Providing Subsidies and Incentives for Norplant,Sterilization and other Contraception: Allowing Economic Theory to Inform Ethical Analysis

Norplant is a hormonal long-acting contraceptive implant. Depo-Provera is a hormonal contraceptive administered through three monthly injections.

For example, by setting gasoline tax rates appropriately, governments could make drivers pay the full social cost of their choice to drive, including the environmental costs of the gasoline burned in their cars and the shared costs of road use. Doing so would, on average, reduce the amount of gas people use. Where gasoline is not taxed, the market price that drivers pay reflects only the costs of gasoline extraction and distribution, leaving the pollution costs of driving to be borne by the people affected (potentially, the entire world) and the costs of road use to be paid by all taxpayers. Similarly, if large numbers of people used electric cars, pollution would fall. Subsidies targeted to support a design for an affordable electric car could increase their use. The subsidy would be socially beneficial if public benefits in the form of less pollution were valued at least as much as the cost of the subsidies.

If American policymakers were to accept the claim that American childbearing should be decreased because the high level of U.S. consumption is harming the rest of the world, then it would be logical to target wealthy families with antinatalist incentives because they consume the most. This is, of course, the reverse of current policy, which targets low-income mothers.

See, e.g., Baumol W.J. Blinder A.S. , Economics: Principles and Policy, Seventh Edition (New York: Harcourt Brace & Company, 1997): At 478–79.

A classic example of a policy-induced distortion that reduces total social welfare is a local sales tax that induces people to travel to neighboring jurisdictions to shop: The tax leads to wasted time and travel that benefits nobody.

Author's calculations based on data from National Center for Health Statistics, Centers for Disease Control, 1995 National Survey of Family Growth, available at <http://www.cdc.gov/nchs/nsfg.htm>.

Chetkovich C. Mauldon J. Brindis C. Guendelman S. , “Informed Policy-Making for the Prevention of Unwanted Pregnancy,” Evaluation Review, 23, no. 5 (1999): 527–52 at 544; Chetkovich C. Mauldon J. Brindis C. Guendelman S. , More Information and Better Choices: What Low-Income Women Seek from Family Planning Services, Report to Office of Family Planning, California Department of Health Services & AFDC Policy Bureau, California Department of Social Services (1996).

Robertson J. A. , “Norplant and Irresponsible Reproduction,” Hastings Center Report, 25, no. 1 (1995): S23–S26, at S24.

See Worden Amy , Critics Slam Judge's No-Pregnancy Sentence, at <http://www.aclumontana.org/inthenews/nopregnancy.htm> (last visited May 16, 2003); Farley Carolynn , Court Drops Birth control Condition of Sentence, at <http://www.aclumontana.org/inthenews/birthcontrol.htm> (last visited May 16, 2003).

See Luker K. , Dubious Conceptions: The Politics of Teenage Pregnancy (Cambridge, MA: Harvard University Press, 1996): At 43–44.

See Gould S.J. , “Carrie Buck's Daughter,” Natural History, 111, no.6 (2002): 12–17.

Solinger R. , Wake up Little Susie: Single Pregnancy and Race before Roe v. Wade (New York, NY: Routledge, 1992): At 41.

Norsigian J. , “The Boston Women's Health Book Collective and Our Bodies, Ourselves: A Brief History and Reflection,” Journal of the American Medical Women's Association, 54, no. 1 (1999), available at <http://www.ourbodiesourselves.org/jamwa3.htm>.

See Gillespie K. , “Defining Reproductive Freedom for Women ‘Living Under a Microscope’: Relf v. Weinberger and the Involuntary Sterilization of Poor Women of Color,” (2000) (unpublished paper, on file with the Georgetown University Law Center) (ordering information available at <http://data.law.georgetown.edu/glh/>).

See Norsigian , supra note 13.

Brown S.S. Eisenberg L. , eds, The Best Intentions: Unintended Pregnancy and the Well-Being of Children and Families (Washington, D.C.: National Academy Press, 1995): At 30.

Henshaw S.K. , “Unintended Pregnancy in the United States,” Family Planning Perspectives, 30, no. 1 (1998): 24–29.

See Akhter F. , Depopulating Bangladesh: Essays on the Politics of Fertility (Dhaka, Bangladesh: UBINIG, Policy Research for Development Alternatives, 1992): Chapter 4, available at <http://www.hsph.harvard.edu/Organizations/healthnet/SAsia/depop/Chap4.html>.

Cleland J. Mauldin P. , “The Promotion of Family Planning by Financial Payments: The Case of Bangladesh,” Studies in Family Planning, 22 (1991): 1–18.

Kimmelman D. , “Poverty and Norplant: Can Contraception Reduce the Underclass?,” Philadelphia Inquirer, December 12, 1990, at A-18.

Rees M. , “Shot in the Arm,” The New Republic, December 9, 1991: At 16.

Depending on the method chosen, the $200 incentive is paid either when the Norplant device or IUD is inserted or in four $50 increments following each Depo shot over a period of one year.

Project Prevention at <http://www.cashforbirthcontrol.com> (last visited September 10, 2003). The data reported in this paragraph were found at <http://www.cashforbirthcontrol.com/reasons/statistics.html> on December 12, 2002.

The effect of the family cap rule has been evaluated in New Jersey and in Arkansas. The Arkansas policy had no effect. See Turturro C. Benda B. Turney H. , Arkansas Welfare Waiver Demonstration Project, Final Report (July 1994 though June 1997) , study conducted by the University of Arkansas at Little Rock School of Social Work, June 15, 1997, cited in Falk G. Devere C. , Analysis Of Evaluations Of The New Jersey Family Development Program , memo from the authors to Ron Haskins of the House Ways and Means Committee, July 9, 1998, available at <http://www.welfareacademy.org/eval/crs.htm>. The New Jersey policy appeared to decrease births (and also increase both contraceptive use and abortions), but methodological flaws lead reviewers to be divided on the validity of this conclusion. See Levin-Epstein J. , Open Questions: New Jersey's Family Cap Evaluation , report published by the Center for Law and Social Policy, February 1999, available at <http://www.clasp.org/DMS/Documents/1011211646.72/view_html>; Falk Devere , supra. If the policy has reduced unplanned births it will have certainly raised overall social utility; if its main effect has been to cut incomes to children conceived on welfare who do not have the resources they need, it might have lowered overall social utility.

Frankel D. , Letter to the Editor, Washington Post , December 29, 1990, at A-18, cited in Roberts D. , Killing the Black Body: Race, Reproduction and the Meaning of Liberty (New York, NY: Pantheon, 1997): At 107.

See Moskowitz E. Jennings B. , “Directive Counseling on Long-Acting Contraception” American Journal of Public Health; 86, no. 6 (1996): 787–90.

See Montgomery M. , “Assessing Program Effectiveness and Cost Effectiveness,” in Brown Eisenberg , supra note 16, at 338–66.

Li G. , Effects of the One-Child Policy on the Number and Sex Composition of Chinese Children , paper presented at the Annual Meeting of the Population Association of America, Atlanta, Georgia, May 2002, (on file with author).

In China, the average income of a family with two working-age adults was 3,800 Yuan in the period of study. Personal communication from Guanghuo Li to author (June 19, 2002). In the United States, expenditures by middle-income parents on a child from birth to age eighteen have been estimated at about four times the median household income (calculated from cost-of-children data in Lino M. , “USDA's Expenditures on Children by Families Project: Uses and Changes Over Time,” Family Economics and Nutrition Review, 13, no. 1 (2001): 81–86, at 84). Applying the same multiplier in China suggests that an additional child might cost about 15,200 Yuan. But given the higher level of public subsidies for many services in China, and China's greater poverty, I will assume that Chinese parents spend a much smaller fraction of their incomes on raising children than American parents do: Say, 10,000 Yuan per child. A birth tax of 2,900 Yuan increases the cost of raising a child to 12,900. Then a 1 percent increase in the fine is a 0.3 percent increase in the cost of children, which in turn generates the estimated decline in fertility of 0.15 to 0.27 percent. An increase in the cost of children from 10,000 Yuan to 12,900 Yuan should reduce childbearing by 12 to 21 percent. Even if the cost of childbearing were larger – for example, 15,000 Yuan – the effect on childbearing would still be a reduction of 12 to 21 percent. Strictly speaking, one should not extrapolate these elasticities across such a large estimated change in the cost of childbearing. When the fine itself is low, the relationship between childbearing and fines might be different from the relationships estimated when the fine is large. But for illustrative purposes, the point is useful.

See Stevens-Simon C. Dolgan J.I. Kelly L. Singer D. , “The Effect of Monetary Incentives and Peer Support Groups on Repeat Adolescent Pregnancies: A Randomized Trial of the Dollar a Day program,” JAMA, 277 (1997): 977–82.

Kahneman D. Knetsch J. Thaler R. , “The Endowment Effect, Loss Aversion, and Status Quo Bias: Anomalies,” Journal of Economic Perspectives, 5 (1991): 193–206.

See Giuffrida A. Torgerson D.J. , “Should We Pay the Patient? Review of Financial Incentives to Enhance Patient Compliance,” British Medical Journal (Clinical Research Edition), 315 (1997): 703–07.

Costs for contraceptive supplies alone (not including medical visits) are approximately $360 per year for oral contraceptives, $180 per year for Depo-Provera, $450 for Norplant, and $240 for an IUD. I also estimate $120 per year for supplies for the 28 percent of recipients using condoms or some other method. Applying the NSFG data regarding what proportion of welfare recipients use each method yields $240 as the per-user cost of supplies. I estimate $160 per year for medical visits.

The $400 estimate is consistent with data from the California Family PACT (Planning, Access, Care and Treatment) evaluation, which calculated the average fiscal year 1997/1998 reimbursement for each client served in the comprehensive reproductive-health program to be $153. Personal communication from Diana Greene, Family PACT evaluation researcher, to author (June 17, 2002). Given that many program clients received services that were less costly than a full year of contraception, an estimate of $400 for a full year of contraception and associated medical care seems reasonable.

See U.S. Policy Can Reduce Cost Barriers to Contraception , the Alan Guttmacher Institute, at <http://www.agi-usa.org/pubs/ib_0799.html> (last visited May 17, 2003).

Excluding miscarriages, 49 percent of the pregnancies concluding in 1994 were unintended; 54 percent of these unintended pregnancies ended in abortion. Among poor women, fewer (49 percent) unintended pregnancies were aborted. See Henshaw S.K. , “Unintended Pregnancy in the United States” Family Planning Perspectives, 30, no. 1 (1998): 24–29.

This conclusion relies heavily on the argument that benefits realized far in the future (when unborn children are grown) are large enough to outweigh costs incurred in the near term; using reasonable assumptions about discount rates, this argument appears to be correct.

According to the Planned Parenthood website, female sterilization costs range from $1,000 to $2,500, All About Tubal Sterilization, at <www.plannedparenthood.org/bc/allabouttubal.htm> (last visited May 17, 2003); a Norplant insertion costs between $500 and $750, Norplant and You, at <http://www.plannedparenthood.org/bc/Norplant.htm> (last visited May 17, 2003); and Depo-Provera (which was chosen almost as often as sterilization) costs $180 per year, Is Depo-Provera for You?, at <http://www.plannedparenthood.org/bc/depoforyou.htm> (last visited May 17, 2003).

See Frank D. , “Growth, Development, and Behavior in Early Childhood Following Prenatal Cocaine Exposure: A Systematic Review,” JAMA, 285, no. 12 (2001): 1613–25, at 1613.

See, e.g., Robertson , supra note 8; Moskowitz Jennings , supra note 26; Sollom T. , “State Actions on Reproductive Health Issues in 1994,” Family Planning Perspectives, 27, no. 2. (1995): 83–87, at 86.

45 C.F.R. § 46 (2001).

U.S. Food and Drug Administration Information Sheets: Guidance for Institutional Review Boards and Clinical Investigators: 1998 Update, available at <http://www.fda.gov/oc/ohrt/irbs/toc4.html>, citing 21 C.F.R. § 50.20.

The IUD carries risks of vaginal and uterine infection. Norplant and Depo share a similar range of possible side-effects, including changes in menstrual cycle, headaches, weight gain, depression, nervousness, dizziness, sore breasts, nausea, changes in sex drive, and gain or loss of facial or body hair. Depo-Provera may continue to depress fertility for many months following the last injection. Norplant users occasionally experience infections at the site of the implant. The presence of the device in the arm, and its removal, can sometimes result in scarring. The cost of removal can also pose a problem: Women who have left welfare often are not eligible for Medicaid and might have to pay for removal themselves. For further details, see the Planned Parenthood website at <http://www.plannedparenthood.org/bc/> (last visited September 9, 2003).

See Vicziany M. , “Coercion In A Soft State: The Family Planning Program Of India, Part I: The Myth of Voluntarism,” Pacific Affairs, 55 (1982): 373–402; Vicziany M. , “Coercion In A Soft State: The Family Planning Program Of India, Part 2: The Sources of Coercion,” Pacific Affairs, 55 (1982): 557–92.

This is especially true now that the majority of welfare recipients live in states that deny benefits to children conceived on welfare, so that the costs of an additional child must be paid out of an unchanged welfare grant. Only in rare cases might women be made better off financially by bearing another child.