In January, Sen. Hillary Clinton (D-NY), in a high-profile speech marking the anniversary of Roe v. Wade, affirmed her long-standing commitment to abortion rights, even as she asserted that for many women, "abortion in many ways represents a sad, even tragic choice." She then urged people on all sides of the abortion debate to find "common ground" in reducing the need for abortion by helping women prevent unwanted pregnancy. Toward this end, she called for enactment of the Prevention First Act, legislation sponsored by Senate Minority Leader Harry Reid (D-NV), designed to reduce unintended pregnancy by increasing and improving contraceptive use.
Clinton's speech has garnered enormous attention from the media and politicos alike. Some Democratic party operatives have mischaracterized her remarks as a call for abortion restrictions, designed to appeal to those "value voters" who purportedly abandoned the party in the 2004 presidential elections. (Said Paul Begala, "It's about time a Democrat stood up and said there are too many abortions in America, we ought to restrict the number, and people who oppose abortions are good people.") Some antiabortion commentators have dismissed them as a transparent attempt to "change the subject." And some prochoice leaders have criticized Clinton, if not for backing away from abortion rights herself, then somehow for giving others permission to do so.
Yet all of this commentary misses the point—both of what Clinton said and what is really important—which is that to the extent that abortion is deemed a "problem," it is best addressed by helping women prevent unwanted pregnancies in the first place. Indeed, focusing on prevention—not as a way of backing away from abortion rights, but as a means of reducing the need for abortion—constitutes both good policy and good politics. It is good policy because it has the potential to address the root cause of most abortions in a constructive way that responds realistically to the problems that many people face in trying to responsibly manage their reproductive lives. And it is good politics because it is in sync with what Americans say they want from their legislators, and because it promises to diffuse the intensity of the debate over abortion that has raged in this country for far too long.
The Prevention Imperative
The reaction to Clinton's speech, and the relative neglect of her extensive remarks about contraception, reflect what appropriately could be deemed a national political obsession with abortion. As a political matter, abortion is typically treated separately from and as virtually unrelated to its precipitating event, namely, an unwanted pregnancy. And it is too often treated as though it were the centerpiece of women's reproductive lives, rather than a last resort, when other options fail.
Instead, women almost universally rely on contraception as the primary and dominant means of controlling their fertility. Virtually all American women—98%—use a contraceptive method at some point in their lives. Moreover, the period of time during which women may need to practice contraception is very long: Because the typical American woman wants two children, she spends roughly five years pregnant or trying to become pregnant and three decades trying to avoid unintended pregnancy.
Many of the most widely used contraceptive methods are extremely effective in helping couples avoid unintended pregnancy. Yet neither contraceptives nor the people using them are perfect, and many women find contraception difficult to use consistently and correctly over such a long period of time. For these reasons, roughly one in three American women will have had an abortion by the time they are 45.
As a political matter, abortion is typically treated separately from its precipitating event and too often as though it were the centerpiece of women's reproductive lives.
Both ineffective contraceptive use and nonuse of contraceptives among at-risk women are responsible for the fact that half of the six million pregnancies each year in this country are unintended—but in very different proportions. Half of these three million unintended pregnancies occur to the overwhelming majority of at-risk women (nine in 10) who report that they used a method during the month they became pregnant. However, the risk of pregnancy is so great in the absence of contraception that the other half of all unintended pregnancies occur to the small proportion of at-risk women (one in 10) who are not using any contraceptive method.
The high rate of unintended pregnancy in the United States, in turn, explains the country's high abortion rate. (Almost half of all unintended pregnancies—1.3 million—end in abortion.) Clearly, improving contraceptive use among those women who are already active users of contraception would reduce the number of abortions in this country. By the same token, moving even a portion of the much smaller number of women who are not using contraceptives into the user column, at virtually any level of effectiveness, would also have a major impact.
Yet, much in American society is not currently structured to facilitate effective contraceptive use. The high cost of health care, including contraceptive supplies and services, is a major issue for many. One in five American women of reproductive age lack health insurance, and even those who are insured may lack adequate coverage of contraception, placing some of the most effective methods beyond their financial reach. Sex education in schools and communities is increasingly teaching young people that the only acceptable option for them is to wait until marriage to have sex; to further this goal, this education either does not discuss the benefits of contraception or portrays it in a negative light. The right of young people to access confidential reproductive health services is perennially under attack in Congress and in many states. And conflicting social attitudes about sex hinder parents' ability to discuss sex with their children, as well as partners' ability to communicate about important intimate matters.
In fact, researchers have noted two troubling trends. Recently released data from the 2002 National Survey of Family Growth (NSFG) show that between 1995 and 2002, the number of women at risk of unintended pregnancy but not using any method of contraception rose by 1.43 million. Research has not yet explained what accounts for this increase. However, should this trend continue, there is a very real potential for the number of unintended pregnancies, and therefore abortions, to also rise over time.
Moreover, while abortion rates for U.S. women overall are currently at their lowest level since 1980 (down 29%, from 29.3 per 1,000 women of reproductive age in 1980 to 20.9 per 1,000 women in 2002), the rate of decline has slowed since the mid-1990s—in part because the abortion rate among poor women rose in the late 1990s. Again, the reasons behind this rise are unclear. The high cost of contraceptives and problems in accessing subsidized services may have played a role. Another contributing factor may have been the 1996 federal law to overhaul the nation's welfare system, which decreased benefits and imposed new work requirements even for welfare recipients with very young children.
Much in American society is not currently structured to facilitate effective contraceptive use.
Meanwhile, the U.S. abortion rate remains among the highest of all industrialized nations—more than twice as high, for example, as the Netherlands (nine per 1,000 women of reproductive age). There, unlike here, government and social institutions support comprehensive sex education and health care services aimed at helping people, including young people, avoid unintended pregnancy and disease; contraceptive use is widely encouraged and contraceptives are easily available; and national health insurance helps ensure that people have access to timely and affordable care. In short, the abortion rate in the Netherlands—and in other western and northern European countries—is low because unintended pregnancy rates are extremely low due to widespread and effective contraceptive use.
Obstacles to Progress
What seems clear is that significant future reductions in abortion levels in this country are unlikely to occur absent a bold societal commitment to helping people avoid unintended pregnancy. It is only through such a comprehensive, systemic and far-reaching effort that the federal government's own public health goal to decrease the percentage of pregnancies that are unintended by 40% will ever be met.
Is such a goal realistic? Clearly not within the 10-year timeframe set more than five years ago in Healthy People 2010. However, American society underwent a comparable stunning transformation during the 25-year period between 1965 and 1990 in smoking rates, which declined among American adults by an identical 40%. Prior to the Surgeon General's first report on the harmful effects of smoking in 1964, such monumental progress was likely unthinkable. Yet, with the encouragement and engagement of all levels of government, the U.S. public health infrastructure mobilized to combat smoking as a major public health problem, and, employing all the means at its disposal, was enormously successful in doing so. There is no reason to think that, given the political will, comparable progress could not be made on unintended pregnancy. And the payoff would be similarly enormous—if today's unintended pregnancy rate were 40% lower than it is, then the annual number of abortions in the United States would be 780,000 instead of 1.3 million.
Unfortunately, the current political state of affairs threatens to stymie any hope of similar progress for reproductive health. The social conservatives currently in power at the federal level and in many state governments are hostile to the very notion of prevention. Their answer to abortion is to make it illegal; their answer to unwanted pregnancy (or out-of-wedlock births, as they define the problem) is abstinence for all people outside of marriage. Accordingly, they are forging ahead with an aggressive antiabortion agenda designed to chip away at the foundation of Roe v. Wade. And they are engaged in a national (and indeed international) campaign designed to portray condoms and other contraceptives as ineffective in protecting against unwanted pregnancy and disease as a way to promote their abstinence-outside-of-marriage agenda.
A prevention agenda is likely to have wide popular appeal, because it addresses real difficulties that people currently face trying to responsibly manage their fertility.
From a public health perspective, denigrating contraception as a strategy to help young people delay and refrain from sexual activity is misguided and counterproductive; it may very well deter contraceptive use among people when they do become sexually active. It would be unthinkable as a matter of public health to tell people that because seatbelts do not offer 100% protection against injury from car crashes, they should refrain from driving. Instead, people are strongly advised to use seatbelts each and every time they ride in a car (and driving without a seatbelt is in fact socially, and in most places even legally, sanctioned).
Prochoice groups, for their part, have been working to advance prevention through federal and state policy for many years and can point to numerous successes that have made a meaningful difference in people's lives. Historically, however, many prochoice leaders have been resistant to the notion of putting prevention first. Because they have feared that doing so would cast abortion in a negative light, they have been unwilling to say that contraception, as an intervention, is preferable to abortionâ€"for women and for society. This has made the prochoice community seem out of touch with the American public. For years, poll after poll has shown that while Americans want abortion to be legal, they are also uncomfortable with abortion, and want it to be treated as a last resort.
A Vision for the Future
Could a broad and inclusive public policy agenda that emphasizes prevention have the potential to bring down the U.S. abortion rate so dramatically to rival a country such as the Netherlands? And what would that do to the vaunted "politics of abortion"? Answers to both questions are currently unknown. What is clear is that a prevention agenda is likely to have wide popular appeal, because it addresses real difficulties that people currently face trying to responsibly manage their fertility, and comports with what many Americans say they want from their policymakers. Indeed, while public opinion polls consistently demonstrate that Americans support maintaining the legality of abortion, they show even stronger support for publicly subsidized family planning services and other measures designed to increase access to contraception.
Establishing the prevention of unintended pregnancy (through more and better contraceptive use) as a major public health priority will require it to be cut free from the twin political anchors of abstinence and abortion. Doing so, however, constitutes both good policy and good politics. As for abstinence, there is no question that helping young people to delay sexual activity is a valid and important component of any national prevention strategy. Yet, the fact is that most American women, over most of their lives, rely on contraception, not abstinence, to help them responsibly manage their sexual lives. With regard to abortion, there is also no question that both sides of the debate, unwittingly or not, have relegated prevention to the position of poor step-child. This subjects those policymakers trying to elevate prevention as the solution to the problem of abortion in this country to criticism that they are trying to "change the subject." In no other area of public health outside of the abortion context would prevention be so denigrated, nor would the motives of those promoting prevention be so called into question.
As for the politics, one can only speculate what the debate might look like if the U.S. abortion rate were on par with those of other countries with widespread contraceptive use and low unintended pregnancy. One quite plausible scenario is that the considerably lower rate would diffuse the intensity of the U.S. abortion debate as nothing else has to date. This, too, would be a social good.
