Reproductive Justice as a Framework for Abortion Care

Abstract

This article presents an in-depth analysis of abortion access and rights within the Reproductive Justice framework, underscoring the health, social, and economic consequences of limited access. It emphasizes the critical role of abortion as essential, safe healthcare and highlights the complexities surrounding abortion decisions and the barriers faced by poor and historically marginalized populations. Amid the escalating access restrictions, the article concludes with a call to action for Obstetricians and Gynecologists and our allied healthcare providers to recognize, support, and advocate for safe, legal, and affordable abortion services as fundamental to healthcare equity and human rights.

Introduction:

In the wake of the Dobbs v. Jackson Women’s Health Organization ruling, a landmark decision of the U.S. Supreme Court in which it was determined that the Constitution does not confer a right to abortion, the landscape of abortion access in the United States was left standing at a crucial crossroads. Since the ruling, almost half of U.S. states have imposed rigorous restrictions or banned access to abortion. These restrictive measures will inevitably hinder access to abortion, thereby increasing the risk of detrimental outcomes in reproductive health, exacerbating maternal mortality, and furthering socio-familial harms.

Historically, the discourse around abortion rights was limited to reproductive rights and autonomy. The consequential policy changes and legislative battles have rendered abortion, post-Roe, less accessible to marginalized people.¹ Now, there is a growing movement within our specialty advocating for a paradigm shift towards a comprehensive approach that embraces Reproductive Justice (RJ) which affirms the right of everyone to make decisions about their body, family, and life through a comprehensive framework that connects reproductive health, human rights, and social justice. ²

In this article, we will discuss the abortion landscape using the reproductive justice lens, analyzing societal elements that infringe upon reproductive freedom, describing the implications of being denied access to safe and legal abortion. Through this framework we will also highlight the ways intersectional identities can further marginalize special populations at risk of unintended pregnancy.

The Reproductive Justice Framework: An Evolution within the Reproductive Rights Movement

“When facing an unplanned pregnancy, if you have good answers to those human rights concerns like job security, educational opportunities, a decent place to raise your child, to house your child, to feed your child, then many people dealing with an unplanned pregnancy may turn that unplanned pregnancy into a child. But if you have bad answers to those human rights concerns, then that increases the likelihood of turning that unplanned pregnancy into an abortion.”³

- Loretta Ross

Loretta Ross, one of the progenitors of the RJ movement, describes the complex interplay between human rights and reproductive decision. Reproductive rights advocacy has not always focused on the way socioeconomic conditions influence reproductive choices. The journey toward reproductive freedom in the U.S. has witnessed several significant movements over the past 150 years. Each has built upon the last, extending our understanding reproductive rights, and culminating in the creation of the RJ framework that is central to today’s discourse and activism.

In the 1870s, the “Voluntary Motherhood” movement marked the beginning of this journey as white women began to assert their right to consciously choose motherhood. ⁴ This initiative was followed by the birth control movement in the 1910s and 1920s concurring with other movements such as socialism, feminism, and eugenics. Later, the family planning and women’s liberation movements emerged, emphasizing future family planning and ultimately paved the way for federal funding for contraceptives. The 1970s-1980s reproductive rights movement centered on the right to choose abortion. ^4,5 However, these movements primarily reflected the interests of elite white women, leaving marginalized and vulnerable populations’ needs largely unaddressed.

The reproductive rights movement of the 1970s into the post-Roe era has been criticized for its narrow perspective, predominantly emphasizing individual reproductive autonomy through legal mechanisms. Recognizing the inadequacy of this approach, a group of Black women, including Lorretta Ross, convened in Chicago, in 1994 to devise their own, more inclusive, movement. They coined the term Reproductive Justice, creating a new framework that prioritized their lived experiences and those of other marginalized groups.

Reproductive Justice (RJ) is defined as the human right to maintain personal bodily autonomy, have children, not have children, and parent children in safe and sustainable communities. ⁶ It acknowledges that complex societal conditions, often shaped by systemic and structural challenges, that impact individuals’ reproductive autonomy and agency.² Reproductive Justice is a comprehensive framework that consider all aspects of reproductive healthcare beyond abortion rights. By embracing the RJ framework, we recognize that reproductive autonomy extends to all facets of reproductive life, including contraception, fertility treatment, prenatal care, childbirth, parenting support, and comprehensive sexual education. For example, a community facing high rates of maternal mortality and limited access to prenatal care can benefit from an RJ approach. Here, the focus isn’t only on the right to abortion but on the right to protect their own lives from bodily harm, and if they choose to have children, they must be able to parent them in a safe and supportive environment.

Through the RJ lens, essential healthcare services, like abortion, is recognized and protected as a human right. The RJ framework does not discount the importance of choice and access, but it moves beyond them as sole determinants of reproductive freedom. It emphasizes the necessity of improving access to reproductive healthcare for all people, and advocates for dismantling systems of oppression that hinder reproductive freedom based on race, gender identity, class, socioeconomic status, or sexual orientation. ⁷

Access Denied: Abortion Restrictions and the Health, Social and Economic Impact

Reproductive Justice advocates for the right to make a personal decision about one’s life, health, and future, which inherently includes the right to an abortion. For nearly five decades, the landmark case Roe v. Wade established legal protections for decisions related to abortion. Despite this protection, access to abortion has remained out of reach for many who need it. The recent Supreme Court recent decision to eliminate federal protection and provision for abortion access and the subsequent enactment of severe abortion bans by many state legislatures has significant implications for reproductive healthcare. By limiting access to abortion services, these measures potentially harm the health and welfare of individuals capable of pregnancy and undermine their reproductive autonomy.

Abortion Restrictions:

1). Waiting Periods

Policies like mandatory waiting periods and abortion bans impedes individuals’ right to access abortion care, especially impacting those in vulnerable positions. Mandatory waiting periods typically require individuals seeking an abortion to wait a predetermined period, usually between 24 and 72 hours, following state-mandated counseling before proceeding with the abortion. ⁸ These mandates are unnecessary as most people decide to get an abortion before they even see a doctor. Furthermore, the waiting periods unjustly burden economically disadvantaged groups by necessitating multiple visits.

The consequences of mandatory waiting periods are not inconsequential. First, appointment rescheduling conflicts due to inflexible work schedules coupled with physician shortages results in even longer wait times, sometimes leading individuals to surpass the gestation age limits for abortion procedures.⁸ Second, multiple visits to an abortion clinic can incur additional travel expenses, lost wages, and childcare costs exacerbating the financial strain for those already experiencing financial hardship.⁹ Restrictions like mandatory waiting periods not only delay access to care, but they also compound the financial obstacles associated with accessing an essential health service such as abortion, particularly for economically disadvantaged individuals.

2). Abortion Bans

Some abortion bans have many to travel across states lines seeking abortion in states with less stringent regulations. However, even in states where abortion bans may not be enforced, people could still face significant obstacles if their closest healthcare facility is in a neighboring state with stringent restrictions, potentially leading to an average increase in travel distances of 249 miles for residents in high-risk states (Figure 1).¹⁰ Such travel requirements make abortion inaccessible to many of those who need it and has the most profound effect on this historically marginalized people.

Figure 1.

Predicted travel distances from county population centroids to the nearest remaining abortion facility in the ANSIRH database under two post-Roe policy scenarios. Panel A, Travel distances if trigger bans take effect. Panel B, Travel distances if all high-risk states ban abortion.⁸

Reprinted from Contraception, Vol. 100, Caitlin Myers, Rachel Jones, Ushma Upadhyay, Predicted changes in abortion access and incidence in a post-Roe world, pp. 367–373, Copyright (2019), with permission from Elsevier. Also, reprinted from The Lancet, Vol. number, Author(s), Title of article, Pages No., Copyright (Year), with permission from Elsevier. This Agreement between Dr. Bianca Hall and Elsevier consists of license details and the terms and conditions provided by Elsevier and Copyright Clearance Center.”

3). Insurance Coverage Restrictions

Direct costs associated with abortion procedures and limited insurance coverage for abortion further complicate the economic impact of abortion restrictions. Policies like the Hyde Amendment, a 1976 law that limits federal funding for abortions, restricts access to abortion for individuals who rely on Medicaid or other federally funded insurance plans and those who serve in the military.¹ A major disadvantage of this policy is that it disproportionately affects poor and marginalized populations, as over half of abortions occur in those living below the federal poverty line and among marginalized individuals. ¹¹ Hyde Amendment regulations have also been harmful to Native American persons using Indian Health Service facilities. With 85% of these facilities neither providing nor referring for abortion, even in circumstances of sexual assault or incest, access to family planning and abortion has been significantly limited.¹ This limited access serves to exacerbate existing health disparities among Native American Communities. ¹

Upadhyay et al. examined patient self-pay charges for abortion during the period 2017–20. They found that the median patient charges for medication abortion were $560, first-trimester procedural abortion $575, and second-trimester abortion was $895. There was also substantial regional variation, with the South having lower costs, but also lower insurance acceptance. To put this into perspective, the Federal Reserve reports that a quarter of Americans are unable to cover a $400 emergency expense using solely their bank account balances.¹²

Even in states where abortion is legal, funding gaps impose barriers to access, often most impacting those from low-income communities.^9,13 For example, in Rhode Island, the Reproductive Privacy Act fails to fully address the needs of economically disadvantaged residents by restricting Medicaid abortion coverage to only covering abortion in the case rape and incest.¹³

The scarcity of government financial support for abortions has prompted nonprofit organizations to fill the gap, offering services like childcare, accommodation, and financial aid to navigate structural barriers⁹. Abortion funds may address structural barriers by providing childcare, lodging, and financial assistance to those who need it.⁹ The majority of abortion fund recipients in the southeastern United States are Black, uninsured or publicly insured, have a high school education, and are parents to at least one child.¹⁴ These demographics reveal the populations most affected by fluctuating abortion policies, highlighting the persisting inequities in abortion access.

Consequences:

The impact of these policies becomes evident when evaluating the health, social, and economic effects, particularly among the most vulnerable. Poor and marginalized populations are disproportionately affected by limited access to abortion, are also the most vulnerable to poor outcomes. This further exacerbates existing health disparities within the U.S.

1). Pregnancy Related Mortality and Adverse Birth outcomes

Abortion restrictions will cause more women to due to pregnancy related complications. Recent studies found that decreased access to abortion has been correlated with increase pregnancy-related mortality (Figure 2).^15–17 A total abortion ban in the United States is estimated to increase the number of deaths in the first year by 7% and the number of deaths in the subsequent years would rise by 21%.¹⁵

Figure 2.

Longitudinal trends in maternal mortality ratios by abortion restriction, 1995–2017¹⁷

2A – Plot of weighted mean maternal mortality ratio (deaths per 100,000 live births) through 42 days from termination of pregnancy for restrictive (orange), neutral (tan), and protective (blue) states from 1995 to 2017 from Global Health Data Exchange. Shaded areas represent 95% confidence interval (CI).

2B - Plot of maternal mortality ratio (deaths per 100,000 live births) through 42 days from termination of pregnancy for restrictive (orange), neutral (tan), and protective (blue) states from 1999 to 2017 from CDC WONDER.

“Reprinted from Contraception, Vol. 104, Amy N. Addante, David L. Eisenberg, Mark C. Valentine, Jennifer Leonard, Karen E. Joynt Maddox, Mark H. Hoofnagle, The association between state-level abortion restrictions and maternal mortality in the United States, 1995–2017, pp. 496–501, Copyright (2021), with permission from Elsevier. This Agreement between Dr. Bianca Hall and Elsevier consists of license details and the terms and conditions provided by Elsevier and Copyright Clearance Center.”

Black women and women without a college degree were more likely to have preterm births in states with restrictive policies.¹⁶ A comprehensive analysis of all U.S. births in 2016 indicated that Black women living in the least restrictive states were 8% less likely to have low birth weight than those living in the most restrictive states.¹⁸ The legalization of abortion in the United States in 1970 has been correlated with a decrease in infant mortality rates.¹⁹ These findings demonstrate that restrictive abortion policy is associated with adverse birth outcomes, preterm births, and increased mortality rates. Such findings highlight the adverse birth outcomes, preterm births, and heightened mortality rates linked to restrictive abortion policies.

2). Mental Health

The detrimental effects of anti-abortion policies extend beyond physical health, also significantly affecting mental well-being.²⁰. In comparison to women who received abortions, women who were unable to obtain abortions reported higher symptoms of anxiety, depression, and lower self-esteem.²⁰ Furthermore, a five-year prospective study found that women denied abortion had higher perceived stress levels and a lower level of emotional support than women who had abortions.²¹ These findings underscore the importance of abortion access in preserving women’s mental health.

3). Socioeconomic Outcomes

Being denied an abortion also has significant social impacts. Research has indicated that women who were denied abortions are more likely to remain in abusive relationships than those who received the procedure, potentially putting their lives and children at risk.^22,23 They also found it challenging to fulfill their long-term goals, including pursuing education, establishing a career, and attaining financial stability.^24,25 Women forced to carry an unwanted pregnancy to term were more likely to experience financial instability, which negatively affected their ability to provide adequate care and resources for their children. In addition, children born to women denied abortions had worse developmental outcomes.²⁶ Through an understanding of the detrimental impacts of denied abortion on mental health, intimate relationships, life ambitions, and the welfare of children, these research findings reinforce the importance of reproductive justice in ensuring that all individuals have access to safe, legal, and affordable abortion services is a critical aspect of advancing human rights.

Intersectional Identities, Stigma and Bias

The interplay between different identities and social positions plays a significant role in an individual’s experience and access to abortion care. This complexity becomes evident when examining special populations, where intersectionality - the interconnected nature of social categorizations such as race, class, and gender - creates unique challenges. Understanding and addressing these layered nuances is essential for equitable abortion care, especially for those who find themselves at the crossroads of various marginalized statuses.

1). Reproductive Coercion

At a health systems level, the intersectionality of race, gender, sexual orientation, and other personal characteristics frequently creates formidable barriers for individuals seeking abortion care. The stigmatization of abortions and implicit bias among healthcare providers can result in coercive or inadequately informed decision-making processes.⁹ Racial disparities in pregnancy options counseling and referral significantly impact how individuals interact with reproductive healthcare providers. ²⁷ For example, Black patients, are more likely to be attended by less trained providers, less likely to engage in comprehensive discussions about abortion, adoption, or other pregnancy options, and less likely to be referred for abortions compared to non-Black patients. ²⁷ Provider biases often leave Black women with unresolved needs for abortion and supportive services.

2). Special Populations

Complexity further arises when poverty intersects with other structural oppressions, disproportionately impacting racial and ethnic minorities, immigrants, LGBT+ individuals, people with disabilities, and women and children. Individuals living with disabilities are more likely to be encouraged by their provider to get an abortion over carrying a fetus to term.²⁸ At times, their decision-making capacity is removed due to power dynamics that are beyond their control contributing to mistreatment by the healthcare system.

Heteronormative structures and dynamics also perpetuate reproductive oppression. A recent study found that over one-third of transgender, nonbinary, and gender non-conforming people who had been pregnant had considered ending the pregnancy on their own without clinical supervision, due to a range of factors including lack of insurance coverage and affirming healthcare.²⁹

3). Criminalization

The undue criminalization of abortion continues to disproportionately threaten the safety of marginalized communities. Legislation like Texas law S.B. 8, does more than just restricts abortion care—it invites civilians to intrude on other’s personal reproductive decisions. An American Bar Association study examining cases from 2000–2020, identified approximately 60 cases where individuals were subjected to the carceral system because they allegedly self-managing an abortion or helping someone else to do so. In most cases, a trusted individual turned this information over to law enforcement (i.e., a healthcare provider, a friend, or a partner).³⁰ Although criminalization is often initiated and enforced by confidants, the laws that criminalize people seeking care are created at the federal, state, and local levels. Existing mistrust in public safety and health systems, especially among communities of color who are already subjected to over-policing and surveillance, is only amplified by such measures. In such an environment, it is paramount that RJ continues to guide efforts in protecting reproductive freedom for all individuals.

The complexities of intersectionality within reproductive healthcare stress the immediate necessity to champion for extensive, culturally aware, and unbiased care to ensure that all individuals have equitable access to abortion and other crucial reproductive health services, regardless of their unique societal positions.

Call to Action

As practitioners at the frontlines of reproductive healthcare, OBGYN physicians are uniquely positioned to counter the challenges that restrict access to abortion and influence the outcomes for those in need of these services. The evidence is clear: the multitude of barriers to abortion care, the resultant detrimental health outcomes, and the pervasive social inequalities underscore the urgency of our action. This is where the principles of RJ become pivotal. The RJ framework, focusing on the intersection of rights, health, and societal contexts, emphasizes the necessity for active and committed engagement in enhancing reproductive healthcare. We, therefore, call upon OBGYNs, allied healthcare providers, policymakers, and the public to adopt these action points for a more equitable and inclusive reproductive healthcare system.

Physicians/Healthcare Providers

1). Stay Informed on State and Local Policies

In the rapidly evolving landscape of abortion access, it is paramount for healthcare providers of all specialties to remain updated on state and institutional policies. Specifically, clinicians who serve populations at risk for unintended pregnancy need to fully comprehend how to provide appropriate support for patients seeking reproductive healthcare, including contraception and abortion.

2). Prioritize patient-centered conversation

Centering patient’s voices and experiences is crucial to combating reproductive coercion and oppression. The RJ framework emphases the right for individuals to have or not to have children, based on their own perspectives. Using patient-centered care models for abortion and contraceptive counseling will help to address some historical predatory and paternalistic practices. Additionally, providing comprehensive sex education and information on abortion within communities can help to combat stigma and ensure that all people are well-informed about their reproductive healthcare options.

3). Participate in advocacy efforts at all levels

Dismantling oppressive systems requires champions at all levels. While it is important to have qualified professionals advocating for abortion rights in Congress, it is equally as important to have educated advocates at the state and institutional level. Engaging in hospital committees, grassroots advocacy groups, and state legislature can advance the Reproductive Justice mission.

Conclusion

The Reproductive Justice (RJ) framework transcends traditional advocacy, offering a comprehensive lens through which to view abortion rights and access. This framework invites us to consider abortion not merely as a medical procedure, but as an integral aspect of comprehensive sexual and reproductive healthcare, firmly rooted in the broader context of social justice. As we confront ongoing legislative attacks on abortion rights and access, the relevance of the RJ framework becomes increasingly clear. It provides critical insights into the complex factors that shape decisions around abortion and can help dispel the enduring stigma associated with it.

We therefore call upon all patients, providers, policymakers, and the public to view abortion through the lens of Reproductive Justice, recognizing it as an essential aspect of comprehensive healthcare. It is through this perspective that we can begin to shift the narrative on abortion, moving beyond divisive rhetoric towards a more nuanced understanding of abortion as a complex social, economic, and healthcare issue. By adopting the principles of Reproductive Justice, we affirm our collective commitment to ensuring access to safe, legal, and affordable abortion care, and to fostering a more equitable society for all.