From the outside, many people see the USA as a super-modern, highly developed country with a fairly uniform culture. But in reality, it is a mass of contradictions. It is a superpower, and yet millions of its citizens are not covered by health insurance – this in a country where medical fees are very high. Many people under 65 receive health insurance from their employers, but then to the fear of losing one’s job is added the real fear of losing medical cover. A recent report from the Centre for Disease Control revealed that nearly one in five Americans do not have adequate access to the health care they need. So when it comes to reproductive health, although the USA has much better average standards of care than most developing countries, it is not altogether surprising that it lags behind most developed countries on maternal mortality. In the year 2000, this stood at a rate of 14 per 100 000 live births in the USA, compared with 5 per 100 000 in Spain .

Foundations

The USA is a diverse country. The US Constitution was a ground-breaking product of the Enlightenment. And yet some of the Founding Fathers who gave the world the modern concept of human rights were themselves slave owners, while the subsequent history of the country showed reluctance to recognize the human rights of the original peoples. And although the USA was founded under the influence of the Enlightenment, the original British colonies date from an earlier period and were peopled by many different groups. A majority were probably enterprising folk who were seeking greater opportunities in their daily lives than were available in the home country. A certain proportion consisted of convicts forcibly transported from Britain. And then there were the religious refugees such as the famous Pilgrim Fathers, fleeing persecution for their religious views but keen in their turn to persecute others and impose a kind of theocracy.

Religion in the public sphere

The original Constitution has survived for over two hundred years without a huge amount of change, and notably has retained its “wall of separation” between church and state . And yet it is this clause that has been under relentless attack by the would-be theocrats of a more recent period. It is a paradox that despite the separation of church and state, the USA is one of the most religious of all developed countries. Moreover, while many religious believers are moderates who accept the constitutional relegation of religion to the private sphere, the Roman Catholic Church and some evangelical Protestant churches do not, so that religion constantly intrudes into political life, and nowhere more so than in the consideration of sexual and reproductive rights.

Most religions seem to be interested in controlling human sexuality and reproduction and, closely connected to that, controlling women. In the age-old Christian tradition, there was a deep-laid suspicion, and even distaste, about sexuality. Sexuality had to be controlled and corralled within marriage, where its overriding purpose was reproduction. And marriage/reproduction was a second-best choice to total chastity. This is still the official policy of the Catholic Church, the single largest Christian denomination in the country, which refuses to accept contraception . Although large numbers of Catholics do not follow the teachings of their church in this respect, it is a very powerful institution with huge political influence, which attempts to impose its views on society at large.

Constitutional protection of privacy

In general, the Protestant churches do not agitate specifically against contraception, although historically it was frowned on socially and even banned in much of the developed world. In 1873, A US federal law, the Comstock Act, was enacted and was followed by a group of state laws to similar effect. These laws banned the distribution of contraceptives and the provision of information about both contraception and abortion. Vigorous opposition by advocates of birth control gradually eroded opposition to contraception during the 20th century. A very important decision by the Supreme Court in 1965, Griswold v. Connecticut, ruled that the law against contraception in Connecticut was unconstitutional. The majority verdict was based on the 9th Amendment to the Constitution, which says that rights not mentioned in the Constitution are not ruled out by it, and the “due process” section of the 14th Amendment, which prohibits states from removing citizens’ rights without due process of law. Another important feature of the judgment was the idea that the Constitution implied a right to privacy, specifically in this case for married couples.

Abortion

Further legal fights ensued over abortion, which had long been illegal in many states. In 1973, the Supreme Court handed down an important judgment on this, Roe v. Wade, that built on the Griswold v. Connecticut decision. At a stroke, a large number of state laws against abortion were ruled unconstitutional, on the grounds that they violated the right to privacy implied by the “due process” section of the 14th Amendment. This judgment has never been accepted by religious conservatives, who maintain that, instead of interpreting the Constitution (its correct constitutional role), the Court was legislating for a right to abortion.

Religious conservatives, both Catholic and Protestant, hate abortion, maintaining that a human being with full human rights is created at conception. Many attempts have been made to evade the consequences of Roe v Wade, at the moment centering on attempts to gain recognition of the fetus as a legal person. Religious extremists have gone further than legal challenges: there has been a series of attacks on clinics providing abortions, including bombings and arson, and the murder of doctors and other clinic workers providing abortion services. The excuse given by the perpetrators of violence is that they are defending unborn fetuses (usually emotively referred to as “babies” or “children”) from being murdered. The quality of some arguments is illustrated by a group of African-Americans who are campaigning against abortion on the grounds that it is genocidal. The argument goes that black women are four times more likely to have abortions than white women and this is therefore genocide of black fetuses. But black women are much more likely to have unprotected sex than white women and to end up with unintended and unwanted pregnancies. If they did not have an unwanted pregnancy, they would not choose to have an abortion.

Abortion is one of the most divisive issues in American society. Religious conservatives often base their electoral decisions largely on candidates’ attitudes to abortion and one or two other questions related to sexuality, such as sex education and the civil rights of homosexuals.

Sex education

Sex education is seen by some as opening the door to promiscuity among the young, despite evidence that sex education not only tends to delay first sexual experiences but teaches students how to avoid unwanted pregnancy and sexually transmitted diseases. As a consequence, the Bush Administration, much of whose support comes from the religious right, has promoted “abstinence-only” sex education. This form of sex education is very incomplete and has been shown to fail in its objectives, but ideology has tended to trump reality. Many Christian parents have encouraged teenagers to pledge themselves to virginity until they are married. But teenagers who have made such a pledge are at least as likely as others to succumb to temptation, and because of inadequate sex education are then more likely to end up with an unwanted pregnancy or infection.

Now many states are refusing Federal funds for abstinence-only sex education, because they have come to realize that it doesn’t work. A group of teenagers from the Bronx, New York, were recently in the news for demanding proper sex education. The Bronx has a higher teenage pregnancy rate than the rest of New York, and they were demanding a sex education program to give lessons on abstinence and puberty, HIV, STD and pregnancy prevention.

Overseas aid

As a very rich country, the USA is a major donor of overseas aid. In the words of the respected non-governmental organization, Population Action International ,

The United States has supported family planning, reproductive health, and population programs as part of its foreign assistance program since 1965 and remains a leader among donor nations in both technical and financial terms. Beginning in the 1980s, however, domestic debates over abortion spilled over into the international arena, helping to erode longstanding bipartisan support for U.S. international population assistance. Since then, efforts from some corners have had some success in reducing U.S. financial support for family planning overseas and to attach onerous funding and policy restrictions.

There is no space here to examine these policies in detail, but their effects have been tragic for many of the poorest people in developing countries. It is to be hoped that a change in Administration may lead to more practical aid in the field of reproductive health.

Margaret Fluck has long been involved in campaigns for reproductive rights