State Family Planning and Abortion Expenditures - NCBI

State Family Planning and Abortion Expenditures: Their Effect on Public Health

Kenneth J. Meier, PhD, and Deborah R. McFarlane, DrPH, MPA

Introduction Except for the obvious impact on maternal mortality,' the debate over government funding for abortions has seldom focused on public health. Instead, the arguments usually pit the equal rights of poor women to control their own bodies against the rights of those taxpayers opposed to abortion. Currently, the Hyde amendment prohibits the federal government from funding abortions except in cases of incest or rape.2 (Recent proposed regulations would require states to fund abortions under these conditions.) States, however, may use their own funds to pay for abortions for Medicaid-eligible women, and 12 states currently do so. Previous studies suggest that the availability of both abortion and family planning services produces public health benefits. Grossman and Jacobowitz found that increased access to legal abortion was the most important factor in the large decreases in US neonatal mortality from 1964 to 19773; the second most important factor was subsidized family planning services for poor women. In a subsequent study, Corman and Grossman reported that increased availability of abortion was by far the most important factor in the decline in Black neonatal mortality4; for Whites, however, abortion availability was only the fifth leading contributor to lower neonatal rates. Abortion affects neonatal mortality by reducing the number of unwanted births. Because unwanted births are less likely to receive early prenatal care and may be linked to low birthweights,5: access to abortion should be indirectly associated with earlier prenatal care and fewer low birthweights. Both reduce neonatal mortality. (It has been found that Medicaid restrictions on abortion funding increase the probability of

birth but have no impact on birth-

weights.8) A 1984 study found that states that did not have public funds available to pay for abortions for low-income women had to spend more money "to provide maternity care, medical care for the infant, Aid to Families with Dependent Children, and nutritional assistance to women on Medicaid."9(PllI) For every dollar used to pay for abortions for poor women, the study found that more than $4 were saved in medical and social welfare costs over the next 2 years.9 The primary purpose of this paper is to examine whether state funding for abortions and family planning from 1982 to 198810 actually produced public health benefits. Both policies attempt to reduce unwanted pregnancies so that a larger percentage of the pregnancies that are carried to term are wanted. This should reduce prenatal problems and result in healthier babies.

Data Sources and Methods Dependent Variables: Public Health Impacts State abortion rates-the number of abortions per 1000 women aged 15 to 44-were obtained from the Alan Guttmacher Institute.11'12 To provide estimates for 1983 and 1986, when the institute did not collect data, the McFarlane and Kenneth J. Meier is with the Department of Political Science at the University of WisconsinMilwaukee. Deborah R. McFarlane is with the University of New Mexico, Albuquerque. Requests for reprints should be sent to Kenneth J. Meier, PhD, Department of Political Science, University of Wisconsin-Milwaukee, Box 413, Milwaukee, WI 53201. This paper was accepted May 5, 1994. Editor's Note. See related editorial by Klerman and Klerman (p 1377) in this issue.

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Famil Planning Funding Meier procedure was used.'3 For 1983 data, the ratio of abortions reported to the Centers for Disease Control (CDC) in 1983 to those reported in 1982 was calculated for each state. This procedure assumes that CDC abortion data, while biased, are biased consistently from year to year. This ratio, the state's annual growth rate in abortions, was then multiplied by 1982 abortion data from the institute to estimate the number of abortions in each state for 1983. These figures were then converted into rates by dividing them by the number of women aged 15 to 44 (in thousands) in that state. Similar estimates for 1986 were constructed using 1985 and 1986 CDC data. All other dependent variables were taken from the National Center for Health Statistics for the years 1982 through 1988. These measures are the teen birthrate (number of births to women under age 20 per 1000 women aged 14 to 19), the percentage of low-birthweight babies ( < 2.5 kg), the percentage of premature births ( < 37 weeks of gestation), the percentage of births with late or no prenatal care (defined as starting after the first trimester of pregnancy), the infant mortality rate (number of infant deaths per 1000 live births), and the neonatal mortality rate (number of deaths to infants < 28 days old per 1000 live

births).'4 Independent Variables The two major variables of interest are policies to fund abortions for Medicaid-eligible women and policies that fund family planning services for low-income women. The measure of abortion funding policy is the funded abortion rate-that is, the number of publicly funded abortions in the state per 1000 women aged 15 to 44.15 The per capita family planning expenditures measure includes all federal (Titles V, X, XIX, and XX) and state

In addition, Henshaw et al. found that the abortion rate is 2.7 times higher for non-White women than for White women.2' Black women are much more likely than White women to have an unwanted birth.7 Latino women also have higher abortion rates than non-Latino women.22 These relationships necessitate including the Black and Latino population percentages in the model. (Data are from the Bureau of the Census, Statistical Abstract of the United States, for various years. For the Latino population, individual years had to be extrapolated from the 1980 and 1990 census data.) States with fewer poor women will have fewer birth-related problems.23 Abortion rates are also related to income; Medoff found that demand for abortions is positively related to the labor force participation of women.24 For this reason, the percentage of women in the labor force and per capita income are also included in the model. A proxy measure of pro-life attitudes in a state-the percentage of the state that is Catholic-is included.25 The Catholic church has actively supported right-tolife groups and opposes abortion and most birth control methods.'5 A negative relationship between the proportion of Catholics in a state and the rate of abortions was expected. One final control variable is access to abortion providers. Shelton et al. found that the farther a woman must travel to obtain an abortion, the less likely she is to get one.26 The availability of abortion services varies widely across the United States; more than 30% of women of reproductive age live in counties with no abortion provider." Owing to the expected positive relationship between access to providers and the abortion rate, the percentage of a state's population living in counties with large providers of abortion is included as a control variable.

funds.*16,19 Public policies toward funding abortions and family planning are not the only factors that influence maternal and child health; numerous socioeconomic factors do also. Precise estimates of the respective impacts of abortion funding and family planning policies on maternal and child health require that these other factors be included as control variables. For example, teen pregnancy rates and proportions of children who are born into poverty (and thus have more severe health problems) are higher among nonWhite women. Black women are also less likely to receive adequate prenatal care.20


Methods The analysis is a pooled time series of all US states from 1982 to 1988. Each dependent variable was examined as the result of the six control variables as well as the funded abortion rate and family planning expenditures. A pooled timeseries design is often plagued by problems of autocorrelation and heteroscedasticity.2728 Although the current data set is

cross-sectionally dominant, preliminary analysis revealed that first-order autocorrelation was the major problem. This problem dictated that all models would be

estimated using generalized least squaresautoregressive moving average models without forced homoscedasticity. After initial model estimation, residuals were examined to determine if significant fixed effects were omitted from the model. As would be expected, in many cases individual states deviated greatly from the model. To control for such influences, a series of state dummy variables were added to the equations.** The state dummys for each regression model are reported in the Appendix.

Results The regression results for all variables appear in Table 1. Because our concern is with the impact of abortion funding and family planning expenditures, we have not interpreted the coefficients for the control variables. These coefficients are usually statistically significant and in the direction predicted by previous research.

Abortion Rates The model predicts state abortion rates fairly well (R2 = .89). Both policy impacts are as predicted. A $1 per capita increase in family planning expenditures is associated with 1.046 fewer abortions per 1000 women, consistent with the notion that effective family planning policies reduce the need for subsequent abortions. Similarly, for each additional abortion funded by a state, the number of abortions increases by 0.42.

Matemal and Child Health Indicators The remainder of Table 1 reveals a

generally good level of prediction for the child and maternal health indicators (R2 > .69). There is no relationship between family planning funding and teen *The Alan Guttmacher Institute data on funded abortions and family planning are available for 1982, 1984, 1985, and 1987. Data were extrapolated for the missing years. That is, 1986 data were the average of the 1985 and 1987 data. The 1988 data were the weighted average of 1987 and 1990 data, weighting 1987 data twice as much as 1990 data. **The dummy variables, as expected, improve the fit of the regression line and reduce the autocorrelation. Their inclusion has little impact on the substantive interpretation of either family planning or abortion funding. The apparent impact is to reduce the size of these coefficients; the result is a conservative estimate of impact compared with the ordinary least squares estimates. For low birthweights, specific time-point dummys were also included for 1987 and 1988 to correct for time-

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Meier and McFarlane

TABLE 1-The Impact of Policy on Abortions, Teen Birthrates, Low Birthweights, and Premature Births: Pooled Estimates

Independent Variables

Abortion Rate

Teenage Birthrate

Family planning funding per capita

-1.046

-.026

(5.47)

(.11)

Rate of publically funded abortions

.394 (10.06) -.027 (1.24) -.217

Percentage Latino population Percentage Catholic population Per capita income, thousands

(3.32)

.076 (1.60) .225

Percentage female labor force participation Percentage population: counties with abortion facilities Buse R2 Adjusted R2 Rho

(17.57) .89 .88 .40

-.134 (2.29) .003 (.25) .130 (24.34) -.019 (4.10) .018

(9.43)

.385 (10.87) .842

(25.15)

(6.01)

(9.59)

-.61 7 (24.86) .407

-.005 (2.48) .009

-.011 (2.96) .058

(13.13) .052

(5.41)

(.99)

(4.58)

(1.16)

(9.48)

-.673

(7.81)

.110

Neonatal Mortality

-.159 (2.29) -.011 (.70) .138 (21.33) -.006 (.79) .001 (.16) -.191

.420

(3.44)

Infant Mortality

-0.49 (2.02) -.024 (2.73) .105 (35.00) .022

(4.76) Percentage Black population

Dependent Variables Late Premature Low Prenatal Care Births Birthweight

-.255 (4.95) -.020 (2.14) .79 .78 .50

-.059 (11.47) .003 (2.79) .79 .78 .60

.045

(1.03)

-.027

(2.83)

.175

(39.08) .039

.016 (1.60) -.006 (3.67) .84 .83 .56

-.261 (1.88) -.263 (7.56) .069 (3.85) .457 (13.09) - .185

-.050 (1.39) -.003 (.49) .74 .72 .71

-.042 (4.06) .005 (2.14) .69 .67 .26

(4.88) -.158 -.046 (5.84) .006 (3.23) .69 .67 .29

Notes. Coefficients are unstandardized regression coefficients; t scores are listed in parentheses. See the Appendix for fixed effects controls.

TABLE 2-NationaP Totals for Abortion Funding 1982 through 1988: Their Impact on Total Abortions and Birth Status Indicator

States That Fund

States That Do Not Fund

Number of abortions Births to teenage mothers Low-birthweight births Premature births Late or no prenatal care

+563 866 -151 907 -21 255 -23 928 -232 570

-503 778 +136 499 +18 453 +20 760 +201 907

aDoes not include the Distrct of Columbia.

birthrates or premature births, but family planning funding is related to all other indicators. All other things being equal, each additional family planning dollar spent per capita by a state is associated with 0.049 percentage points fewer lowbirthweight babies, 0.261 percentage points fewer births with late prenatal care, and 0.159 fewer infant deaths and 0.134 fewer neonatal deaths per 1000 live births. Funding abortions, in turn, has somewhat different impacts. All other things being *This finding contradicts Currie et al.,8 who find no impact. Their model used individuallevel data and estimated models using least squares dummy variables. The 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. A more precise measure of abortion funding is used here.

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equal, an increase of one funded abortion 1000 women of childbearing age is associated with 0.673 fewer teen births per 1000 teenage women, 0.024 percentage points fewer low-birthweight babies,* 0.027 percentage points fewer premature births, and 0.263 percentage points fewer births with late or no prenatal care. Two comments about the size of these coefficients are in order. First, funded abortions are associated with a major drop in births to teen mothersperhaps as many as 0.67 teen births for every abortion funded. Second, many other impacts of abortion funding or family planning appear modest; however, even small changes in these variables can have a major impact. The equations generated in Table 1 were used to estimate the impact of abortion funding and family planning per

expenditures in each state. To estimate the impact of abortion funding policies in states that fund abortions, the regression coefficients in Table 1 were multiplied by the actual funded abortion rate. The results were then translated from rates per 1000 women, or percentages, to actual numbers. For states that did not fund abortions, an estimate was made of what would have happened if the state had funded abortions. With all other statelevel factors remaining the same, the mean funded abortion rate for states that actually funded abortions (4.97 per 1000 women) was used for these states. These numbers suggest the impact of not funding abortions. (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.) Table 2 shows the national estimates. In states that funded abortions for one or more of the 7 years under analysis, there were an additional 563 900 abortions, 151 900 fewer births to teen mothers, 21 300 fewer low-birthweight babies, 23 900 fewer premature births, and 232 600 fewer births with late or no prenatal care. States that did not fund abortions had 503800 fewer abortions, 136500 more births to teen mothers, 18 500 more low-birthweight babies, 20 800 more premature births, and 201 900 more births


Family Planning Funding

with late or no prenatal care. The cumulative impact of funding or not funding abortions for Medicaid-eligible women over this time period, therefore, could be substantial. Table 3 estimates the impact of 1982-1988 family planning funding on abortions, low birthweights, late prenatal care, infant deaths, and neonatal deaths. These estimates were generated using the actual amount spent per capita in each state, and the predicted rates were then transformed into raw numbers. The total for abortions prevented, 670 000, suggests that an absence of family planning funding would likely have increased the number of abortions by about 6% nationwide. Family planning funds are also associated with 20 000 fewer low-birthweight babies and 106 900 fewer births with late or no prenatal care. These two impacts probably explain family planning's impact on infant and neonatal mortality; family planning funding was associated with 6500 fewer infant deaths and 5500 fewer neonatal deaths. Although these numbers are dwarfed by the national totals for neonatal and infant deaths, they represent a significant spillover benefit, given that family planning is directly targeted at unwanted pregnancies rather than at infant mortality.

Conclusion Our analysis links public funding for abortion to public health benefits. States that fund abortions have substantially fewer teen births and about one-fourth fewer cases of inadequate prenatal care. Because maternal age of less than 20 years and inadequate prenatal care29 are both risk factors for premature and low-birthweight infants,30 it is not surprising that abortion funding is associated with a modest reduction in each of these birth outcomes. Publicly subsidized family planning services also produce public health benefits, although the dynamics are different. Family planning funding is associated with fewer low-birthweight babies and fewer births with late or no prenatal care, and these impacts reduce neonatal and infant mortality. In contrast to abortion funding, however, family planning expenditures show almost no effect on teenage birthrates. Therefore, even though both abortion and family planning address unwanted fertility, their respective public health outcomes are distinctly different. These outcomes can be attributed to September 1994, Vol. 84, No. 9

differences in clientele, delivery systems, and funding mechanisms.

Clientele Patient characteristics may explain differences in maternal and child health outcomes. Women who have abortions are predominantly young, single, and of modest means3"; more than half are nulliparous and have not experienced prior induced abortions.21 Many family planning patients are also young, single, and of low income.32 With the cutbacks in public funds for family planning during the 1980s, however, family planning clinics focused on serving existing patients. For the most part, there was no outreach to new patients and teenagers.33 Therefore, we believe that fewer teens were served during the past decade than in previous periods. We would also surmise that a greater proportion of family planning patients have experienced a live birth or pregnancy.

Delivety Systems Family planning services are more geographically accessible than abortion services. Publicly subsidized family planning services are delivered through provider agencies operating at 5460 sites,34 while 90% of abortions are provided in only 1542 nonhospital facilities.11'35 Family planning services are offered in nearly every county in the United States; on the other hand, 51% of metropolitan and 93% of nonmetropolitan counties lack an abortion provider.'1 Family planning clinics also provide more continuous care than do most abortion providers. When a woman receives services at a family planning clinic, she is expected to be a continuing patient. Moreover, a family planning patient has entered a health care delivery system where she will be provided with or referred to other matemal and child health services as needed. In contrast, a woman who receives an abortion is far more likely to get only a single health service. This is because most abortions are performed in clinics where abortion is the main service provided,35 and referral patterns are unlikely to be as well established as they are in a family planning clinic. An abortion patient is also more likely to live in another county or state, which also decreases the likelihood of a successful referral to another health care provider.

TABLE 3-National Totals for Benefits from Family Planning Indicator Decline in low-birthweight births Decline in late prenatal care Decline in infant deaths Decline in neonate deaths Decline in number of abortions

50-State Total 20 025 106 867 6 498 5 476 670 384

Funding Mechanisms A third difference between abortion and family planning services is how they are financed. The 12 states that fund abortions do so through state Medicaid programs, a fee-for-service funding mechanism whereby patients go to a health care provider for a single service. In contrast, even though Medicaid is now the largest single contributor to the national family planning effort, most family planning providers receive funds from a variety of public sources.19 If the family planning agency receives any Title X funds, it must provide an array of services including appropriate referrals for other health services. The difference in the public health outcomes of abortion and family planning services presents a strong argument for a more integrated approach to the delivery of both services. The fact that so many young women initiate family planning after an unwanted pregnancy certainly calls for a greater and more effective family planning effort. Given the current realities of service delivery and funding, the projected outcomes in Tables 2 and 3 provide reasonable data for policy deliberations concerning family planning and abortion funding. States seldom make policy on abortion funding based on public health benefits. The recent congressional debate on abortion funding indicates that this holds true for the federal government as well. However, we hope that this information will at least contribute to the debate when it inevitably recurs. O

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modification. Washington Memo. July 1, 1993; Wm-11:1-2. 3. Grossman M, Jacobowitz S. Variations in infant mortality rates among counties of the United States. Demography. 1981;18: 695-713. 4. Corman H, Grossman M. Determinants of neonatal mortality rates in the US. JHealth Econ. 1985;4:213-236. 5. Joyce TJ, Grossman M. Pregnancy wantedness and the early initiation of prenatal care. Demography. 1990;27:1-17. 6. Weller RH, Eberstein IW, Bailey M. Pregnancy wantedness and maternal behavior during pregnancy. Demography. 1987;24: 407-412. 7. Marsiglio W, Mott FL. Does wanting to become pregnant with a first child affect subsequent maternal behaviors and infant birth weight?JMamiageFam. 1988;50:10231036. 8. Currie J, Nixon L, Cole N. Restrictions of Medicaid funding of abortion. Cambridge, Mass: National Bureau of Economic Research; 1993. NBER Working paper 4432. 9. Torres A, Donovan P, Dittes N, Forrest JD. Public benefits and costs of government funding for abortion. Fam Plann Perspect. 1986;18:111-118. 10. Alan Guttmacher Institute. Hill attention on FOCA, FACE increases following murder of Florida physician. Washington Memo. April 14,1993;Wm-6:2-3. 11. Henshaw SK, Van Vort J. Abortion services in the United States, 1987-1988. Fam Plann Perspect. 1990;22:102-108,142. 12. Henshaw SK, Van Vort J.Abortion Services in the United States, Each State and Metropolitan Area, 1984-1985. New York, NY: Alan Guttmacher Institute; 1988. 13. McFarlane DR, Meier KJ. Determinants of abortion levels in the American states, 1982-1988. Presented at the 120th Annual Meeting of the American Public Health Association; November 8-12, 1992; Washington, DC. 14. Vital Statistics of the United States. Hyattsville, Md: National Center for Health Statistics; 1982-1988. 15. Meier KJ, McFarlane DR. The politics of funding abortion: state responses to the political environment.Am Polit Q. 1993;21: 81-101. 16. Gold RB, Macias J. Public funding of contraceptive, sterilization, and abortion services, 1985. Fam Plann Perspect. 1986;18: 259-264.

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17. Gold RB, Guardado S. Public funding of family planning, sterilization and abortion services. Fam Plann Perspect. 1988;20:228233. 18. Gold RB, Nestor B. Public funding of contraceptive, sterilization, and abortion services, 1983. Fam Plann Perspect. 1985;17: 25-30. 19. Gold RB, Daley D. Public funding of contraceptive, sterilization, and abortion services, fiscal year 1990. Fam Plann Perspect. 1991;23:204-211. 20. National Center for Health Statistics. Advance report of final natality statistics, 1991. Month Vital Stat Rep. 1993;42(3): Tables 30 and 31. 21. Henshaw SK, Koonin LM, Smith JC. Characteristics of US women having abortions, 1987. Fam Plann Perspect. 1991;23: 75. 22. Henshaw SK, Silverman J. The characteristics and prior contraceptive use of US abortion patients. Fam Plann Perspect. 1990;22:162. 23. Joyce TJ. The impact of induced abortion on black and white birth outcomes in the United States. Demography. 1987;24:229244. 24. Medoff MH. An economic analysis of the demand for abortions. Econ Inquiry. 1988; 26:353-359. 25. Quinn BH, Anderson H, Bradley M, Goetting P, Shriver P. Churhes and Church

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Membership 1980. Atlanta, Ga: Glenmary Research Center; 1982. Shelton J, Brann EA, Shultz KF. Abortion utilization: does travel distance matter? Fam Plann Perspect. 1976;8:260-262. Hsiao C.Analysis ofPanel Data. New York, NY: Cambridge University Press; 1986. Pindyck RS, Rubinfeld DL. Econometnc Models and Econometnc Forecasts. New York, NY: McGraw-Hill; 1991. Singh SS, Torres A, Forrest JD. The need for prenatal care in the United States. Fam Plann Perspect. 1985;17:118-124. Brown SS. Can low birth weight be prevented? Fam Plann Perspect. 1985;17: 112-118. Gold RB. Abortion and Women's Health. New York, NY: Alan Guttmacher Institute; 1990. Alan Guttmacher Institute. Current Functioning and Future Priorities in Famid Planning Services Delivery. New York, NY: Alan Guttmacher Institute; 1990. Dryfoos JG. What President Bush can do about family planning. Am J Public Health. 1989;79:689-690. Henshaw SK, Torres A. Family planning agencies: services, policies, and funding. Fam Plann Perspect. 1994;26:52-59. Henshaw SKI The accessibility of abortion services in the United States. Fam Plann Perspect. 1991;23:247.

APPENDIX-Fixed Effects Estimated for the Following States in the Equations Listed in Table 1 Abortion rate: Arkansas, Connecticut, Delaware, Florida, Georgia, Idaho, Indiana, Kentucky, Maine, Maryland, Massachusetts, Mississippi, Nevada, New Mexico, North Carolina, Rhode Island, South Carolina, South Dakota, Utah, West Virginia, Wyoming. Teen birthrates: Colorado, Iowa, Kentucky, Louisiana, Maryland, Minnesota, Mississippi, New York, Oklahoma, Rhode Island, Utah, Virginia, Washington. Low birthweights: Alaska, Colorado, Hawaii, Nevada, Washington, Wyoming. Premature births: Connecticut, Hawaii, Kentucky, Maryland, Minnesota, Rhode Island, Washington, West Virginia, Wyoming. Late prenatal care: Arkansas, Iowa, Minnesota, New Mexico, New York, Oklahoma, South Carolina, South Dakota, Utah, Virginia, West Virginia. Infant mortality: Alaska, Arkansas, Illinois, Louisiana, South Dakota, Wyoming. Neonatal mortality: Alabama, Arkansas, Delaware, Illinois, Louisiana, Mississippi, New Hampshire, Washington.
