budget for FY 2002 and, specifically, is raising the level of U.S. support for reproductive health programs overseas. USAID's family planning and reproductive health program will receive $446.5 million in FY 2002, $21.5 million more than last year. In addition, the U.S. contribution to the United Nations Population Fund (UNFPA) will rise to $34 million, which amounts to a $12.5 million increase over last year.

A majority of the Senate also felt strongly about retaining in the appropriations bill the operative language of the Global Democracy Promotion Act, which would negate the president's "global gag rule" ("Global Gag Rule: Exporting Antiabortion Ideology at the Expense of American Values," TGR, June 2001). Conference committee member Sen. Barbara A. Mikulski (D-MD) commented that she was especially reluctant to yield on the gag rule at a time of raised sensitivity concerning the rights of women and their role in development and democracy promotion. In the face of House recalcitrance and a presidential veto promise, however, Senate negotiators did relent in exchange for substantial increases in funding.

Congress will continue to be consumed with national security and the economy, and attention to the needs of women must be given high priority.

At home, support for domestic family planning through the Title X program also will increase over its current level of $254 million to $265 million. The president had requested level funding for both Title X and the international programs for FY 2002. That Congress has exceeded the administration's request on both should send a clear message to the Bush administration as it is preparing its budget request for FY 2003 that family planning remains a priority.

Next year, Congress will be considering reauthorization of the Temporary Assistance for Needy Families (TANF) block grant to the states—the "welfare reform" program enacted in 1996 and expiring in September 2002. In some respects, TANF may be considered the core of the domestic equivalent of development assistance. To that end, and to the extent one of TANF's main goals is to reduce out-of-wedlock childbearing, providing individuals who rely on TANF more, rather than less, access to reproductive health information and services in order to prevent unintended childbearing could contribute to greater and more sustained success.

States could be required again, as they were until 1996, to make family planning services and information available to all those on welfare. Rather than withholding information about contraception from teenagers through abstinence-only education programs, the federal government could support comprehensive sexuality education that would include but not be limited to information about abstinence. Indeed, the federal government could repeal the Hyde amendment and resume subsidizing medically necessary abortions for indigent women eligible for Medicaid, as 18 states now do on their own.

Admittedly, the political obstacles to achieving all of these goals will be formidable in the short-term. As a matter of policy and in the real lives of people, however, it is unrealistic to expect to see progress in development, or in moving people off welfare, without providing women with the assistance and the rights they need to take more responsibility for their lives and the lives of their families.