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Building coalitions to support women's health and rights in the United States: South Carolina and Florida.

Abstract: There is a health care crisis in the United States and women, particularly low-income women and women of colour, are paying the price. The politicisation of pregnancy, sexuality and women's reproductive rights has created a uniquely contradictory situation in many states. Policymakers are working to control women's reproductive choices and sexuality, and restricting sex education, but doing little to address the overall lack of access to quality reproductive health tare. This article describes a new reproductive rights advocacy model that was implemented starting in 2003 in two US states, South Carolina and Florida. In-depth research on the status of reproductive health and rights in each state, analysed by race, economic status, county and state policy initiatives relevant to women's health, showed that in both states access to contraception and abortion, cervical and breast cancer screening and treatment, HIV/AIDS-related tare and pregnancy care were poor, with African American and Hispanic women faring even worse than white women. Implementing the advocacy model involved identifying and bringing together a diverse set of health care professionals, academics and activists who formed coalitions and are now working together and developing advocacy strategies in support of policies to improve access to reproductive health tare and protect reproductive rights in both states.

Keywords: advocacy and political process, coalition building, reproductive rights, reproductive health services, reproductive health policy and programmes. United States

Resume

Les etats-Unis connaissent une crise de la sante et les femmes, particulierement les femmes a faible revenu et les femmes de couleur, en payent le prix. La politisation de la grossesse, de la sexualite et des droits genesiques des femmes a cree une situation contradictoire dans de nombreux etats. Les decideurs veulent controler les choix genesiques des femmes et leur sexualite, et reduire l'education sexuelle, mais font peu pour combler le manque d'acces a des soins de sante genesique de qualite. Cet article decrit un nouveau modele de plaidoyer pour les droits genesiques applique des 2003 en Caroline du Sud et Floride. Une recherche sur la sante et les droits genesiques dans chaque etat, avec une analyse par race, situation economique, initiatives politiques du comte et de l'etat pour la sante des femmes, a montre que dans ces deux etats, l'acces a la contraception et l'avortement, le depistage et le traitement du cancer de l'uterus et du sein, les soins lies au VIH/SIDA et les soins obstetricaux etaient mediocres, le sort des afro-americaines et hispaniques etant pire que celui des Blanches. Le modele de plaidoyer demandait d'identifier divers professionnels medicaux, chercheurs et militants qui ont forme des coalitions et collaborent maintenant pour definir des strategies de communication soutenant des politiques destinees a ameliorer l'acces aux soins de sante genesique et a proteger les droits genesiques dans les deux Etats.

Resumen

En Estados Unidos existe una crisis de atencion en salud y las mujeres, particularmente de bajos ingresos y de color, son las que pagan por ello. La politizacion del embarazo, la sexualidad y los derechos reproductivos de las mujeres, ha creado una situacion contradictoria unica en muchos estados. Los formuladores de politicas se esfuerzan por controlar las opciones reproductivas y la sexualidad de las mujeres, y restringir la educacion sexual, pero hacen poco por tratar la falta de acceso a servicios de salud reproductiva de calidad. En este articulo se describe un nuevo modelo de promocion y defensa de los derechos reproductivos implementado a partir de 2003 en Carolina del Sur y Florida. Las investigaciones a profundidad sobre el estado de salud y los derechos reproductivos en cada estado, analizados por raza, situacien economica e iniciativas nacionales y estatales pertinentes a la salud de las mujeres, mostraron que, en ambos estados, existia acceso deficiente a metodos anticonceptivos y servicios de aborto, deteccion sistematica y tratamiento del cancer cervical y de mama, tratamiento del VIH/SIDA y atencion del embarazo, y que las mujeres africo-americanas e hispanas estaban aun peor que las blancas. La implementacion del modelo implico identificar y reunir diferentes profesionales de la salud, academicos y activistas, que formaron coaliciones y trabajan juntos, formulando estrategias que apoyen las politicas para mejorar el acceso a los servicios de salud reproductiva y proteger los derechos reproductivos en ambos estados.

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THERE is a health care crisis in the United States (US) and women, particularly low-income women and women of colour, are paying the price. The politicisation of pregnancy, sexuality and women's reproductive rights has created a uniquely contradictory situation in many states. Policymakers work on controlling women's reproductive choices and sexuality but do little to address the overall lack of access to quality reproductive health care. Nearly 17 million women in the US have no health insurance, which translates to roughly one in five women aged 18-64, and the problem is growing. When women lack health insurance they are more likely to postpone seeking needed health care, especially preventative care, such as mammograms and Pap smear tests. (1)

The 1996 Personal Responsibility Work Opportunity and Reconciliation Act (PRWORA) reformed the law on welfare provision and exacerbated the problems many low-income women face in seeking health care. The Act de-linked federal financial assistance from Medicaid, the federal health care safety net programme for the poor, ending federal guarantees of income support to poor families with children. (2) PRWORA eliminated the long-standing requirement that welfare recipients be given access to family planning services and required compliance with specified maternal behaviours, including caps on number of children and marriage requirements. PRWORA also included financial incentives for states to enact measures to reduce out-of-wedlock childbearing and to promote abstinence-only education. (2)

This article looks at two states at the forefront of this policy trend, South Carolina and Florida, which rank 19th and 6th in the nation, respectively, for having the greatest number of non-elderly uninsured women. (3) Both states report poor reproductive health outcomes for women, such as high HIV and breast cancer mortality rates, as well as racial disparities in access to care. This article describes the implementation of a new public health advocacy model in both these states, starting in 2003, when neither had any groups working specifically on women's health care at the legislative level. The strategy addresses the disconnect between continuing efforts to restrict women's reproductive rights and lack of action to try to improve access to health care or mitigate the racial disparities in health outcomes in these states.

Development of a new reproductive health and rights advocacy strategy

The current coalition-building and advocacy efforts in South Carolina and Florida are informed by advocacy strategies used by the HIV Law Project in New York City in the 1990s. Founded in 1989, the HIV Law Project was created to provide legal assistance to low-income, HIV positive women who were severely ill bur unable to qualify for existing AIDS-related benefits and services.

In the early days of the AIDS epidemic, there were few advocacy groups fighting for the rights of low-income women who were HIV positive. Only a few grassroots groups and the physicians and nurses caring for them were even aware that HIV positive women throughout the country were unable to qualify for AIDS-related benefits, largely because their illnesses did not fit within the epidemiological definition of AIDS issued by the Centers for Disease Control and Prevention (CDC). This was because, at that rime, the epidemiological understanding of AIDS was based on studies of white gay men. Thus, a man with Kaposi's sarcoma was immediately identified as an AIDS patient, while a woman with cervical cancer or recurrent aggressive yeast infections, pelvic inflammatory disease or bacterial pneumonia was not.

Because so few of the major AIDS organisations were aware of this problem, the issue was not on the advocacy agenda for the major service providers or state and national groups. Nor had the gender equality and social justice advocacy groups taken much initiative in understanding how the emerging HIV epidemic affected women. Rather, it was women with HIV, their health care providers and grassroots advocates who noticed that the CDC definition excluded the HIV-related diseases women had. Women were dying without access to Medicaid or any AIDS relief programmes since every agency--from the Social Security Administration to local AIDS housing programmes--was using the restrictive AIDS definition. As there could be no remedy without a major shift in federal policy, a partnership was formed between grassroots, community-based organisations, AIDS activists, the medical community and lawyers at the HIV Law Project that campaigned for and eventually achieved major changes in federal policies regarding HIV and women.

This partnership was able to gain many major policy victories by operating outside the parameters of the long-standing movement for gender equality, reproductive rights and social justice. These victories were achieved with affected communities through leadership development and technical assistance, the development of clear achievable goals, the use of credible research, the use of media to highlight the impact of discriminatory practices and potential solutions, and the presence of new and extremely credible voices in the policy arena.

The early work of the HIV Law Project has informed current research and efforts focused on improving state-level policies affecting reproductive health. Initial research analysed the current status of women's health in three states, Texas, Idaho and Florida, by studying reproductive health care data, relevant funding streams, health care provider networks and the legislative advocacy presence as well as current reproductive health policy and rights in each state. These investigations indicated that groups working at the legislative level to preserve access to reproductive health care did not have the resources to focus on disparities in women's access to health care. There were no advocacy organisations or lobbyists fighting specifically for women's health care. Instead, much of the work on women's health were defensive actions focused on fighting the scores of proposed reproductive rights restrictions.

Moreover, advocates working with low-income and immigrant women in both the health and labour arenas were often estranged from the traditional reproductive rights movement, in part because of the refusal of social justice groups to work on reproductive choice and the narrowness of the abortion rights agenda. The extreme right is able to use these divisions to isolate abortion rights advocates and discredit any of their attempts to address disparities in women's health. The Law Project showed that it was essential for advocates to work together for broad changes in women's health and that major governmental shifts in policy can be brought about by the combined strategic activism of women many would consider powerless.

Methodology

In 2003, the Women's Health and Human Rights Initiative (WHHRI) of the Mailman School of Public Health, Columbia University, offered research and organising assistance to develop the advocacy capacity of local groups in South Carolina and Florida. The aim was to build coalitions of advocates working towards improving the reproductive and overall health care of low-income women.

This initiative began by conducting, compiling and disseminating research on the status of women's health in each state. The available data were analysed by face, economic status, county and recent state policy initiatives relevant to women's health. A CD-rom was made that contained all available data on women's health indicators in both states. A database of funding resources was developed and made available to interested parties. In addition, a comprehensive report provided information on women's health needs throughout the two states, including comparative statistics on disease incidence and prevalence among racial and ethnic groups as well as background on related policy efforts. Secondly, WHHRI identified a diverse set of representative individuals, academic researchers, health care providers and advocates from grassroots communities interested in improving health outcomes for women.

The state of women's health in South Carolina

Women in South Carolina face greater health risks than most women living in the US. In nearly every arena of women's health, African American women fare significantly worse than their white counterparts. In 2004, 15.2% of South Carolinian women, 8.9% for white women to 19.7% for African American women, were uninsured. (4) From heart disease to diabetes, African American women in South Carolina experience higher morbidity and mortality rates than white women. (5) There is little data on the health status of Latinas or other women of colour in South Carolina. (6)

Reproductive health

Particularly in the arena of reproductive health care, data suggest that the African American community receives inadequate preventive care such as clinical breast cancer screening, mammograms or Pap smears. In South Carolina, breast cancer is the second leading cause of death for women, but the mortality rate among African American women is nearly double that of white women. (6) Similarly, a significantly higher percentage of black women are diagnosed with late stage cervical cancer than white women (39.5% vs. 28.5%, respectively), and black women are more than twice as likely as white women to die from cervical cancer. (5)

Many women in South Carolina cannot exercise their right to control their reproductive lives. The South Carolina Department of Health's 2005 Annual Report found that almost hall of the women (47.5%) in South Carolina who gave birth had become pregnant unintentionally. African American women were almost twice as likely as white women to have an unintended pregnancy, (5) yet 66% of women in South Carolina live in a county without an abortion provider, compared with 34% nationally. (4)

South Carolina's AIDS and HIV rates are disproportionately high. According to the CDC, South Carolina was the ninth most affected state nationwide in 2003, with an AIDS rate of approximately 18.7 cases per 100,000 persons, compared with a national average of 15. (7) Women in South Carolina represented 25% of the state's cumulative AIDS cases in 2004 compared to 19% nationally. (8) Of those living with HIV and AIDS per 100,000 in 2003, the rate was 12 times higher for black women than white women. (5)

For cumulative HIV cases (not AIDS), South Carolina ranks as the eighth most affected state in the nation, with 7,635 cases reported through 2003. (9) Women represent 35% of HIV cases diagnosed in South Carolina. (10) Although African Americans make up 30% of the population of South Carolina, they represent 77% of newly diagnosed HIV cases. African American women have been hit hardest by HIV, more than eight in every ten women diagnosed. (5)

Where South Carolina is failing women, it is also failing infants. In 2004, the National Center for Health Statistics ranked South Carolina 46th in the nation, with one of the highest rates of infant mortality, (11) with African American infants dying at twice the rate as white infants [14.2 vs. 5.5 deaths per 1,000 live births). (12) Although South Carolina offers pregnant women Medicaid coverage for up to 185% of the federal poverty level, there is no presumptive eligibility, which would allow pregnant women to receive antenatal services immediately rather than waiting until their application is processed, which is the norm in most other states. (13)

Restrictions on reproductive rights Although state policymakers have resisted increasing government involvement in health care, the state has been quite active in regulating abortion, sexuality education and access to treatment for drug addiction. Since April 2003, the US Supreme Court upheld the right of the South Carolina Department of Health and Environmental Control to obtain, copy and catalogue the identity and medical records of women who seek abortion. (14) South Carolina does not allow Medicaid funding for abortion except in cases of rape, incest or to save the life of the woman and passed a post-viability abortion ban with ah exemption only to preserve the life or health of the woman. (15) South Carolina also passed a "partial-birth" (late) abortion ban and requires parental or grandparental consent for minors age 17 or younger to obtain abortion services. (16) Recently, South Carolina implemented a mandatory waiting period of one hour and allows any individual health care provider or health facility not to provide ah abortion for any reason. (17)

Additionally, South Carolina has some of the most restrictive sexuality education laws in the country. (18) Although three-fourths of state residents believe that sexuality education should emphasise abstinence but also address contraception, and should be taught in South Carolina schools, (19) the state Department of Education prohibits instruction in sexual practices outside of marriage or practices unrelated to reproduction except within the context of the risk of disease. These restrictions limit teachers' ability to discuss communication and negotiation skills about sexual practices such as oral and anal sex. Furthermore, methods of contraception can only be explored in the context of marriage and future family planning. Teachers may not discuss them as being relevant to young people's current or potentially active sexual lives. (20) Of those requiring health education, only 37.6% of schools in South Carolina taught students how to correctly use a condom. (21)

Furthermore, South Carolina has increased its efforts to incarcerate pregnant women found to be using drugs, rather than providing them with treatment. (22) In 2004, the state was only able to offer treatment to 57,421 of the 235,884 residents identified with drug problems. South Carolina's women and pregnant women remain underserved. The Department of Alcohol and Drug Abuse Services and its local provider network have received the largest proportional state funding cut of any agency, amounting to a loss of 55% of funding since May 2001. (23) In the late 1980s prosecutors in the state began interpreting the state's child abuse and related laws as a basis for arresting pregnant women who they claimed risked harm to viable fetuses. (24) The primary targets of these arrests were low income African American women who tested positive for illegal drugs. (25) This expanded interpretation of the state's child abuse statute was codified in 1997 with the South Carolina Supreme Court decision Whitner v. State. The court in that case declared that viable fetuses were persons, and as a result, the state's criminal child endangerment statute applied to a pregnant woman who used an illicit drug or engaged in any other behavior that might endanger the fetus. (26) According to Lynn Paltrow, Director of National Advocates for Pregnant Women (NAPW), the group that has focused on defending the women, the Whitner decision around fetal endangerment still stands and has had a significant impact on the ability and willingness of women suffering from drug addiction to access antenatal and delivery care. (27) Advocates report that the number of drug abuse treatment facilities statewide is lacking, particularly for drug-addicted pregnant and parenting women. (28)

Building a coalition in South Carolina

In light of the numerous restrictions being placed on women's reproductive choices in South Carolina and poor health outcomes among many, particularly low-income and minority women, WHHRI began researching possible groups to collaborate with in strengthening women's health advocacy capacity in the state. National Advocates for Pregnant Women had litigated South Carolina v. Whitner and has been involved in several other cases regarding the prosecution of pregnant women as child abusers because they had a drug or alcohol problem. NAPW represents women who are being arrested for child endangerment, or if they unintentionally lose a pregnancy, homicide by child abuse. They proved to be a valuable resource and partner in identifying and establishing contacts with South Carolina advocates at the state legislative level. Most of these advocates working at the legislative level, however, were not in contact with health care providers or activists at county and local level. Similarly, these state-level advocates had few connections with academics researching or writing about women's reproductive health.

WHHRI set about identifying and contacting activists in the many different arenas of women's health to build an inclusive coalition, many of whom had previously not been in contact. To do this, WHHRI traced federal funding stream data to identify recipients of funds for rural health, community health centres, migrant health, maternal and child health, and family planning grants. WHHRI also contacted public health schools within the state and identified researchers and academics with expertise in women's reproductive health. The South Carolina state health department also offered contact information for service providers. We began calling organisations and individuals from these lists to assess their interest in participating in a statewide advocacy strategy meeting on women's health as well as asking each contact to identify other possible participants.

This research culminated in a May 2004 meeting in South Carolina hosted by WHHRI, in collaboration with NAPW. The project staff collaborated with women working in the most affected communities to prepare presentations on the barriers and gaps in services. Statewide advocates were invited to present on the state of the legislature and possible coalition opportunities. Over 50 people attended the meeting, and many reported that the opportunity to meet and gain information on the status of women in South Carolina was extremely useful. WHHRI continued to work with advocates in South Carolina over the next few months, providing information about funding opportunities and research as requested, as well as facilitating contact among the growing network of potential coalition members.

WHHRI and NAPW held a follow-up strategy meeting in September 2004. We prepared a memorandum outlining some of South Carolina's greatest obstacles in the area of women's reproductive health and detailing how and where South Carolina differed from other states in addressing these problems. The group who met agreed to continue as the newly formed Women's Health Coalition of South Carolina, involving 59 health organisations, agencies and university departments and has met seven rimes. The Coalition has taken up several letter-writing campaigns, one of which emphasised South Carolina's poor record on women's reproductive health in response to the Right to Life Act of South Carolina and another on the need to offer drug-addicted pregnant women treatment rather than incarceration. The Coalition also conducted an information session on Medicaid, focused on members' advocacy roles in the upcoming state legislative battles.

Moreover, Coalition members have crafted a series of commentary articles in local papers illustrating the poor status of women's health. For example, one piece criticised the South Carolina legislature for passing a law making it a felony to subject roosters to abuse but no similar law on behalf of women. Another opposed the Right to Life Act, which confers a right to legal protection to embryos at fertilisation. The Coalition is also mobilising around SC Senate Bill 1084, Unborn Victims of Violence Act.

The state of women's health in Florida

Women in Florida also face a dire situation when it comes to reproductive health care. A recent survey found that in Florida there are about 900,000 women aged 13-44, who live in severe poverty, earning 250% less than the Federal Poverty Level (FPL). Roughly 50% of these poorest women are white (4% of all whites), 25% are black (8.8% of all blacks) and 25% are Hispanic (6.8% of all Hispanics). (28) Women of reproductive age represent 23% of the uninsured in Florida yet they are only 7% of Medicaid recipients. (29) For many adolescent girls and women, access to reproductive health services is limited to those offered at publicly-funded health care institutions. (30) Bur accessing reproductive health care can also be a problem for Florida women who do have health insurance. For the three million non-elderly, adult women with workplace insurance, the state government does not guarantee that providers include basic reproductive health services in their plans. (29)

Reproductive health

In Florida, breast cancer is the second leading cause of cancer-related death among black and white women; however, black women die of breast cancer at a higher rate. (31) In part, this suggests a lack of preventive care: white women in Florida were twice as likely to report having a mammogram in the past five years than black or Hispanic women. (32) Seven of the counties with the highest breast cancer death rates are concentrated in Florida's eastern panhandle, a poor rural area, with 13-22% of residents living below the Federal Poverty Level. (33,34) There are few mammography facilities in these areas. (35)

Last year, Florida's cervical cancer incidence and mortality rates were both higher than the national average, with new cases diagnosed 1.5 rimes more frequently and death occurring over two rimes more frequently among blacks than whites. (36) Population studies confirm a negative association between socio-economic status and prevalence of invasive cervical cancer. (37) In fact, in the counties with the five highest rates of cervical cancer mortality in 2002, an average of 130% of residents lived below the Federal Poverty Level. (38)

Contraception

of the 1.7 million women in Florida in need of contraceptive services, half depend on one of only 311 publicly funded family planning clinics. Medicaid is the primary source of federal funding for these clinics. At the height of the fiscal upswing, the state's legislature expanded Medicaid assistance for family planning services. (39) In November 2006, however, funding for Florida's Family Planning Waiver Program was discontinued and pregnant women and mothers who are poor, bur not poor enough, lost access to state-financed contraception-related health care and supplies. Although this programme offered many women family planning services who might have otherwise gone without, more than half a million of the state's poorest women were not receiving contraceptive health care by 2002. (28)

Preventing unwanted pregnancies is further complicated by Florida law, which prohibits pharmacists from dispensing emergency contraception (EC) without a physician's prescription. Nor are hospital emergency room staff members required to provide women with information on EC. (40) Moreover, Florida health care providers are not legally required to give women EC even if they ask for it. In cases of sexual assault, hospital-based providers inconsistently prescribe EC to patients, often leaving treatment up to the sexual assault treatment centres that patients go to after they are discharged flora the emergency room. Although these centres are more consistent in providing treatment than emergency room providers, only half of sexual assault treatment centres report always offering EC to sexual assault victims. (41)

Pregnancy and birth outcomes

The last time the Department of Health conducted a Pregnancy Risk Assessment Monitoring System (PRAMS) survey, 25% of women who received some antenatal care were found not to have received any care during the first trimester of pregnancy. (42) In 2000, Florida had the sixth highest rate of adolescent pregnancy in the nation. (43) Twice as many black and Hispanic teenagers have given birth as white teenagers. Birth outcomes for pregnant women in Florida also vary by race and ethnicity. For 2001-03, an average of 17% of infants born to black women were pre-term, whereas for Hispanic and white women about 11% of infants were born pre-term. (44) When compared to white newborns, black newborns were twice as likely to be admitted to neonatal intensive care units and 2.5 rimes more likely to die before their first birthday. (42)

HIV/AIDS

Florida currently has the second highest number of known cases of HIV infection and the third highest number of AIDS cases in the nation. (45) Some 33,000 men, women and children are living with AIDS and 97,000 more are HIV positive. Women account for about one-third of HIV and AIDS cases in the state. (46,47) Among HIV positive women, approximately 70% are black, 11% are Hispanic, and 16% are white. (46) The rate of HIV infection for black women is 20 times that of white women and six times that of Hispanic women. (48) The adult AIDS mortality rate is more than two rimes greater than the national AIDS mortality rate. (47)

In the face of such poor reproductive health care and outcomes, Florida sponsored a statewide Abstinence Education Program in 1998. In 2002, the Florida Department of Health launched a statewide abstinence-only-until-marriage campaign "It's Great to Wait". (49) The campaign sponsors teacher training, youth rallies and parent workshops that incorporate biased perspectives on sexual activity and lifestyle choices, as well as discourage contraceptive use. Additionally, Florida mandates all high school students to complete a life management skills course in order to graduate, which includes information on HIV/AIDS, STIs, the consequences of teen pregnancy and the benefits of abstinence, but nothing on contraception. (50)

Restrictions on reproductive choice

A woman's right to privacy is protected by the Florida state constitution. (51) In years past, the state Supreme Court has interpreted this claim as guaranteeing the right to an abortion. Florida's current governor and the majorities of both houses of the legislature have led constant legislative battles to restrict women's access to abortion, however. The state has introduced amendments to the constitution that would require a mandatory waiting period, the presentation of inaccurate information to patients by providers, and parental notification and consent. (52)

After 24 weeks of pregnancy, a woman cannot qualify for an abortion in Florida unless two physicians agree that her health and life are threatened by the pregnancy. (53) The court has also prohibited physicians from performing late abortions, except when a woman's health or life is at risk. (54) Anti-abortion politicians in Florida have also sought to impose strict operational regulations on abortion facilities. Targeted Regulation of Abortion Provider (TRAP) bills mandate abortion facilities to adhere to onerous structural, staffing and licensing requirements. (55)

Incidents of violence and disruption intimidate abortion providers across the state. (56) Florida has the highest death toll flora anti-abortion extremism in the country. Of the seven physicians and clinic workers who have been murdered in the US and Canada from 1993-98, three were in Pensacola, Florida. (57) As recently as 2005, arsonists terrorised the Presidential Women's Center of Palm Beach County. (58) Between 1982 and 2005 there were 17 recorded arsons and four major bombings of clinics in Florida, with damage estimated at over US$2 million. (59) The threat of violence has contributed to the closing of clinics and the loss of personnel. In 1992, there were 133 clinics providing abortions; by 2005, less than hall were still providing abortion services. (60) Roughly 93% of counties in all four bordering states have no abortion services. (61)

Building a coalition in Florida

As we had done in South Carolina, WHHRI partnered with the Bylley Avery Institute, which has a long history of women's health advocacy in Florida. Once again, we identified potential coalition members by tracing funding streams, contacting larger statewide organisations, and seeking academics from local schools of public health. Using the South Carolina model and with the help of the Avery Institute, WHHRI contacted and developed alliances with a diverse group of advocates, academics and service providers throughout Florida. The first statewide meeting on women's health was held on 2 December 2005, organised by WHHRI. This meeting in Orlando brought about 40 health care providers, legislators, academics and activists representing 20 organisations from across the state. The meeting included informational sessions on rural and migrant women's health issues, HIV/AIDS, access to care, current research on reproductive health and an overview of state level reproductive health policy. During a second meeting in March 2006, the group's focus was on strategies to improve women's health, such as Medicaid reform to increase coverage and eligibility for women. Recent meetings have focused on the development and growth of the coalition as well as media messaging, research needs and advocacy strategies. The coalition adopted the name All Women's Health: A Florida Partnership for Change.

Benefits of this model

Advocates in South Carolina and Florida have reported that the short-term presence of an organizing force was positive. WHHRI was not seen as a funding competitor or as outside institution seeking to establish a base in these states, and groups were therefore willing to participate in the advocacy efforts. Moreover, new leadership has developed and these coalitions have become self-sufficient. Both coalitions work on access issues and reproductive rights, with an emphasis on women of colour, avoiding traditional divides between rights advocates and access advocates.

WHHRI's university-based setting provided freedom from the constraints of organization-centred approaches. We provided technical assistance to grassroots advocates and supported extensive opportunities for collaboration with a wide range of mainstream human rights groups, academics and health experts. Relying upon the research and community organizing work of graduate students has also proved cost effective and efficient. As the coalition has grown, the tasks related to maintaining it have also grown. Members are exploring organisational structures and consulting mechanisms that may allow the coalition to remain independent with minimal staffing.

Conclusion

This advocacy model was developed to confront the tendency of a growing number of states to focus on restricting women's reproductive rights rather than on guaranteeing access to care. Divisions between service providers and advocates have kept some of the most powerful evidence of state policy failures from reaching the public. The strength of the model we developed lies in its dependence on a broad and diverse set of actors who have the credibility to highlight the cynicism of the current approach. These two state-level coalitions, built around a commitment to advocacy for access to health care and the reproductive rights of all women, defy traditional divisions between advocates. In the years to come, these initiatives are likely to produce new leadership, new media messages and a powerful critique of policy approaches to women's health care that focus exclusively on restrictions on reproductive rights.

Acknowledgements

Thanks to Byllye Avery, Rana Barar, Kimberly Bylander, Wendy Chavkin, Kirsten DeFur, Luu Doan, Sarah Henry, Amourence Lee, Piyapa Praditpan, Katy Quissell, Susanna Smith and Alexandra Teixeira.

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(17.) S.C. Code Ann. [section][section] 44-41-330 (c).

(18.) Alan Guttmacher Institute. State policies in brief: sex and STD/ HIV education. January 2006. At: <www.guttmacher.org/ statecenter/spibs/spib_SE. pdf#search='south% 20carolina%20sexuality% 20education%20guttmacher>. Accessed 28 February 2006.

(19.) Centers for Disease Control and Prevention. South Carolina 2004 school health profiles results: selected topics fact sheet. At: <www.cdc.gov/ healthyyouth/profiles/pdf/facts/ SouthCarolinaST.pdf>. Accessed 28 February 2006.

(20.) Alton F, Oldendick R, Draughon K. The sex education curriculum in South Carolina's public schools: the public's view. Institute for Public Service and Policy Research, University of South Carolina. May 2005. At: <http:// ipspr.sc.edu/ejournal/ejmay05/ sexrev3.htm>. Accessed 28 February 2006.

(21.) South Carolina Department of Education. 6-12 health and safety education: 2006 Textbook Caravan. At: <dev.myscschools. com/offices/ace/healthyschools/ documents/2006CaravanHealth andSafetyEducation.ppt>. Accessed 28 February 2006.

(22.) Whitner v. State, 328 S.C. 1,492 S.E.2d 777 (1997).

(23.) South Carolina Department of Alcohol and Other Drug Abuse Services. Accountability report, fiscal year 2003-2004. Columbia: DAODAS, 2004.

(24.) S.C. Code Ann. [section] 20-7-50 (1985).

(25.) Paltrow L, et al. Whitner vs. South Carolina. Petition for writ of certiorari: opinion. New York, NY: National Advocates for Pregnant Women, 1997. At: <http:// www.drugpolicy.org/library/ certiorari2.cfm?printpage>. Accessed 28 February 2006.

(26.) Whitner v. State, 328 S.C. 1,492 S.E.2d 777 (1997).

(27.) National Advocates for Pregnant Women. Pregnant and parenting women, access to treatment in South Carolina: questions and answers. New York: NAPW, 2000. At: <http:// advocatesforpregnantwomen. org/issues/pregnant.htm>. Accessed 28 February 2006.

(28.) Alan Guttmacher Institute. Contraception counts. New York: AGI, 2004. At: <www. guttmacher.org/pubs/state_data/states/florida.html>. Accessed 28 February 2006.

(29.) Henry J Kaiser Family Foundation. Florida: health insurance coverage of women 19-64, States (2003-2004), US (2004). At: <www. statehealthfacts.org/cgi-bin/ healthfacts.cgi?action=profile& area=Florida&category=Health+ Coverage+%26+Uninsured& subcategory=Health+Insurance+ Status&topic=Nonelderly+ Adult+Women>. Accessed 28 February 2006.

(30.) Frost JJ, Frohwirth L, Purcell A. The availability and use of publicly funded family planning clinics: US trends, 1994-2001. Perspectives on Sexual and Reproductive Health 2004;36(5):206-15.

(31.) National Cancer Institute. Mortality, breast cancer, female, all ages. State Cancer Profiles 2006. At: <http://statecancerprofiles. cancer.gov/>. Accessed 28 February 2006.

(32.) Centers for Disease Control and Prevention. Screening program data: Florida. National breast and cervical cancer early detection program 2005. At: <www.cdc.gov/cancer/nbccedp/ sps/profiles/florida.htm>. Accessed 25 February 2006.

(33.) US Census Bureau. Percent of families below the poverty level in 1999:2000. US Census 2000. At: <www.census.gov>. Accessed 25 February 2006.

(34.) National Cancer Institute. Breast cancer: death rate report for Florida by county, death years through 2002. State Cancer Profiles 2004. At: <http:// statecancerprofiles.cancer.gov/>. Accessed 25 February 2006.

(35.) Centers for Disease Control and Prevention. Women aged 40+ who have had a mammogram within the past two years. Behavioral Risk Factor Surveillance System 2004. At: <http://apps.nccd.cde.gov/ brfss/>. Accessed 25 February 2006.

(36.) Women in Government. Florida: progress report 2006. The "State" of cervical cancer prevention in America 2006. At: <www. womeningovernment.org/ prevent ion/statereport/PDF/ States/Florida.pdf>. Accessed 25 February 2006.

(37.) Liu T, Wang X, Waterbor JW, et al. Relationships between socioeconornic status and race-specific cervical cancer incidence in the United States, 1973-1992. Journal of Healthcare for the Poor and Underserved 1998;9:420-32.

(38.) US Census Bureau. State and county estimates. Small Area Income and Poverty Estimates 2003. At: <www.census.gov/ cgi-bin/saipe/saipe.cgi>. Accessed 25 February 2006.

(39.) Agency for Health Care Administration. Family planning waiver, Medicaid services 2003. At: <www. fdhc.state.fl.us/Medicaid/ Family_Planning/index.shtml>. Accessed 25 February 2006.

(40.) Alan Guttmacher Institute. Emergency contraception. State policies in brief 2006. At: <www.guttmacher.org/sections/ contraception.php>. Accessed 25 February 2006.

(41.) American Civil Liberties Union of Florida. Availability of emergency contraception for sexual assault patients in Florida emergency care facilities. Fact sheet 2005. At: <www. aclu.org/reproductiverights/gen/ 20322prs20050620.html>. Accessed 5 February 2006.

(42.) Florida Department of Health. Florida Pregnancy Risk Assessment Monitoring System: 2003 Surveillance data book. Tallahassee: FDH, 2003.

(43.) US teenage pregnancy statistics: overall trends, trends by face and ethnicity, and state-by-state information. New York: Alan Guttmacher Institute, 19 February 2004.

(44.) Henry J Kaiser Family Foundation. Florida: preterm births as a percent of live births by race/ethnicity, 2001. At: <www.statehealthfacts. org/cgi-bin/healthfacts.cgi? action=profile&area=Florida& category=Women%27s+Health& link_category=Health+Status& link_subcategory=Births&link_topic=Preterm+Births+by+ Race%2fEthnicity>. Accessed 9 February 2006.

(45.) National Center for HIV, STD and TB Prevention. Cases of HIV infection and AIDS in the United States, 2004. HW/AIDS Surveillance Report 2005. At: <www.cdc.gov/hiv/stats/ 2004SurveillanceReport.pdf>. Accessed 13 February 2006.

(46.) Florida Department of Health. HIV/AIDS: trends & statistics. Fact sheets 2004. At: <www. doh.state.fl.us/disease_ctrl/aids/ updates/facts/facts.html>. Accessed 13 February 2006.

(47.) Henry J Kaiser Family Foundation. Florida: reported deaths among persons with AIDS, cumulative through 2004. At: <www. statehealthfacts.org/cgi-bin/ healthfacts.cgi?action=profile& area=Florida&category=HIV% 2fAIDS&subcategory=Deaths& topic=Deaths+Among+ Persons+with+AIDS>. Accessed 28 February 2006.

(48.) Florida Department of Health. HIV and AIDS cases in racial/ ethnic minorities: Florida, 2004. HIV/AIDS slide shows 2005. At: <www.doh.state.fl.us/disease_ctrl/aids/trends/slides/slides. html>. Accessed 13 February 2006.

(49.) Florida Department of Health. It's great to wait. At: <www. greattowait.com/program.html>. Accessed 21 February 2006.

(50.) Sexuality Information and Education Council of the United States. State profile: Florida. At: <www.siecus.org/policy/states/ 2004/mandates/FL.html>. Accessed 28 February 2006.

(51.) Florida State Constitution. Article 1, Section 23: Right to Privacy. Adopted May 5, 1998.

(52.) Alan Guttmacher Institute. State policies on mandatory counseling and waiting periods for abortion. State Policies in Brief 2006. At: <www.guttmacher.org/ statecenter/spibs/spib_MWPA. pdf>. Accessed 7 February 2006.

(53.) Alan Guttmacher Institute. State policies on later-term abortions. State Policies in Brief 2006. At: <www.guttmacher.org/ statecenter/spibs/spib_PLTA. pdf>. Accessed 7 February 2006.

(54.) Alan Guttmacher Institute. Bans on "partial-birth" abortion. State Policies in Brief 2006. At: <www. guttmacher.org/statecenter/ spibs/spib_BPBA.pdf>. Accessed 7 February 2006.

(55.) National Abortion Federation. Reproductive choice in the states in 2005. Washington DC: NAF, 23 January 2006.

(56.) National Abortion Federation. Clinic violence: analysis of trends. About Abortion 2004. At: <www.prochoice.org/about_abortion/violence/2003.html>. Accessed 6 February 2006.

(57.) National Abortion Federation. History of violence: murders and shootings. At: <www. prochoice.org/about_abortion/ violence/murders.asp>. Accessed 28 February 2006.

(58.) Minor EJ. Clinic owner steadfast amid arson's ashes. Palm Beach Post. 7 July 2005:A1.

(59.) National Abortion Federation. History of violence: arsons and bombings. At: <www.prochoice. org/about_abortion/violence/ arsons.asp>. Accessed 28 February 2006.

(60.) Isger, et al. Florida "hot spot" for foes of abortion. Palm Beach Post. 7 July 2005:A1.

(61.) Alan Guttmacher Institute. State facts about abortion: Florida. State Center 2006. At: <www. guttmacher.org/pubs/sfaa/florida. html>. Accessed 4 February 2006.

Theresa McGovern

Director, Women's Health and Human Rights Initiative, Assistant Professor of Clinical Population and Family and Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York NY, USA. E-mail: tm457@columbia.edu
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Date:May 1, 2007
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