Last week, the United States Supreme Court decided Burwell v. Hobby Lobby, and ruled the federal government could not require closely-held corporations to provide no-cost contraception for their employees. Although that was the question before the Supreme Court, there were many things the Supreme Court didn’t have the jurisdiction to rule on yesterday. And the most important of these issues–the basic premise at the root of the case’s ideological divide–was not up for debate: that contraception is preventive health care.
Yes, contraception prevents pregnancy–that’s the whole point–but why is pregnancy considered to be a disease? It is an odd disease that is frequently welcomed by women.
Contraception as preventive care was not actually written into the Affordable Care Act (ACA). The ACA simply states that health insurance must cover ‘‘such additional preventive care and screenings” as are ordered by the Health Resources and Services Administration (HRSA). The HRSA didn’t define contraception and sterilization as preventive care either. Instead, they consulted the Institute of Medicine (IOM), which wrote a 250 page report entitled “Clinical Preventive Services for Women.” This report recommended that the HRSA adopt contraception and sterilization as preventive care to be provided under the Affordable Care Act.[1]
The 250 page IOM report included a page on the “prevalence/burden” of unintended pregnancy and concluded with: “Recommendation 5.5: The committee recommends for consideration as a preventive service for women: the full range of Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling for women with reproductive capacity.”
Noticeably, the report doesn’t consider all pregnancies as an ailment to be avoided. The report doesn’t mention hemorrhaging, pre-eclampsia, or any significant maternal health problems. Ignoring legitimate maternal health issues, the IOM only considers unintended pregnancies an ailment. Their prescription? Contraception and sterilization.
Women whose pregnancies are unintended, the report states, “are more likely than those with intended pregnancies to receive later or no prenatal care, to smoke and consume alcohol during pregnancy, to be depressed during pregnancy, and to experience domestic violence during pregnancy.”
The IOM ignores the fact that many women who experience unintended pregnancies belong to demographics that disproportionately suffer from domestic violence. No amount of condoms in the world will end domestic violence. Nor is synthetic progesterone a magic pill that will prevent immoral men from harming their partners. No matter–the Institute of Medicine has prescribed contraception and sterilization to those women suffering from domestic violence.
The report also blissfully ignores the fact that sex can result in pregnancy even if partners are using contraceptives. According to a study published in Perspectives on Sexual and Reproductive Health: “Contraceptives were used during the month of conception for 48% of the unintended pregnancies that ended in 2001”[2]. That is, almost half of all unintended pregnancies in the United States occur among women actively using contraception during the month of conception. This puts the IOM report in the awkward position of recommending as a remedy the contraceptives that allowed half the unintended pregnancies in the first place. (Ironically, this study is selectively cited several times in the Institute of Medicine’s report.)
Unintended-ness is different from unwantedness. Even the Institute of Medicine’s report acknowledged the fact that: “Unintended pregnancy is defined as a pregnancy that is either unwanted or mistimed at the time of conception” [Emphasis added]. Among the other half who hadn’t been using contraception before they had an unintended pregnancy, 23% (about 1 in 4 women) said they weren’t using contraception because they “didn’t really mind if [they]got pregnant”[3].
If a child is wanted, the health system should help women to have a healthy pregnancy. Instead, doctors and Washington bureaucrats wag their fingers at women, saying “You’re pregnant earlier than intended? Tsk. tsk. You should have been contracepting.” The facts about what women actually want are being shamelessly misinterpreted for ideological political ends.
The heart of the U.S. controversy around government-funded birth control is the question of whether contraception is preventive health care. Those who claim that it is have every right to argue for their position. But they should stop buttressing their assertions with bad science and skewed statistics. America’s healthcare policies need to be based on facts–not ideologies.
[1] IOM (Institute of Medicine). 2011. Clinical Preventive Services for Women: Closing the Gaps. Washington D.C: The National Academies Press.
[2] Finer, Lawrence B., and Stanley K. Henshaw. “Disparities in rates of unintended pregnancy in the United States, 1994 and 2001.” Perspectives on sexual and reproductive health 38.2 (2006): 90-96.
[3] Trussell, James, Barbara Vaughan, and Joseph Stanford. “Are all contraceptive failures unintended pregnancies? Evidence from the 1995 National Survey of Family Growth.” Family Planning Perspectives (1999): 246-260.
