This past March, I wrote an article for RH Reality Check entitled Looking for Common Ground on Abortion? You’re Standing on It. In it, I reviewed the evidence on abortion trends in the United States–they have been declining overall—as well as the main factors leading to both unintended pregnancy and abortion in the United States.
The abortion rate in any society is a function of what are known as “proximate determinants” or “most direct” factors, and social science evidence from throughout the world underscores that the two most important proximate determinants of abortion are 1) desired number of children and 2) the rate and user-effectiveness of contraception.
If access to and effective use of contraception does not increase as the desired number of children in a society falls, there will be more abortions. Likewise, increased access to contraception will in turn reduce unintended pregnancy and the need for abortion. (To be clear, “access” is a function of a number of factors, including the economic and social costs involved in gaining access to contraceptives, and the ability to use contraception without, for example, threat of violence at the hands of an intimate partner.) Many secondary and tertiary factors of course influence the proximate determinants but at the end of the day, these two factors most directly affect unintended pregnancies and by extension abortions.
In the United States, desired family size is quite small and many women want to delay having their first child until well into their twenties. The highest rate of abortions –in the United States and abroad–occurs among those populations of women (or all ages) who want to delay, limit or space the number of children they have but who also have the least secure access to contraception and/or the least ability to control the timing or frequency of sex or the use of contraception.
Bottom line: All the public health data suggests that the most direct route to achieving the outcomes we say we desire, e.g. reducing unintended pregnancies—and by extension the need for abortion—while promoting both reproductive health and rights lies with improving access to and effective use of contraception as a key input. Not the only input, for sure, but the most important at the end of the day for those who are sexually active. This is shown to be a pattern for sexually active people across cultures.
Likewise, if we want to reduce sexually transmitted infections and achieve a range of other public health benefits, we should focus on those strategies proven by the evidence to achieve them, including comprehensive sexual and reproductive health education (which, before the flood of comments starts please note includes but is not limited to abstinence), and access to and use of barrier methods (or dual protection where there is risk of both pregnancy and infection).
In the original article, I suggested we focus on dramatically increased funding for these proven interventions, and also suggested 9 concrete recommendations the Administration could take to use its political mandate to end the bickering over these issues and fulfill the promise made by President Obama to ensure that science and evidence would guide public policy.
In response, one frequent visitor to RHRC, DerekP, wrote a comment under the heading “Not Very Appealing,” stating:
Your idea of common ground for pro-lifers is that they should just give up and become pro-choice (and probably support government funding of abortion). That doesn’t sound very appealing.
This sentiment is echoed by other comments throughout our site and also is inherent in the opposition to increased funding for critical programs like Title X by the institutional Catholic Church, as one example.
And therein lies the dilemma in which we find ourselves in these conversations: What do “I” get? Not what women need, not what couples do and how they act, not about healthy, safe sexual lives, but what do “I/we” as representatives of vested political interests, get out of this. What do the institutional Catholic Church and Evangelical fundamentalist Christians get? What does the “pro-life” politician from a conservative district get? What do ultra conservative Representatives Chris Smith and Ileana Ros-Lehtinen get?
But what DerekP, Jodi Jacobson, Chris Smith and the United States Council of Catholic Bishops “get” is (or should be) irrelevant to the real question: What do people need? What does the evidence say? We have to start with these two concepts to achieve the outcomes we say we desire. Otherwise we are engaging in a dangerous political contest in which the real lives of real people are at stake. If DerekP and others are interested in reducing the need for abortion, then they should live their own lives the way the feel best for them, but also be able to support the broader investments and interventions shown to result in the outcomes we all claim to seek.
What does the evidence say about how real people act, what women need in regard to primary reproductive and sexual health care, what needs to be in place to ensure women—and men–can exercise their rights? What women “need” is clear not just from what they say, but also as expressed by their actual choices or their patterns of “voting with their feet” so to speak: In the United States, one-third of all women have at least one abortion during their reproductive years, and nearly all women use some form of contraception at some point in their lifetime. Women of all religious persuasions—Catholic, evangelical, Jewish, Islamic–and all cultural backgrounds use contraception and abortion.
According to the Centers for Disease Control:
Contraceptive use in the United States is virtually universal among women of reproductive age: 98 percent of all women who had ever had intercourse had used at least one contraceptive method. In 2002, 90 percent had ever had a partner who used the male condom, 82 percent had ever used the oral contraceptive pill, and 56 percent had ever had a partner who used withdrawal.
What women need, therefore is both access to contraception that addresses their changing needs throughout their lifecycle and access to safe abortion services. Ensuring universal access to contraception and to comprehensive sex ed, for example, will without question reduce the number of unintended pregnancies and ultimately of abortions. If these are the outcomes we seek, then we can’t let ideology drive the inputs.
Given this reality, the political demands of the (male) US Council of Catholic Bishops (among other religious institutions) should not be in the equation. At all. Especially not when even the laity of these institutions does not agree with the ideology in practice. I realize this is a controversial, even “blasphemous” suggestion if you will, but Catholic women clearly are much less squeamish about the issue than the Bishops.
It is true that I am pro-choice—I believe all people have the right to make decisions about sex and reproduction, including lifelong abstinence or consensual sex—and it is also true that I believe the pro-choice community generally represents women’s needs because the movement itself grew out of the advocacy of women and providers and advocates working on behalf of women they serve. But if we are really interested in solving the issues about which we profess to care, and if we are really interested in the health and wellbeing of people, then we should stop thinking about common ground between divergent political positions based on ideology—pro-choice, anti-choice, pro-life, Catholic, Protestant, etc–and start and end with the real needs of real people, letting evidence guide the way.
Because it is so often completely divorced from real evidence and the needs of real people, today’s common ground debate is similar to the constant talk about “bipartisanship.” “Common ground” and “bipartisanship” are political concepts and can be achieved by political entities seeking to serve their own political interests or ideologies while actually undermining public health and human rights.
Affected populations often are not even in the "room" literally or figuratively when the deals are cut.
Concrete example: In May 2003, Congress passed the President’s Emergency Plan for AIDS Relief or PEPFAR, a landmark program authorizing $15 billion for efforts to end the global AIDS epidemic around the world, with a priority focus on 15 countries in sub-Saharan Africa, Asia and the Caribbean.
PEPFAR was hailed as a “victory” for promoters of common ground, bipartisanship, and “common sense compromise.” Advocates for AIDS treatment and care secured billions of dollars destined to increase access to anti-retroviral medication (ARVs) and to care needed by those suffering from AIDS-related illnesses. The Bush Administration put a much-needed “compassionate conservative” gloss on its otherwise bellicose and disastrous foreign policy. And Congress looked good for creating a new humanitarian program with what appeared to be bipartisan support. The mainstream media fell all over itself praising the legislation.
There was only one problem. The “common ground,” “common sense” compromises reached to pass PEPFAR came at the cost of the lives of untold numbers of women and youth. In fact, from the get-go, it was made clear the achievement of a “bipartisan,” “common ground” outcome and a good political photo op was the greatest priority irrespective of the policies contained in the legislation, as long as enough money was in the pot.
In the spring of 2003, Republicans controlled both houses of Congress, so “bipartisanship” was a somewhat questionable concept to begin with.
To get buy-in from Republicans on the unprecedented levels of funding sought for AIDS treatment and care, AIDS groups needed the support of conservative evangelical and Catholic leadership. And in exchange for that support, the USCCB and evangelical political leaders led by Rick Warren sought two things: first, they wanted prevention policy to be written in such a way as to ensure it was ideologically compatible with their own religious views, and second they wanted to secure funding for their own prevention programs in the field, despite the fact that their ideological position on such intrinsically important issues as safer sex meant they would be using federal tax dollars for what would in effect be religious purposes, and not to promote public health.
This “common ground bill” resulted in women and youth being pushed off a cliff. The law contained an earmark requiring that 33 percent of all funding for prevention programs go to abstinence-until-marriage programs, which, as a result of even narrower program guidance, resulted in the allocation of 60 percent of all funds for prevention of sexual transmission going to abstinence-only-until marriage programs in the first several years. This was true despite the fact that the highest rates of new infection were found among women and youth who were already sexually active but did not have access to prevention services, information, and methods, and the fact that a growing number of infections in women were occurring “within marriage” and to women who themselves were faithful to their husbands.
Other policies included were also based on purely ideological considerations, such as those prohibiting organizations receiving US funds from working with organizations representing the human rights of sex workers and prohibiting syringe exchange programs for intravenous drug users.
Over the 5 years following passage of PEPFAR, an overwhelming body of evidence accumulated showing these policies did not work. In fact, as a recent Stanford University study showed, after spending some $20 billion of US taxpayer funds on global AIDS programs, US funding had made no contribution to slowing the spread of HIV in the countries receiving the most funding.
Put another way: untold numbers of women and youth were needlessly infected with HIV during the period of the greatest ever expenditure on a public health problem because our “common ground” solution was to cater to ideology over evidence. So there are now more people living with HIV who were unnecessarily infected as a result of misguided, ideologically-based US policy and the majority of them will never get access to treatment.
In 2008, this grave mistake in policy was repeated when, once again, the US Council of Catholic Bishops and evangelical groups insisted on stripping out changes to these damaging policies in exchange for supporting higher levels of funding in the PEPFAR reauthorization process. Another achievement for “common ground” and “bipartisanship,” and another loss for millions of innocent people at risk of HIV, and the likely waste of billions of taxpayer dollars at a time when we are unable to provide our own citizens with decent health care.
And yet, when I ask why in common ground debates we are not starting first with filling the estimated $300 million gap in Title X funding, for example, or ensuring that we pass the Prevention First Act, or demanding full funding of comprehensive sex education, or fully funding HIV prevention initiatives, I am constantly told the “Catholics” or the “Evangelicals” won’t agree to this. When I ask why we are not confronting these issues for the sake of people’s health and lives, I am told we don’t have to agree on everything, and when I ask why we don’t push for what we know is right, I am told, "let’s reach common ground first and we can go on and work for our own principles."
Here is a dirty little secret: I heard the exact same arguments during the PEPFAR process and many other policy debates. But…as is usally the case, once Congress deals with one piece of legislation on a controversial issue, it is "done." During the first and second rounds of PEPFAR authorizations, those of us concerned about evidence-based prevention were constantly told "we’ll fix it later," but later never came.
Later still has not arrived. Once the bill was passed, the message changed to "PEPFAR? Huh? We did that already." Let’s face it: once the press release is "released" declaring "mission accomplished" on a controversial issue there is little to no impetus for Congresspeople to go back and reopen these debates again. "Fixing it later," or getting the policy right afterward is more myth than reality in 95 percent of the cases.
My questions are these: Are we more interested in some so-called common ground solution to claim “victory” for political interests or are we interested in the real victory of better health, reductions in unintended pregnancies, sexually transmitted infections, and abortions that only evidence-based approaches can bring?
Are we willing to risk the health and rights of people for an as-yet
unarticulated set of compromises that don’t address real needs? Can we honestly say that insititutional actors whose ideological opposition to solid evidence should play a greater role in determining the lives and health of people–many of whom do not share the same religious ideology and the majority of which affiliated with the same institution do not adhere to the practices?
I know I will be called "politically naive," but I feel that to give in on the evidence before we have even fought the fight is to repeat mistakes made on PEPFAR, the recent stimulus bill, and any number of other policy issues where we either put our lowest ask on the table first without a fight or caved to conservative political pressure to once again "politicize" a public health issue.
The only common ground that should matter is the one on which the vast majority of people in need of evidence-based sexual and reproductive health care are now standing. Otherwise, we are standing on a precipice and the people most at risk have already been thrown off the cliff.