At some point this year, somewhere in the US, a teenage girl will decide she wants to have sex. She might not know when, or who with, but she has made that choice. Unfortunately for her, this is a turbulent and uncertain year to be making sexual and reproductive health choices in the US.
If a student, she might have been relieved when Barack Obama's Affordable Care Act passed in June, knowing she can access student health plans that provide free contraception. She may already be benefiting from the Teenage Pregnancy Prevention Initiative launched by Obama in 2010, which funds school sex education programmes that show evidence of success, those predominantly promoting contraception over abstinence.
But this is an election year and early in 2012 voters got an idea of what to expect from the Republicans' presidential candidate, Mitt Romney, when he challenged contraceptive coverage included in the health reforms. Along with many Republicans, Romney supported an amendment that would exempt employers with moral objections from including contraception in employees' health plans. Though the amendment failed, Romney promised to not only "undo" the contraceptive mandate but to repeal the entire act on his first day in office.
"They could starve it financially, cripple it even if they can't repeal entirely," explains Adam Sonfield, of the Guttmacher Institute, which specialises in sexual and reproductive health and rights. "There are lots of opportunities to do damage."
Whatever the route, his point is clear: as president, Romney will do all he can to ensure federal money isn't spent providing contraceptives.
Voters could be forgiven for thinking Romney is less clear on abortion. When running for Senate in 1994 he said he believed "abortions should be safe and legal in this country". Now he wants Roe v Wade, the court decision that legalised abortion nationally, overturned and would make further substantial cuts to reproductive health services, despite a federal ban on funding abortion.
"Republican and independent-leaning women may believe Romney is the man he said he was in 1994, but he's not," says Emilie Ailts, director of campaign group NARAL Pro-Choice Colorado. "If he gets to the White House he will defund Planned Parenthood."
Whereas pro-choice Obama refused to bow down to Republican threats in 2011 to shut down government unless funding was cut to Planned Parenthood, Romney promises the opposite. Underscoring this is Romney's VP running mate, Paul Ryan. A fiscal conservative driven by pro-life ideology, Ryan co-sponsored a federal measure to ban abortion in all cases and is consistent with his position.
"Ryan practices what Romney preaches: Romney has pledged to 'get rid of Planned Parenthood'; Ryan voted repeatedly to defund Planned Parenthood. Romney said he would end the Title X program that funds birth control and cancer screenings; Ryan voted to eliminate Title X," says Ailts.
The Guttmacher Institute estimates the Title X family planning programme is used by 25% of poor women wanting to obtain contraceptives and is vital to reduce unintended pregnancies. Obama wants more funding for this programme but Romney wants it axed and would also cut the widely used Medicaid programme through which low income women receive reproductive healthcare.
Programmes promoting safe sex among young people could also be at risk under Romney, who supports sex education based on abstinence until marriage and funded such programmes when governor of Massachusetts. According to Douglas Kirby, senior research scientist at health and education research non-profit ETR Associates, Obama's pregnancy initiative is likely to reduce unprotected sex. The opposite could happen if the focus returns to abstinence.
"Because abstinence programs are generally less effective at reducing sexual risk, if they are promoted instead of comprehensive programs, more young people will probably engage in unprotected sex and teen pregnancy and STI rates will be a little higher than they otherwise would be," says Kirby.
On some youth reproductive health policies, the candidates stand closer together. Last year, going against scientific advice, Obama restricted giving emergency contraception over-the-counter to under 17-year-olds unless they had a doctor's prescription. As a father of two daughters the decision to him was "common sense". Romney vetoed emergency contraceptive legislation in Massachusetts because it "disregarded the importance of parental involvement". Neither helps young girls wanting to discreetly access the morning-after pill.
Overwhelmingly though, Romney would cause bigger problems for reproductive rights in the US and internationally. He promises to reinstate the "Global Gag rule", a policy that prohibits international organisations receiving US funds from providing any abortion-related care. The rule, rescinded by Obama on his second day, has been an early act of every new party president since introduced in 1984 and has big repercussions.
Improving access to reproductive services is key to millennium development goal 5 – the target to improve maternal health. With this target lagging, there is a pressing urgency to ensure it is at the top of the agenda as discussions begin on future development goals.
As a member of the UN, the US will contribute to negotiations about the post-2015 development agenda, which will steer a course for future sustainable development. But in contrast to Obama, a Romney administration is unlikely to recognise that a lack of access to sexual and reproductive health services only worsens cycles of poverty – at home and abroad.
