The current national discussion over contraceptives — whether insurance coverage without co-pays should be mandated, whether religiously affiliated businesses should be exempted, and whether the government should play a role in regulating and underwriting contraception — is largely focused on health care costs, religious choice and morality. But the reason I support this effort is because of the public health benefits that family planning provides to our nation.
“Public health” is not the same as health care. According to the American Public Health Association, “public health is the practice of preventing disease and promoting good health within groups of people, from small communities to entire countries.”
Those of us who practice public health focus on populations, not individuals, and we look at rates of health indicators across those populations. We want to decrease the rates of negative indicators like infant mortality and increase the rates of positive indicators like childhood immunization. “Health care” is the provision of health-related services by a provider to an individual. Health care is one of many tools that impacts public health, and enhancing access to health care is a public health goal. I’ve often illustrated the difference between public health and health care, colloquially, by saying that a health care provider treats a patient with an STD for the benefit of that patient, while a public health provider treats the same patient for the purpose of preventing the spread of the STD and keeping the STD rate in check for the population.
Healthy People 2020, the current iteration of our national public health goals, explains the public health benefits of family planning (including supporting research). First and foremost, contraceptives enable women to determine the number and spacing of their children. This greater control over their fertility since the 1960s has allowed most U.S. couples to have fewer children. Smaller families and more spacing between births have contributed to the better health of infants, children and women, and have improved the social and economic role of women.
Healthy People 2020 also seeks a reduction in the rate of unintended pregnancies because of the associated negative outcomes, including decreased utilization of prenatal care, reduced likelihood of breastfeeding, maternal depression and increased risk of physical violence during pregnancy.
Births resulting from unintended pregnancies have an increased chance of birth defects and low birth weight. And children from unintended pregnancies are more likely to experience poor mental and physical health, and have lower educational attainment and more behavioral issues in their teen years. These consequences are even greater for teen parents whose educational attainment and lifetime earnings lag substantially behind their counterparts, while their dependence on government aid is nearly twice as high. Sons of teen mothers are more likely to be incarcerated and daughters of teen mothers are more likely to become teen mothers themselves.
The Centers for Disease Control and Prevention named family planning as one of the top 10 public health advancements of the 20th century. (The other nine include vaccines, recognition of the dangers of tobacco, motor vehicle and food safety, and fluoridation). The March of Dimes, the nation’s preeminent organization promoting healthy births, recognizes the value of family planning in service of its mission.
Because of the public health value of family planning, the United States has built contraception into our health and human services systems. In 1970, President Richard Nixon signed into law Title X, the nation’s first comprehensive family planning program that enables millions of women to obtain low- or no-cost contraceptives. Two years later, Medicaid began covering contraception as a public health and cost savings strategy. In fact, family planning saves Medicaid so much money by averting unintended pregnancies that the federal government provides $9 for every $1 provided by a state for these services. (The usual Medicaid match is closer to 50/50). And federally qualified health centers, which provide primary care to millions of low-income and uninsured Americans, are mandated to provide family planning services because of the public health and economic benefits.
As I began writing this piece and looking for citations to well-respected sources to recount the public health benefits of family planning, I found that the most recent research was almost exclusively focused on developing countries, where family planning is an integral part of international development work alongside access to clean drinking water, elementary and secondary education, and gender equality. I was reminded that the original research that documented these benefits in the United States was published decades ago. Follow-up studies continue to confirm and expand upon the findings. The health care, cultural and political communities in the U.S. have accepted these benefits and family planning has been woven into our national public health fabric, like childhood immunization and smoking cessation, for half a century. Have we forgotten our own experience?
It’s hard to believe that in 2012 we are seriously debating the value of family planning to our nation. Perhaps it’s just a byproduct of the hyperbolic, partisan rhetoric that seems to surround everything these days. It would be a real shame for us to backtrack on one of our greatest public health achievements because we let politics get in the way.
Elena M. Marks is the Baker Institute Scholar in Health Policy. She is an attorney with a master’s degree in public health and currently works as a consultant to the health care industry. From 2004 through 2009, Marks served as the director of health and environmental policy for the City of Houston. She also serves on the board of Planned Parenthood Federation of America, the nation’s largest women’s health care provider.