The Public Impact of <i>Griswold</i> : A Provider's Perspective

I'd like to offer you the perspective of a provider who has been working directly in the women's health movement for the past thirty-plus years. I'm proud to say that I've spent the majority of my career with Planned Parenthood, first as a physician's assistant providing direct patient care and for the past eighteen years as the CEO of PPSNE. I've seen first-hand the positive impact of this decision in ensuring women's access to contraceptive and reproductive health care.It was the arrest in 1961 of one of my predecessors, Planned Parenthood League of Connecticut (PPLC) executive director Estelle Griswold along with Dr. Lee Buxton, for counseling and providing patients with birth control that set this historic case in motion. The PPLC board president at the time, Lucia Jenny Parks, would later recall that “all hell broke loose” at that point, but not before Estelle provided the arresting officers with a tour of our facility and gave them a lecture on family planning. Estelle's commitment to securing the rights of women would become the benchmark for all of us. Indeed, when I interviewed for this job, the board chair asked me point blank if I would be willing to be arrested in my role as CEO if it helped to further our cause. Well, I got the job, so I think you can guess how I responded to that question.From my point of view, the public health legacy of Griswold cannot be overstated. Today there are 62 million U.S. women in their childbearing years1 and 99 percent of them who have ever had sex have used at least one contraceptive method. In fact, the Centers for Disease Control named family planning, including access to contraception, as one of the ten greatest public health achievements of the twentieth century. The bottom line is: birth control is mainstream health care, and it has a profound impact on women's lives.After the Griswold decision was rendered and all the publicity died down, our Planned Parenthood chapter was faced with the serious task of opening health centers across the state. It was a daunting challenge, but our volunteers and staff were undeterred. They worked tirelessly to raise money, raise awareness, and engage the public in pressing for additional public policies to support women's access to contraceptives and reproductive health care. There were Planned Parenthood volunteers and staff doing this same work across the country in the years following Griswold.Today, Planned Parenthood is one of the nation's leading providers of high-quality, affordable healthcare for women, men, and young people. We're also the nation's largest provider of sex education.2 Every year, Planned Parenthood's approximately 700 health centers nationwide provide birth control information and services to 2.1 million patients. We also provide nearly 400,000 Pap tests, close to 500,000 breast exams, and almost 4.5 million tests and treatments for sexually transmitted infections. Here at PPSNE, we provided services to close to 70,000 patients in Connecticut and Rhode Island last year.So what is the impact of all these services? According to a 2010 report, publicly supported contraceptive services helped women prevent an estimated 2.2 million pregnancies in the U.S., which would have led to 760,000 abortions and over one million unintended births.3 Use of contraceptives also promotes positive outcomes for planned pregnancies and births. For example, delaying pregnancy until after the adolescent years is associated with reductions in infant mortality.4 Planned pregnancies are also associated with increased and earlier access to prenatal care.5The positive public health effects of contraceptives extend well beyond preventing unintended pregnancies and promoting healthier outcomes for planned pregnancies and births. For many women, seeking birth control opens the door to many other critical reproductive and sexual health services like testing and treatment for sexually transmitted infections (STIs). This widespread screening and treatment of STIs not only dramatically decreases the transmission rates of these infections among partners, but it also helps women avoid complications of untreated infections such as pelvic inflammatory disease, which increases a woman's risk for ectopic pregnancies, infertility, and cervical cancer.Women seeking contraceptive care also tend to receive screenings for breast and cervical cancer, and have access to the HPV vaccine, leading to greater rates of prevention, early diagnosis, and treatment. Moreover, millions of women experience health benefits unrelated to pregnancy prevention by using oral contraceptives. In fact, 14 percent of pill users use the pill exclusively for non-contraceptive reasons, to treat conditions such as heavy menstrual bleeding, migraines, and endometriosis.6 Studies have also shown that long-term use of oral contraceptives is linked to significant risk reductions for ovarian and endometrial cancers.As if all these tremendous health benefits weren't enough, research also indicates a whole host of positive socio-economic benefits when women can determine whether and when to have children. As we know, the Griswold decision established the right to privacy for married couples seeking contraceptives. Yet it would take almost another ten years for nearly every state to pass laws granting legal contraceptive access to minors aged 17 or 18, rather than 21.7 Since this time, dozens of studies have documented increased rates of postsecondary education and employment among young unmarried women, as well as increased earning power and a narrowing of the gender gap in pay.8 Highlighting the fact that birth control is a top economic driver for women, Bloomberg Businessweek recently listed contraception as one of the most transformational developments in the business sector in the last eighty-five years.9Another way that our society benefits from birth control is through the savings realized as a result of publicly supported family planning services. These government savings largely result from helping women and couples avoid unplanned births, as those births would otherwise lead to billions of dollars in spending on maternity care and medical care for children through Medicaid and the Children's Health Insurance Program. After subtracting out the full public costs of the U.S. family planning effort, the services provided in 2010 resulted in a net government savings of $13.6 billion, over $7 saved for every public dollar spent.10 Family planning also enhances children's well-being in the long run. A study of the long-term effects of access to contraception found that individuals born in the years immediately after the federal family planning programs started were less likely to live in poverty in childhood and adulthood.With all the evidence supporting these health, social, and economic benefits, it is truly a wonder that access to birth control is not universally seen as the best thing to come along since sliced bread. Yet unfortunately, one only needs to open a newspaper on any given day to see that our public policy conversations are light years away from reflecting this point of view. Since Griswold, we have faced a myriad of legal and legislative challenges aimed at restricting women's access to contraceptives. At best, these efforts are a distraction from the important work we should be doing to ensure the broadest possible access to family planning services for all women and girls in our country. At worst these misguided policies have a dramatically negative impact on some of our most vulnerable populations—young women, low-income women, and women of color. These policies directly contribute to the persistence of stark disparities in sexual and reproductive health outcomes for millions of women. For example, a poor woman is more than five times as likely as an affluent woman to have an unintended birth. Yet the sexual activity rates among unmarried Americans do not vary along class lines.11 The difference lies in rates of use of contraceptives.12 Further, while the overall teen pregnancy rate in the U.S. is at an all-time low, disparities persist in the rates among black and Latina teens. In 2010, the teen pregnancy rates among black and Latina teens were more than twice as high as the rate among white teens.13 This is particularly alarming when we consider 30 percent of teenaged girls cite pregnancy as a key reason for dropping out of high school.As discussed earlier, the impact of accessible contraception has health benefits that extend well beyond preventing unintended pregnancies. Conversely, barriers to accessing birth control poorly influence other related health outcomes, like rates of testing and treatment for STIs. Latinas are more likely to be diagnosed with cervical cancer than women of any other racial or ethnic group.14 As you can see, barriers to accessing safe and effective contraception contribute to a multitude of grave negative consequences for women and their families.Yet even as we acknowledge these serious challenges, there are also many areas where we are making notable progress. The Affordable Care Act is the greatest advance in women's health in a generation. Nearly fifty million women now have expanded access to basic preventive care, including well-woman exams, cancer screenings, and birth control with zero co-pays. American women saved $483 million over the past year alone thanks to this benefit. However, in the nineteen states that chose not to expand their Medicaid programs, millions of women most in need of increased contraceptive coverage have yet to benefit from this aspect of health care reform.Another promising area involves the resurgence of long-acting reversible contraceptives (LARCs), such as the intrauterine device (IUD) and contraceptive implants. These are some of the safest and most highly effective contraceptive methods currently available. In fact, last fall the American Academy of Pediatrics updated its recommendations on teen pregnancy prevention. They now recommend LARCS should be the first-line contraceptive choice for adolescents who choose not to be abstinent.Yet in 2013, only seven percent of 15–19-year-olds seeking contraception at Title X family planning clinics chose LARC methods.15 However, when researchers at Washington University conducted a project offering free contraception and counseling to over 1,400 teens, 75 percent of them chose a LARC.16 Further, LARCS are important options for all women, beyond the teenage years. Once again, this is why policies like the Affordable Care Act and the Medicaid expansion are critical to removing financial barriers to accessing effective birth control.Several years after the Griswold decision, Catherine Roraback, one of the attorneys who worked on the case, recalled that “we thought in 1958, when we began litigation, that we would win contraception for Jane Doe, our patient, who was poor, partially paralyzed, and who would die if she carried a pregnancy. In 1965, we won that right for all women.” Griswold opened a pivotal door for the expansion of vital reproductive health services for women and their families. While we have made phenomenal progress in the past fifty years, we still have a long way to go before all women can fully realize the rights that were won with the Griswold case. Troubling health disparities persist across race and class lines in our society. The United States still has the highest teen pregnancy rate in the developed world. Yet just as all those involved in the Griswold case knew they could make a difference, I know that we too can create positive change. In 2012, the Centers for Disease Control declared teen pregnancy a “winnable battle,” stating that with “additional effort and support for evidence-based, cost-effective strategies that we can implement now, we will have a significant impact on our nation's health.”17 The time to act is now.Let's imagine fifty years from now when we celebrate Griswold's 100th anniversary. By then we can erase the health disparities that currently exist among young women, low-income women, and women of color. Let's build a future where everyone can access the information and services they need. Let's build a future where all women can fully pursue their dreams, wherever they may lead.