Birth Control, Medicaid, Poverty, Racism, and the Future

In America, about half of births are "unplanned," around two-thirds among poor women. This seems like a socio-technological failure. We have the means to reduce this number; birth control has gotten a lot better over the past twenty years, and new IUDs and long-term implants work much better than the pill. Yet many women who would rather not get pregnant don't use them, because they aren't cheap and require them to 1) make a big decision, and 2) visit a doctor's office to carry it out.

The people who pay for all those unplanned births have hit an a new method to get women to use more effective birth control: offer it to them right after they give birth.

The idea behind the policy is to seize the day when a woman is sure to be interacting with the health care system — at the birth of a child. It is also the moment she is most likely to be insured: Pregnant women who are poor and do not have insurance are put on Medicaid temporarily. Birth control is usually discussed in a checkup about six weeks after delivery, but a majority of women on Medicaid, which covers 57 percent of births in South Carolina, do not return, officials said. Nearly half of all births in the United States are covered by Medicaid.

The change seems to have done the unimaginable: connect large numbers of poor women with new methods of birth control that have the potential to give them a lot more say over when, and with whom, they have children. Since South Carolina started the policy in 2012, unplanned pregnancies have declined by 6 percent, and the state Medicaid office has saved $1.7 million.

On the one hand, this could save taxpayers a lot of money, prevent pregnancies that come at the worst possible time for the mother, and reduce poverty.

But.

We are, right now, reproducing ourselves at right around the replacement rate; what would happen if we eliminated half of births? Some of those would happen later in life instead, but surely not all of them. We might be talking about a dramatic reduction in childbirth in America, concentrated among poor people. We could quickly end up like Japan, wondering what to do about our shrinking population.

There are also class factors. Offering birth control to women on Medicaid can bee seen as a sort of plot to dragoon more women into the middle class model of life, where everything is planned and happens at the right time. Unplanned pregnancies can be seen as an expression of a different attitude toward life, in which stuff just happens and you adapt as best you can. I have known two black women professionally in Washington who had babies when they were teenagers but then got themselves together, went back to school and ended up in office-manager type jobs. When I knew them they both felt that their lives had worked out well, since they got the hard work of raising babies out of the way early and could then focus on their careers. It is likely that those choices were subsidized by the government in the form of welfare or WIC or what have you, but if the country is worried about demographic decline that might turn out to be a good investment. In general I think the notion that the most carefully planned life is the best life is dubious.

It is also an inconvenient fact that if fully implemented this program would have a bigger impact on black and Hispanic birth rates than those of whites and Asians, since more black and Hispanic women are poor. The legacy of forced sterilization programs for poor, minority women makes many activists very suspicious. Childbirth is a traumatic (in the medical sense) act that is accompanied by massive hormonal changes and often leads to complications like post-partum depression, so is six hours after birth the right time to ask a single woman to make a decision with major life consequences? It smacks of taking advantage of a moment of weakness to sign women up for the agenda of the state.

Realistically, this program will probably not have huge effects; if Medicaid pays for half of births, and the program reduces Medicaid births by 6 percent, that means an overall birth-rate decline of 3 percent. Plus these are all women who have given birth once already, so they already have families. But there are demographic and ethical issues that we need to think about separately from the question of how to save money.