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Contraception Editorial April 2009
A Call to Incorporate a Reproductive Justice Agenda into
Reproductive Health Clinical Practice and Policy
By: Melissa L. Gilliam, Amy Neustadt, and Rivka Gordon
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Incorporating a reproductive justice framework into health care practice has the potential to enrich provider education, increase access to health care for marginalized populations and enhance the quality of life for the greatest number of people. The clinical lens of reproductive justice gives health professionals a critical opportunity to connect family planning and other aspects of sexual and reproductive health with the disparities and complexities that impact our patients' lives.
To address these issues, the Section of Family Planning and Contraceptive Research at The University of Chicago, joined by a broad group of speakers, collaborating organizations and co-sponsors (see Appendix A), hosted an all-day conference entitled: Beyond Choice: Examining Reproductive Justice from Scholarship to Activism, on May 22, 2008. This conference was the first to bring scholars, clinicians and activists together to examine common issues related to reproductive justice. It also identified important opportunities for reproductive health practitioners to advocate for change in clinical practice, policy and education to promote reproductive justice for all women and girls.
What is the reproductive justice framework?
The reproductive rights framework has historically focused on protecting everyone's legal rights to abortion and contraception, and their freedom to make reproductive choices. In contrast, reproductive justice places the issue of reproductive rights within a social framework. This helps address the limited attention paid to diverse communities within the reproductive rights movement.1 Reproductive justice gives a voice to poor women, women of color, incarcerated women, immigrant women, female youth, women with disabilities and other women and girls on the margins who have been subject to reproductive coercion and discrimination. Reproductive justice extends beyond rights and choice to address historical, social and economic factors contributing to the disempowerment of women. These inequities are mediated through discrimination based on race, culture, socioeconomic status, gender identity, sexual orientation, immigrant status, religion, age and other factors. Furthermore, they contribute to poor reproductive health outcomes and threaten a woman's decision making regarding her body, her family and her community.
Reproductive justice has deep historical roots. It draws on the history of slavery, civil rights and coercion relating to sterilization and contraception.2 It encompasses current discrimination experienced by diverse communities such as women living with drug addictions, disabilities or in impoverished communities. Women of color have largely led this movement by connecting social justice issues with reproductive health. In the 1960s and 1970s, women like Shirley Chisholm and Frances Beal worked with others in feminist and mainstream reproductive rights organizations to shift the reproductive rights discourse to address the breadth of social justice issues that affect women, such as access to health care, child-care and economic opportunities.3 Women from Latina and underserved communities also mobilized against acts of reproductive coercion, such as sterilization abuses, which ultimately led to tougher sterilization guidelines that continue today.3
The definition and relevance of reproductive justice have been advanced over the past few decades through conferences, consensus statements and the work of national advocacy organizations. For example, the International Conference on Population and Development held in Cairo, Egypt and the Millennium Development Goals strongly endorsed the broad definition of sexual and reproductive health and rights.4,5 Women of color-led advocacy organizations such as African American Women Evolving, Asian Communities for Reproductive Justice, The SisterSong Women of Color Reproductive Health Collective and many others have promoted, articulated and advanced the reproductive justice agenda.
Why is the reproductive justice framework useful and relevant to clinical practice and policy?
Reproductive justice provides a fresh framework that gives context and perspective to the underlying social injustices and daily obstacles preventing low-income women, women of color, youth, immigrant women and women with disabilities from seeking necessary reproductive health care including family planning, abortion care and routine preventive services.
- Barriers to contraception: While highly effective methods of contraception are available, women from vulnerable populations face multiple personal, economic and social barriers to using available methods. Lack of contraceptive insurance coverage and lack of money to purchase contraception, lack of contraceptive knowledge, or fears about contraceptive side effects or complications may disproportionately affect low-income women and women of color.6,7,8 Other populations such as women with disabilities also face unique barriers to using contraception. Studies show disabled women are not routinely offered contraception or educated about contraceptive options thoroughly because they are erroneously presumed to be asexual.9,10 Additionally, many youth have received abstinence-only education which has been determined to be woefully inadequate for promoting safe sexual behaviors.11,12
- Lack of access to infertility treatment: New infertility therapies often make headlines but rarely as an integral part of reproductive justice. Due to disproportionate rates of sexually transmitted infections (STIs), tubal factor infertility rates are 1.5 to 2 times higher among African-American women.13 Yet, in vitro fertilization, originally designed to address tubal factor infertility, is predominately used by white women with incomes greater than 300% of the poverty level.13 Thus, women of color and women with limited resources do not have equal access to techniques that would enable them to bear children when they face impaired fertility.
- Low rates of general reproductive care: Lack of access to reproductive care is a reproductive justice issue influenced by economic, health care system and social barriers. Many recent immigrant populations are less likely to access needed or preventive reproductive services (breast exams, physical exams, family planning visits, prenatal care and pelvic exams) which can result in high rates of STIs, including HIV/AIDS and higher rates of reproductive tract cancers.14,15,16 Additionally, Latinas who have recently immigrated have better pregnancy outcomes than the general population it becomes equal to or worse than the general population as they live in the US longer.14 Experiences of discrimination or stigmatization, fear of legal actions such as deportation or prison, and cultural and linguistic barriers impede access.17,18 Similarly, due to clinicians' limited knowledge about their unique sexual and reproductive needs and lack of specialized facilities and equipment to perform gynecological examinations and procedures, women with disabilities often do not receive appropriate gynecologic care.9,19
- Accessing abortion care: The legal right to abortion is necessary but not sufficient for ensuring reproductive justice. Federal and state laws have disproportionately burdened young, rural, undocumented, poor women and women of color. Populations that rely on federal funding to cover health care costs such as Native Americans, prisoners, federal health workers, members of armed forces, and low-income women are currently denied federal coverage of abortion because of the Hyde Amendment.20,21 In 21 states, pregnant teenagers are forced to obtain parental or court approval to obtain an abortion which infringes on their reproductive rights.21
- Abortion stigma: As depicted in Faith Pennick's film Silent Choices, abortion-related stigma and shame and perceptions that abortion is associated with genocide are pervasive in certain communities and are important aspects of reproductive justice.22 For example, an African-American or Latino woman may not seek an abortion or delay an abortion because she fears negative reactions to the abortion by her family or religious community.
- Sexual violence: A major social issue, sexual and physical abuse, has been connected with negative reproductive health outcomes: unintended pregnancies, STIs and inconsistent contraception use.23,24 Sexual violence can affect reproductive decision making among women. For example, a woman may be forced into an abortion or a pregnancy by her partner within the context of an abusive relationship. Yet, the number of reproductive health practitioners who routinely ask about and screen for violence is disappointingly low.24
The multiple, social, economic and personal factors that make up the reproductive justice framework have concrete clinical implications:
- Higher rates of unintended pregnancy among women of color and poor women.25,26
- Low rates of prenatal and late entry into prenatal care among low-income populations, women who use illegal substances, Latinas and teenagers.27,28,29,30
- High rates of STIs and HIV among certain segments of the population: African-American women, Latina immigrants and incarcerated populations.16,31,32
- Low rates of routine preventive care among Latinas which can lead to life-threatening conditions such as cervical cancer and infertility.14,17,18
- Delays in seeking abortion which carry medical and economic consequences.21,33
How can clinicians use the reproductive justice framework to advance reproductive justice?
The clinical lens of reproductive justice exposes the real-life connections between family planning and other aspects of sexual and reproductive health (infertility services, safe and healthy pregnancies, and promotion of healthy sexuality), and interrelated social and environmental issues (poverty, access to care and insurance, domestic violence, low resource neighborhoods, stigma and substance abuse). As clinicians, members of national professional organizations and academic researchers, we can play an influential role in protecting reproductive justice. Through our work in professional organizations, we can raise awareness and promote education of a reproductive justice framework and incorporate reproductive justice into medical education curricula. When called upon by the media or policymakers, we can address the social and economic realities that hinder our patients' sexual and reproductive rights. We can promote clinical practices and public policies to ensure that our patients have the necessary medical, social and educational resources to have healthy families, if and when they want and live in a culture that supports healthy communities. Furthermore, as academic researchers, we can work closely with advocacy organizations committed to reproductive justice to develop shared policy messages and expand our research agendas to explore the underlying reasons for disparities in reproductive health outcomes among women.
Adopting a reproductive justice agenda calls upon us to:
- Advocate for policies and/or practices that enable marginalized populations to access early prenatal care, and promote policies and clinical practices that facilitate needed family support like child-care, housing stability and transportation.
- Address the role of abortion-related stigma and shame in our clinical practices through improved staff education on compassionate and culturally competent abortion counseling.
- Promote policies that expand coverage to the under- and uninsured and reduce linguistic and cultural barriers to care.
- Develop tools to screen for sexual violence and abuse and improve clinician training on using the tools.
- Remove the attitudinal and structural barriers (lack of proper equipment, examination tables and specialized knowledge) that limit contraceptive and reproductive care and access to women with disabilities.
- Promote increased investment in reproductive and sexual education by redirecting abstinence-only education to comprehensive sexual education that includes HIV and STI prevention, contraception, pregnancy planning, fertility and partner/domestic violence.
Dorothy Roberts, J.D., Kirkland & Ellis Professor of Law at Northwestern University; Christine Stansell, Ph.D., Professor in the Department of History at The University of Chicago; Toni Bond Leonard, African American Women Evolving; Lisa Harris, M.D., Ph.D., Assistant Professor in the Departments of Obstetrics and Gynecology and Women's Studies at The University of Michigan; Lori Chaitin, J.D., Director of the Reproductive Rights Project at the ACLU of Illinois; Heather Boonstra, M.A., Senior Policy Analyst, Guttmacher Institute; Elena Gutierrez, Ph.D., Professor of Gender/Women's Studies at the University of Illinois at Chicago; Gaylon Alcaraz, Executive Director of the Chicago Abortion Fund; and Cassing Hammond, M.D., Director of Family Planning at Northwestern University.
Melissa Gilliam, M.D., M.P.H., Associate Professor and Chief, Section of Family Planning at The University of Chicago; Rivka Gordon, Director of Strategic Initiatives, Association of Reproductive Health Professionals.
Center for the Study of Race, Politics and Culture at The University of Chicago; Association of Reproductive Health Professionals; Center for Gender Studies at The University of Chicago; The Fellowship in Family Planning; National Women's Health Network; National Latina Institute for Reproductive Health; Office of Community Affairs at The University of Chicago; Physicians for Reproductive Choice and Health; Chicago Foundation for Women; and Department of MedicineHealth Disparities Collaborative at The University of Chicago.
Melissa L. Gilliam
Section of Family Planning, Department of Obstetrics and Gynecology
The University of Chicago
Section of Family Planning, Department of Obstetrics and Gynecology
The University of Chicago
Association of Reproductive Health Professionals
- Ross L. Understanding Reproductive Justice. Atlanta (Ga): SisterSong Women of Color Reproductive Health Collective; 2006.
- Roberts D. Killing the Black Body: Race, Reproduction and the Meaning of Liberty. New York: Vintage; 1998.
- Nelson J. Women of Color and the Reproductive Rights Movement. New York: New York University Press; 2003.
- Programme of Action of the United Nations International Conference on Population and Development. [cited December 4, 2008]; Available from: http://www.iisd.ca/Cairo.html 1994.
- United Nations Millennium Development Goals 20052008 Reports. [cited December 4, 2008]; Available from: http://www.un.org/millenniumgoals/reports.shtml.
- Frost J, Singh S, Finer L. Factors associated with contraceptive use and nonuse, United States, 2004. Perspec Sex Reproduc Health. 2007;39:9099.
- Improving Contraceptive Use in the United States. In: In Brief: Series. 2008. Guttmacher Institute; 2008.
- Forrest J, Frost J, The family planning attitudes and experiences of low-income women. Family Planning Perspectives 1996;28:246-55, 277.
- Lipson J, Rogers J. Pregnancy, birth, and disability: women's health care experiences. Health Care Women Int. 2000;21:1126.
- Thomas C, Curtis P. Having a baby: some disabled women's reproductive experiences. Midwifery. 1997;13:202209
- Lindberg L, Santelli J, Singh S. Changes in formal sex education: 19952002. Perspect Sex Reprod Health. 2006;38:182189.
- Trenholm C, et al. Impacts of Four Title V, Section 510 Abstinence Education Programs. Final Report. Princeton (NJ): Mathematica Policy Research, Inc.; 2007.
- Jain T, Hornstein M. Disparities in access to infertility services in a sate with mandated insurance coverage. Fertil Steril. 2005;84:221223.
- Access to Health-Care and Preventive Services Among Hispanics and Non-Hispanics United States, 20012002, in MMWR: Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention.
- Cancer - United States Cancer Statistics (USCS) Data 2004 U.S. cancers by type. Atlanta (Ga): Centers for Disease Control and Prevention; 2008.
- HIV/AIDS among Hispanics/Latinos. In: CDC HIV/AIDS Fact Sheet. Atlanta (Ga): Centers for Disease Control and Prevention; 2007.
- Jones M, Cason C, Bond M. Access to preventive health care: is method of payment a barrier for immigrant Hispanic women?. Womens Health Iss. 2002;12:129137.
- Carrasquillo O, Carrasquillo A, Shea S. Health insurance coverage of immigrants living in the United States: differences by citizenship status and country of origin. Am J Public Health. 2000;90:917923.
- Mingus M. Disabled women and reproductive justice. [cited October 1, 2008] http://www.protectchoice.org/article.php?id=140.
- State funding of abortion under Medicaid. In: State Policies In Brief. New York: Guttmacher Institute; 2008.
- Boonstra H. The heart of the matter: public funding of abortion for poor women in the united states. In: Guttmacher Policy Review. New York: Guttmacher Institute; 2007.
- Pennick F. Silent Choices. 2007; USA.
- Gazmararian JA, et al. Violence and reproductive health: current knowledge and future research directions. Matern Child Health J. 2000;4:7984.
- Moore M. Reproductive health and intimate partner violence. Fam Plann Perspec. 1999;31:302306.
- Santelli J, et al. The measurement and meaning of unintended pregnancy. Perspect Sex Reprod Health. 2003;35:94101.
- Cubbin C, et al. Socioeconomic and racial/ethnic disparities in unintended pregnancy among postpartum women in California. Matern Child Health J. 2002;6:237246.
- Gazmararian JA, et al. Prenatal care for low-income women enrolled in a managed-care organization. Obstet Gynecol. 1999;94:177184.
- Egerter S, Braveman P, Marchi K. Timing of insurance coverage and use of prenatal care among low-income women. Am J Public Health. 2002;92:423427.
- CDC . Home: adolescent reproductive health. [cited August 22 2008] http://www.cdc.gov/reproductivehealth/AdolescentReproHealth/index.htm.
- Knight M, Plugge E. The outcomes of pregnancy among imprisoned women: a systematic review. Int J Obstet Gynecol. 2005;;112:14671474.
- Franklin C, Fearn N, Franklin T. HIV/AIDS Among female prison inmates: a public health concern. Calif J Health Promotion. 2005;3:99112.
- HIV/AIDS among women. In: CDC HIV/AIDS Fact Sheet. Atlanta (Ga): Centers for Disease Control and Prevention; 2008.
- Henshaw SK. Factors hindering access to abortion services. Fam Plann Perspec 1995;27:54-9, 87.
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Used with permission from Elsevier, Inc.