Friday, December 17, 2010

The Failure of the Pro-Choice Movement in the United States to Influence Public Perception and Increase Access to Services – Alex Schwarzer

Approximately 1.2 million abortions were performed in United States in 2005, a drop from 8% in 2000, and a rate decline of 9% (1). Reasons for the decline are unclear and detailed analysis have associated with both increase in contraception use and effectiveness, trends in keeping unintended pregnancies to birth, and decreased access or awareness of alternative options (1). It is estimated that half of the annual pregnancies in the United States are unintended and 42% of those end in abortion (2). Abortion rates tend to be higher among women who are unmarried, at an economic disadvantage, in their 20’s, or are a minority (3). The disproportionate burden coupled with the ramifications of unequal access and poor outcomes, makes abortion a clear public health issue.

Reproductive rights have been an issue hotly debated by the government and the public. Abstinence-until marriage programs have been found to be ineffective, especially when compared to comprehensive sex education programs, but had received larger federal funding support (4). The legislative record on curbing reproductive rights is clear: 21 abortion rights and 29 anti-abortion measures were passed by the states in 2009. Even with a decline in abortions, the issue remains at the forefront. The public abortion debate has an incredible impact on the health professions: federal funding is restricted in most circumstances under the Hyde Amendment and under the Partial-Birth Abortion Ban Act of 2003 has been federally controlled in an “unprecedented intrusion” that “promotes both bad medicine and bad law” (5). The intense political atmosphere surrounding abortion places it in another level of public health in terms of the intensity in which public opinion shapes abortions and reproductive rights access and regulations, beyond questions of health and effectiveness.

The current public health campaigns by major pro-choice entities are reactive and target legislation more than they target public opinion. Public opinion has been shown to be congruent with, and most likely influence by, public policy particularly in areas of social policy (6). Several 2009 polls show that the majority agree that abortions should be legal in all or most cases and women who want an abortion should be able to obtain one (7). Public identification has shifted: 51% of people in 2009 considered themselves pro-life, up from 33% in 1995, and only decreasing to a 47% majority in 2010, according to Gallup polls, with Republican leaning independents and people ages 18-29 having the greatest rate increase and impact on the change (8). While this trend of identification has switched, the same polls show the right of women to have an abortion under certain circumstances to be consistently in the majority, with the other responses of “illegal always” or “legal always” oscillating for second highest polling at around 24%. The media and public perception considers this an “Abortion Reversal” (9) but fails to separate identification from policy preference.

A focus on “abortion reduction” (10) and a change in political leadership, and a focus on other issues, has taken abortion out of the mainstream debate, but recent events may return it to the forefront. Funding is excluded for abortions and division of finances is required for insurance companies covering abortions in the Patient Protection and Affordable Care Act. Recent elections have put in place many abortion opponents and leadership who may try to ban any insurance funding for abortions, even in medically necessary situations (11,12). The pro-choice movement and abortion access and rights supporters will have to mobilize a consistent message to bring pro-choice back to the mainstream. The campaign has failed to maintain public awareness through poor issue framing, identification of core value identification, and brand messaging. I recommend a strategy that addresses these deficiencies that will provide an effective public health campaign to change public opinion and policy and increase public access to abortion and reproductive health.

Framing of the Abortion Debate

The current pro-choice movement’s public health campaign fails to adequately account for the effects of framing theory in the public debate. Framing theory illustrates how individuals make irrational choices depending on how the information is presented or perceived (13). Particularly applicable to the abortion debate is the “evaluation of prospects”, whereby people gravitate toward guaranteed gains and away from guaranteed losses, and the “framing of outcomes”, whereby benefits are judged from a reference point that is assumed to be neutral but can be adjusted. These are two key areas that the anti abortion movement has incorporated into their messaging that, if not countered, the pro-choice movement will be at a distinct disadvantage.

The pro-choice movement is typified by reacting to threats and a focus around policy change, but has had difficulty in sustaining coalitions due to sharing of resources and continued maintenance of the organizations (14). Currently, organizations, such as National Organization for Women (NOW) and NARAL Pro-Choice America (NARAL) organize around access to clinics, public policy measures at state and federal levels, and sharing women’s stories (15). NARAL is focused primarily on legislative and lobbying efforts to “ protect a woman's right to choose” and NOW “affirms that reproductive rights are issues of life and death for women, not mere matters of choice”. The consistent messaging is that the debate is about a woman’s choice and trying to frame that decision as a life and death matter. Ethically, this may arguably be true, but it is not factually correct nor is it consistent with the views of society.

The anti abortion movement presents a stark message when framed as “pro-life”. In their campaign, you are for or against life. The “Quick Facts” section on the National Right To Life (NRTL) website highlights that the heart “begins to beat around 22 days from conception.” The Family Research Council (FRC) describes themselves as “the leading voice for the family in our nation's halls of power” and they “advanced faith, family and freedom in public policy and public opinion.” Here, the decision (and support of) abortion is a choice between saving a guaranteed human life, or destroying it.

Conversely, the pro-choice framing is around a probable loss of a woman’s right to choose. Surveys for the reason women have abortion indicate their reasons as “concern for or responsibility to other individuals”, they “cannot afford a child”, or a “baby would interfere with work, school or the ability to care for independents.”(16) These reasons are important and valid, and disproportionately affect those with reduced means. However, they present a choice between the sure life of a child, and a potential life of a child that will be compromised. In addition, the loss of this choice is not guaranteed, as abortions can be obtained in many circumstances, and the need for an abortion only exists for women in certain circumstances. The life of the child is always present, and under framing theory, is the clearer choice.

The power of the pro-life message also comes from the framing of outcomes of abortion as a guaranteed loss of a child comes from the focus on the developed fetus or future baby. The neutral reference point of choice is adjusted to be at the moment where the fetus looks human or at the moment of birth, instead of at conception or embryo development. Through framing the outcome reference, pro-life movements have associated reproductive health choices made at any stage of the reproductive process to have a direct effect on the life of a newborn. The “partial-birth” abortion focus has been a great asset for the pro-life movement: by creating urgency around a procedure that occurs a small part of the time, but would sound offensive to a general population, they’ve created an association and need for change within the general public. Further efforts are gaining ground to shift the reference point further into personification of the reproductive cycle by focusing on “fetal pain” (17).

The pro-choice movements focus on choice places the reference point on the woman and the outcome of her life choices and the loss of her ability to make a decision. Two potential problems occur: the movements are arguing past each other (woman vs. fetus) and allowing the debate to continue within certain populations and the arguments have different levels of appeal to the general population. The effect happens within groups: polls show that self-identified Democrats and liberals are consistently pro-choice, but Republicans, conservatives, and moderates are increasingly pro-life (18). Perhaps, the choice of outcome framing has an intended effect on the audience addressed. However, to the general population, the outcome framing of the fetus and future newborn as reference point may have a stronger effect than the potential loss of freedom or harmed life in the pregnant woman seeking an abortion.

Core Values of the Abortion Debate

At its core, the pro-choice and pro-life campaigns face similar issues of how to influence behavior and preferences of the population through associations to core values. The second criticism relates to advertising theory. Advertising theory describes changing behavior and ideas through associations of products with an audience’s core values by deciding “what…benefit you are going to promise.”(19) By addressing these core values through advertisement, marketers “[sell] the product without drawing attention to itself.” The Truth anti-smoking campaign achieved success by avoiding messaging that focused on health and supplied an alternative outlet for the core value of rebellion, a core value tobacco companies had teens associating with their products (20). Life and choice are strong core values, but the pro-choice campaign fails to make strong associations.

The pro-life campaign has clearly identified the core values of its constituents of family, faith, and freedom, and messages to those values. FRC releases press releases that frame abortion issues as issues of family and raising new families with new children (21,22). These press releases do speak to abortion and abortion issues, but they are packaged with family values at its core. Abortion is not mentioned in their mission statement. The family values focus creates a strong message that can broaden the appeal of the message, and stay with the audience because it is attached to their core values.

The pro-choice movement attempts to identify with the message of choice as a core value but falters in execution. NARAL has created a “What is Choice?” campaign to highlighting pro-choice as “protecting women’s access to safe, legal abortion.” NARAL highlights a pro-choice and anti-choice dichotomy. NOW’s mission statement states reproductive rights are beyond choice and are a matter of “life and death.” Their mission lists goals to increase access to birth control and reproductive services and fails to follow through on the messaging of choice as a core value. They are advertising the choice of health which is parochial and health focused and missing advertising core values, like choice or freedom. Worse, by not addressing the family values messaging of their opponents, pro-choice advocates are trapped with a health issue (abortion), while their competition operates with expansive core value level (family, freedom, faith).

Lifestyle associations are also problematic for the pro-choice campaign. Pro-choice has identified their issue as a cause that must be sustained, even though it is reactive to current political climates. It is difficult for consumers to identify with the choice message beyond the abortion and reproductive rights setting because advocates make this the issue focus and center their activities on protests and lobbying for these causes. Pro-life advocates focus on family, freedom, and faith and make that the rallying cry for lobbying and protests, but also for how they live their everyday lives. The FRC website has social and commercial aspects, for communicating and shopping, which are part of the overall platform. The message is one of a lifestyle, not just a cause.

Social Marketing and Branding in the Abortion Debate

The third criticism of the pro-choice campaign is their failure to establish an overarching brand relationship with the consumer. “Branded communication s provide a distinctive strategy to alter the perceived costs and benefits associated” with health behaviors and the appeal of those behaviors (23). Brands are based on associations with the brand and the consumer to develop “brand equity” and identity that exists outside of advertising communications (23). Reviews of branding campaigns found rapid growth, but some campaigns underdeveloped in terms of their planning and execution (24). Abortion and reproductive rights are unique public health topic in that abortion rights advocates face direct competition from other non-commercial sources. The non-commercial competition makes brand theory even more important, as there are separate public interest groups competing for legislation and public opinion, in addition to potential commercial interests.

A true brand needs to establish a relationship between consumer and product, add value for the consumer from the product, and foster an exchange between product and the consumer (24). The pro-life campaigns attempt to achieve full brand status by delivering on their relationship with their constituents. Pro-life advocates and those who identify as pro-life relate to the messages of faith, family, and freedom. There is a segmentation of supporters that groups like the FRC target. More conservative members are targeted with more direct rhetoric, while less conservative members may be approached with messages of adoptive families on the rise, or are influenced indirectly through core FRC members. The relationship is one of identity, as seen in the rise of those who identify themselves as pro-life. It is a philosophy and way of life being offered and maintained by the FRC and others.

The pro-choice campaign establishes relationships with its core group, but efforts to advocate beyond the core are mixed. Pro-choice constituents may assume abortion access to be secure, and thus are disinterested, but messages from pro-choice organizations make clear this is not the case. With a focus on legislative advocacy and protest, the relationship of the movement to is not developed in the public space. Those who identify themselves as pro-choice, don’t necessarily identify themselves with the pro-choice campaigns. And those in the Gallup polls who have pro-choice policy preferences, self-identify as pro-life. The pro-choice relationships have weak ties and are less active: pro-life bloggers were identified as having more frequent links to one another and in stronger clusters (25). Collaboration involves physicians and lay interest groups which are typically disparate, and sometimes antagonistic, groups (26).

The FRC packages and delivers information to consumers, the media, and politicians on a constant and focused basis. A search review of “abortion” and “funding” in ProQuest news database reveals almost entirely news articles and press releases related to abortion funding as part of the healthcare legislation with a pro-life perspective or around a pro-life groups action. These messages also appear in official media outlets when the FRC works on campaigns. This activity is part of the FRC’s added value to influence public opinion and policy, and to create an atmosphere that supports the belief system of their constituents. The FRC stays aware and involved in the current news cycle and immediately updates its membership with opinion pieces, press releases that reframe current news, and podcasts.

The value added to the consumer from the pro-choice campaign is unclear. The pro-choice campaign offers interactivity though the internet but does not have the information packaging and dissemination resources similar to pro-life organizations, like the FRC. Online content is not as frequently updated, nor is the technology as up to date. The press releases are few and pro-choice influences register less in official news media. For the consumer to see the value, small wins need to be heralded frequently, messages need to go beyond the legislation that is enacted and address key topics of the day, opportunities for consumer involvement need to be increased. NARL is significantly underdeveloped compared to the FRC, and NOW is more developed but spreads its resources into more than abortion rights. Neither groups activities have as much public perception as FRC.

The pro-life value exchange follows the generalized (AàBàCàA) and complex (A<->B<->C) exchange models in branding theory (27). In the generalized exchange model, the FRC gives content to politicians and media, who give legislation to the public, who in turn support the FRC and the politicians. The FRC also gives value to the public’s core values, who in turn give support to politicians, who in turn support the FRC. This model works well for the FRC as they gain in capital and donations, and the politicians can in support and influence. The consumer gains value through a proliferation of their beliefs, and influence on the greater society.

The exchange with pro-choice groups are also limited, and appear as a restricted exchange model (A<->B) (27). This closed loop system exists between pro-choice groups and legislators or between pro-choice groups and their members, but does not seem to enjoy network effects that grow the value of the exchange outside of these restrictions. The increased of member involvement, increases the value of NOW, but only to those that are involved. For example, there are over 4,000 crisis pregnancy centers in the U.S. that are pro-life organizations that try to persuade women from having abortions (28). Compared to the shrinking 1,800 abortion providers, the crisis pregnancy centers are growing at an alarming rate (29). In business terms, they are a success: pro-life organizations are creating value through their exchange with consumers that are growing new value and exchange opportunities in society. The cost of involvement in pro-choice activities is high because the opportunities are limited and can’t be completed in the day to day activities of the pro-choice self-identifier.

Pro-Choice Intervention: “When I’m ready…”

Three criticisms of the current pro-choice movement to institute an effective public health campaign to increase abortion and reproductive rights access and positive public opinion are outlined, above. The current movement fails to properly frame the abortion debate in accordance with framing theory, does not communicate to its audience on their core values, and does not create a sustained branding strategy that grows value in its relationship with the consumer.

I propose and intervention that addresses these three criticisms through the creation of a branding campaign that publicly reframes the abortion debate to focus on the core value of “control”, addresses the pro-life core values head on, is targeted to different consumer segments (30), and creates opportunities for sustained alliances through the slogan “When I’m ready…”.

Re-Frame the Debate

To focus on core values, pro-choice campaigns must reframe the debate to counter the pro-life movement’s successful “evaluation of prospects” and “framing of outcomes”. The choice should not be framed as the life of a fetus or child versus choice, but as the consumer’s life and their life in their control. One option is to frame the pro-life campaigns, and other entities, as taking away the consumers control, in general. This approach would be similar to the Truth campaign, where the focus wasn’t health but a core value. Instead of portraying limited access to abortions, the media campaigns would highlight the pro-life legislation as restricting your decisions and freedom to decide who you can see, and when, where, and how. Positive messaging can also be used, like the lovelife AIDS campaign in South Africa that focuses on empowered women succeeding in a world that wants to control their actions (24).

The outcome reference point of abortions must be reframed. 88% of abortions occur in the first 12 weeks of pregnancy, but the public debate has been focused on partial-birth abortions (1.5% of abortions) that occur after 20 weeks (16). Before 12 weeks, the fetal development is in its 4th week; earlier, there is even less human resemblance. Advertisements that run could show a woman, or a couple, in the midst of a difficult decision intercut with the gestational development, that stops at the point they make the decision to abort. This would raise awareness at how different the majority of abortions are from the public concept.

This outcome reframing could be used to establish alliances by bridging opportunities in abortion reduction. The number of abortions within 12 weeks could be increased: 34% of delayed abortions were due to funding and access issues (31). Medication abortions are conceptually less graphic and constitute 22% of all abortions taking place under 9 weeks (1). Abortion should be portrayed for what it is in a majority of circumstances to gain wider acceptance and focus the debate more on unintended pregnancy prevention and access to reproductive health services, overall, and away from ending of newborn life.

Address Core Values

The core value of control, and lack of freedom, will have greater resonance with audiences, especially in America. Gallup polls show that while peoples identification on the issue of abortion have changed, the majority of people still agree that women should have access to abortion in certain circumstances. The core value of control would appeal to this audience, and could be used to move more of those respondents into the category of those that feel women should always have access, and increase those that self-identify as pro-choice (or whatever the terminology). The campaign would focus on the slogan “When I’m ready…” which implies that reproductive (or any) decisions are made when the consumer is ready. The consumers can be women who are married, single, pursuing studies or careers, and a mixture of all demographics making the decision that’s right for them (to start a family, adopt, wait, or abort) when they are ready. The core values can even be extended to men who are in the relationships and directed at their core value of control of decisions and love from their significant other and family because of their loved ones own control.

As stated above, control as a core value needs to be communicated as an empowering feature and something that others are working to restrict. For empowerment, the core value can be attached to different population segments and even address family issues. Over half of the women receiving abortions are in their 20’s (16) which is fastest growing group of pro-life self-identifiers (8). By targeting aspects of control that appeal to this age group (studies, career, family responsibilities) and are similar to the reasons cited by women who had abortions (16, 30). Family values and deciding when you want to extend your family can be targeted further as 61% of abortions are obtained by women with more than one child (16).

Men can be similarly targeted, with control as a way to achieve their, and their families goals. Using contraception, communicating with their partner, and planning ahead, are all ways to increase control. Love is another core value that applies to both men and women. Advertisements should highlight the love that comes from being in a relationship that discusses and plans the future, and that respects the autonomy and control of each other. Core values should be marketed with depictions of individuals in circumstances similar to the target audience. These core values allow the pro-choice campaign to target consumers with messages beyond health, make the messages applicable to a larger audience, and address their competitions messages, head on, when competing for family values and freedom.

Create a Brand

Reframing the issue and addressing the consumer’s core values will allow for a successfully branded pro-choice campaign, which is necessary to sustain behavior and belief change in the public while competing with pro-life organizations. A successful brand marketing campaign establishes a relationship with the consumer, adds value for the consumer, and increases the benefit to cost ratio through an exchange with the consumer (23). A successful campaign also needs to segment and target the market (30), and position itself amongst the competition and focus on the 4P’s of marketing: product, price, place, and promotion (32).

The “When I’m ready…” campaign will establish a relationship by defining the “when” and circumstances of “ready” to several targeted demographics, described earlier. The message must be consistent, of empowerment and control, to encourage people to think about the issues and factors involved. The relationship should empower the consumer to control their own life through activities, group connections, and quality information: portrayal of the consumer as in control and effective programs to educate and facilitate that they gain control of their lives. One example is helping potential students focus, study, and apply to the schools of their choice. Other examples are helping parents find other families to get together for study groups for their children.

This relationship must be ongoing, and partnerships with multiple organizations can help increase the relationship with the consumer and the value of that relationship. Partnerships would allow for shared resources to address multiple public health areas, concentrate on public facing activities that raise awareness, and demonstrate frequent success. Further value is added by growing the network and including more consumers under the banner of control and empowerment. Information sharing between consumers on best tips for their lifestyle needs (family, study, career) would generate consumer participation and value creation.

By growing the consumer base, the political and media presence will grow. The marketing exchange can be realigned to be a generalized, and eventually complex, relationship where all players are adding value to the product and growing the need for more of the product (27). The product will be sufficiently developed and marketed to coexist in the daily life and values of the consumer. Promotion will be done publicly, and in partnership with other organizations and consumers. Placement in channels of legislature and media will add to the positive network effect and value for consumers participating in a program that reinforces their beliefs value in society. Finally, the price must be placed below pro-life if pro-choice is low-cost, or above pro-life if it is differentiated. Better still, with segmentation and targeting of the market, the exchange can have price discrimination based on the customer. High priced consumers would be targeted donors and participants, while low priced consumers could be recipients of services who share their personal, non-health, stories online, all increasing the value of the public health program.


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