REPRODUCTIVE HEALTH THROUGH A JUSTICE LENS
As we move beyond Roe, we must center the experiences of people who are — and have been — most impacted by systemic inequities and injustices. Many gynecological techniques were developed using enslaved and immigrant women without proper consent or anesthesia. Abuses continue today with forced sterilization as recently as 2020, incentivized use of long-acting reversible contraceptives and resistance to remove them, and threats to parenthood (including differential referrals to child protective services). These abuses have been disproportionately imposed upon Black, Indigenous, and People of Color, low income people, those with disabilities, immigrants, LGBTQIA+ and incarcerated individuals (NPWF 2020, Owens 2017). This history continues to shape the perception of family planning services by marginalized individuals and communities (Thorburn 2005).
In response to this discriminatory history, Black communities have organized and developed frameworks to fight for their reproductive autonomy (Silliman 2004). The Reproductive Justice framework was named and conceptualized by 12 Black women in 1994, and it is defined by the SisterSong Reproductive Justice Collective as the:
- Right to maintain personal bodily autonomy
- Right to have children
- Right to not have children
- Right to parent the children we have in safe and sustainable communities
It is one of three distinct frameworks that together provide a complementary solution for addressing reproductive oppression: [1] Reproductive Health, [2] Reproductive Rights, and [3] Reproductive Justice. A Reproductive Health framework emphasizes access to the very necessary reproductive health services that people need. A Reproductive Rights framework is based on universal legal protections, and sees these protections as rights. A Reproductive Justice framework explains that reproductive oppression is a result of the intersections of multiple factors and is inherently connected to the struggle for social justice and human rights. It recognizes that people may have limited options regarding their pregnancy outcomes based on their race, gender, class, sexual orientation, and age. Reproductive experience occurs within a social, structural, political, environmental, and economic context that includes things like insurance, employment, food, safe water and air, and education. Supporting reproductive justice and bodily autonomy requires that we examine, understand, and improve the structural and social context in which people experience reproduction and parenting (Ross 2017, ACRJ 2022, Chrisler 2012).
Where reproductive health and rights are limited by a “pro-choice” framework, the reproductive justice framework draws on concepts of social justice, intersectionality, and other scholarly and intellectual work throughout Black history (NBWRJ 2022, BMMA 2020). Moreover, in contrast to the reproductive rights movement which was known to center the voices of cis-gender white, heterosexual women on the legal right to abortion (Nichols 2020), the reproductive justice movement is an expansive, transformational, and grassroots movement led by Black, Indigenous and People of Color to improve institutional policies and create systems changes that improve the reproductive lives of marginalized communities (NBWRJ 2022).
Given the historical devaluation of the childbearing of marginalized populations (Brandi 2018, Brown 2014), we must remain focused on providing care that is respectful of, and responsive to individual patient preferences and values (Gomez 2014) to ensure that patient preferences guide our clinical decisions (Institute of Medicine 2001). Our curriculum is informed by this history and lens.
DEFINING PREGNANCY DESIRES AND OUTCOME INDICATORS
Although researchers have been measuring unintended pregnancy for decades, the concept of pregnancy intention is complex, and unintended pregnancies are not created equally. The conventional approach of categorizing recalled pregnancy desires does not capture the complexities of patients’ desires, their experiences prior to pregnancy or the context in which a pregnancy occurs (Gomez 2019, Borrero 2015). Ambivalence, partner influence, and cultural perspectives all inform how patients feel about pregnancy intention (Aiken 2016).
There has been recent work on how to identify contraceptive needs in a person-centered way that does not rely on a framework of pregnancy intention or reproduce oppressive narratives (Samari 2020). In initiating sexual and reproductive conversations, it is important to ask for consent and honor a patient’s answer. Screening for self-identified service-needs, rather than pregnancy intention, is aligned with evidence for how people want to be asked about their reproductive needs (Manze 2020). How we focus our quality metrics will help us to stay focused on patients’ needs.
PROFESSIONAL ETHICS IN REPRODUCTIVE HEALTH
Prevention is increasingly recognized as the most effective means of ensuring health by initiatives such as Healthy People 2020 and U.S. Affordable Care Act. A comprehensive approach addressing patients’ pregnancy preferences is an essential component of prevention within a public health framework (Samari 2020, Taylor 2011). Primary care clinicians are uniquely positioned and have ethical responsibilities to provide reproductive health screening, pregnancy options counseling, contraceptive services, miscarriage management, and appropriate referral or provision of abortion services.
The provision of care may represent a greater ethical challenge to clinicians in countries that challenge the legal status of abortion or other services. Stigma can lead to different kinds of unethical behavior, including the refusal to provide abortion services to patients, alleging conscientious objection or religious directives, and discrimination against patients who may have complications of ectopic pregnancy or abortion, without tending to the obligation of preventing harm to patients for whose care they are responsible (Faundes 2016).
Medical institutions and training programs should also be transparent about their religious affiliations and the potential impact on health services at their institutions. Patients of reproductive age want information about a hospital’s religious restrictions on care when deciding where to go for reproductive care (Freedman 2018). Trainees want and deserve the same information. Growth in the religious health care sector demands an increasing need for transparency so that patients and trainees can make informed decisions.
COVID-19 AND ABORTION CARE
Most aspects of healthcare have been impacted by the COVID pandemic, and abortion care is no exception. Some states introduced legislation restricting abortion access by declaring it “elective” or “not medically necessary” for example. Numerous national and international organizations strongly opposed responses that cancel or delay abortion procedures, and explicitly classified reproductive health care as an essential health service that must be accorded high priority in COVID responses (Bayefsky 2020, Todd-Gerr 2020). Many providers pivoted rapidly towards innovative practice models streamlining diagnostic tests and contact between the patient and the healthcare system, and using telemedicine, mailing medications, and remote follow-up (Raymond 2020).