March 8, 1995

International conferences present a unique opportunity to share strategies and pool resources to influence global policies of central concern to women. In this decade following the 1994 International Conference on Population and Development, we call upon NGO's participating in such meetings to seek to hold their governments accountable for policies regarding women's reproductive health and rights. As a United States-based NGO, we hope to contribute to this process by sharing our perspective on U.S. policy. The following is a brief summary of many of the most significant reproductive health problems in the U.S. We hope this information will facilitate a dialogue between women of the North and the South, a dialogue that we believe will contribute to making the goals of women everywhere a reality.

Disparities in Reproductive Health Care

The United States has a two-tiered system of reproductive health care. Low-income communities, particularly communities of color, generally do not have access to the high quality reproductive health services that are available to middle- and upper-class communities. As a result, reproductive health indicators reveal enormous disparities between groups.

• The maternal mortality rate per 100,000 live births is 6.7 for Caucasians, 8.2 for Native

• Americans, and 21.5 for African Americans. The risk of ectopic pregnancy, one of the leading causes of maternal death in the United States, is 1.6 times greater for women of color than for white women.

• Although an African American woman is less likely to get breast cancer than a Caucasian woman, once she has breast cancer she is more likely to die as a result: the mortality rate for African American women with breast cancer is 10 percent higher than that for white women.

• The mortality rate of Native American women with cervical cancer is more than twice the mortality rate of white women with the disease.

• Women of color are less likely than white women to receive necessary gynecological care. For example, Native American women are the least likely to visit a gynecologist regularly while Asian American women are the least likely to have ever received a pap smear.

• 40 percent of Native American women, 40 percent of Latinas, and 37 percent of African American women receive no prenatal care compared to 21 percent of white women.

• Due to the high incidence of low-birth-weight infants, the United States ranks unfavorably among industrialized countries with respect to infant mortality. The neonatal mortality rate among Native American infants, like that of African American infants, is nearly twice that of white infants. Washington D.C., a predominately African-American district, has a higher infant mortality rate than any of the 50 states in the United States.

• Rates of sexually transmitted diseases ("STDs") in the United States are among the highest in the industrialized world. In fact, in some low-income areas, STD rates approach those found in many Southern countries. More than 4,500 women die annually of cervical cancer, which is strongly associated with several strains of human papilloma virus. More than one million women in the United States suffer an episode of pelvic inflammatory disease each year; as many as 150,000 women may become infertile.

• Nationwide, 1 in 800 women are HIV positive; 72 percent of HIV-positive women are either African American or Latina. In 1988, the death rate from AIDS among African American women was nine times higher than that among white women.

• In 1989, the rate of primary and secondary syphilis among African American women increased 176 percent, reaching as high as 99 per 100,000.

Barriers to Reproductive Health Care

Many factors operate to restrict the ability of women and men in the United States to obtain high quality reproductive health services. Financial barriers, as well as legal, political, and geographic barriers, can combine to prevent individuals from obtaining even medically necessary health care.

Financial Barriers

The median earning per full-time worker in the United States was $23,100 in 1992. That year, about 35.7 million people lived below the federal poverty level - set at $13,924 per year for a family of four. Meanwhile, an estimated 37 million people are not covered by health insurance, either because they cannot afford it or because they are ineligible for Medicaid. Quality reproductive health care is thus out of reach for many individuals.

• Nationwide, maternity care (including prenatal care, delivery, postpartum services, and hospital charges for mother and healthy newborn) typically costs $2,200 or more.

• The average cost of female sterilization is $1,300; vasectomy is $240; and insertion of Norplant ranges from $500 to $750. The approximate cost of other contraceptives are: $172 for a one-year supply of birth control pills; $160 for the diaphragm; $131 for an IUD; $130 for an injection of Depo-Provera; $50 for a one-year supply of contraceptive foam; and $30 for a one-year supply of condoms.

• The average cost of a first-trimester non-hospital abortion is $280 and for a first-trimester hospital abortion is $1,757. In 1989, the average second-trimester non-hospital abortion cost $509, while a second-trimester hospital abortion cost from $1,539 to $2,246. Many low-income women and men, including many people of color, are only able to obtain reproductive health care through Medicaid - the government health insurance program for the very poor - or from publicly funded family planning clinics.

• Even after taking inflation into account, total government expenditures for family planning decreased by 27 percent between 1980 and 1992.

• Only 63 percent of doctors practicing obstetrics will provide care to low-income patients who depend on Medicaid for payment of the bill.

• Approximately 17 percent of women of reproductive age in the United States have neither public nor private health insurance; 26 percent have no insurance coverage at the beginning of pregnancy; 15 percent have none even at the time of delivery.

• In 1980, 18 percent of African Americans under age 65 lacked any form of health insurance while only 9 percent of Caucasians lacked such coverage.

• 50 percent of all typical fee-for-service insurance plans provide no coverage for contraception.

In the United States, many legal and political barriers to reproductive health care have centered on abortion. Although the U.S. Supreme Court has recognized that the U.S. Constitution protects a right to choose abortion, many laws and regulations currently restrict this right.

• At least half a dozen states require a woman to delay an abortion for a specified number of days or hours after she has received information discouraging the procedure. In addition to exposing women unnecessarily to greater health risks associated with continued pregnancy, these requirements add to the costs of obtaining abortion.

• The Supreme Court has upheld some laws requiring minors to notify or obtain the consent of one or both parents before obtaining an abortion. Nearly half of the states are now enforcing such measures, which make it even more difficult for women under 18 to obtain abortions.

• Since 1976, many low-income women may not use Medicaid (government health insurance) to pay for abortions, even though Medicaid will cover the medical costs of pregnancy and childbirth. Thus, low-income women, including many women of color, are effectively denied the right to choose abortion although this right remains available to women with greater economic resources.

• From 1984 through 1993, there were more than 1,200 incidents of violence against abortion providers, 6,000 incidents of disruption, and 500 incidents of clinic blockade activity. These figures include one murder, one attempted murder, and nearly 150 death threats.

In the United States, the geographic distribution of reproductive health care providers is extremely uneven. Communities of color and residents of rural areas tend to have far less access to these services.

• 26 percent of counties in the United States have neither a hospital nor a health clinic that provides prenatal care.

• The availability of reproductive health care varies considerably from region to region. For example, states in the southern United States have the highest proportion of women receiving inadequate prenatal care and higher infant mortality rates than states in any other region. In general, low-income communities have particularly high infant mortality rates.

• While many rural areas have few or no providers of reproductive health services, health facilities in urban communities are overburdened, under-funded, and understaffed.

• In 1988, 93 percent of suburban or rural counties and 51 percent of urban counties did not have an abortion provider. 31 percent of women in the United States live in counties without an abortion provider.

In the United States, reproductive rights violations are most often committed against low-income women and women of color.

• African American, Latina, and Native American women are more likely than white women to be targeted for involuntary sterilization or hysterectomies. By 1982, 15 percent of white women were sterilized, compared to 24 percent of African American women, 35 percent of Puerto Rican women, and 42 percent of Native American women.

• Although people in the United States have a legal right to refuse medical treatment, hospitals have sought to force some women to have Caesarean section deliveries against their will. 81 percent of these women have been African American, Asian American, or Latina.

• Just one month after Norplant was approved for use in the United States, a judge in the State of California ordered a woman convicted of child abuse to use the long-lasting contraceptive implant as a condition of her probation. Nationwide, other women, many of whom are women of color, have been coerced into using contraceptives as a condition of reduced penalties.

• Some legislators have introduced laws providing financial incentives to low-income women who agree" to use Norplant or other contraceptives. Although none of these measures have been enacted, they demonstrate that some policy makers are willing to impose discriminatory restrictions on the reproductive choices of low-income women.