The Politics of Fertility Control: Family Planning and Abortion Policies in the American States

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Deborah R. McFarlane & Kenneth J. Meier

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    Dedication

    To Catherine Azalea Arthur Bastian (1902–1994) for sharing her truth

    Figures and Tables

    • Figure 1.1 The Reproductive Process 5
    • Figure 1.2 Demand Curve for Fertility Control 6
    • Figure 1.3 Demand Curve for Sex 7
    • Figure 1.4 Demand Curve for Contraception 7
    • Figure 1.5 Demand Curve for Abortion 8
    • Figure 3.1 Mazmanian and Sabatier's Conceptual Framework of the Policy Implementation Process 56
    • Table 1.1 Frames for Fertility Control Policies 10
    • Table 1.2 Gormley's Typology of Issue Politics 16
    • Table 3.1 Federal and State Expenditures for Family Planning 40
    • Table 3.2 Title X Authorizations and Appropriations for Family Planning 43
    • Table 3.3 Statutes Authorizing Federal Funding for Family Planning 48
    • Table 3.4 Statutory Coherence Scores for Titles V, X, XIX, and XX 61
    • Table 4.1 Supreme Court Decisions on Abortion since Roe v. Wade 63
    • Table 4.2 Changes in Federal Abortion Policies, 1992–96 76
    • Table 4.3 Statutory Coherence Scores for Federal Abortion Policy 77
    • Table 5.1 Number of States Using Specific Sources of Federal Funding 81
    • Table 5.2 State Organization of Title X Grantees, 1981 and 1996 83
    • Table 5.3 State Discretion by Source of Federal Family Planning Funds 84
    • Table 5.4 States Funding Abortions for Medicaid Recipients in Most Circumstances 90
    • Table 5.5 States Requiring and Enforcing Parental Involvement in Minors’ Abortions 91
    • Table 5.6 Mandatory Waiting Periods for Abortion 92
    • Table 5.7 State Abortion Policies 94
    • Table 5.8 Determinants of States’ Use of Multiple Sources of Public Family Planning Funds 102
    • Table 5.9 Determinants of State Abortion Funding Policy 103
    • Table 5.10 Determinants of Parental Involvement Policies 103
    • Table 5.11 Determinants of Enforced Parental Involvement Policies 104
    • Table 6.1 Number of Patients Served by Publicly Subsidized Family Planning 107
    • Table 6.2 Public Expenditures for Family Planning Services 108
    • Table 6.3 Public Expenditures for Family Planning Services, Adjusted for Inflation 109
    • Table 6.4 1994 State Family Planning Expenditures per Woman at Risk and per Capita 110
    • Table 6.5 Number of Reported Abortions, Abortion Rate, and Abortion Ratio 113
    • Table 6.6 Coefficients of Variation for State Family Planning Expenditures per Woman at Risk 115
    • Table 6.7 Correlation Coefficients for State Family Planning Expenditures, 1990 and 1994 116
    • Table 6.8 Hypothesized Relationship between Independent Variables and State Family Planning Expenditures 117
    • Table 6.9 Determinants of 1994 Family Planning Expenditures from State Appropriations 118
    • Table 6.10 Determinants of Funded Abortion Rate 119
    • Table 6.11 Determinants of Funded Abortion Ratio 120
    • Table 6.12 Determinants of Abortion, 1982–92 124
    • Table 7.1 Effects of Funding Policies and Control Variables on Abortion Rates and Maternal and Child Health: Pooled Estimates, 1982–88 136
    • Table 7.2 National Totals for Abortion Funding, 1982–88: Impact on Number of Abortions and Birth Status 138
    • Table 7.3 National Totals of Benefits from Family Planning Funding, 1982–88 139
    • Table 7.4 Intergovernmental Grant Mechanisms 141
    • Table 7.5 Statutes Authorizing Federal Funding for Family Planning: Grant Characteristics, Administrative Mechanisms, and Grant Type 142
    • Table 7.6 Descriptive Statistics for All Variables 144
    • Table 7.7 Impact of Family Planning Expenditures and Control Variables on Birth Rate, Abortion Rate, and Infant Mortality 147
    • Table 8.1 Statutory Variables for Effective Policy Implementation and Signs and Examples of Undermining a Policy 155

    Preface

    IN HANDING DOWN its Webster v. Reproductive Health Services decision in 1989, the U.S. Supreme Court not only permitted the states far more discretion in abortion policy; it also revealed itself as very much divided on the abortion issue. This case brought renewed interest to the study of abortion politics, and the ensuing scholarship has increased our understanding of abortion policy, federalism, and state politics. Both the field of public health and the discipline of political science have benefited from this work, and we are happy to be counted among the many contributors.

    This book reflects our view that larger questions loom behind abortion politics. First of all, we consider nearly all induced abortions as sequelae to unwanted pregnancy, most of which can be avoided with effective contraception. Second, we contend that abortion politics are part of a larger political struggle about values, which we have termed morality politics.

    Our focus here is on fertility control policies and politics, namely, those concerned with family planning and abortion. We also consider abstinence policies. We believe that to a large extent, the same political winds affect each. Our methods are both descriptive and analytic. We describe the disparate evolution of national policies toward contraception and abortion. We also describe how fertility control policies developed in the states and how they have been implemented. In analyzing these policies, we use models of policymaking, intergovernmental transfers, and policy implementation and, in so doing, demonstrate how these models can inform our understanding of fertility control policies. We also show how this substantive area can contribute to our understanding of American public policy.

    Chapter 1 introduces the concept of fertility control and presents the overall theoretical framework for the study. Fertility control is viewed as part of a set of policies generally called morality policies. We argue that this concept is important because it determines how issues are framed and how policies are developed.

    The contentiousness of late twentieth-century American fertility control politics has led many observers to conclude that this is a unique period in history.

    In fact, nearly all human societies have practiced both contraception and abortion. At intermittent times throughout the ages, there have been organized attempts to restrict fertility control. Chapter 2 highlights the universality of fertility control and describes various historical efforts to curtail birth control and abortion. Although this chapter offers thumbnail sketches of other societies, the emphasis is on Western history, particularly the American experience.

    Chapter 3 describes how family planning policies have evolved since the mid-1960s. From that time to the present, federal family planning policy has been multistatutory and has employed several grant types. After describing policy developments up to the present, we use criteria from the well-known Mazmanian and Sabatier model of policy implementation to rate the likely effectiveness of each federal statute that addresses family planning.

    Chapter 4 reviews the history of federal abortion policy since the Roe v. Wade decision in 1973. To a large extent, the U.S. Supreme Court has determined the parameters of abortion policy, and the Court's changing composition has made abortion a particularly volatile policy area. The Mazmanian and Sabatier model is versatile enough to accommodate different types of policies, including those created by judicial decisions, and in this chapter, we use it to rate the likely effectiveness of federal abortion policy over time.

    Both chapters 3 and 4 show that over the past two decades, much of the responsibility for implementing fertility control policies has devolved to the states. In turn, the states have chosen different ways to implement these policies. Chapter 5 documents this variation and attempts to explain the reasons for state policy variation.

    Given the variation in state fertility control policies, it is not surprising that there are vast differences in the levels of services that the states provide. Within the limits of existing data, chapter 6 examines the immediate effects of fertility control policies in the fifty states. These policy outputs include patients served and money spent.

    Chapter 7 considers the long-term effects of fertility control policies. Here, we analyze the health and fertility impacts of fertility control policies. We also assess whether statutory structure, or grant type, affects policy effectiveness. In this chapter, we employ not only the Mazmanian and Sabatier model, but also the Gramlich typology of intergovernmental grant mechanisms from public finance economics. While this typology predicts the magnitude of policy effects, it is applicable only to fiscal transfers. In the case of fertility control, the Gramlich typology is thus useful for analyzing family planning policy but not abortion policy.

    Chapter 8 concludes the book with a discussion of the implications of our findings for both family planning and abortion. We note how public policies toward family planning and abortion have been rendered less effective over time and how fertility control policies could be designed to be more effective.

    The publication of this book marks the tenth year of a collaboration between a political scientist and a public health researcher. During the course of that collaboration, we have learned a great deal and recognized that we have a great deal in common. Each of us recognizes that politics create policies and influence their implementation. Each of us is committed to improving health outcomes. We agree that family planning and abortion comprise an inextricable policy area.

    By testing theoretical constructs as well as making policy recommendations, we hope that this book offers something of value to both scholars and practitioners. We certainly are indebted to individuals in both categories. Daniel Mazmanian and Paul Sabatier have contributed a rich framework with a clear hypothesis. Judith Blake, Kingsley Davis, William Gormley, Edward Gramlich, and others have provided valuable conceptual tools for model building. Patrick J. Sheeran, director of the Office of Adolescent Pregnancy, has been an invaluable source of information and insight. Both he and Deborah Oakley of the University of Michigan read the entire manuscript and provided excellent suggestions. Rachel Gold at the Alan Guttmacher Institute answered questions tirelessly and with good humor, as well as giving us many leads. Very early in the project, Barry Nestor, formerly of the Alan Guttmacher Institute, provided data and patient explanations. Gloria Roberts, librarian at the Katharine Dexter McCormick Library of Planned Parenthood of America, generously located historical materials. Joy Dryfoos, Vivian Lee, Jack C. Smith, and the late Paul Smith each provided explanations, offered encouragement, and furnished documents for this endeavor. We also acknowledge the silent contributions of the family planning providers who have shared their expertise; their desire to remain anonymous speaks volumes about morality politics.

    We would also like to thank Alesha Doan, Donald P. Haider-Markel, Rebecca Leggitt, and Anthony Stanislawski for research assistance. Deborah McFarlane would like to acknowledge the University of New Mexico for the 1996–97 sabbatical leave provided for this project.

    We thank Robert Gormley, our publisher, for his confidence in and support of this book and Katharine Miller for keeping our work on track. We are especially indebted to Sarah Evans, our copyeditor. Her diligence and dedication contributed greatly to the quality of this book. Any remaining errors are, of course, solely our responsibility.

    A project of this length takes time and attention away from our families. We wish to thank Juan Javier Carrizales and Diane Jones Meier and to acknowledge their patience, support, and intellectual contributions.

  • Notes

    Chapter 1 Fertility Control Policy: A Theoretical Approach

    1. The figure is 21.5 for whites only.

    2. Whether these individuals will also avoid sex is a separate question.

    3. We do not consider totalitarian policies of coercion in relation to abortion or family planning. Legge's (1985) study of Romania suggests that the demand for fertility control is so strong that such policies will have major second-order health consequences.

    4. This position is held by 88.9 percent of men and 93.5 percent of women.

    5. For abortion, payment may well involve transportation costs because the number of abortion providers is decreasing; in many geographic areas, abortion is not available even to those who can pay the cost of the procedure.

    6. Fourteen states currently fund abortions for low-income women.

    7. Obviously, contraceptive technology and abortion involve some highly technical issues, but these are not the issues that drive the policy adoption process. For the most part, fertility control issues have been framed to focus on results rather than on the technical issues.

    8. Emergency contraception refers to postcoital contraception that can be used within seventy-two hours of unprotected sexual intercourse to avert an unintended pregnancy. Emergency contraceptives are not abortifacients; they do not terminate a pregnancy, which is medically defined as the implantation of a fertilized egg (Grimes 1997). Rather, they prevent implantation from occurring. Emergency contraceptives available in the United States are emergency contraceptive pills, minipills, and the copper-T intrauterine device (IUD) (Trussell et al. 1997; Hatcher et al. 1998). Mifepristone, when taken by itself, is an effective abortifacient 65 to 80 percent of the time. When combined with a prostaglandin, such as misoprostol (which has been approved in the United States as an ulcer medication), mifepristone produces a nonsurgical, or “medical,” abortion in approximately 95 percent of women when used up to forty-nine days after the last menstrual period (Population Council 1999).

    9. Clearly, the Title X program would be better served by looking at the prevalence of unplanned pregnancy within a given population and measuring the impact of a grantee's services. Grantees report that this type of outcome measurement would be particularly important in negotiations with managed care organizations when demonstrating the “value” of their covering contraceptive services.

    Chapter 2 Contraception and Abortion: A Historical Overview

    1. Crocodile dung has no spermicidal properties. The later substitution of elephant dung, which is more acidic, would have improved contraceptive effectiveness (Himes 1970, 62).

    2. “Rue is a traditional abortifacient among the Hispanic people in New Mexico and has been used as a tea for abortion purposes throughout Latin America” (Riddle, Estes, and Russell 1994, 32).

    3. Albert believed that if a woman would spit thrice in the mouth of a frog or eat bees, she would not become pregnant.

    4. Europe's population shrank from 80 million to 60 million between 1320 and 1400; between 1350 and 1450, the English population decreased by 60 percent (Heinsohn and Steiger 1982, 197).

    5. The reason for using this population is simply that vital statistics for this group are far more accurate than for women of color or immigrant women (Brodie 1994).

    6. Increasing birth intervals among married couples in certain communities suggest the use of this practice (Brodie 1994).

    7. Coitus reservatus is coitus without ejaculation (Himes 1979, 127).

    8. The “social purity” movement included dozens of organizations of men and women interested in promoting temperance and Sunday closing laws, controlling prostitution, ending white slave traffic, and suppressing obscenity (Brodie 1994, 261–62).

    9. These states were Colorado, Indiana, Iowa, Massachusetts, Minnesota, Mississippi, Missouri, Montana, Nevada, New Jersey, New York, Pennsylvania, Washington, and Wyoming.

    10. These states were Colorado, Indiana, Iowa, Minnesota, Mississippi, New Jersey, New York, North Dakota, Ohio, Pennsylvania, and Wyoming.

    11. These states were Colorado, Idaho, Iowa, and Oklahoma.

    12. This growth in female participation in the labor force continued a trend from the nineteenth century. Between 1870 and 1900, the number of women working outside the home increased from 1.8 million to 5.3 million (Dienes 1972, 76). Between 1910 and 1920, the proportion of women in nonmanual jobs increased from 17 to 30 percent, “and work outside the home became socially acceptable” (Reed 1978, 59).

    13. In 1939, the American Birth Control League and the Birth Control Clinical Research Bureau merged to form the Birth Control Federation of America. In 1942, the Birth Control Federation was renamed Planned Parenthood Federation of America, Inc.

    14. One Package did not completely end Comstockery. In 1940, the Connecticut Supreme Court of Errors upheld a state law that made the use of contraceptives illegal and denied any exception for physicians (Planned Parenthood 1992).

    15. Not very many states took advantage of the opportunity afforded them in 1942; by 1958, only seven states (Alabama, Florida, Georgia, North Carolina, South Carolina, Mississippi, and Virginia) were using maternal and child health monies to provide birth control services and then only in token fashion (Jaffe 1967, 146).

    16. In 1985, the risk of death was 0.4 per 100,000 legal abortions compared with 6.6 per 100,000 births (Gold 1990, 28).

    Chapter 3 Family Planning Policies: An Intergovernmental Labyrinth

    1. By 1973, four states (Alaska, Hawaii, New York, and Washington) had already guaranteed a woman the right to choose for herself whether to terminate her pregnancy (Tribe 1992, 49–50).

    2. These services include child care, foster care, family planning, employment, and health (AGI 1974, 31).

    3. The AFDC welfare program was replaced by Temporary Assistance for Needy Families (TANF) in the mid-1990s.

    4. Child Health Act of 1968 (PL 248).

    5. DHEW was changed to the Department of Health and Human Services (DHHS) in 1977.

    6. The gag rule was a duly promulgated regulation; that is, it went through the entire federal rule-making process. Technically, then, this regulation had to be repealed and replaced through the legally established process of “notice and comment” (AGI 1993f; Kerwin 1999). To date, the process has not been completed. This neglect of the rule-making process by the Clinton administration worries family planning advocates because another president could easily reinstate the gag rule.

    7. The health care industry receives payments from Medicaid, so it would not be supportive of converting this entitlement program into a block grant. Moreover, unlike welfare, Medicaid functions as a middle-class subsidy in the financing of nursing home care. The cost of nursing home care is exorbitant and is for the most part not covered by Medicare, but it is covered under state Medicaid programs. However, Medicaid eligibility depends on spending down one's savings. Increasingly, the middle class has viewed Medicaid as an entitlement, a way to protect life savings. “Thus families transfer funds from the elderly person to the other members of the family so that the elderly person can become eligible for Medicaid,” which saves the family from having to pay for their relative's long-term care (Patel and Rushefsky 1995, 98; Anton 1997, 707). Support for Medicaid from health care providers and many middle-class persons, along with public opinion that is generally more supportive of health subsidies than of welfare (Schlesinger and Lee 1993), may explain why AFDC was blocked while the larger Medicaid program was not.

    Chapter 4 Abortion Policy

    1. The Hyde amendment was passed in 1977, but it was enjoined and not enforced until after the Supreme Court's ruling in Harris v. McRae in 1980.

    2. When it issued this requirement in February 1995, ACGME specifically exempted residents who had moral or religious objections to abortion (AGI 1995g).

    Chapter 5 State Fertility Control Policies

    1. Categorically needy individuals are those who would have qualified for welfare cash assistance under AFDC even though it has been replaced by TANF. Medically needy recipients are those who meet the nonfinancial standards for Medicaid eligibility but whose income or resources are in excess of AFDC cutoffs (Andrews and Orloff 1995; U.S. DHHS 1996a).

    2. Except for a handful of training grants, including grants for nurse practitioners.

    3. In 1991, the Medicaid program was administered by the welfare department in thirty-one states, by the health department in six states, by a combined health and welfare department in seven states, and by a specialized agency in six states.

    4. DHHS Region I (Boston) administers funds for Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. Region II (New York City) administers funds for New Jersey, New York, Puerto Rico, and the Virgin Islands. Region III (Philadelphia) administers funds for Delaware, the District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia. Region IV (Arlanta) administers funds for Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, Tennessee, and South Carolina. Region V (Chicago) administers funds for Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. Region VI (Dallas) administers funds for Arkansas, Louisiana, New Mexico, Oklahoma, and Texas. Region VII (Kansas City) administers funds for Kansas, Iowa, Missouri, and Nebraska. Region VIII (Denver) administers funds for Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming. Region IX (San Francisco) administers funds for Arizona, California, Hawaii, Nevada, and the Pacific Basin. Region X (Seattle) administers funds for Alaska, Idaho, Oregon, and Washington.

    5. In 1999, the federal poverty levels were $8, 240 for a nonfarm family of one person; $11, 060 for a nonfarm family of two persons; $13, 880 for a nonfarm family of three persons; $16, 700 for a nonfarm family of four persons; $19, 520 for a nonfarm family of five persons; $22, 340 for a nonfarm family of six persons; $25, 160 for a nonfarm family of seven persons; $27, 980 for a for a nonfarm family of eight persons; and $2, 820 for each additional family member.

    6. A capitated system is a payment system in which providers receive a given allocation per person; if the provider can deliver services at lower costs, the difference can be kept as profit.

    7. Title X grantees are required to provide client education; counseling, including both contraceptive method and special needs; history, physical assessment, and laboratory testing; fertility regulation; infertility services; pregnancy diagnosis and counseling; adolescent services; treatment and referral for sexually transmitted diseases; and identification of estrogen-exposed offspring. Title X guidelines recommend, but do not require, that grantees provide gonorrhea screening, treatment of minor gynecologic problems, genetic screening and referral, and health promotion and disease prevention. The guidelines also suggest that Title X projects offer some reproduction-related health services—prenatal care, postpartum care, and special gynecologic procedures (e.g., colposcopy and biopsy)—if appropriately skilled personnel and equipment are available (U.S. DHHS 1981, 9–15).

    8. The procedures used by HMOs to send statements to heads of households may reveal that a family planning service was provided to a minor (Gold and Richards 1996, 26).

    9. These states are Idaho, Illinois, Iowa, Virginia, and Wisconsin.

    10. These states are California, Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, Montana, New Jersey, New Mexico, New York, Oregon, Vermont, Washington, and West Virginia.

    11. The states that enforce parental consent or notification laws are Alabama, Arkansas, Delaware, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, Ohio, Pennsylvania, Rhode Island, South Carolina, South Dakota, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. States that have parental involvement laws on the books but do not enforce them are Alaska, Arizona, California, Colorado, Illinois, Montana, Nevada, New Mexico, and Tennessee.

    12. These states include Arkansas, Colorado, Illinois, Iowa, Kansas, Minnesota, Nebraska, South Carolina, Virginia, and Wisconsin.

    13. These states are Delaware, Illinois, Iowa, Maine, North Carolina, Ohio, South Carolina, and Wisconsin.

    14. Title X was then and remains the most evenly distributed funding (McFarlane 1989; McFarlane and Meier 1993b).

    15. This has been the case since 1981, when Arizona became the fiftieth state to develop its own Medicaid program, which is known as ACCESS.

    16. Some states include rape or incest as reasons for Medicaid funding of abortions, but so few abortions are performed for these reasons that this restriction can be viewed as identical to the mother's life-endangerment restriction. A more elaborate classification of funding policy can be found in Weiner and Bernhardt 1990.

    17. Abortion policy data for 1990 are from Gold and Daley 1991; 1987 data are from Gold and Guardado 1988, 231; 1985 data are from Gold and Macias 1986.

    18. Data on church membership are from Quinn et al. 1980. The following churches were identified as Protestant fundamentalist: Church of God, Church of Jesus Christ of Latter Day Saints, Church of Christ, Church of the Nazarene, Mennonites, Conservative Baptist Association, Missouri Synod Lutherans, Pentecostal Free Will Baptists, Pentecostal Holiness, the Salvation Army, Seventh Day Adventists, Southern Baptists, and Wisconsin Synod Lutherans.

    19. Data on partisanship are from U.S. Bureau of the Census, Statistical Abstract of the United States, 1990 and earlier editions.

    20. All data are from U.S. Bureau of the Census, Census of Population, 1980.

    21. In 1996, North Carolina ceased funding abortions.

    Chapter 6 The Outputs of Fertility Control Policies

    1. An exception to this observation is a 1991 study by the Centers for Disease Control and Prevention that collected patient data solely from Title X clinics. This study, of course, missed publicly subsidized patients who were served in non-Title X settings (Smith, Franchino, and Henneberry 1995). For completeness, we also recognize that the Association for State and Territorial Health Officers (ASTHO) collect patient statistics for persons receiving family planning services provided by state and local health agencies only. These data are not complete or comparable. An example of the incomplete nature of these figures is that in 1983, only forty states provided data (California, the state with the largest population, was not among them), and in 1984, only thirty-three states did (California and Texas, another of the most populous states, were among the missing ones).

    2. The term women in need was used from the late 1960s until 1981, when it was changed to women at risk. Notwithstanding the change in terms, only slight modifications over time have been made to the methodology for estimating target populations for publicly subsidized family planning services (Dryfoos 1973, 1975; AGI 1981b; AGI 1988d, vii-xi).

    3. Vital statistics bureaus of state health departments report births and deaths to the National Center for Health Statistics, which is not part of CDC.

    4. The coefficient of variation is the standard variation divided by the population mean (Ott 1977). This statistic is required because each of the four statutes has a different annual appropriation.

    5. In this case, the incrementalism was examined over a two-year period because state family planning expenditures were not available for 1993.

    6. Funded abortion data for 1990 are from Gold and Daley 1991; for 1987, they are from Gold and Guardado 1988, 231; and for 1985, they are from Gold and Macias 1986. We calculated the number of women aged fifteen to forty-four by taking the number of women reported in the 1980 Census of Population, aging these population figures to get the appropriate year (1985, 1987, 1990), and further adjusting them to account for migration to the state. The data on live births are from U.S. National Center for Health Statistics 1982–88.

    7. The rate and ratio measures all had standard deviations twice the size of their respective means. All measures had a large positive skew. To avoid problems with states that funded no abortions, we added a constant of 1 to each rate and ratio before making the log transformation.

    8. Wetstein (1995) employs a similar logic in his ARIMA model of national abortion rates, in which he controls for past abortion rates by differencing the dependent variable.

    9. The rate of abortions funded in this data set is correlated with public policy in regard to funding at .85. We used the funded rate rather than announced policy because the former captures the nuances of policy, such as the limited amount of funds allocated in states like North Carolina.

    10. Abortion funding rates and abortion providers may not be exogenous; that is, the abortion restrictions also might affect these variables directly or indirectly. To determine whether the inclusion of these variables in the model influenced our results, we replicated Table 6.12 but omitted abortion funding and abortion providers. The results were identical to those presented here.

    11. The decreases found by other researchers in single-state studies may well be balanced out by increases in other age groups. The number of abortions performed on minors is a relatively small proportion of the total.

    Chapter 7 The Impact of Fertility Control Policies

    1. During the period of study (1982–88), the Hyde amendment prohibited the use of federal Medicaid funds “unless the life of the pregnant woman is at stake” (AGI 1993q).

    2. AGI data on funded abortions and family planning are available for 1982, 1984, 1985 (Gold and Macias 1986), and 1987 (Gold and Guardado 1988).

    3. Data are from U.S. Bureau of the Census, Statistical Abstract of the United States, various years. For the Hispanic population, individual years had to be extrapolated from the 1980 and 1990 census data.

    4. Data are from U.S. Bureau of the Census, Statistical Abstract of the United States, various years.

    5. Homoscedasticity is “the assumption in linear regression that the size of the errors is not affected by the size of the independent variables” (Meier and Brudney 1997, 45).

    6. As expected, the dummy variables improved the fit of the regression line and reduced the autocorrelation. Their inclusion had little impact on the substantive interpretation of either family planning or abortion funding. The apparent impact was to reduce the size of these coefficients; the result was a conservative estimate of impact compared with the ordinary least squares estimates. For low birth weights, we included specific time-point dummies for 1987 and 1988 to correct for time-dependence problems.

    7. This finding contradicts Currie, Nixon, and Cole (1993), who found no impact on birth weight. Their model used individual-level data and estimated models using least squares dummy variables. Our inclusion of regional and year dummy variables might have eliminated the impact of state laws, since states that fund abortions do cluster in some regions. We also used a more precise measure of abortion funding.

    8. The ecological analysis presented here cannot rule out the possibility that other factors caused these changes, but any such changes would have to be collinear with either funded abortions or family planning expenditures.

    9. Teen mothers, especially low-income ones, are less likely than older mothers to receive adequate prenatal care (Singh, Torres, and Forrest 1985). The Institute of Medicine (1995) has noted that “maternal age is an especially important risk factor. … Girls under 15 are a particularly high risk group. Except for the very youngest women, however, being a teenager probably does not have an independent impact on the risk of having a baby with a low birth weight. Most of the increased risk probably comes from other factors associated with teenage pregnancy such as low socioeconomic status, poor nutrition, and late or no receipt of prenatal care.”

    10. Metropolitan areas that provided fewer than fifty abortions per year were counted as not having an abortion provider (Henshaw 1998).

    11. We use the total birth rate rather than birth rates by age groups as our dependent variable. Meier and McFarlane (1994) found that family planning expenditures do not affect teen birth rates. If family planning funding affects birth rates in any age group, however, it should also show up in the birth rate for all age groups.

    12. The Forrest analysis did not include miscarriages because “the number of pregnancies ending in miscarriage is not well established and because there is no information on the distribution by intention status” (Institute of Medicine 1995, 25). The proportion attributed to each outcome changes, of course, when the incidence of miscarriage is estimated. About 12 percent of pregnancies will end in miscarriage (Gold 1990, 11).

    13. Data on total state births are from U.S. National Center for Health Statistics, Vital Statistics of the United States, various years. Population data are from U.S. Bureau of the Census, Census of Population, annual updates. Except for 1983, 1986, 1989, and 1990, all abortion data are from AGI (Henshaw and Van Vort, 1988, 1990, 1994). To provide estimates for other years, we used an interpolation procedure similar to that of Meier and McFarlane 1994; these estimated data can be obtained from the authors.

    14. All data on infant mortality are from U.S. National Center for Health Statistics, Vital Statistics of the United States, various years. Additional measures were considered. However, data that measure known risk factors for infant mortality, such as late prenatal care and low birth weight (Institute of Medicine 1985, 1988), were not available for the last three years of the study because of the lag time in the publication of national vital statistics. Similarly, state-level data measuring neonatal mortality, a major component of infant mortality, were not available. These factors are all related to infant mortality, so infant mortality is probably the best overall indicator of child health.

    15. Title X data were available for every year (Bickers and Stein 1994). Other family planning data are from the Alan Guttmacher Institute. For specific citations of individual years, see note to Table 6.2 (p. 108). We interpolated data for the missing years by averaging data from the year before and the year after.

    16. Data are from U.S. Bureau of the Census, Statistical Abstract of the United States, various years. For the Hispanic population, individual years had to be interpolated from the 1980 and 1990 census data.

    17. Data are from U.S. Bureau of the Census, Statistical Abstract of the United States, various years.

    18. We ran the Hausman specification test to compare the fixed effects models with random effects models. In each case, the insignificant result suggests that the fixed effects model is the appropriate one. The dummy variables, as expected, have a substantial impact on the fit of the regression line and reduce the degree of autocorrelation. Their inclusion does not have much impact on the coefficients that indicate the impact of family planning. If anything, the introduction of state effects appears to reduce the size of the family planning coefficients; the result is a conservative estimate of the impact compared with the ordinary least squares estimates.

    19. Because Medicaid is an insurance program, its impact in a state will depend on the cost and quality of care delivered by the amalgamation of Medicaid providers.

    20. In fact, Title X has forbidden the use of its funds for abortion since 1970, when it was first enacted. During the 1980s, the national office of Planned Parenthood Federation of America (PPFA) became a vocal advocate of freedom of choice in the abortion debate. Because of this and because many PPFA affiliates were Title X grantees, the anti-abottion movement tried to link Title X and all Planned Parenthood activities to abortion (McKeegan 1992).

    Chapter 8 Conclusion

    1. Indeed, the most encouraging results for abstinence are coming from programs with “more complex messages stressing both abstinence and contraceptive use once sexual activity has begun” (Institute of Medicine 1995, 265).

    2. See chapter 1, note 8 (p. 167), for a description of these methods.

    3. Other than the condom, vasectomy, and abstinence, current contraceptive methods are women-centered.

    4. Although we have demonstrated that family planning funding produces maternal and child health benefits and others have documented savings in terms of welfare expenditures, this research has not been exhaustive in analyzing the benefits of family planning funded by Title X and other programs. While we expect that family planning programs contribute to child welfare, educational attainment, and economic stability, we do not wish to imply that family planning eliminates poverty. That poverty leads to teenage childbearing has been convincingly argued by other researchers (Luker 1996).

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    About the Authors

    DEBORAH R. MCFARLANE is a professor in the Department of Political Science at the University of New Mexico. She holds master's degrees in Public Health/Population Planning (University of Michigan) and in Public Administration (Harvard University) and a doctorate in Public Health from the University of Texas. She has published many articles in the fields of public health, reproductive health, and public policy; worked as a family planning program administrator; and consulted for numerous organizations involved in reproductive health. In 1998–99, she was chair of the Population, Family Planning, and Reproductive Health Section of the American Public Health Association in Washington, D.C.

    KENNETH J. MEIER is the Charles Puryear Professor of Liberal Arts, Professor of Political Science, and coordinator of the Program in American Politics at Texas A&M University. He earned his M.A. and Ph.D. in Political Science at the Maxwell School of Citizenship and Public Affairs at Syracuse University. He is the author of Politics and the Bureaucracy: Policymaking in the Fourth Branch of Government and The Politics of Sin: Drugs, Alcohol, and Public Policy. He has published numerous articles on a variety of subjects in American politics and public policy, and he serves on the editorial boards of several scholarly journals.


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