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    • Drawing on methods employed from political

    2018-11-05

    Drawing on methods employed from political sociology (Clayton & Pontusson, 1998), our study innovatively modeled the state-only family planning and abortion service expenditures both in per capita terms (per woman, age 15–44) and as fraction of total state spending. An additional strength is that our exposure variable (actual state funding) avoids reliance on defining exposures in relation to laws that may or may not be implemented or enforced (Winter, 2012; Cole & Fielding, 2007) and, given the time period examined, also avoids complications of comparisons before and after passage of the Affordable Care Act (SACIM, 2016). Furthermore, in aniracetam to the handful of prior analyses of US state reproductive health funding and birth outcomes (Grossman & Jacobwitz, 1981; Corman & Grossman, 1985; Joyce, 1987a, 1987b; Meier & McFarlane, 1994; McFarlane & Meier, 1998, 2001), we employed two complementary multilevel statistical approaches (Goldstein, 2011), each premised on different statistical assumptions, which allowed us to examine (controlling for the same covariates) both: (a) the year-specific exposure-outcome associations across states (with random state effects), and (b) the associations within states (with state fixed effects) over time. By triangulating (UNAIDS, 2010; Reiss, 2009; Baggaley & Fraser, 2010; Richmond et al., 2014) these different analytic approaches and different methods of modeling the exposure variable, each with their different assumptions, we were able to identify associations robust to analytic and modeling approach. The similarity of our findings to those of the earlier studies (Grossman & Jacobwitz, 1981; Corman & Grossman, 1985; Joyce, 1987a; 1987b; Meier & McFarlane, 1994; McFarlane & Meier, 1998, 2001) is especially noteworthy because the time periods analyzed by these earlier studies (i.e., 1970–1972 (Grossman & Jacobwitz, 1981), 1969–1978 (Corman & Grossman, 1985), 1976–1978 (Joyce, 1987a), and 1982–1998 (Meier & McFarlane, 1994; McFarlane & Meier, 1998, 2001)) differed with respect to available contraceptive technologies and laws regulating access to both contraception and abortion (Frost et al., 2015; Schreiber and Traxler, 2015). One plausible explanation for why an inverse association between state-only expenditures and infant death rates occurred for family planning services prior to 2000 (in 1994) and for abortion services after 2000 (for 2001, 2006, and 2010) involves changing patterns of access to and use of these publicly funded reproductive health services (Frost et al., 2015; McFarlane & Meier, 2001; Schreiber & Traxler, 2015; Kost, 2015; Jones & Kavanaugh., 2011; Jacobs & Stanfors, 2015). In particular, the use of abortion services in the US has become increasingly concentrated among low-income women of color (Jones & Kavanaugh., 2011; Jacobs & Stanfors, 2015; Guttmacher Institute, 2016), far more so than use of contraceptives (whether or not publicly funded) (Frost et al., 2015; Jones et al., 2012; Frost et al., 2010; MacDorman et al., 2013; Guttmacher Institute, 2016). Because deficiencies in policies and resources render infants born impoverished at the highest risk for infant mortality (SACIM, 2016; David & Collins, 2014; Singh & Kogan, 2007; Krieger et al., 2008; Blumenshine et al., 2010; Christopher & Simpson, 2014), endergonic logically follows that infant deaths would be more sensitive (in relative terms) to reductions in public funding for abortion services as compared to contraceptive services. Our finding that parameter estimates were robust to inclusion of state-level data on percent of counties with no abortion services likely reflects the high value of this percentage over time (on-average range: 67–76%). Substantial research documents that when women choose to terminate a pregnancy, the reasons are complex, interrelated, and contingent on societal context (Biggs, Gould & Foster, 2013; Foster, Gould, Taylor & Weitz, 2012; Kirkman, Rowe, Hardiman, Mallett & Rosenthal, 2009; Finer, Frohwirth, Dauphinee, Singh & Moore, 2005; Moore, Terzian, Dariotis & Sacks, 2014; Luna & Luker, 2013). At issue, as underscored by a reproductive justice framework (Cottingham et al., 2010; Silliman et al., 2004; Christopher & Simpson, 2014; Luna & Luker, 2013), are women׳s life circumstances, as influenced by policies and programs promoting or impeding women׳s health and family well-being, as well as such factors as: women׳s socioeconomic resources and educational level, relationship status, number of prior children, age, health status, and their sense of responsibilities to themselves, to their existing children, to another possible child, and to others, including, as relevant, the biological father, partner, and other family members (Biggs et al., 2013; Foster et al., 2012; Kirkman et al., 2009; Finer et al., 2005; Moore et al., 2014; Luna & Luker, 2013). A reproductive justice frameworks emphasizes the need for women to have the right and the ability (including resources) to determine if and when want to have children – and, if they do have children, to be able to bear healthy infants who can survive and thrive (Cottingham et al., 2010; Silliman et al., 2004; Luna & Luker, 2013).