Family Planning Kick-Starts Prosperity

Cascadia is known for mountains and salmon, technology, and modern urban gateways to Asia.

But wellbeing is marred by economic hardship for a third of families, who struggle to pay for basic household necessities.

For many, unsought pregnancy compounds this hardship, with poverty and mistimed or unwanted pregnancy fueling each other in a cycle that stacks the odds against many parents and their children.

Poverty is a complex equation. But if current policies and cultural trends continue, the good news is that the reproductive empowerment factor is changing, and not just in Cascadia. According to Pew Research Center projections based on recent trend lines, by 2060, American women from four major demographic groups—Black, White, Hispanic and Asian-American—may have approximately the same stable near-replacement birthrate, a sign that parenthood is more often becoming an intentional choice and less an unexpected circumstance.

Couples across all of these groups will be having babies later than our parents and grandparents did and having them under circumstances of their own choosing. This shift in family formation may create a window of opportunity to reduce poverty.

The converging trend lines in the 2060 Pew projections reflect two factors:

1. Typical preferred family size has been dropping in the United States for half a century.
2. More recently, more women are now able to bring their lives into line with their intentions, avoiding mistimed and unwanted pregnancy because of remarkable improvements in contraceptive technologies, access, and services.

In King County, Washington, for example, teen pregnancy is down by 55 percent, thanks, in part, to the fact that young women can now obtain safe, modern IUDs and implants through Planned Parenthood, school-based clinics, public clinics and a growing number of primary care settings.

Advocates who care about childhood poverty, in particular, are cheering this news. As the Annie Casey Foundation states in its 2017 Kids Count report (p. 10-11): “Delayed childbearing has many positive benefits. When young women postpone having children, they are more likely to complete high school and obtain postsecondary education or training, and they are more likely to be employed. However, it’s not just maternal age that matters: outcomes for children are better when pregnancy is planned and parents are emotionally and economically prepared to raise a child.”

Reducing inequality

Improvements in contraceptive technologies and services benefit all demographic groups but especially families in poor and disadvantaged communities because they are disproportionately vulnerable to early and unsought pregnancies and associated impacts. Some 35-50 percent of all pregnancies in Washington and Oregon are unintended according to the mother’s own report, but the experience of mistimed and unwanted pregnancy skews dramatically against people whose lives are already most brittle. As documented by the New England Journal of Medicine, US women below the poverty level are five times more likely to have an unintended pregnancy than women with incomes at more than 200 percent of the federal poverty level.

The consequences cascade across generations.

Of the 1.5 million unplanned births in the United States each year, 1 million of these children are born into poverty. Half of these children are born to women who were using some form of contraception at the time, suggesting they were actively attempting to delay pregnancy for better timing or different circumstances. Unplanned pregnancy increases the likelihood that young parents drop out of school. It can disrupt a budding career and lead to a less healthy birth. These impacts on education, employment, and health limit economic opportunity for parents and children.

For many reasons, upward mobility is decreasing in the United States, and most American children born into the lowest two quintiles stay there as adults. Some segments are finding themselves downwardly mobile. According to the Population Reference Bureau, the poverty rate has increased for all young women except for those with college degrees. Less than ideal birth timing doesn’t explain this lack of mobility—or, worse, descent into poverty—but it does compound it. When pregnancy is unexpected, parents often miss the chance to build resources–social, emotional, educational and financial—before getting hit with the demands of parenthood. The inability to prepare can be especially consequential for people who already have the odds stacked against them because of racism, class, or education status.

In communities plagued by mistimed and unwanted pregnancies, modern family planning services hold potential to make a transformative impact. The benefits accrue not just to women themselves but also to men and children, and the communities of which they are a part, including the benefits that are economic.

The demographic dividend

Internationally, economists discuss a phenomenon called the demographic dividend or demographic bonus. A demographic dividend occurs when the birthrate drops quickly, across a generation or two, so that the number of working adults is high compared with the number of dependent children and elders. The reduced number of dependents allows households to save and invest, and it lets parents—especially women—participate more wholly in the economy. As fertility rates fall, resources free up to start or expand businesses or invest in public education and infrastructure.

This windfall is time-limited, because within a few decades, the curve flattens out and societies must then address the needs of an aging population. But when managed well, the demographic dividend opens a window of opportunity through which an individual family—or even a whole country—can jump to the next level of prosperity.

Many Asian countries experienced a demographic dividend in the 1950’s and 1960’s, with Japan leading the way followed by “tiger economies” including Taiwan, South Korea, Singapore, and Hong Kong.

After South Korea’s fertility rate plummeted, its gross domestic product grew by 2,200 percent between 1950 and 2008. But a drop in birthrate doesn’t automatically create an economic boom according to  United Nations analysts.

“To maximize this dividend, countries must ensure young people entering the work force are equipped to make the most of the opportunities before them. To do this, countries must do more to protect human rights, including reproductive rights, improve health, including sexual and reproductive health, and provide skills and knowledge to build young people’s capabilities and agency.”

This is exactly what South Korea did—expanded access to family planning and invested heavily in the competency of young people. Challenges remain as South Korea now enters the next phase of the demographic curve, but the country’s trajectory stands in contrast to Latin America, which has done neither to the same degree and now faces a “lost generation” of almost 20 million young adults who are considered “NiNis” (ni estudian, ni trabajan, “neither studying, nor working”). Many would be willing workers, but a global knowledge-based economy in which technology is rapidly replacing unskilled labor leaves them few options.

What’s happening in Cascadia? 

Leaders in Washington and Oregon have made strong commitments to modernizing family planning, ensuring broad access to top tier contraceptives—long acting IUDs and implants that otherwise can be hard to obtain or cost prohibitive. In August, Oregon passed a Reproductive Health Equity Act. The law encodes into state law some of the same protections as the national Affordable Care Act, and it extends coverage to those who had been left out because of gender identity or immigration status. In primary care settings, Oregon’s One Key Question program has created a national model for asking women about their pregnancy desires so that clinicians can support their objectives.

In Washington, advocates for reproductive freedom plan to submit an Oregon-style bill in the 2018 legislative session. The governor’s office has worked to ensure that providers receive fair compensation when they provide family planning services to low-income women, including top-tier IUDs and implants.  Barriers remain: most significantly, only a small percentage of health professionals—even those who say they provide family planning services—are trained to offer IUDs and implants, the most effective contraceptives. But if public commitments hold, positive trends toward later and more intentional parenthood will continue.

And yet, weak investments in education and job training create uncertainty about how much young Washington residents will be able to continue gaining from the potential economic advantage of better family planning.  Washington has yet to meet even the minimum constitutional responsibility to fully fund public education as laid out in the McCleary Decision. Washington falls below the national average on graduation rates. Cuts to higher education funding led to the second highest tuition increase in the nation between 2008 and 2014.

Education in Oregon is also seriously underfunded—which creates particular challenges for the whopping 58 percent of Oregon children being raised by someone with a high school diploma or less. According to the 2015 report “Decades of Disinvestment: The State of School Funding in Oregon” high school graduation rates are the fourth lowest in the country and class sizes are the third highest. Matching the per-capita investment in education of high-achieving Massachusetts would require an additional $3 billion annually.

British Columbia also falls behind the East Coast in funding, with the second lowest level of funding per student in Canada, but in contrast to Oregon, British Columbia has maintained high levels of academic achievement.

Again, many factors are at play, but one may be that in Washington and Oregon teen pregnancy—the most common reason girls drop out of school and a top reason that boys drop out—is more common than in British Columbia. The rate of births to teen mothers in Oregon and Washington is double that of British Columbia (and to continue the East Coast comparison, double that of Massachusetts).

Who is at risk in our region?

Among those who have not reached America’s middle class, including many recent immigrants, families and whole communities may yet reap a form of demographic dividend from better access to modern family planning information and service—or, conversely, may fall further behind without that access.

About a third of the population in Idaho, Oregon and Washington lies either below the federal poverty line or just above it. (The United Way recently conducted a series of regional analyses called The ALICE Project, where ALICE is an acronym used to describe folks who are living just one step above the federal poverty line: Asset Limited, Income Constrained, Employed, in other words, people who are employed full time but struggle to pay for basic household necessities. One ALICE report covers Idaho, Oregon and Washington.)

People often associate poverty with minority racial and ethnic groups and with recent immigrants, but the poor-plus-ALICE population of the Northwest states is a microcosm of the region’s racial and ethnic mix, with only modest overrepresentation of Black and Hispanic people among the poor. A stronger statistical predictor of membership in the poor-plus-ALICE cohort—one that cuts across racial and ethnic groups—is being a single woman who is the head of a household.

In British Columbia, poverty is similarly associated with gender and parenthood, and more births. Women are more likely to be poor than men. And while only 10 percent of the population falls below the poverty line (a different poverty line than in the United States, unfortunately), 20 percent of children do.

A promising model for Cascadia

A bold anti-poverty program in Delaware with a focus on family planning suggests that it doesn’t have to be that way.

In 2016, a donor collective called the Blue Meridian Group decided to pool a billion dollars to make some “big bets” that would reduce poverty and increase opportunity for young people. Blue Meridian methodically analyzed interventions, seeking powerful theories of change, strong leadership, and the potential to scale up. (See What Makes a Nonprofit Big Bettable?) Then they made multiyear multimillion dollar commitments to a handful of nonprofits that fit the bill.

One of these grantees was Upstream USA. In 2012, Upstream teamed up with Delaware governor Jack Markell to upgrade contraceptive access statewide, ensuring that all Delaware women have same-day, no-barrier access to all contraceptive methods including previously hard-to-get IUDs and implants. Governor Markell explains the program’s purpose:

“I got into politics with the simple idea that I could create an environment where more people could achieve their full potential. I’ve come to believe that helping women achieve their own goals and become pregnant only when they want to may be one of the most important things we can do in this regard. There are very, very few times when you can create better outcomes, save money, and create opportunity all at once – and this is one of those rare times.”

Results in Delaware are just starting to trickle in, but a similar program in Colorado has been life changing and state changing. Teen pregnancies and abortions are down by 54 and 64 percent respectively, and repeat teen pregnancies dropped by 63 percent.  Delaware Contraceptive Access Now and the corresponding locally-attuned awareness campaign, brought together health care systems, policy makers, generous donors, technical consultants, insurers, trainers from across the country and even Uber, which provided free transportation for women traveling to and from medical appointments.

Today, a third of Cascadian families are financially precarious—struggling to pay for basic household necessities. Full, free access to modern contraceptive technologies and services isn’t the whole answer—not even close—but it is a powerful upstream solution. The ability to time pregnancies and make parenthood a choice rather than a circumstance creates space for young people to invest in themselves.

Whether young Cascadians get this intergenerational advantage depends in part on our collective courage and will. Systemic transformation like that in Delaware and Colorado requires not only strong leadership but strong partnerships—in this case mutual trust and teamwork between three major sectors of society: the public sector, philanthropic sector, and private sector. Luckily all are strong here in Cascadia.

Our region has the opportunity to create our own demographic dividend. By making focused investments in health and education that build our human capital, we can take advantage of dramatically improved family planning to help Cascadian families who are currently being left behind to flourish instead.

Valerie Tarico, Ph.D., Sightline fellow, is a psychologist and writer in Seattle. She is the author of Trusting Doubt and Deas and Other Imaginings and the founder of WisdomCommons.org. Her articles can be found at Awaypoint.Wordpress.com.

Katharine Harkins, CNM, MPH, is Co-founder of Resilient Generation, a field catalyst focused on advancing reproductive health and rights in Washington state and beyond.