The Future of Sexual and Reproductive Health

Amie Newman

A new administration, a new agenda for sexual and reproductive health and rights advocates. What's new? What's changed? What are we still fighting for after all these years and how can a new leader make the greatest impact on women's health and lives globally?

Ask the average American their thoughts on the economy, the effects of the leadership over the last eight years, and what needs to be done to remedy the fiscal spiral we’ve wound up with and they’ll likely ramble off any number of opinions related to the yo-yoing stock market, home foreclosures, or progressive taxation vs. tax cuts for all. We’re now a nation of economists and we all know which policies we want put in place in the coming weeks and months, after a new administration is voted in.  Pose a similar question to the average American about reproductive and sexual health care and, though these issues affect every American just as deeply as the economy, it’s doubtful you’d get much more than a tirade on their anti- or pro-choice perspectives on abortion.
VIDEO: Framing The IssuesVIDEO: Framing The Issues

The reality of both our current economic and sexual and reproductive health and rights (SRHR) situations, however, is that we have a tough uphill climb ahead of us and the best thing we can do right now is to strategize on how we’re going to find a way to fix much of what went wrong under the Bush administration and, for most of the eight years, a Republican, anti-choice Congress. From impeding access to contraception in the U.S. and abroad to chipping away at a woman’s legal right to abortion to stagnant and disastrous rates of maternal mortality in this country, the United States has been anything but a leader on SRHR over the last eight years.

Women’s reproductive and sexual health have hardly been the focus of this presidential campaign season, either (beyond the media frenzy over John McCain’s thoughtlessness at putting the words "women’s health" in air quotes during the final debate). But there has been a key difference in this election from previous ones that may signal a new approach to reproductive and sexual health issues by the federal government. Senator Obama has worked hard to broaden the conversation to include a focus on solid pregnancy and STI prevention strategies and comprehensive sexual health education, in an attempt to expand the conversation beyond the tired pro/anti choice discussion that ultimately does little to improve health outcomes or women’s lives in any way. Whether this new dialogue provides enough energy for a new administration to advance a reproductive health agenda that will make a more profound difference in the health and lives of women, men and families in the U.S. and globally remains to be seen.  Of course, the potential for change depends in many ways on which candidate takes office come January 2009.

Regardless, reproductive health advocates are gearing up to make a strong call for change from the reproductive and sexual health policies and rhetoric carried through by the current presidential administration and urging a new administration – whomever is at the helm – to take concrete steps to prioritize theses critical issues in the first few days, weeks and months.  Some of these issues will be a "harder ask" than others, according to Heather Boonstra at The Guttmacher Institute. "All of these priorities are important and the right thing to do but some are easier to get done than others."

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Ensuring Women Globally Have the Same Access to Care U.S. Women Do (or Wish They Did)

There is no doubt that of the array of restrictions the Bush administration has placed on access to reproductive and sexual health care for women around the world, two of the most damaging have been the reinstatement of the Global Gag Rule and the barring of funds to UNFPA (United Nations Population Fund). President Bush initiated both restrictions upon taking office (the Global Gag Rule, however, is an executive order first put in place by President Reagan) and both compromise or outright deny funds for family planning services abroad. The Global Gag Rule (GGR) forces family planning health centers in developing nations (sometimes the only source of healthcare for women and their families available) to censor any discussion about safe abortion in their own centers and even prevents those centers from using their own money to advocate for safe abortion laws, or refer for abortion or abortion related services. If they do not abide by this rule, they are not eligible for the U.S. family planning funds so critical to their sustainability. Heather at Guttmacher says that if Obama is elected her organization is "hoping that on his first day in office, the gag rule would be overturned by executive order. That’s a high priority for us."

More than 170 countries contributed to UNFPA, a fund that supports voluntary family planning and promotes maternal health in 150 countries, in 2007. The United States has not contributed a dime since 2001. President Bush has instructed Congress to withhold the funds our representatives allocate every year. Tens of thousands of women around the world could have benefited from the U.S. support that in reality would go for reproductive health services like contraception, prenatal care and HIV/AIDS prevention tools.

By censoring health care providers in other parts of the world and withholding funds to global governing bodies that do so much to improve women’s health and lives, the United States is also making a statement to the rest of the world – that our government places politics above women’s health and lives. According to Adrienne Germain, president of the International Women’s Health Coalition (IWHC), "lifting the GGR and refinancing or once again funding UNFPA…are not simply important in their own right but they are symbolically, critically important in terms of letting the world know that in the first instance the US will not deny women in other country rights that U.S. women have. In regards to UNFPA, it would be a clear signal that we’re rejoining the rest of the world in supporting the lead UN agency in supporting reproductive health and rights. They are much more than single actions in and of themselves."

Promoting Science Over Ideology: Abstinence-Only Out, Comprehensive Sex Ed In

One of the complaints most frequently aimed at the Bush administration byVIDEO: Max's StoryVIDEO: Max’s Story scientists, scholars, health care providers and advocates is over the administration’s adherence to ideology above, and sometimes in place of, evidence-based science and medicine. Despite the government’s own reports that reveal the failure of abstinence only programs, for example, the federal government has poured over $1 billion into such programs over the last eight years.  Numerous studies by public health experts, scholars and scientists have shown abstinence-only programs to be ineffective and in some cases dangerous (see video on right) by providing false and misleading information to young people on pregnancy and STI prevention tools. It is a top priority, therefore, for reproductive health advocacy organizations that the next administration not only immediately de-fund abstinence-only programs but to "invest in the good programs" as Guttmacher’s Heather Boonstra calls them – the programs that have been proven to work.
VIDEO: Abstinence Comes to AlbuquerqueVIDEO: Abstinence Comes to Albuquerque

The Center for Reproductive Rights says that one of their three top priorities for a new administration is "promoting reproductive health policies that are guided by science and not ideology." The National Partnership for Women & Families’ Marilyn Keefe tells me that it’s not just about getting rid of the abstinence-only program money for good. It’s about "giving young people the information they need to keep themselves safe." Guttmacher Institute, for example, doesn’t see comprehensive sex-education as simply education that includes information on contraception and STI prevention tools.  Comprehensive sex-ed, says Boonstra, is education that addresses healthy relationships, parent/child communication, empowering young women and men in their relationships and violence reduction. "All of that is really important," Boonstra tells me. "And we’ll have to do a lot of thinking about…how best to ensure that there is a pot of money available." She reminds us, however, that once again it’s not just about the money. Money at the federal level will make it possible but a lot of work will need to go into encouraging states to "do the right thing. There will need to be work on both ends to make communities receptive."

The call for a new administration to re-prioritize evidence-based science over ideology may also rear its head in the discussion over access to emergency contraception for women of all ages. The Center for Reproductive Rights, among its top priorities, wants to address "the FDA’s refusing to make Plan B available without a prescription to women of all ages even though its own scientific review staff recommended as much." Women’s access to emergency contraception, a safe and effective form of birth control, has been hampered by the Bush administration from its approval process by the FDA to the pharmacy counter today. Advocates are calling on a new administration to ensure that EC is included in guidelines for hospital treatment of sexual assault survivors, as well as made available to military women (something that has been blocked by the Bush administration).

Prevention, Prevention – Did We Mention Prevention?

Senator Obama has framed reproductive health and rights in a way that links together the clear, proven cause and effect relationship between prevention, education, and governmental and personal responsibility. This perspective is especially important when it comes to funding domestic pubic health programs. The number of women in need of publicly-funded contraception is increasing. Considering the current economic crisis, it’s likely to skyrocket. The Title X program is our country’s most successful public health program to date – it provides much needed preventive health services to nearly five million low-income and uninsured women (and men) each year. And it’s cost effective. According to the Guttmacher Institute, for every $1.00 spent to provide services through publicly funded family planning clinics around the country, $4.02 is saved in Medicaid expenses. But the unfortunate reality is that this program has not been funded to keep up with inflation or with the increased demand for services.

Marilyn Keefe tells me that funding for Title X "deserves a big boost. These are economically difficult times on one hand. But on the other hand, this program is cost effective. A new administration should feel good about making a greater investment in that program." While it is currently funded at $300 million/year, Title X should be funded at over $700 million/year if it is to keep up with inflation.

The call to increase and expand federally funded family planning programs from the reproductive health advocacy community is rooted in clear data that shows how these programs can prevent half a million unintended pregnancies per year. "Based on our own data, lower income women have a harder time preventing unintended pregnancies than higher income. It’s why their abortion rates are higher as well," says Heather Boonstra. 

In response to the above, the National Partnership for Women and Families wants a new administration to change the eligibility for Medicaid’s family planning programs in order to expand coverage and make more women eligible. It’s a priority Guttmacher shares, says Boonstra:  "We’re zeroing in on expanding Medicaid coverage so that women who are not just poor but low-income, who might be above the poverty level but still have a hard time affording contraceptives, have coverage."

Most of these prevention strategies are addressed in a comprehensive bill called The Prevention First Act, yet to be signed into law, co-sponsored by Senator Obama.

Safe Abortion = Improving Maternal Health and Lifting Restrictions

Though most Americans wouldn’t know it from tuning into mainstream media news coverage of the election, reproductive health advocates are a) concerned about much more than just safe abortion and b) extremely concerned about safe abortion as it relates to ensuring the safety and well-being of mothers here and in the rest of the world.
VIDEO: Monica's AbortionVIDEO: Monica’s Abortion

Approximately 70,000 women a year die from complications from unsafe abortions. It is crucial for women’s health and lives that safe and legal abortion access is prioritized by a new administration. Clearly, the candidates hold polarized perspectives on the issue. Optimistically, Keefe says that advocates will continue to fight restrictions, if need be, that bar particular populations of women from accessing abortion services. The restriction on many advocates’ list is the Hyde Amendment – a law that bars federal funds from being used to subsidize abortion care (and as such essentially makes abortion completely inaccessible for low-income women who may rely on Medicaid for their health care coverage, Native American women, and women in federal prisons).
VIDEO: Access DeniedVIDEO: Access Denied

Overturning the Hyde Amendment will be a "hard road" says Boonstra but still, it’s at the top of  Guttmacher’s list of priorities for a new administration to address. Banning public funding for abortion services has created undue obstacles for low income women who have the legal right to abortion as bestowed upon all women in the U.S. in Roe v. Wade. Keefe is particularly frustrated that in Washington DC, where she lives, taxpayers cannot spend their own tax dollars on abortion because of the ban on public funding for abortion services. The Hyde Amendment has kept safe and legal abortion out of reach for so many American women simply because they don’t have the means to pay out-of-pocket for a procedure. Just as illegal abortion endangers women’s health and lives around the world, this undue obstacle to care does the same thing here in the United States.

Advocates will also look toward removing bans on abortion at military facilities, a restriction that has serious implications for our female soldiers who have no recourse when faced with an unintended pregnancy and are stationed either in the U.S. or overseas without the ability to travel to a non-military hospital.

Judging A New Administration

"Appointing federal judges committed to supporting established Constitutional rights" is at the top of the Center for Reproductive Rights’ priority list for a new administration. For example, they say, right now, only four of nine Supreme Court Justices have expressed clear support for Roe v. Wade.

And while there is debate, even among the reproductive health and rights community, about the likelihood of whether, or when, Roe v. Wade will be overturned, it is clear that judicial nominations can and already have tipped the balance dangerously far in one direction on the constitutionality of Roe v. Wade and about related court cases like Gonzales vs. Carhart (on the Partial Birth Abortion Ban). There are also judicial appointments to lower courts that can and do have as much impact on the laws that govern women’s access to health care. Advocates will be eyeing these closely as well.

A new president will also have the opportunity to appoint leaders to key positions related to a range of reproductive and sexual health and rights issues to his cabinet. "… for us to be effective and accomplish what I’ve suggested, we have to consider the appointments," says Adrienne Germain. "You must have people you can work with – this is a big one and there are fifty positions that are key for reproductive and international health."

The truth is that reproductive and sexual health advocates juggle many balls at once and it’s not easy to keep them all in the air at once. In addition to the priorities addressed, there are so many other funding priorities of prime importance if this nation is to deal with some of our most disastrous and pressing health issues. The United States ranks 30th in the world in preventing maternal death with most causes of death preventable or treatable, if only we expanded health care coverage to all Americans or if we had the dedicated infrastructure and funding streams to address health care disparities according to race, ethnicity, and socio-economic status.

Reproductive health advocates have all of this and more – much more – on their agenda about which they will press a new administration. But Adrienne Germain reminds us that, in fact, in the midst of an economic crisis there is much this country, under a new president, can do to cement our dedication to improving women’s health and lives globally and here at home, unrelated to money and budget levels.

From "planning and preparing the new administration to take very clear policy positions in global forums," says Germain, that signal a return to a strong commitment to reproductive health and rights that 174 countries made together in Cairo in 1994, to providing guidance on how global AIDS funding can and should be spent, it’s crucial that the United States return to its leadership role on the global stage.

"One reason I’m emphasizing these areas that don’t cost money is because I’m really worried about this fiscal crisis and what it might mean for levels of foreign aid," says Germain. "[IWHC] will be fighting as hard as we can for foreign assistance allocations to sexual and reproductive health and rights. However, I think we may find we’re facing a really difficult battle and I’d just like everybody to keep sight of the fact that there are significant steps a new administration can take regardless of budget levels."

A new sexual and reproductive health and rights agenda for a new administration will not only require a commitment to new policies and funding of programs. A new administration has the power to reinstate the United States as a health and rights leader for women, men, and children globally. In order for that to be attainable, reproductive health advocates say, the United States must come to the table with a new sexual and reproductive health and rights message ("We see up front and close the power the U.S. wields whether or not there is money at the table. It is of enormous significance," says Germain). It’s a message that must be clear in its conviction to tackle the world’s most pressing SRHR needs free from ideological imperatives, a message that conveys, as Germain says, that with a new administration the United States is rejoining a world that must support women’s health and rights.

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