The contraception mandate: What is the government's interest in promoting infertility?

There has been a lot of public discussion on the Health and Human Services (HHS) January 20 announcement regarding the narrow scope given to a religious exemption to the general August 2011 mandate that every employer’s health insurance plan include contraceptive drugs, some post-conception  abortifacient drugs, sterilization, and family planning counseling. (I will shorthand this as “contraception.”) My focus here is the Federal Government’s interest in people’s infertility. Even if the U.S. Supreme Court strikes down Obamacare, this interest will no doubt continue to have its advocates.

In this public debate, supporters have argued that contraception is important for women’s health. Contrary to the matter-of-factness with which this claim is treated by the media, it isn’t obvious. If it were obvious, there would not be voluminous HHS reports on the subject which I examine below. After all, through almost all of human history, infertility was a problem, not a solution. In every land and time, people prayed to their gods for the blessing of fertility – even when pregnancy and childbirth resulted in high rates of maternal mortality. Even today, the 10% or so of the couples who experience infertility are deemed to have a health problem because fertility, pregnancy, are normal and healthy.

Although fertility is normal and healthy, clearly many individuals and couples want to render themselves infertile for certain periods of time for a variety of reasons. But why is this, and the promotion of this, a Federal Government interest? And, when I use the word “interest,” I don’t mean an interest motivating Federal research grants. I mean an interest that rises to the level that the Federal Government mandates the private sector to pay for and provide contraception.

My bottom line after wading through two reports: There is no rational basis to support a Federal mandate.

Senator Mikulski (D-Md) introduced an amendment to the Obamacare bill that required a referral by HHS to a learned society for recommendations to identify preventive care services for women that would be mandated for coverage and would prohibit insurers from imposing a  charge (that is, without co-pays or deductibles). These preventive services concerning only women would be in addition to recommendations under Obamacare on other issues by the U.S. Preventive Services Task Force, the Centers for Disease Control and Prevention, and the American Academy of Pediatrics. Obamacare was enacted on March 23, 2010. HHS made the referral under Senator Mikulski’s amendment to the Institute of Medicine. Less than six months, in July 2011, the IOM issued its recommendations.   

The full 235-page IOM Committee’s report, Clinical Preventive Services for Women: Closing the Gaps (2011) is available online. http://books.nap.edu/openbook.php?record_id=13181 The discussion of its recommendation to HHS concerning contraception is just eight pages (pages 102-109). In this discussion, the IOM cited as authority recommendations HHS itself had made in a report called Healthy People 2020 (2011), which had been published after Obamacare, with its Mikulski amendment, had been signed into law on March 23, 2010. That HHS report proclaimed a national objective of increasing the proportion of pregnancies that are intended from 51 to 56 percent. . . to be achieved by:


•    increasing the number of insurance plans that offer contraceptive supplies and services
•    reducing the proportion of pregnancies conceived within 18 months of a previous birth
•    increasing the proportion of females or their partners at risk of unintended pregnancy who used contraception during the most recent sexual intercourse


So, HHS had stacked the deck. When HHS published Healthy People 2020 in 2011, HHS knew of the Mikulski requirement of the March 23, 2010, Obamacare law. When HHS sought IOM’s expert advice under the law, HHS knew that IOM would turn to HHS’ just-issued Healthy People 2020 report. From IOM’s point of view, given the objectives stated by HHS just months earlier, how could IOM not recommend to HHS in July 2011, that insurance policies cover contraception with no co-pays or deductibles? HHS used taxpayer dollars to pay IOM to parrot back to HHS the recommendations made by HHS.

    Three additional points about this July 2011 IOM Report:


•    The IOM Report states (p. 109) that the policies of 15% of large employers and 38% of small employers did not cover FDA-approved contraceptives, yet in its conclusion it states that “most” private insurers cover contraception (p. 108). This is what the public hears – that most private insurers cover contraception. By IOM’s admission, “most” is not nearly all.  


•    The IOM quotes the charge (“Statement of Task”) given it by HHS (p. 2.) It acknowledges that it departed from the charge in taking a full page – of its eight pages -- to assess the cost-effectiveness of contraception (pp. 107-08). The issue of cost-effectiveness has been part of the public debate, namely, that the cost of the contraception mandate imposed on insurers is totally offset by the savings of not having to insure pregnancies. California’s Medicaid program alone saved the state $1.1 billion over two years, $2.2 billion over five, in medical and social services costs. (pp. 107-108) “[T]he theoretical benefit of all conceptions being intended is enormous.” (p. 72) If the United States had no children, the cost savings would be astronomical.      

•    The title of the relevant discussion is “Preventing Unintended Pregnancy and Promoting Healthy Birth Spacing.” (p. 102) So, the Federal Government interest in infertility is stated to include “optimal” birth spacing. It is not enough that pregnancies be intended, but now even intended pregnancies must be optimally spaced apart. A government aspiration for optimal spacing is related to an aspiration for the optimal number of children and of course for “the optimal child.”

    In its eight pages, the IOM cites some studies published since 2006. The most notable study upon which it relies, however, is a 380-page IOM report (“the Report”) from 1995: S. Brown and L. Eisenberg, eds., Committee on Unintended Pregnancy, The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families, also available online. http://www.nap.edu/catalog.php?record_id=4903 The name of the committee and the name of the Report deal with “unintended pregnancy.” The first chapter defines and describes “unintended pregnancy.”

One would expect that a medical committee would first identify a medical, a physical, condition – an illness, a disease that results in mortality or morbidity. And then it would consider possible causes for this illness or disease. This is “the scientific method.” The IOM used this sequence in its 2011 report with diabetes, STDs and cervical cancer. But when it treats pregnancy, IOM in 2011 and in 1995, does the reverse. It first describes a condition and then its effects.

In fact, the IOM does not really describe a medical condition whatsoever. Instead it describes a subjective condition. The physical condition is pregnancy and, of itself, it is no illness or disease. The IOM deals rather with subjective intent – unintended pregnancy.

    In defining the subjective condition of “unintended pregnancy,” there is no medical science. It is sociological. It is polling. To its credit, IOM is explicit about the methodological problems in these polls. (1995 Report, pp. 21-25; 64-66):

•    The 1995 IOM Report noted that it was relying on 1988 data and described various ways in which that data may have been out-dated.
•    There are variations in meanings given to terms such as “unintended” and “intended” across the globe and across the decades. (IOM includes under “unintended pregnancies” those pregnancies that are “mis-timed” (that is, pregnancy was desired but the timing of it was not) and “unwanted” (that is, no pregnancy at all was desired).
•    The polls may not distinguish between pregnancies whose mis-timing was a few weeks or a few months.
•    There is a similar problem of gradation in that the polls are taken about “feelings” and feelings vary in intensity. (How deeply felt was it that the pregnancy was unintended?)
•    The respondent to the poll must recall the feelings at the time of conception, even though the poll may occur months, even years, after conception.
•    The feelings may change over time. One study showed a shift in feelings between the times polls were taken concerning the same pregnancy. Some women in late pregnancy (12.5%) changed their minds from what they declared earlier and now wanted their unborn child. Some (10%) changed their minds and did not want their child.  
•    The polls measure the feelings of women. Yet while the woman may not have intended the pregnancy, her male partner may have. And vice versa.  
The 1995 IOM Report recommended that “researchers develop more refined and differentiated measures of intention status.” Sixteen years later, the 2011 IOM document does not address this issue. (p. 102)      
    
The Stated Consequences of Unintended Pregnancies


The 2011 Report devotes only two paragraphs to the consequences of unintended pregnancy. In its opening sentence it includes a huge qualifier: “The consequences of an unintended pregnancy for the mother and the baby have been documented, although for some outcomes, research is limited.” (p. 103) Unlike the 1995 Report, the 2011 Report does not mention consequences to the siblings of the unborn child or to the father of the unborn child. It relies in these two paragraphs wholly on the 1995 Report except for two 2008 studies. One says  that unintended pregnancies result in less breastfeeding. Breastfeeding is the subject of another recommendation in the 2011 Report. (pp. 110-14) Another study says it results in “significantly increased odds of preterm birth and low birth weight.” (p. 103) I discuss this issue below.

One entire paragraph in the 2011 Report is devoted to the consequences of a pregnancy, intended or not, if the birth spacing is less than optimal. (pp. 103-4)

The IOM 1995 Report (hereafter “the Report”) identifies five consequences of unintended pregnancies. The second and fifth, and the third and fourth, are very closely related, so I will use three instead of five. In reviewing these consequences, bear in mind, first, that the various contraceptive methods vary a great deal in their effectiveness. When they fail, the consequences occur. Second, STDs are not listed as a consequence of unintended pregnancy. STDs are discussed in the Report’s Chapter 4 on “Patterns of Contraceptive Use” after a discussion of condoms. At that point the Report notes that there is no contraceptive method that “provides maximum protection against both unintended pregnancy and all STDs” (p. 119) and the “whole process of [contraceptive] method selection has been complicated by the increasing presence of STDs and the importance of sexually active couples protecting themselves against both threats.” (p. 122) I italicize the pejorative “threats” in describing pregnancy.  

First Consequence: Abortions. (pp. 51-54) The Report says abortions are one of the consequences of unintended pregnancies. It further states that abortion poses physical and psychological complications. (It modifies this assessment by noting that abortion is less harmful than pregnancy and childbirth.) The Report asserts that reducing the number of unintended pregnancies will reduce the number of abortions and will, therefore, cut back on the physical and psychological complications posed by abortion.

Comment No. 1: This is the argument used by proponents of the Contraception Mandate to persuade pro-lifers. There are statistics that show, however, that increased use of contraceptives does not reduce abortions while less use of contraceptives reduces abortions. http://old.usccb.org/prolife/programs/rlp/Doerflinger.pdf Increased use of contraception leads to increased sex which leads to increased absolute number of failures in contraception, therefore, an increase in unintended pregnancies. http://onemoresoul.com/news-commentary/studies-birth-control-contraception-don%E2%80%99t-cut-abortions.html

Comment No. 2: As discussed below, the Report argues that the mother of an unintended pregnancy is less likely to obtain early prenatal care. It states that such women “may not be able to take the fullest advantage of the explosion of research in human genetics.” (p. 78) One such advantage, the Report states, is the abortion of an unborn child with congenital issues. (p. 78, n.6) The “explosion of research in human genetics” allows for a greater number of abortions – whether the pregnancy is unintended or intended.

Comment No. 3: If optimal birth spacing is desired, as cited above (2011 IOM Report, p. 102), then it can be achieved not only by reducing the number of unintended pregnancies, but reducing intended pregnancies. And both can be reduced, after the fact, by abortion.

Comment No. 4: The Report should set out, side-by-side:

•    the complications of abortion,
•    the complications of pregnancy and childbirth,
•    the failure rates of contraception,
•    the health risks of contraceptive methods,
•    the risks and consequences of STDs, and
•    the consequences of unintended pregnancy.

The 2011 Report lists contraceptive methods (including the “no action alternative”) and the failure rates. (2011 Report, p. 106) The 1995 Report provides the risks to health of contraceptive methods, but describes them qualitatively rather than quantitatively. (1995 Report, pp. 112-14)    
 
Second and Fifth Consequences: “Demographic Attributes.” This portion of the Report concerns the harm to parents (male and female) and children when the woman is either young (teenaged) or old (over 40), or unmarried. (pp. 55-63)

The IOM consistently uses pejorative language to describe pregnancy. In its chapter on describing unintended pregnancy, it defines the women who are “at risk” of unintended pregnancy. Unremarkably, the women supposedly at risk consist of half of all reproductive-age women: all those who are fertile, who are not pregnant, and who may become pregnant by engaging in sex. (p. 28) Surprise! Some women who become unintentionally pregnant are married, some are teenagers, never married, formerly married, over the age of 40, poor, wealthy. (pp. 29-33)

Based on 1988 data, 43% of all pregnancies were intended at the time of conception. (p. 25). 20% were unintended only in the sense of their timing. (p. 26)  IOM’s overall goal is to reduce the number of unintended pregnancies to Zero (p. 3), so that every pregnancy will result only when it was intended at the moment of conception. (Query: Should every gift be wanted?)

Teenage Mothers and Their Children

The Report discusses poverty and lack of education for teenage mothers and their children. The Report admits that “there are important questions about whether these many [socioeconomic] associations are directly caused by the mother’s young age.” (p. 56) Comment: Even if causality were demonstrated, it would be an argument that no teenaged woman should have a child, intended or not. Furthermore, poverty and level of education are sociological not medical issues. Neither poverty nor a 10th grade education is an illness or a disability. Besides, if the issue being addressed is poverty, rather than unintended pregnancy, Isabel Sawhill and Ronald Haskins have done research, well-publicized by candidates Romney and Santorum, that if an individual finishes high school, works full-time, and marries before having any children, their chances of being poor drop from 15% to 2%

The Report discusses mortality and morbidity for teenaged women, but several studies concern only girls under 15. Comment: The Report does not at this juncture address the criminal aspect of males having sex with girls under 17 or under 15. In Chapter 7, “Socieconomic and Cultural Influences on Contraceptive Use,” the Report discusses rape and sexual abuse. (pp. 203-5) In the context of adolescents and pre-adolescents, the Report continually refers to “unwanted” or “nonconsensual” or “non-voluntary” sexual contact. It never refers to statutory rape. For example, it states that the data show that
an appreciable portion of the sexual relationships and resulting pregnancies of young adolescent girls are with older males, not peers. . .[A]mong girls who were mothers by the age of 15, 39 percent of the fathers were ages 20-29. . . Although there are no data to measure what portion of such relationships include sexual coercion or violence, the significant age difference suggest an unequal power balance between the parties, which in turn could set the state for less than voluntary sexual activity. (p. 205)

The Report also discusses health risks posed to infants of teenage mothers but these are “due to environmental factors such as poverty, poor health habits, and insufficient supervision [rather] than to the age of the mother per se.” (p. 59) Comment: This is either an argument against any teenaged mother having children, intended or not, or an argument in favor of education in parenting.

Older Women and Their Children

As to older women, the Report first discusses socioeconomic issues. On the positive side, it observes, is that older parents may be better educated, more likely to be married, have higher incomes, and possess “presumed” increased wisdom, than younger parents. On the other hand, the birth is likely to be a “higher order” child – like fourth or fifth -- “whose addition to the family may add appreciable strain,” and, moreover, “elderly” parents (presumably the Report means once the children reach ages 10 or 15 years after birth) “may have less physical energy and perhaps less flexibility in outlook...” (p. 60) (my emphasis) Comment: No studies are cited to support these biases in favor of education, youth, and wealth.

    The Report then details the incidence of mortality and morbidity for pregnant women over 40 and their infants. It singles out Down syndrome. Comment: This is an argument against any older woman having a child, intended or not, including an adopted child.  

    Unmarried Women and Their Children

As to unmarried women, the Report goes through a litany of socioeconomic harms to children reared by single women (or single men) whether they are never married or divorced: lack of educational achievement, leave home earlier, more likely to become teenaged and/or unmarried parents, more likely to divorce, problems in finding or keeping a job, more likely to engage in crime. (pp. 61-63). Comment: This argument is against single parenthood, whether a child is intended at conception or not. Furthermore, the Report does not address the fact that the law allows single men and women to adopt and single women to be artificially inseminated.

Additionally, one may think that the Report would find it beneficial to the woman and child if the woman were to marry. But the Report dampens this prospect by discussing the rates of divorce (again a sociological, not medical, issue). The Report states that divorces occur at a greater rate if marriage is after conception, intended or not. Moreover, if the conception occurs within marriage, divorces occur at a greater rate if the conception was unintended. Finally, the Report does not mention any medical issues (such as premature death, suicide, psychological issues, obesity, whatever) experienced by single men or women, or their offspring.  

Final Comment regarding “Demographic Attributes”: If this part of the Report demonstrates anything, it demonstrates that the number of unmarried, teenaged or older women having children should be reduced, regardless of whether the children at conception are intended. There is no scientific basis, no basis at all, by the Report’s own words for singling out unintended children – except that unintended children are the narrow-minded focus of the Report.

What the Report labels as its fifth consequence is closely related to the “demographic attributes” of the second consequence. The Report argues (pp. 79-80) that an overall reduction in the number of unintended pregnancies would come disproportionally from unmarried women, leading to larger numbers of children being born to married women. The Report says, without citation, this would lead to the enhanced well-being of children and the general population. The Report does not say that unmarried women should wait for sex until marriage, but that they should wait for children until marriage. Waiting for children until marriage would have the effect of reducing unintended pregnancies since it is more likely that a child born within marriage is intended.

Comment: The increasing use of contraception since this 1995 Report has not had the desired effect. As Professor Helen Alvare mentioned on “The Diane Rehm Show” of July 11, 2011, about the 2011 IOM Report in the presence of another guest, Dr. Linda Rosenstock, the chair of the IOM committee and Dean of the School of Public Health at the University of California, Los Angeles (UCLA), the “IOM [2011] report cherry-picked when it looked at evidence regarding the relationship between government funding of more birth control and pregnancies. They didn’t grapple with any of the leading studies by serious economists, sociologists, psychologists on that topic [citing the authors and names of studies].”

She explained that the “phenomena [] here, as explained both in the law and economics literature, sociological and psychological, is the same phenomenon you saw with things like seat belts or drugs for AIDS. It’s called risk compensation, and it’s a well-accepted explanation in these fields as to people moving to riskier behavior when they believe that the risk has been shut down. It’s the insurance effect, if you will.” http://thedianerehmshow.org/shows/2011-07-21/new-debate-over-contraceptives-and-womens-health/transcript Dr. Rosenstock pleaded ignorance of such concerns. She said, “We felt we looked at all of the evidence relevant to our charge. . .[W]e rest soundly that we identified the appropriate literature, and we searched broadly.” Perhaps it was not included in the charge (2011 Report, p. 2) but then should have been raised voluntarily (as it did cost-effectiveness) or been raised by the HHS before issuing its Contraception Mandate.

The issue raised by Professor Alvare is well known to the public. In early June, 2012, this headline appeared in the media:

Concussion Crisis: Questions Plague Maker of Headband Sold to Female Soccer Players – As Families Choose to Outfit Their Young Athletes with Specialized Headgear, Experts Ask Whether the Product Is Actually Giving Girls a False Sense of Security.

Professor Alvare didn’t say this but, yes, people will more readily climb Mount Everest or ski back country if they have a satellite telephone. What she did say was, if you make sex less risky (for pregnancy or abortion or STDs), if you cut the link between sex and babies, people will more readily engage in sex. So, the logic is: more contraception, more sex, more failed contraception, more unintended pregnancies.

Third and Fourth Consequences: A Variety of Bad Outcomes for Parents or Child. (pp. 66-76) This is the nub of the Report. And it demonstrates how it has the cart before the horse. It describes the studies it uses in this section of the Report as “complex.” (pp. 50, 63) Time and again, it finds “associations” rather than cause and effect.

Impacts on Children

Prenatal Care

The Report states that women who experience unwanted pregnancies, more so than mis-timed ones, will be less likely to get prompt prenatal care. (pp. 66-68) By the same token, the same women will be more likely to use alcohol or tobacco and engage in other behaviors that may harm an unborn child.  (pp. 68-70) Conceptually, this consequence is very close to what the Report labels as the fourth consequence, namely, the possible ill effects of women who fail to plan for a pregnancy by identifying and managing behavioral risks (alcohol, tobacco), diet, early prenatal care, exercise and managing medical conditions such as STDs, diabetes, genetic screening (for the contingency of abortion), etc. (pp. 76-79) 

The Report admits that “no large-scale prospective intervention trial has conclusively demonstrated the health benefits to mother or child from a broad program of preconception counseling and care.” (p. 77) The Report does say that intervention has been demonstrated as useful, however, in cases of diabetes and for neural tube defects. (pp. 77-78) Comment: The better the preconception and prenatal care, the less concern there would be whether the pregnancy was intended or not. Furthermore, contraception reduces but does not eliminate the prospect of becoming pregnant. Therefore, it behooves women who engage in sex, and ipso facto may become pregnant despite the use of contraception, to pay attention to their bodies and anticipate the possibility of becoming pregnant. It is normal for human beings to plan for the foreseeable consequences of their actions.
   
Low Birthweight

The Report never educates its readers about the significance of low birth weight. The Report assumes that low birth weight is to be avoided. It stated, in passing and in the section on older women, that low birth weight, whether due to slow fetal growth or prematurity, is a risk factor for asphyxia, birth injuries, and susceptibility to infection. (p. 61)

Thus, there are two immediate causes of low birth weight, preterm delivery or slow fetal growth. One would expect a medical report to list the precise medical causes of preterm delivery or slow fetal growth, but it does not. [The precise medical causes are: multiple simultaneous pregnancies (e.g. twins, triplets), maternal diseases (diabetes, heart defects, kidney diseases), issues concerning the uterus, cervix or placenta, poor nutrition, stress, smoking, alcohol or drugs.]

The next step in a medical report would be to rank these specific causes, and then to link them, if possible, to unintended pregnancy. Instead, the Report looks at studies that link pregnancy intent to low birth weight without showing how such intent is related to multiple pregnancies, diabetes, cervix issues, etc. Thus, it states the data on the relationship between pregnancy intent and either preterm delivery or slow fetal growth is “sparse.” but “suggests” more preterm delivery than slow fetal growth. (p. 70) As to mis-timed pregnancy, the Report acknowledges that “it is not clear that better timing would reduce the risk of low birthweight.” (p. 70) (emphasis in original) Nonetheless, it reports that clinicians “have the strong impression” that very closely spaced pregnancies are not planned and that a study showed a relationship between white infants conceived within three months of a previous pregnancy, and black infants within nine months of a previous pregnancy, having a greater risk of preterm delivery and low birthweight. (p. 70) Why three months for whites and nine for blacks is left unexplained.

Comment: Clearly, each of the specific medical causes for low birthweight would be addressed and ameliorated with preconception care and/or early prenatal care, as discussed above. And this is the link between unintended pregnancy and low birthweight – the failure of women to expect the possibility of becoming pregnant when they engage in sex.

Infant Mortality

The Report describes three different methods to estimate the impact that pregnancies being intended rather than unintended would have in lowering the rates of infant mortality. The methods all assume that contraception reduces the number of unintended pregnancies, so the only question for the different methods is how they estimate the number. (p. 72) Comment: These studies ignore the fact that increased conception increases sexual activity which, due to failed contraception, results in increased unintended pregnancies.

Poor Child Health and Development

The Report cites conflicting studies about whether children of unintended pregnancies are the subject of more abuse and neglect and thus require more work by juvenile courts and the foster care system. (pp. 73-74)  

The Report employs studies of the various problems evidenced in children in other countries who were born after their mothers had been denied abortions. (p. 73)

Since every child is the result of either an intended conception or an unintended conception, and since the Report maintains, as mentioned above, that there are very high percentages of each type, researchers could easily identify them, and track them to determine exactly how “bad” it is to be a child whose conception was unintended. Tracking such children would constitute what is called a longitudinal study. Neither the 2011 IOM Report nor the 1995 Report identifies any longitudinal study for support.

The sole longitudinal study is cited in this section on child health and development. The Report relates a study of 1,545 children at ages 0-2 and 3-5. (pp. 72-73) One third of the children had been the result of mis-timed conception. Five percent had been unwanted. The remainder had been wanted at the time of conception. The first two groups before age 2 “exhibited higher levels of fearfulness and lower levels of positive affect. When they were of preschool age, they had lower scores on verbal development tests, even though they had no deficit of verbal memory.” And how might this be caused by intent at the time of conception? The authors of the study hypothesized that the mother may have been less available to the children.

Comment No. 1: A better study would compare children born of the same mother, some intended and some not. Comment No. 2: There’s something wrong with this study because there was something wrong with the entire group of 1,545. The Report states that the “study revealed significant deficits in the developmental resources available to these children.” Supposedly, as compared to a more representative sample of children. The Report continues that, because these deficits were associated with the sociodemographic differences among the families, these characteristics could be controlled (that is, manipulated so that they would constitute background noise). Surely, we would need to know the “significant deficits,” the sociodemographic differences, how these two were related to each other, and how the differences were statistically controlled. And lastly, we’d want to know what numbers demonstrated “higher levels” in these children compared to “normal” children.

Impacts on Parents

The Report describes a parade of horribles for parenthood itself, regardless of whether conception was intended or not. Having a child:

can cause severe disruption to other life plans, decreased resources for children already born, temporary or permanent lowering of educational and career aspirations, and a threat to present and future economic security. Its effects can be surprisingly far-reaching, contributing, for example, to the problem of insufficient child care in the United States. . .can place a strain on parental relationships. . . (p. 74)

Comment: So, why have children when they can ruin the lives of adults?

Mothers

The Report begins this section with a parade of horribles that it admits does not occur in the United States. It says that, at the world level, childbearing at a very young or very old age, the bearing of many children, and the bearing of children spaced less than two years apart contribute to a high rate of death and to reproductive complications. Even in the United States, pregnancy and childbirth can result in permanent disability and death. (pp. 74-75)

The Report makes this claim: The women who are at the “highest risk of maternal morbidity and mortality. . . are also the most likely to have an unintended pregnancy.” But the Report immediately undercuts this overblown and unsupported claim with this language: “Current reports provide little systematic assessment of women’s health following pregnancy and childbirth, but some data suggest that unintended pregnancy increases health risks for women.” (p. 75) (my emphasis). It cites depression during pregnancy, postpartum depression, and domestic violence.      

Fathers

The Report acknowledges “scant available evidence” on the impact of unintended pregnancies on fathers, be it an impact on their education, emotion, employment or parenting. (pp. 75-76)

Conclusion

Thus concludes the first three chapters, 100 pages, of the 1995 IOM Report that seek to define “unintended pregnancy” and the consequences of unintended pregnancy. As we have seen, there is no rational basis for claiming that unintended pregnancies are a problem, much less one that necessitates a Federal mandate imposed on the private sector. In fact, I question that there is a rational basis to use taxpayer dollars to support Federal funding for contraception.

Having made this conclusion, there is no need to review the remaining 300-plus pages which assume that a case has been made that unintended pregnancies have deleterious consequences. These pages also assume that contraceptive methods are the proper response. They seek to ascertain the reasons for the causes of unintended pregnancy, that is, the reasons why contraceptive methods are not used.

Chapter 4 examines why the United States has high rates of unintended pregnancies. (It is the 2011 IOM Report that defines “high” – higher than other Western democracies. (2011 Report, p. 102).) This examination breaks down the statistics into race, ethnicity, religion, etc., as to who does not use contraceptives or misuses them.

Chapters 5, 6 and 7 discuss factors that influence contraceptive use. Chapter 5 discusses “Contraceptive Knowledge and Access,” including insurance coverage, price, and sex education in schools. Chapter 6 discusses “Personal and Interpersonal Determinants.” It has a single reference to a (1990) study on adolescent risk-taking (p. 162). It also discusses self-esteem, sexual prowess, fear, guilt, the incapacity to plan for contraception, alcohol, drugs. Chapter 7 discusses “Socioeconomic and Cultural Influences.” Included here (p. 187) are churches, church political activity, and dissenters, and also the media’s promotion of sex without consequences. Chapter 8 discusses the failures and successes of programs to reduce unintended pregnancy.

Spero columnist James M. Thunder is an attorney practicing in the Washington DC area.






 

The views and opinions expressed herein are those of the author only, not of Spero News.

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