US Sexual and Reproductive Health Policy: Which Frameworks Are Needed Now, and Next Steps Forward

Sexual and reproductive health (SRH) is a key component of people’s overall health and quality of life. A variety of policies, programs, and services support individuals’ and communities’ attainment of SRH, including public health interventions at the national, state, and local levels; maternal and child health–related services; and access to the full range of SRH services, including contraception and abortion. Yet despite private and public investments in SRH, individual- and population-level outcomes in the United States continue to lag behind those of other nations and are marked by persistent and pervasive inequities.¹

The current US approach to SRH policy is inadequate to solve these problems. Well-intentioned efforts often fail, achieve only limited impact, are easily rolled back during times of political change, or even occasionally perpetuate harms.² Improving health outcomes and achieving equity will require a fundamental and holistic shift in how policymakers, clinicians, researchers, and the public understand and address these issues.

This article introduces two linked frameworks—sexual and reproductive health and well-being (SRHW) and sexual and reproductive health equity (SRHE)—that are intended to link and improve upon existing frameworks, including sexual and reproductive health, reproductive justice, and health equity.³ SRHW and SRHE frameworks bring a particular focus on patient-centered approaches and de-siloing of systems and issues, both necessary for achieving goals like enhancing reproductive autonomy and reducing maternal mortality.^4,5

Adopting SRHW and SRHE frameworks could provide a new paradigm for SRH policy in the United States, catalyze these needed changes, and ensure their durability as political winds and priorities shift. This article describes the initial development of these frameworks, their application to policy interventions, and next steps for improving public policy.

HOW THE FRAMEWORKS WERE DEVELOPED

The working definitions of SRHW and SRHE were framed as part of efforts to develop the Coalition to Expand Contraceptive Access (CECA) Recommendations for Achieving Universal, Equitable Access to Quality Contraception.⁶ Through reviews of the evidence and expert consultations, CECA determined that guiding principles, such as SRHW and SRHE, would be necessary to connect contraception to a larger US government purpose and mission, as well as to advance the goal of universal, equitable access.

To shape these new frameworks, CECA first conducted a comparative analysis of the foundational constructs that currently shape SRH care and policy. CECA reviewed relevant literature and compiled a crosswalk of key terms and frameworks, including health disparities, health equity, person-centeredness, and reproductive justice, and described definitions of these constructs, how they were developed, and the context in which they are currently used.^7–10

CECA then convened an interdisciplinary technical expert panel in spring 2020. Twenty-seven experts with relevant, diverse expertise—including SRH, reproductive justice, health equity, disability rights, LGBTQ+ (lesbian, gay, bisexual, transgender, queer, plus) health, public health, and familiarity with federal executive branch processes to expand contraceptive access—were selected to participate. Technical expert panel participants analyzed the relevance of various frameworks to federal policy, explored past and present federal actions to advance equity, and worked to develop a common framework for integrating reproductive health equity into government processes. Technical expert panel participants highlighted the important role that systems and structures play in equity, and in integrating a sexual health framing, particularly with respect to incorporating the perspectives and experiences of LGBTQ+ people. This resulted in CECA’s definitions of SRHE and SRHW presented in the next section, and the identification of these as key frameworks to develop and implement.

DEFINING THE FRAMEWORKS

SRHW is a self-defined state that includes reaching one’s individual sexual and reproductive goals. An SRHW approach necessitates framing aspects of policy and health care broadly, including a wide range of health services and social supports to de-silo clinical care, public health programming, and policy to reflect how people live and envision their health and well-being. The relevant policies, programs, and services that help people achieve SRHW include areas traditionally associated with SRH, including contraception and abortion, and also maternal and child health, fertility, childcare, paid leave, and housing, among others. Aligning work across these areas is consistent with how people envision their own health: a recent survey of 900 women regarding their health care priorities found that “Women view ‘women’s health’ as more than just reproductive health—it encompasses physical, mental, and emotional wellbeing.”¹¹ This approach is consistent with the reproductive justice focus on “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.”⁷

SRHE means that systems ensure that all people, across the range of age, gender, race, and other intersectional identities, have what they need to attain their highest level of sexual and reproductive health, and includes self-determining and achieving their reproductive goals. Government policy, health care systems, and other structures must value and support everyone fairly and justly.¹² An SRHE lens must be applied to all SRHW efforts, meaning that policies, programs, and services must account for historical and current forces that lead to inequities based on race, location, income, and other factors and center the needs of those who have been most harmed. SRHE would mean that these forces no longer limit individuals’ attainment of SRHW and that everyone is treated fairly and justly.

CECA’s technical expert panels and evidence analyses resulted in the call for an SRHW framework, focused on ensuring that all people have access to health care services that enable them to prevent and treat illness, experience the best health outcomes possible, and make the reproductive decisions that are right for them. Yet disparities in access to needed supports persist, exacerbated by the siloing of SRHW policies, funding streams, and infrastructure. Supports can be difficult to understand and navigate for federal agencies, states, health care systems, providers, and people seeking services.

HOW THESE FRAMEWORKS CAN BE APPLIED

How do we get to a place where historical and current forces that lead to inequities no longer limit individuals’ attainment of their highest level of SRH, which includes self-determining and achieving their reproductive goals?

Reframing Our Goals

In reframing national goals as SRHW and SRHE, a new paradigm for SRH policy would focus on (1) improving health outcomes and reducing inequities, including maternal mortality; (2) increasing bodily autonomy for all people, including those whose autonomy has historically been restricted, particularly Black, Indigenous, and people of color (BIPOC); and (3) reshaping the national conversation to define well-being holistically and not by the absence of disease and distress, but by the presence of sexual and reproductive fulfillment, pleasure, healing, and joy. Global models like The World Health Organization Framework for Ensuring Human Rights in the Provision of Contraceptive Information and Services offer promising models for integrating a systems approach but are still inadequate for achieving the changes needed, including a holistic understanding of well-being.¹³

Four principles can help guide such a fundamental paradigm shift.

Principle 1

Existing structures, systems, and processes must be examined and changed. To fundamentally change processes to reflect equity, we must reconsider the questions we ask and how we design, measure, interpret, and share the results. As part of this process, we need to redefine “evidence” in a way that emphasizes a broad range of voices, fields, and outcomes and does not reinforce systemic bias. We must also alter structures to enhance collaboration and communication. An equity-informed approach to research requires that we critically examine and confront research practices and structures rooted in systemic racism and oppression, and center the experiences, priorities, and needs of communities. One promising example that could be adapted to other areas is the work done to “decolonize” research with Indigenous communities.¹⁴

Principle 2

Inclusion must be prioritized. We must engage more diverse and new voices in a meaningful way that includes the power to make decisions. This means that professional and expert organizations, academic partners, and the federal government must invite end users and others not traditionally invited from the beginning, rather than as an afterthought. This includes patient partners, community-based organizations, and those who do adjacent work (e.g., reproductive health advocates partnering with doula organizations). This also includes demonstrating the value of stakeholders’ time by compensating participants and equitably dividing resources and funding among partner organizations. For many, this will be a cultural shift that can be supported by explicit guidance about who should be at the table and how they can be involved during every stage of the process.

Principle 3

Accountability must be built into the system and processes. Systems must be held accountable for demonstrating results and effectiveness that center equity. Guidelines, performance measures, and funding streams can be leveraged to drive equity, for example, through development of clinical guidance that centers the principles of SRHE and aligns patient-centered performance measures with payment. This would include involving patients and families in all phases of guideline development, consistent with best practices. Identifying patient and family values, preferences, and goals better enables guidelines to meet the needs of the individuals for whom they are intended and to avoid harm.¹⁵

Principle 4

Language and definitions must follow values. We must explicitly acknowledge historical context and harms and how they manifest today, be clear in our values and intention, and prioritize alignment between language use and behavior change. Contextualizing our work in history and within the context of people’s lives begins with consistent use of inclusive, equity-focused language and principles that resonate with diverse groups—particularly those historically marginalized, such as BIPOC, adolescents, people with disabilities, and LGBTQ+ people—and address issues in an intersectional way. In the case of CECA’s work, engagement with LGBTQ+ communities and experts in LGBTQ+ health led to the inclusion of “sexual” alongside “reproductive” in our conceptualization of SRHE. Similar engagement would likely lead to linguistic and framing adjustments in other organizations and efforts.

Translating the Frameworks Into Action

Translating SRHW into action requires a “whole systems thinking” and “health in all policies” approach that expands beyond a biomedical model of health to include aspects of life, such as economic stability and freedom from discrimination. Access to comprehensive health services, including noncoercive sexual health services, contraception, fertility care, and full-spectrum pregnancy-related care (i.e., abortion, miscarriage management, prenatal care, birth services, and postpartum care), is essential to an individual’s ability to exercise reproductive autonomy and improve health outcomes, as a recent National Academy of Medicine report emphasized.¹⁶ Social supports, such as quality child care and comprehensive paid family leave, are needed as well and have been shown to improve maternal and infant health, including physical health and well-being.¹⁷ Governments could adapt its structures to better apply an SRHW approach. At the federal level, this would necessitate sharing goals, norms, and progress across the many agencies and departments currently responsible for aspects of reproductive and sexual health and social supports, with oversight from the highest levels of government (i.e., Congress and the White House).

Translating SRHE into action requires acknowledging and understanding the multidimensional historical context of how inequity has structured the experiences of people with marginalized identities. Sexual and reproductive coercion has driven racial and gender oppression throughout US history, beginning with the violence of slavery, including forced procreation and sexual assault.¹⁸ Other examples include oral contraceptive trials on Puerto Rican people without informed consent and the state-sanctioned eugenic sterilization of Black, Latinx, and Indigenous people, and people with physical and intellectual disabilities.^19,20 These oppressions are not only in the past: coercive sterilization practices continue in both detention and correctional settings.¹⁹ Although there are limited examples of reflection on this history, such as Planned Parenthood’s reconsideration of Margaret Sanger’s legacy, the racist history of “family planning” has yet to be fully acknowledged; authentic truth and reconciliation has never taken place despite decades of scholarship, historiography, and advocacy.²¹ We must work to understand and redress the root causes of SRH inequities—particularly patriarchy, racism, colonialism, and capitalism—if SRHE is to be achieved.

To be in service of advancing SRHW and SRHE, we must shift the work away from some of the frameworks that have traditionally guided SRH work to more meaningful ones. This includes asking essential questions about what matters—which processes, structures, and outcomes are deemed important and thus considered worth funding and measuring. In the case of contraception, this has historically been the reduction of unintended pregnancy, which has been regarded as a proxy for women achieving their desired reproductive outcomes. A growing body of literature has questioned the validity of the unintended pregnancy framework and suggested alternative ways of conceptualizing reproductive health and well-being.^22,23 The unintended pregnancy framework should be replaced by more patient-centered outcomes and recognition that a spectrum of outcomes may be acceptable to people, dependent on their personal and social context. Measurement frameworks in contraceptive care are important for assessing quality and ensuring that this service is prioritized, as in other areas of health care, such as chronic disease management and preventive health screenings. Yet careful attention to centering bodily and reproductive autonomy in care delivery, with specific attention to inequities in care experience, is required. New measures to better understand sexual and reproductive well-being are in development and must be fully integrated to prioritize people’s experience of reproduction in a holistic and comprehensive manner.

These frameworks should also be integrated into the training and clinical care models adopted. Clinical practice, when (re)designed with an SRHW and SRHE approach, can both increase equitable access to SRH care for all people and improve the experience and expand the power of people who have experienced harm in the health care system and face the greatest barriers to care. The full scope of SRH services must be offered in as many settings as possible, and clinicians and clinical teams should be competent to provide patient-centered and trauma-informed SRH care broadly, not just contraception.

CONCLUSION

In the absence of new frameworks, public and private work to improve health outcomes and reduce inequities will continue to miss the mark. Frameworks provide an opportunity to ground our work in shared values and evidence and enable transparency and accountability. CECA’s experience has demonstrated the feasibility of applying the principles of SRHW and SRHE to policy work, and these models also have the promise to transform research and clinical practice. Fully developing and adopting SRHW and SRHE frameworks could catalyze needed changes, enhance their relevance and accountability to communities, and lead to enduring impact. As all aspects of health care, including SRH, seek to minimize harm and maximize justice, it is necessary to continually examine the underlying frameworks that guide all work.