Lawmakers’ Use of Evidence in Making Reproductive and Maternal Health Policy in U.S. States

Background/nHealth practitioners, researchers, and advocates alike call for policies that influence health outcomes to be grounded in the best possible evidence. However, political scientists assert that evidence is only one of many important drivers of policy; political considerations, habit, anecdotes, stereotypes, and “gut instincts” may be equally or even more important to policymakers. This research explores the question of how policymakers use scientific evidence in making state-level policy decisions on two contested maternal and reproductive health issues in the U.S.: abortion, and the use of alcohol during pregnancy. Both these issues are current dynamic policy issues at the state level, affecting important aspects of maternal and reproductive health, with large numbers of restrictive or punitive state laws being passed in apparent contravention of current evidence. The aim of the work is to shed light on why state policies in these areas do not appear to reflect current best evidence on these issues, and explore implications for reproductive and maternal health practitioners and researchers./nMethods/nData for the study are drawn from semi-structured interviews with 29 state lawmakers and their aides in Maryland, North Carolina, and Virginia. These neighboring states share many socio-political similarities yet have different mixes of policies on the two health areas of interest. Participants were recruited from the primary health-related committees of the General Assembly in all three states, as well as from among sponsors and co-sponsors of 2017 bills on abortion or substance use in pregnancy, and members of committees that voted on 2017 bills on abortion or substance use in pregnancy. Interviews were conducted between March and July 2017. Interviews were audio-recorded, transcribed, and uploaded into Dedoose, qualitative data analysis software, for coding and analysis by inductive and deductive methods./nFindings/nPapers One and Two present findings from the inductive analysis regarding use of evidence in abortion policy (Paper One) and substance use in pregnancy policy (Paper Two). We find that evidence does not instrumentally shape state legislators’ views on these issues. Legislators appear to trust anecdotes more than evidence; they feel that the knowledge they get from specific personal anecdotes is more “real” than scientific evidence. We find that despite evidence pointing to the harms of alcohol use in pregnancy, most lawmakers were not concerned about this topic; instead they prioritize the issue of opioid use in pregnancy over that of alcohol in pregnancy. However, evidence does appear to inform legislators’ high-level understanding of some issues, particularly regarding the safety of abortion./nPaper Three presents the results of a deductive analysis, applying a conceptual framework on policy use of evidence from political science literature to data from the current study. This paper reinforces prior political science literature that state lawmakers may use evidence more to substantiate and support existing policy preferences than for any other use, even “citing” “evidence” that doesn’t actually exist. However, legislators widely refer to and use evidence symbolically in a way that may help reinforce the value of evidence in policy deliberations./nConclusions/nWhile our study finds that evidence does not directly inform policy decisions, we also find that evidence plays an important role in policy making. Even if it is not instrumental to decision making, research is still important to motivate, inform, and even provide persuasive “ammunition” to those lawmakers who are predisposed to support a given position. This work has important implications for the fields of reproductive and maternal health. If practitioners and researchers grapple with the political reality of use of evidence, this may help them target their research dissemination efforts more strategically and effectively. Such a pragmatic approach to policy use of evidence may provide the best hope for good research to be applied in improving reproductive and maternal health.

Advisor: Keller, Ann C