Archive for June, 2009

Dick Morris Doesn’t Understand Birth or Health Care

This post also appeared on the Huffington Post on June 29 at this URL.  You can comment there.

On the June 24 edition of The O’Reilly Factor, Dick Morris said that “right now the government is telling people, cut back on cesarean sections, go through natural childbirth. It’s a lower cost.”  Aside from the simple fact that this is false, there’s a lot wrong with this picture, especially given that he chose the example of cesarean sections.

It would be understandable that Americans are worried about the rationing of health care, except that private insurance companies do a lot more rationing of care than single-payer systems in other developed countries.  But it’s especially interesting that Morris made his false claims about childbirth, since American maternity care is unnecessarily expensive and has very poor results. The U.S. pays twice as much per birth as other developed nations.  The American infant mortality rate is the second-worst in the developed world and ranks 37th in the world, behind South Korea and Cuba. Maternal mortality rates have been rising since 1982 in the U.S., which currently ranks 41st among 171 countries. In August 2007, the CDC reported that the number of women dying in childbirth in the United States increased in 2004 for the first time in decades. National data on infant mortality rates in the U.S. also reveal an increase in 2005 and no improvement since 2000.  In fact, countries with universal health care systems have much better maternal and infant outcomes, as well as lower cesarean rates.

The correlation between poor outcomes of the American maternity care system and high cesarean rates, which have risen from 4.5% of U.S. births in 1965 to 31.8% in 2007, is not spurious.  Morris implies that cutting back on cesareans and encouraging natural childbirth would do a disservice to the health of mothers and babies – an implication that is patently false.  Cesarean can be a lifesaving procedure, but it also increases the risk of neonatal respiratory problems and carries a much higher risk of maternal complications and a four times higher risk of maternal death than vaginal birth. Based on scientific evidence, the World Health Organization (WHO) recommends a cesarean rate of 10-15%: below 10% the benefits of the surgery outweigh the risks to the health and life of mothers and infants, while over 15% the risks of surgery outweigh the benefits. According to the WHO, the rate of cesarean section should not exceed 15% in any country because maternal deaths increase at higher rates. However, the cesarean rate in the contemporary United States is more than double this recommended upper-limit.

As Media Matters reported with respect to Morris’ absurd claims, the AMA and five other health care organizations issued proposals to address the overuse of certain procedures on June 1. “In its attachment to the letter, the AMA stated that the ‘AMA-convened’ Physician Consortium for Performance Improvement (PCPI) recommended addressing ‘the overuse of certain services or procedures,’ including ‘Induction of labor/Caesarean Sections.’”  The proposals addressed overuse, and it is clear from the medical research literature are that labor induction and cesarean sections are over-used in the United States, and that this overuse is detrimental to the health of women and babies.  If healthcare reform in this country leads to fewer c-sections, it will save money and lives.  Aside from a few obstetricians who prefer the surgical route, whatever its ultimate health consequences, who can really complain about that?

 

Address Medical Liability with Science, Not Caps: The “Standard of Care” is not the same as evidence-based medicine

This post originally appeared on the Huffington Post on June 17, 2009 at this URL.

On June 15, the New York Times described how Obama is open to reining in medical suits by trying to reduce malpractice suits.  There are some fundamental issues that need to be on the table when thinking about this issue, the most important being that the “standard of care” is not necessarily evidence-based.  There are also far more medical errors than there are malpractice suits, and the few frivolous suits that exist rarely make it to settlement, let alone court.  I am currently exploring the effects of malpractice on maternity care, and will address these issues below.

The AMA and doctors are in favor of protecting doctors from malpractice lawsuits, and they have good reason: medical liability insurance premiums are absurdly expensive, especially in some states (e.g. Florida).  Practitioners must then pass along the costs to consumers, leading to inflation of healthcare costs.  However, premiums are not based entirely on the risk of being sued: liability insurers invest the premiums and then must increase their rates when their return on investments decline (as would be happening now in the recession).  They also raise their rates when they don’t face competition, and some states have only one or two liability insurers.  So liability insurance isn’t in sync with actual malpractice activity.  Using the National Practitioners Data Bank, I have found that obstetric malpractice suits have fluctuated over the years 1991-2004 rather than increasing over time.  This is not what one would expect based on the increased fear of litigation that doctors express.

In fact, many doctors practice in fear of litigation, and some have argued that this leads to “defensive medicine”: medical practices designed to avert the future possibility of malpractice suits, rather than to benefit the patient.  This drives up the cost of healthcare, because payers end up paying for unnecessary procedures.  But again, their fear is out of proportion to the actual risk: the risks of lawsuits have not increased, and the average awards in medical malpractice suits have increased only slightly (adjusted for inflation).

On the other hand, negligent medical errors are far more common than people in favor of capping damages want to acknowledge.  In the Harvard Malpractice Study, Dr. David Studdert led a team of eight researchers from Harvard School of Public Health, Brigham and Women’s Hospital, and the Harvard Risk Management Foundation.  The study used a conservative methodology to determine whether or not negligence occurred in 31,000 medical records, dating from the mid-1980s.  Practicing doctors and nurses evaluated the cases, and the study made a finding of negligence only if two doctors, working independently, separately reached that conclusion.  The study found that doctors were injuring 1 out of every 25 patients, and only 4% of these injured patients sued.  So the actual rate of negligent medical error is much higher than the litigation system suggests.  Also, fewer than 10% of cases were “frivolous,” meaning that no negligent medical error occurred, and the courts efficiently threw them out.  Only 6 cases where researchers couldn’t detect injury received even token compensation.

This issue of medical error is already part of the argument against reform: many who are against caps on damages point to the high rate of error and its impact on patients and their families.  But the missing piece that no one on either side of this debate seems to talk about is that the “standard of care” is part of the problem.  The New York Times article suggests that President Obama is “open to offering some liability protection to doctors who follow standard guidelines for medical practice.”  But standard guidelines are often not based on the best scientific evidence, and this is especially true in the case of obstetrics.  Evidence-based medicine suggests that optimal management of birth involves minimal interventions, and yet the standard of care involves high rates of induction of labor, often using drugs like Cytotec that are contra-indicated for this purpose (see here and here on the dangers of this drug), artificial stimulation of labor, amniotomy, confinement to bed, restriction of food and drink, non-physiologic positions for pushing, and very high rates of cesarean section (currently about 1/3 of births nationwide).  This is the “standard of care” but is not evidence-based – there is a large body of scientific research that finds that all of these practices are harmful and lead to unnecessary and preventable instances of fetal distress, cesarean section, and maternal mortality and morbidity.  Moreover, there is some evidence that doctors do more interventions and more cesareans as a defensive practice, because it fits the standard of care and despite the fact that it goes against the scientific evidence.  So offering protection to doctors who follow standard guidelines for medical practice will not reduce medical errors and preventable injuries, at least not in obstetrics.  In order to do that, President Obama’s healthcare reform should think about offering liability protection to doctors who practice evidence-based medicine.  To let the “standard of care” continue to rule is akin to letting the fox guard the henhouse.

 

Still Selling Women Short

This post originally appeared on the Huffington Post on December 2, 2007 at this URL.

A Dec. 1 NYT article, “Top Ranks of Women on Wall Street are Shrinking” tells tales of political infighting and the subprime mortgage crisis as catalysts for the ouster of Zoe Cruz from a high executive position at Morgan Stanley. Since she was Wall Street’s best bet for a woman chief executive, it now seems there are no women with “a viable chance of becoming chief executive anytime soon.” Are women back to square one, circa 1970, on Wall Street?

Landon Thomas Jr. says that industry insiders wonder if this high-powered executive’s “status as a demanding woman in a male-dominated industry” may have tipped the scales against her. Of course her gender was part of it.

When I interviewed women and men who worked on Wall Street in the 1990s, I found that stereotyping profoundly influenced the way that women were treated. Like Zoe Cruz, some women were able to be successful, especially if they had powerful mentors. But women who moved up were increasingly held to double standards: expected to be tough, competitive, aggressive workaholics on one hand, and yet to be nice, nurturing, kind, and family-oriented because they were women. It is, of course, impossible for anyone to fulfill these expectations simultaneously. I found that women who had proven themselves and attained positions of power on Wall Street were often especially negatively regarded.  These women faced expectations that they would behave in appropriately feminine ways, even though cultural ideas of femininity clashed with definitions of managerial competence in Wall Street’s male-dominated culture.  People have a difficult time accepting aggressive and dominant behavior from women, like speaking with a stern facial expression, making a lot of eye contact while speaking, or making verbal or non-verbal threats.  At the same time, women on Wall Street had to exhibit these types of “masculine” personality traits and contradict expectations of femininity to prove their competence within Wall Street’s culture.

This created a double standard for their actions, made it difficult for them to wield authority in the workplace. One of the women I interviewed observed, “I’ll talk firmly to an analyst and say, ‘I need these numbers by this time.  And you better proof it.  And I want it right and formatted.’ That will come back to me that I was being a ‘bitch.’  I’ll get a call from the staffer that says, ‘You can’t talk like that.’ Whereas a guy, my officemate, would say to some guy – same guy – ‘You know, you’re such an asshole. How can you be so stupid? Don’t you know this is how you do this?  And don’t come back into my office until it’s right.’ And that doesn’t warrant a phone call.” Women in high positions receive more negative evaluations than men who exhibited similar behavior. When expectations for their behavior are so contradictory, how can women compete?

It’s unfortunate, perhaps tragic, that industry insiders like Elaine La Roche are saying “I think in recent years the advances made by women in the 1990s have reversed.” Things weren’t so great for women in the 1990s, as my research shows, but there were some women making headway in this lucrative industry. Is retrenchment a sign of a general backlash against principles of gender equity in the Bush era (as denial of systematic gender inequity has escalated while statistics about it have been removed from government webpages)? Or is a sign of backlash against the lawsuits and settlements of the past decade?

Louise Marie Roth is an Associate Professor of Sociology at the University of Arizona, and author of Selling Women Short: Gender and Money on Wall Street published by Princeton University Press.

 

Moms Gone Wild: Why Bill Maher is Wrong about Breastfeeding

This post originally appeared on the Huffington Post on September 17, 2007 at this URL.

On Friday’s episode of Real Time, Bill Maher introduced one of his “new rules,” “Lactate Intolerant,” in which he argues against breastfeeding in public. As he explained, he doesn’t want women showing their tits in public unless they are appropriately packaged for heterosexual male consumption. (Revealing what he thinks is appropriate, he made a snide reference to Britney Spears’ body in one of the other new rules, drawing a good laugh. My goal here is not to defend her, but only to point out that Bill Maher’s idea of an acceptable female body, along with many members of his audience, is incredibly narrow.)

For someone who claims to believe in science, Bill’s queasiness around breastfeeding seems more than a little bit irrational. A huge body of evidence suggests that breastfeeding provides incredible health benefits to both infants and mothers. (For the FDA statement on this, click here.) It not only provides babies with antibodies that help them avoid illness, it also may protect mothers against breast and ovarian cancers later in life. There is evidence that breastfeeding provides psychological benefits to infants and that breastfed infants develop higher IQs. There’s even evidence that breast-fed babies are less prone to obesity later in life – and obesity is something that Bill Maher is clearly against. Breastfeeding saves on healthcare costs, and it is clear that advocating in favor of breastfeeding is in the interest of public health. And yet the vast majority of mothers do not breastfeed for the full 12 months recommended by Health and Human Services. In fact, less than 30% of mothers are breastfeeding when their babies reach 6 months of age.

Given that it’s so good for their babies and themselves, why don’t more mothers breastfeed? One reason is that there is inadequate maternity leave for most women, making it hard for women who want or need to work outside the home to establish breastfeeding. Another reason is that many employed women don’t have enough privacy at work to pump milk. Then there’s the fact that formula is readily available, and hospitals and pediatricians give out free samples. But we shouldn’t underestimate the impact of people like Bill Maher who are squeamish about the fact that humans are mammals. Coworkers who don’t want women leaving icky breast milk in the office refrigerator because it grosses them out. Those who can’t handle the idea that babies should also get to eat when the family is at Applebees, even if they are having something healthier than what’s on the menu. So Bill Maher says that breastfeeding mother’s are too lazy to plan ahead, presumably because they can arrange it so that their babies don’t need to eat while they’re out. Obviously he has never had to manage life within small windows of opportunity between feedings or he would know that timing a baby’s hunger is just not possible. Perhaps he would prefer that breastfeeding mothers never leave the house – another recipe for reducing breastfeeding rates. Sometimes people, especially those without children, seem to forget that mothers are people too – we need to have friends, social lives, and activities beyond the confinement of our living rooms.

Bill Maher obviously doesn’t understand the benefits of breastfeeding to public health, since he claims that breastfeeding is not worthy of activism. He says that it’s “petty and parochial.” Apparently he also doesn’t understand that supporting breastfeeding is not only good for public health, it’s also part of reproductive justice – along with the availability of contraception, the legality of abortion, the right to informed consent or refusal of medical procedures when giving birth – all rights that many women currently do not have. When he claims that women’s reproductive activities are yucky and should go underground, he is colluding with the people who want to control reproduction and sexuality – not normally the folks he counts among his friends (with the possible exception of Ann Coulter). He may be in favor of the kind of sex he wants to have with the kind of bodies he wants to have it with, but his attitudes toward women are stuck in the Dark Ages.

Of course, so are his attitudes about babies, which he says are not special because creating a baby is “something a dog could do.” First, Bill, dogs don’t make human babies. But all babies, including puppies, are adorable – they have to be so that we want to protect them. It’s a survival thing. Beyond that, we can all respect that Bill Maher doesn’t want to have children and perhaps we’re all better off for that. But Bill needs to respect the fact that other people’s children are the ones who will be paying into Social Security when he reaches retirement age. If anyone is going to make the scientific discoveries that help to resolve the problems that Bill cares about, like global warming, it will be other people’s children. Parents, and especially mothers, are providing a public good by taking care of their children’s health and development. So instead of criticizing them for making you queasy, maybe you should cheer them on.

 

Homebirth is Safe, but should be assisted

This post originally appeared on the Huffington Post on August 1, 2007 at this URL.

A recent Washington Post Article describes a movement toward “freebirth,” or unassisted home birth. It says, “Some experts worry that vulnerable or gullible women will be misled into thinking that giving birth alone at home is a viable, even reasonable, alternative. These mothers, they maintain, may not understand that calling 911 — which many homebirthers cite as their emergency backup — is a poor contingency plan when every second counts.”

What really alarms people about “freebirth,” or unassisted home birth?  Is it the fact that women are shunning the hospital birth experience and choosing to give birth at home, or is it the fact that it is unassisted?

Obstetricians and the American College of Obstetricians and Gynecologists (ACOG) are against any home birth, claiming that it is unsafe. As the article states, “The college “strongly opposes” all home births on safety grounds.” But what is the evidence? In fact, the scientifically-sound evidence all suggests that homebirth, when assisted by a qualified midwife, is safe. In fact, the scientific evidence shows that homebirths assisted by midwives are safer than hospital births attended by obstetricians, and countries where more women give birth at home with midwives have lower maternal and infant mortality rates than the United States. What ACOG doesn’t want the American public to know is that maternal and infant mortality rates in the U.S. are actually going up – largely because obstetricians engage in interventions that are not evidence-based and haven’t been approved by the FDA or the scientific community. (For example, the use of Cytotec against label to induce labor is common, in spite of explicit warnings against ever giving it to a pregnant woman. There is no evidence that the drug is safe for labor induction, and yet many doctors use it anyway, often without informing women of what they are doing.) Marsden Wagner, an MD and perinatal specialist has written a brilliant expose of the obstetric community that discusses these issues, and the scientific evidence, in Born in the USA: How a broken maternity system must be fixed to put women and children first.  I’m surprised that the obstetric community doesn’t have a price on his head.

That women are choosing to give birth unassisted suggests that many women know that something is amiss with the maternity care system. They want childbirth to be an experience that honors their personhood and doesn’t turn them into patients when they are not sick. They don’t want their birth experience to be dictated by surgical specialists who are not even in the hospital when they are in labor. But the scientific evidence suggests that it is births assisted by midwives, whether they occur at home or in independent birth centers, that are the safest alternatives to hospital birth – not “freebirths.” I had both of my sons in a birth center, attended by wonderful midwives who knew what to do when complications arose, and I felt honored and empowered by the experience. Women have always needed the support of other women in childbirth and the anthropological record shows this. As a culture, we need to affirm that fact, as well as women’s needs to control birth rather than having it controlled by doctors, by educating the public about midwifery and making midwifery services a more integral part of the maternity care system.

 

American Healthcare: Frustration, being surgically implanted

This post originally appeared on the Huffington Post on June 29, 2007 at this URL.

Every time I drive by a billboard for United Healthcare that says, “Frustration, being surgically removed,” I wonder if they’re being sarcastic.  My employer pays through the nose to cover my family with United Healthcare, and it’s considered one of the more comprehensive plans.  But they still work really hard to deny coverage.  Last week my newborn came down with thrush.  When I tried to get a refill of the prescription to treat him, the pharmacy told me that it was too soon to get a refill – it could only be refilled after 15 days, even though the supply that they gave me the first time was only enough for 7.5 days.  It was simple math: at the dosage they prescribed, the bottle would only last half as long as the insurance company seemed to think it should.  It took about 10 phone calls to the insurance company, the doctor, the pharmacy, the insurance again, the pharmacy again, the insurance again, each time explaining the arithmetic, before I was able to obtain the refill.  The prescription cost United Healthcare $9.99.  The wages of the people I had to wrangle with over the phone probably cost them more than that, given all of the times I had to call.

I don’t remember ever having such problems when I lived in Canada.  I showed my card, got treatment, and that was it.  Preventive care was available, and even encouraged.  A single-payer system can reap the benefits of preventive care, since it reduces overall costs.  One might think that private health insurance companies could also reap savings from paying for prevention but that’s not true.  They don’t cover a large enough population to benefit from the overall improvements in health gleaned from providing more preventive measures like regular physicals.  And they are able to deny coverage to those with existing conditions, which reduces the cost to them of chronic health problems and debilitating diseases.  When everyone has to be covered, as in a universal single-payer system, existing conditions can’t be excluded and that means the system has to cover them.  There’s no downside to allowing people access to low-cost drugs like my son’s prescription.  But what saves private insurance companies money?  Denying coverage.  So much for the “culture of life.”

I haven’t seen Sicko yet, but I’m looking forward to it.

 

On Giving Birth

This post originally appeared on the Huffington Post on June 13, 2007 at this URL.

On May 27, I gave birth to my second son.  He was born in a large bathtub at a birth center, where I had the assistance of a doula and a certified nurse midwife (CNM).  I gave birth without drugs or an epidural.  Fewer women give birth this way, or even can choose this type of birth, because birth centers have been closing – in spite of the fact that birth centers and CNMs provide quality woman-centered care that is much more cost-effective than standard obstetrical care.

You may be thinking “So what?  Natural childbirth is over-rated anyway.  Why would anyone want to go through the pain of childbirth?”  I remember hearing someone I know talking to a pregnant woman and saying that giving birth without drugs doesn’t make you a better mother.  I agree.  I have given birth twice without drugs and I am still an imperfect mother.  But the claim to superiority is not what made natural childbirth the right choice for me.  Being able to give birth to my babies without medical interventions was empowering.  I used to teach four aerobics classes in a row, but giving birth was the most strenuous physical challenge of my life.  I did it.  I have no need now to do Iron Man.  And my sons were born in a softly lit room, both of them so calm that they didn’t even cry.  You forget the pain so quickly – all you remember is the beautiful experience of bonding with your baby right from the start.  Most women who choose this type of birth describe it as a positive and empowering experience.  (In contrast, many women remember their hospital births as horrible experiences.)  And it is well known that birth centers provide safe and effective care with a much lower incidence of cesarean sections, even accounting for the fact that they only deal with low-risk pregnancies.

So why are birth centers closing?  Why has the natural childbirth movement been dying out?  With all of the talk about “choice” – the choice to have a cesarean, the choice to have an epidural, the choice to induce early to avoid stretch-marks or to accommodate the schedule of one’s doctor or relatives – why is the choice to give birth outside a hospital becoming less common and increasingly scorned?  People have largely forgotten some of the abuses of the 1950s and 1960s, which led to the natural childbirth movement in the first place.  There seems to be greater cultural acceptance of the choice to have a surgical birth than there is to have a natural one.  Perhaps the prevalence of cosmetic surgery leads people to think of surgery as no big deal.  Some of the reason that the movement is dying out is that women are reluctant to trust their own bodies or are discouraged to do so.  And mothers don’t want to do anything to jeopardize the well-being of their babies.  (Of course, the evidence suggests that natural childbirth, especially in a birth center setting with physician back-up, is as safe as hospital birth, although most people don’t know this.)

Another reason that we are losing birth centers is because they, and CNMs more generally, face rising malpractice insurance costs that make continued operation financially infeasible.  Midwifery care costs insurance companies less that hospital births, but this makes it harder for birth centers to offset the rising costs of their insurance.  Also, obstetricians are increasingly discouraged from working with CNMs by medical malpractice insurance companies, making it difficult for birth centers to find physician back-up.  Ignoring the evidence about safety and cost-effectiveness, medical malpractice insurance companies view CNMs as risky.

In January I attended a conference of the National Advocates for Pregnant Women on reproductive justice.  Many of the birth activists there attend or encourage homebirths, but only 1% of American births occur at home.  Most women are simply too frightened of what would happen if there were complications.  Birth centers offer the opportunity for a woman-centered natural birth experience, with hospital and physician back-up in the case of complications.  One of the other scholars who studies birth asked me what women who use birth centers would be likely to do if they didn’t have access to a birth center.  I replied that most of them – including me – would choose a hospital birth over a homebirth.  This is all the more reason that we need birth centers as an option for women who want natural childbirth.  The loss of birth centers is a tragedy for reproductive justice, which involves the right to choose where and how to give birth as well as the right to decide when to have children and how many to have.

 

Lily Ledbetter: Another Setback from the Roberts Court

Originally written May 31, 2007.

On Tuesday, the Supreme Court delivered a huge blow to the fight against pay discrimination for women in Ledbetter v. Goodyear Tire & Rubber Co., Inc. (See http://www.nytimes.com/2007/05/30/washington/30scotus.html?_r=1&th&emc=th&oref=slogin and http://www.nytimes.com/2007/05/30/us/30pay.html) In the case, the only woman supervisor at a Goodyear Tire plant in Gadsden, Alabama was paid less than any of her 16 male colleagues, including those with less seniority. She did not learn of the pay discrepancy until late in her 20-year career at Goodyear. But in arguing that pay discrimination cases require a formal complaint to be filed within 180 days after pay is set, the 5-4 decision ignored the fact that most workers have no knowledge of how much their coworkers make. Most employers do not make pay rates public and, in fact, make every effort to conceal salary information. Only state organizations are required to make such information public. Because most employers lack this transparency, the ruling takes all accountability away from employers – and permits them to discriminate with impunity on the basis of sex, race, religion, or national origin.

Patterns of discrimination are often subtle and difficult to discern at the beginning of one’s career. The more that managers have discretion over pay, the more that pay inequities tend to exist. Small inequities at the beginning of workers’ careers tend to grow larger as their careers progress. And workers often don’t know the extent to which they are underpaid relative to their peers because they have no accurate information about other people’s pay. Often it is far longer than 180 days before workers discover that someone else does the same job in the same organization but is paid more than they are – largely because most discrimination is cumulative in nature. I found this on Wall Street when I did my research for Selling Women Short: Gender and Money on Wall Street, and sound social science research on inequality in a wide variety of occupations and fields has shown the same. The ruling Ledbetter v. Goodyear will make this problem worse by shielding employers from challenges to their inequitable pay practices.

The Supreme Court ruling suggests that the Roberts Court is completely out of touch with the realities of pay discrimination, and with how employers set pay rates. This ruling violates the spirit of equal employment opportunity laws and makes these laws impotent. But this is clearly in step with the intentions of the Bush administration, which has already removed data on discrimination from official government websites and publications, and has undermined efforts to continue collecting such data. In addition to the assault on women’s reproductive autonomy, the recent Supreme Court nominees were appointed to sustain a more subtle attack on vulnerable workers. Bush has succeeded in delivering on his promises in this realm, once again undermining justice and the rule of law.

 

Leaky Pipelines and Revolving Doors

This post originally appeared on the Huffington Post on April 24, 2007 at this URL.

A new report from the American Association of University Women (http://www.aauw.org/research/behindPayGap.cfm) confirms what many gender equity scholars have demonstrated for decades: while women are more highly educated than men, they enter different majors in university and different jobs after graduation, there is a gender gap in negotiation, and women face greater burdens when it comes to balancing work and family.  The pay gap begins as soon as women leave university and widens over time.  A substantial pay gap remains even when comparing men and women who work the same number of hours, have the same work experience and credentials, and have the same marital and parental status.

In the AAUW report, some of this is attributed to women’s choices, but it’s important that the issue of “choice” not be overblown.  Our culture tends to emphasize choice, and most people embrace this idea – no one wants to think they don’t have choices because it’s disempowering.  But research by Jerry Jacobs has shown that women frequently enter male-dominated university majors and occupations, only to find them inhospitable and end up leaving them in a “revolving door” pattern.  It’s not only that women choose careers in education or social services instead of science – they are often actively pushed to make those choices and discouraged from entering science, mathematics, or technical fields.  The revolving doors continue to rotate women in and out of male-dominated jobs long after graduation.  Often this looks like women’s “choices” to focus more on their families than their jobs, but the push factors are there.  But women (and employers) view this is a personal choice because it’s better than feeling like a victim (or a perpetrator).

Also, the report notes that female graduates with the same scientific and technological degrees do not enter the higher-paying jobs in those fields for some of the same reasons.  This is what many have described as a “leaky pipeline,” in which women obtain jobs in lower proportion than they obtain degrees, and then obtain promotions and salary increases in lower proportion than they obtain entry-level jobs.  Why do women “leak” out of high-paying fields over time, or receive lower wages than men in the same fields?  Salary inequity and blocked promotions are discouraging, leading women to find other “choices” more appealing.

The gender gap in negotiation is also part of the problem, and the AAUW report suggests that women need to become tougher negotiators.  The book Women Don’t Ask: Negotiation and the Gender Divide (http://www.womendontask.com/index.html) clearly outlines the research on this: men have more sense of entitlement than women and are more apt to promote themselves, while women seek to preserve relationships by acting in self-sacrificing ways.  When women don’t ask, the long-term effects of small differences in starting salaries lead to much larger long-term gaps.  But when women do ask, they are not treated the same way as men – employers and wage-setters need to take some of the responsibility here.  Women who ask do not receive as much as men who ask, especially when those with the power to offer think that women will not leave or will take a low-ball offer more readily than men.

What can we take away from this report and the dynamic metaphors of “leaky pipelines” and “revolving doors”?  We need interventions at every stage: encouragement for girls and women to pursue male-dominated fields and high-paying jobs, sanctions against those who discourage the recruitment and retention of women in these fields, standardization of negotiations, and vigilant review of salary and promotional inequities.  And we need to re-examine the context in which women, and their employers, make choices.

 

Whose Bargain? Whose Choices?

This post originally appeared on the Huffington Post on April 5, 2007 at this URL.

Why are women willing to fight against legal protections for women in the workplace? A majority of women are in the workforce, and there is solid evidence that women face systematic discrimination. But there are always those who insist that women’s disadvantages are all about choice. In “A Bargain at 77 Cents to a Dollar,” (http://www.washingtonpost.com/wp-dyn/content/article/2007/04/02/AR2007040201262.html?hpid=opinionsbox1 ) Carrie Lukas claims that “all the relevant factors that affect pay – occupation, experience, seniority, education, and hours worked – are ignored” in discussions of the wage gap. It must be nice to be able to ignore the evidence that social scientists have been accumulating for decades. Research on the effects of each of these “relevant factors” has consistently found that they cannot explain the wage gap. Even when men and women work the same hours in the same occupations and have the same amount of work experience, education, training, and seniority, women still earn less than men. While the wage gap is often smaller when “the comparison is truly between men and women in equivalent roles,” it is inequitable nonetheless. And sometimes the gap is actually larger – research shows that inequality between men and women in the same jobs is greatest in high-paying positions, where managers have more discretion over pay rates and they use that discretion to pay men more. In my research on securities professionals, women earned 29% less than men in the same jobs with the same credentials, experience, and hours.

Of course, men and women don’t always work in equivalent jobs and occupations dominated by women pay less than male-dominated occupations with similar credentials, skill levels, and working conditions. But if credentials, skill levels, and working conditions are similar, then what is the justification for paying women’s jobs less than men’s jobs? Most social science suggests that it is organizational customs and the cultural devaluation of women that leads to this difference. That’s not my definition of equity.

Interestingly, Lukas claims that men “disproportionately take on the dirtiest, most dangerous and depressing jobs.” I wonder how Lukas has decided which occupations fit these descriptions. There are plenty of jobs dominated by women that are dirty (nurses come to mind), dangerous (sex worker), and depressing (social work).

Lukas also argues that “surveys have shown for years that women tend to place a higher priority on flexibility and personal fulfillment than do men, who focus more on pay.” It would be interesting to know which surveys she is citing, since most research on job satisfaction finds that men and women value the same qualities in paid employment, with pay, autonomy, and responsibility at the top of the list. In order to justify their lot in life, people also learn to accept and value what they have. So any differences could reflect post-hoc justifications for staying in particular jobs despite their lack of remuneration. This makes it all the more striking men and women tend to say they value the same things in paid work.

Lukas then talks about the trade-offs that men and women make in paid work. The reality of many women’s lives, especially women with children – many of whom are single – is that they have to “avoid jobs that require travel or relocation,” and “take more time off and spend fewer hours in the office than men do.” Lukas portrays this as a choice, and many would agree with her, but I doubt that it feels like a choice to most women. Do men choose to travel a lot, relocate, and work long hours – or is this structured by the workplace rather than by people’s choices? Carrie Lukas says that this is all about choice – at least in her case and those of “hundreds of thousands of women” like her. And then there’s the nasty issue of the facts again: systematic research using large random samples has demonstrated that jobs dominated by women actually have less scheduling flexibility and autonomy, and larger penalties for taking time off, than jobs dominated by men. Obviously many women work in low-wage jobs where flexibility is far from a reality, so what advantages lead women to choose these low-paying jobs? Perhaps Lukas isn’t thinking about low-wage workers when she talks about “women.”

Carrie Lukas is worried that the Women’s Equality Amendment and Hillary Clinton’s Paycheck Fairness Act would give “Washington bureaucrats more power to oversee how wages are determined” and that this would make workplaces less flexible for women like her. But there is evidence that manager accountability for non-discrimination can lead women to rise to higher levels within organizations. My research with Doug Guthrie found that equal employment opportunity laws make a measurable difference in the likelihood of women moving to the top of U.S. organizations. And recent research shows that women managers improve employment outcomes for women below them in the hierarchy – possibly increasing, not decreasing, flexibility. So even if we agree with Lukas that we’re “better off not feeling like victims,” why wouldn’t we want anti-discrimination legislation with some teeth?