HSPH student examines government policies and social forces that affect the sexual and reproductive health of women.
Should poor women on welfare have additional babies while receiving cash assistance? In the wake of welfare reform in 1996, some U.S. policymakers answered “no” by passing “family cap” policies. While cash grants had typically been based on family size, the new measures excluded from the calculation of a family’s cash grant the children who were conceived by moms on welfare. With this attempt to regulate the reproduction of a specific segment of the population — poor, predominantly black and Latina women — policymakers committed human rights violations, according to Madina Agénor, doctoral student in the Department of Society, Human Development, and Health.
“Family cap had one major purpose: to send a clear message about which women are worthy of being mothers and which are not,” says Agénor, whose paper on the policy appears in the November/December 2009 Women’s Health Issues. “Poor women were seen as profiting from the system — even though welfare was an entitlement — and intentionally having babies while on the rolls in order to get more money.”
The policy violates the right of every woman to have a child, if she chooses, says Agénor. It also violates the right of children to the resources needed to lead healthy lives. To back her claims, Agénor cites eight international human rights and reproductive rights documents, several of which are signed by the United States, including the United Nations Universal Declaration of Human Rights. Such efforts to control fertility, she adds, are reminiscent of coerced sterilizations of women of color and other “undesirables” in the twentieth century.
Such far-reaching analysis typifies Agénor’s approach to public health research. She is driven to understand how societal forces — from government policies to household decision making — affect the sexual and reproductive health of women, particularly those on the margins. “I want my research to have real-world policy implications for the health of real women,” she says.
A Reform in Need of Reform?
Passed in 1996, welfare reform dramatically altered the nation’s approach to supporting needy families, converting the 60-year-old cash entitlement program into Temporary Assistance for Needy Families (TANF), which provides states with the funds to run their own programs, in addition to the power to adopt new rules aimed at promoting heterosexual marriage and two-parent families. Twenty-four states have introduced family cap policies. Three states have repealed them.
Agénor’s interviews with administrators in charge of enforcing family cap policies revealed that many of them agreed with studies showing that the measures have little effect on poor women’s reproductive decisions. Those who supported the policies lacked empirical evidence to back up their case.
Congress’s fall 2010 reauthorization of TANF provides an opening to re-evaluate family caps, but Agénor isn’t optimistic. Although public health professionals and others opposed the measures when welfare reform passed, the issue has since fallen off the radar of most advocacy groups, she says. The three states that have repealed their policies, however, leave her hopeful that the remaining family caps gradually will be chipped away. Agénor argues that officials would better help poor women and children — and reduce welfare caseloads — by promoting education and economic opportunities for women.
A Witness to Poverty, A Passion for Change
Agénor’s passion to improve the lives of marginalized women has roots in her early childhood. Born in Martinique, she lived in Haiti, her father’s home country, from ages three to six, before her family moved to the United States. “Poverty has always been something that I’ve witnessed,” Agénor says. “Living in Haiti, that’s part of what you see around you day to day.”
Early in her undergraduate studies at Wellesley College, she sought to gain a complex understanding of how the social context of women’s lives affects their health. But an internship in Costa Rica provided one of the most transformative lessons of her academic career: reading about people’s lives doesn’t always convey how the people themselves view their situation.
“I had read that Costa Rican women followed traditional gender roles, so I took that into account when I was doing a workshop on HIV prevention,” Agénor says. “But while I was talking, a number of the women pointed out to me that they worked outside the home and that they had decision-making power in the household. They really challenged me to rethink what I had read and to learn from their lived experiences.”
Screening to Save Lives
Having earned her master’s degree at Columbia University’s Mailman School of Public Health, Agénor now is beginning her doctoral thesis work on potential differences in rates of HPV screening between young U.S.-born black women and young black women from the Caribbean and sub-Saharan Africa, and how any discrepancies relate to cervical cancer mortality. She’s particularly interested in finding out whether differences within these groups of women — such as the amount of time they’ve lived in the United States, their access to health insurance, and cultural norms around gender and sexuality — affect their likelihood of being screened for HPV.
“HPV caught my eye because black women die at higher rates in the United States than any other group from cervical cancer, despite the fact that it is entirely preventable,” Agénor says. “I’m excited that my work could have policy implications for the way that we think about HPV and cervical screening, and could shed light on whether the recent sweeping recommendations that women should delay receiving a Pap smear and forgo annual screening make sense.”
Like Agénor’s work analyzing family cap policies, this project falls into an area where there’s little previous research. “That seems to be a trend with the questions I want to look at,” she says. “It’s a challenge, but it bolsters my resolve.”
Amy Roeder is assistant editor of the Harvard Public Health Review. Photo by Kent Dayton.