Abstract
The Supreme Court decision to overturn Roe v. Wade and the growing onslaught of state laws that criminalize abortion are part of a long history of maintaining White supremacy through reproductive control of Black and socially marginalized lives.
As public health continues to recognize structural racism as a public health crisis and advances its measurement, it is imperative to explicate the connection between abortion criminalization and White supremacy.
In this essay, we highlight how antiabortion policies uphold White supremacy and offer concrete strategies for addressing abortion criminalization in structural racism measures and public health research and practice. (Am J Public Health. 2022;112(11):1662–1667. https://doi.org/10.2105/AJPH.2022.307014)
“One of the key problems addressed by Reproductive Justice is the isolation of abortion from other social justice issues that concern communities of color: issues of economic justice, the environment, immigrants’ rights, disability rights, discrimination based on race and sexual orientation, and a host of other community-centered concerns.”
—Loretta Ross, “What is Reproductive Justice”1
Across the country, public health agencies and academic institutions are following the lead of health equity scholars and the charge from the Centers for Disease Control and Prevention to recognize and confront racism as a core driver of health inequities. As the public health field continues to work toward addressing structural racism as a public health crisis and as we enter a post-Roe era, conceptualizing and connecting antiabortion policies as structurally racist and rooted in White supremacy is fundamental to advancing health equity.
Abortion criminalization aligns with the undercurrents of structural racism through both whom it disproportionately impacts and how power is wielded to erase, suppress, and threaten the livelihoods of racially minoritized communities. There were a record-breaking 108 state laws enacted in 2021 that criminalized abortion, including gestational age bans, restrictions on medication abortion, trigger bans that automatically banned abortion when Roe was overturned, and “Texas-style” bans that rely on bounty-hunter enforcement mechanisms.2 This follows decades of laws such as the Hyde Amendment that prohibit federal funds from covering abortion services and undermine abortion rights and access for pregnant people in federally funded programs, including 7.8 million people on Medicaid, half of whom are people of color.3
This has made the legal precedent of Roe a minimal baseline that has failed to protect abortion access for all. For all public health professionals and all people concerned with the ties between social injustices and health, it is crucial to consider how these policies of reproductive control uphold White supremacy both historically and contemporarily.
Abortion criminalization is an overlooked dimension of state control in existing measures of structural racism. Structural racism refers to the “state-sanctioned and/or extralegal production and exploitation of group-differentiated vulnerability to premature death”4(p28) that works through “mutually reinforcing inequitable systems.”5(p1454) Structural racism is sustained through White supremacy, which is the system of conditions and ideologies that underscore the hegemony of whiteness and White political, social, cultural, and economic power.6
In this essay, we provide a historical overview of how the origins of antiabortion policies are rooted in White supremacy and outline the current disastrous public health effects of abortion criminalization. A guiding framework for understanding abortion criminalization as rooted in White supremacy is reproductive justice, which was coined by Black women in 1994 as the right to maintain personal bodily autonomy, have children, not have children, and parent children in safe and sustainable communities.7 Following the lead of Black feminists and reproductive justice scholars,7,8 we propose an intersectional9–11 approach to measures of structural racism in the public health literature that makes the critical connections between abortion criminalization and the other interrelated dimensions of structural racism that maintain White supremacy.
HISTORY OF WHITE SUPREMACY AND REPRODUCTIVE CONTROL
The policing of bodies of pregnant-capable people racialized as Black is central to the historical perpetuation of White supremacy, starting with the forced reproduction of women who were enslaved. After 1808, when slaveholders could no longer rely on the international slave trade, the expansion and sustaining of slavery depended on the reproduction of those already enslaved.12 This gave enslavers an economic incentive to control and govern Black women’s reproduction because the law made the enslaved women’s children the property of the enslaver.13 As Dorothy Roberts explains, “it marked Black women from the beginning as objects whose decisions about reproduction should be subject to social regulation rather than to their own will.”13(p23)
Indeed, some of the first laws in the United States involved control over enslaved women’s reproduction, and the country’s legal system was built off this racial and gender subjugation.13 Critically, women who were enslaved were not passive victims of this reproductive control and practiced resistance using methods of birth control and abortion to resist the oppressive conditions of slavery that, if discovered, were punished by slaveholders.14
Whereas this controlled reproduction laid the foundation of the US legal system, medical experimentation on and violence against women who were enslaved were the foundation of the medical field, particularly obstetrics and gynecology. The career of J. Marion Sims, recognized as the “father of American gynecology,” was entirely built on the grotesque obstetric and gynecological experimentation on enslaved women, specifically Anarcha, Betsey, and Lucy.15 Years later, the medical and public health fields contributed to the state-sanctioned strategy of eugenics and forced sterilization to maintain White supremacy through reproductive control.
The 20th-century eugenics movement supported forced birth for “socially desirable” women through racist, classist, and ableist standards while simultaneously implementing a widespread campaign of involuntary sterilization among Black, poor, immigrant, and incarcerated women.13 This abuse continued with the involuntary sterilization of between 25% and 50% of Indigenous women in the 1970s by the federal government via the Indian Health Service.16 The impact of the scale of this government-sponsored reproductive coercion cannot be understated. It is estimated that in 1972 alone the federal government funded 100 000 to 200 000 sterilizations, which is an annual number equivalent to the estimated total number of all sterilizations carried out during Hitler’s reign in Nazi Germany under the Nazi Hereditary Health Law.17
To this day, as evident with recent laws and policies, White supremacy continues to operate through reproductive control of certain lives. One example is family cap policies that deny additional assistance to families who have another child while receiving Temporary Assistance for Needy Families benefits. These policies are rooted in racist narratives that mothers have more children to qualify for more public assistance.13 Since their introduction in the 1970s, these family cap policies that discourage childbearing have received bipartisan support, disproportionately affect Black families, and wield societal “ideals” of family size unto Black communities.13
A second example is the increasing number of state laws that aim to prosecute people for drug use during pregnancy, which serves as another mechanism of reproductive control.18 Black women are more likely to be screened for drug use during pregnancy, reported to child welfare authorities, lose custody of children, and face criminal prosecutions than women in other racialized groups.18
A final example of how White supremacy is wielded through policies of reproductive control is seen in our immigration system, with the high rates of hysterectomies performed on individuals detained by Immigrations and Customs Enforcement, abortion bans for unaccompanied minors in detention, mistreatment of pregnant immigrants in detention, and forced separation of families at the border.19,20 These anti-immigrant policies utilize reproductive coercion to control the reproductive agency of immigrants and punish migrants with the goals to deter future immigration and maintain White demographic and political power.19,20
ANTIABORTION LEGISLATION
The original laws that criminalized abortion intended to ensure that the United States remained a White nation.12 The first antiabortion laws enacted in the 19th century made abortion illegal and criminalized midwives, who were primarily Black and Indigenous and provided the majority of reproductive health care including abortion.21 The campaign was led by physicians to consolidate power and medical legitimacy among White, male doctors and to ensure demographic stability and dominance of White Anglo-Saxons.21–23
Whereas these laws are historically grounded in maintaining White political power through childbearing of White offspring,23 the current onslaught of antiabortion legislation is also part of a long history of criminalizing bodily autonomy, especially for Black, Indigenous, migrant, disabled, working-class, and trans people who experience the harshest effects of antiabortion laws.24 Recent laws such as SB8 in Texas, which deputizes civilians to police each other’s reproductive decisions, harken back to the Fugitive Slave Act, which deputized citizens to aid in the capture of enslaved people who were seeking freedom.25 Laws such as SB8 increase the surveillance and carceral power of the state, adding to the existing harms of surveillance and policing that already disproportionately criminalize, punish, and disrupt access to multiple social determinants that affect the health of undocumented, Black, Indigenous, and low-income communities.24,26,27
PUBLIC HEALTH EFFECTS
There have already been upwards of 1200 people arrested, disproportionately Black, Latinx, Indigenous, and working-class individuals, because of their pregnancy outcomes (e.g., stillbirth, miscarriage, abortion) since 1973, the year Roe was decided.28,29 A recent harrowing example of this increasing criminalization was the arrest of a Latina woman in Texas who was charged with murder after seeking care at a hospital whose staff reported her to the police for allegedly self-managing an abortion.30
This expansion of the carceral state further into our health care systems is detrimental to public health. The adverse population health effects of policing and incarceration, both within and outside the health care system, are well documented.31,32 Beyond the impact on individuals and families who are criminalized for seeking pregnancy care, these laws have collateral effects that can contribute to larger patterns of racism-related daily stressors among Black and other minoritized women that have serious health consequences.33,34 Medical and public health professionals cannot be complicit in this expansion of the carceral state but, rather, should mobilize around abortion criminalization as a public health crisis that is grounded in White supremacy and has deleterious effects on population health inequities.
As argued by birth equity scholars in an amicus brief for the Dobbs v. Jackson Women’s Health Organization case that overturned Roe, abortion criminalization directly contributes to the profound disparities in maternal health in the United States.35 Evidence suggests that abortion restrictions contribute to rising US maternal mortality.36–38 Overturning Roe is estimated to lead to a 21% increase in the number of pregnancy-related deaths overall and a 33% increase among Black pregnant people because there are higher risks in pregnancy relative to abortion.39
Abortion bans not only restrict access to essential health care but can also have destructive implications across the life course and wide-reaching effects on families and communities as a result of the negative economic and health consequences of being denied an abortion.40,41 People denied a wanted abortion have experienced increases in household poverty, debt, and evictions and elevated levels of anxiety and stress, and their existing children have shown worse child development than children of people receiving a wanted abortion.41–43
Alongside increasing economic inequality and the rising costs of housing, food, and health care, abortion restrictions continue to suppress the socioeconomic power of families and communities to make decisions that are aligned with their wishes and abilities to reproduce in safe, supportive environments. It is critical to consider laws restricting or criminalizing abortion as part of the larger web of structural racism that leads to population health inequities, particularly when considering reproductive, maternal, infant, and child health outcomes.
ABORTION CRIMINALIZATION AND STRUCTURAL RACISM
Recent studies have advanced our epidemiological approaches toward examining multiple interconnecting political, economic, and social forces that maintain White supremacy and perpetuate population health inequities.44–52 These distinct analytic approaches (e.g., indices, latent constructs) generally include similar dimensions indicative of social determinants of health (e.g., racialized inequities in education, employment, homeownership, and political participation) that reflect the structural limitations of bodily autonomy dictating where minoritized people can live, work, vote, learn, and raise families in safe and healthy environments.
Most of the common structural racism measures capture area-based inequities, but it is also important to consider the laws and policies that either explicitly or implicitly contribute to population health inequities.49,52,53 Although separate measures of racial and gender oppression have been introduced,49 it is critical to include antiabortion laws as a dimension of the underlying forces of structural racism given the disproportionate individual and population-level health effects of abortion restrictions as well as the racist justifications and implications of these restrictions. Recognizing abortion criminalization as a key component of the system that perpetuates structural racism allows for a more complete interrogation of the institutional connections that maintain White supremacy.44
States have been conceptualized as racializing institutional actors that play critical roles as legal and administrative entities to shape population health.49,50,54 According to the Guttmacher Institute, 26 states either had laws in place to ban abortion or were likely to ban abortion once Roe v. Wade was overturned on June 24, 2022.55 Using the most recently available data from all sources (Table A, available as a supplement to the online version of this article at http://www.ajph.org), we mapped common measures of structural racism (e.g., index of concentration at the extremes, education and employment inequity) and racist policies to show the glaring overlap between structural racism measures and abortion hostility at the state level. States that are hostile to abortion also pass policies that gut welfare and the social safety net, restrict voting access, and involve high levels of racialized inequities (Figure A, available as a supplement to the online version of this article at http://www.ajph.org).
Most measures of structural racism focus on political and socioeconomic patterns of exclusion and suppression embedded in American institutions; however, missing from these measures are the reinforcing ways in which bodily and reproductive autonomy is structurally limited. Abortion criminalization is central to the intersecting oppressive systems that undergird the US racial hierarchy.
PUBLIC HEALTH MOBILIZATION
Abortion criminalization has and will continue to have devastating public health implications. The public health field must heed the calls of reproductive justice advocates and scholars to examine and address structural determinants of reproductive health in our research, advocacy, and clinical care.56 The public health critical race praxis offers multiple approaches for doing so.57 Namely, we must first acknowledge our field’s historic and contemporary complicity and perpetuation of racist policies of reproductive control, coercion, and harm. Beyond this acknowledgment and repair, there are several actions public health professionals can take to, at a baseline level, interrogate and disrupt the White supremacy embedded in abortion criminalization and, most necessarily, mobilize with communities to advance reproductive health equity and justice.
Measurement
Conceptualizing abortion criminalization laws as a measure of structural racism meets recent calls to capture the intersectionality, historical, and geographic contexts to improve the measurement of structural racism.50 In addition to a stand-alone measure, abortion criminalization laws could be included in multidimensional measures of structural racism to more fully capture the multifaceted, intersecting webs of structural racism and its impact on population health. Particularly when studying reproductive health inequities, it is important to understand the potential compounding effects of racial, gender, and class oppression to develop multifaceted interventions for structural change.58 In accord with the public health critical race praxis, the individuals and communities directly affected by this structural violence must be centered and lead the knowledge production of how White supremacy is enacted through abortion criminalization.57
Data
The lack of funding (e.g., from the National Institutes of Health and the Centers for Disease Control and Prevention) for abortion-related research and large gaps in abortion surveillance data in the United States further uphold the process of science that reinforces White supremacy and limits advances in structural approaches to achieving equitable access to abortion. Following previous calls, we need timely public health indicators for abortion access and a public health abortion surveillance system that respects the confidentiality of abortion clients and providers.59 Together, data and measurement will allow the public health field to develop antiracist methodologies and strategies to disrupt these structural limitations to bodily autonomy. In addition, and central to the public health critical race praxis, it is critical that we share these data and findings with community advocates.
Action
Most important, public health professionals should leverage their political capital and public health training to support local and state efforts to protect and fund abortion access while uplifting reproductive justice activists and abortion funds who have been fighting these gendered racist policies and supporting people to live self-determined lives for decades. Resistance to these structural barriers has always been cultivated in Black, Indigenous, trans, immigrant, and other marginalized communities. We must work in solidarity with communities in building power to disrupt these oppressive systems and attacks on reproductive freedom to advance our field’s equity-oriented goals.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to disclose.
HUMAN PARTICIPANT PROTECTION
No protocol approval was needed for this research because no human participants were involved.
Footnotes
See also Hing et al., p. 1529.
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