Equity and Justice in Family Medicine Clinical Care and Teaching Must Incorporate a Reproductive Justice Framework

While the June 2022 Dobbs decision to overturn Roe v Wade seems to have woken the collective consciousness of many Americans about US abortion access, it is only one of many instances of unjust reproductive health policies and restrictions that has led to poor health outcomes for communities of color. ¹, ² The Reproductive Justice (RJ) framework, ¹ conceived in 1994 by the Women of African Descent for Reproductive Justice, addresses the reproductive health needs of Black women and communities from a human rights perspective. Specifically, RJ is defined as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities."³ Achieving these rights requires the transformation of all systems that impact reproduction, including political, social, environmental, and economic institutions and policies. Since 1994, the framework has been expanded with an intersectional approach ⁴ to include all marginalized groups, encompassing both communities of color and lesbian, gay, bisexual, transgender, queer (or questioning), asexual, intersex, and gender diverse people (LGBTQIA+) communities.

While the impact of racial injustice on inequitable health outcomes is now increasingly recognized in clinical practice and family medicine education, the tenets of RJ have not been universally incorporated into care provision or family medicine education. ⁵ Including the RJ framework in family medicine education is pivotal for learners to understand how structural, economic, and political factors influence reproductive health outcomes so that, as a family medicine community, we may subsequently improve health care delivery from a justice and human rights perspective. Notice that throughout this commentary, we use binary gender terms (eg, women) when such terms correspond to the related data, literature, specific framework, or gender identity of individuals being discussed; otherwise, as a demonstration of the Reproductive Justice principle of addressing intersectional oppressions, we use gender nonbinary terms (eg, pregnant people) to center and include all people who are capable of pregnancy.

Since European settlement, the reproduction of communities of color has been systematically controlled in the United States, from forced pregnancies, sterilizations, and abortions, ² to policies that separate children and families. ¹, ⁶, ⁷, ⁸, ⁹ Oppressive systems, including racism, colorism, homophobia, transphobia, ableism, and misogyny, have disproportionately impacted the health and well-being of communities of color. Involuntary sterilization, including vasectomies, hysterectomies, and tubal ligations, began in the early 1900s with the eugenics movement. ¹ State-sanctioned sterilization programs targeted Black, Indigenous, and Latine/x people, many of whom were in psychiatric institutions, incarcerated, or living in poverty. ⁶, ¹⁰, ¹¹ Family separation and control of family formation have been practiced extensively since colonization¹, ¹² and the inception of American slavery. ² Even in cases where a societal gain has been touted with respect to reproductive health, that gain often has come at a cost to communities of color. For example, now known as the mothers of gynecology, Anarcha, Lucy, Betsey, and other enslaved Black women whose names are lost, suffered innumerable experimental and tortuous surgeries at the hands of physician J. Marion Sims, who is credited with developing vesicovaginal fistulas repairs and the speculum, and has been touted as the father of modern gynecology. However, the names and stories of those he experimented on without consent or anesthesia are the true founders of gynecology. ⁶, ¹³ While we praise the advent of the birth control pill, Puerto Rican, Mexican, and Haitian patients were primary subjects during the initial testing phases, which were conducted without consent and specifically targeted low-income, disadvantaged populations that were not informed of potential and known adverse reactions. ¹⁴

While marginalized and oppressed communities have long organized and resisted state-sanctioned reproductive coercion and control, ² the dominant systems of modern medicine have maintained and promoted the status of reproductive injustice. ², ⁶, ⁸, ¹⁰ Systemic reproductive injustice perpetuates health inequities that disproportionately impact communities of color, particularly Black, Indigenous, and Latine/x people. ¹, ⁸, ¹⁵ Notable inequities include disproportionate rates of maternal mortality, ¹⁵ infertility, ¹⁶ preterm birth, ¹⁷ and infant mortality. ¹⁸, ¹⁹ State surveillance of pregnancy outcomes and poor health outcomes from family separation disproportionately impacts individuals and families of color. ²⁰, ²¹ Less obvious but just as critical are the social, political, and health care systems and policies that cause race-based stress, ¹⁷, ²² leading to negative pregnancy outcomes, poorer infant and child health, and parenting in unsafe and unstable environments. Simultaneously, the health impacts on other communities are poorly understood due to a lack of data or refusal to disaggregate existing data.

The legacy of reproductive control, including eugenics, is reflected in laws, policies, and clinical recommendations developed to care for “at-risk" populations. Such policies and recommendations ultimately target communities of color, limiting reproductive autonomy and reinforcing environments of surveillance and mistrust. ²³, ²⁴ Moreover, fertility control and pregnancy planning are often viewed as a panacea for economic empowerment and liberation, ignoring the root causes of inequities. ¹⁰, ²³ For example, reducing unintended pregnancy and abortion rates often is used as a marker for programmatic success, while reproductive autonomy is ignored. In 2015, multiple medical organizations, including the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, recommended a tiered-effectiveness contraceptive counseling model preferentially endorsing long-acting reversible contraception (LARC). ²³ Yet, recent research shows that clinicians are more likely to recommend LARC for Black and Latine/x patients and patients with language barriers. ²⁵ Further, clinicians routinely decline to remove LARC devices despite explicit requests from patients. ⁹ The focus on reducing unintended pregnancy results in the erasure of other reproductive health needs. For example, while infertility disproportionately impacts Black, Latine/x, and Asian individuals, persistent disparities exist in treatment outcomes and access due to inadequate research, lack of insurance coverage (especially among publicly funded insurances), and limited clinical provision. ²⁶ Additionally, assisted reproductive technology and comprehensive reproductive health care are often unavailable to LGBTQIA+ individuals and families. ²⁷ 

State control over pregnant people’s bodily autonomy and ability to raise children in safe environments has persisted and now manifests as criminalization of pregnancy loss, stillbirth, and abortion as well as family separation through the child welfare system—which again, disproportionately impact people of color. ²⁴, ²⁸, ²⁹ Disconcertingly, the health care system often cooperates with the criminal justice system, ²⁸ whether purposefully or compelled, in the disproportionate surveillance and criminalization of pregnant and birthing people of color and separation from their children. ²⁴, ²⁹ Criminal investigations and arrests of individuals suspected of either self-managing or helping to self-manage abortion are rising, and a homicide consideration is two times more frequent in cases involving a person of color compared to cases involving a White person. Nearly half of criminal reports come from health care providers or social workers, despite the clear violation of patient privacy regulations, lack of any state or federal laws mandating reporting, and the similarities in presentation and management of early pregnancy loss and self-managed abortion. ³⁰ While White pregnant people have similar or higher prevalence of drug use, ³¹ Black and Latine/x pregnant people are more likely to be selected for nonconsensual drug testing; and those positive tests are more likely to result in punitive charges or loss of parental rights. ³² Black and Indigenous families are disproportionately more likely to be reported by health care providers for child abuse or neglect and to experience forced separation and termination of parental rights. ²⁹ Black and Indigenous children also are more likely to enter the foster care system despite the availability of biologic and chosen families. ³³ These examples of forced separation and surveillance reflect clear violations of one of the main, and perhaps most important, tenets of RJ: the right to parent children in safe environments, free from harm. Recent reports noting that many pregnant and birthing people and their families enter the criminal justice system at the hands of health care providers who notify the authorities should be cause for concern by educators and clinicians, and highlight the need for investing in relationships with community-based organizations to support families as alternatives to the unintended consequences of criminalization. As clinicians, we must remember our responsibility to protect our patients’ rights.

As a specialty, we can act to mitigate the problem of reproductive injustice. Family medicine has already made strides toward health equity by considering models of care that apply principles of justice and antiracism. ³⁴ We would be remiss if we overlook the importance of teaching and applying an RJ framework to clinical care. Let us remind ourselves that our specialty prides itself on whole-person, multigenerational, community-based, comprehensive, and socially just care. As educators, we can include broader human rights and racial justice perspectives on delivering health care, including patient autonomy, decision-making, and liberation, using an RJ framework. We can incorporate RJ into family medicine residency through curricula, care modeling, and care delivery.

First, sexual and reproductive health (SRH –which specifically includes the provision of and access to clinical sexual and reproductive health services) curricula in family medicine residency training can guide learners to community-led, community-centered educational resources that provide historical contexts of reproductive violence, genocide, and coercion of marginalized groups. These curricula include resources on RJ, intersectionality, human rights, decolonization, critical race theory, and the historic and contemporary legacy of white supremacy in medicine. ³⁵ Such resources can be used as references and guides for educators and learners to begin to understand the contemporary contexts for inequities in SRH (Table 1). In addition, existing online curricula are available to guide both educators and learners ³⁶, ³⁷ (Table 1, last row). Such web-based platforms present case-based modules to engage family medicine residents and assess their understanding of RJ principles and their clinical application through knowledge-based questions. The resources listed in Table 1 are specifically meant to provide background information for learners (including family medicine residents and faculty) about the importance of incorporating an RJ framework into teaching and clinical care so that learners understand their own biases and then consider how the knowledge provided and gained can be applied to clinical care and practice. Importantly, the incorporation of RJ and patient-centered care principles into the current Accreditation Council for Graduate Medical Education family medicine milestones ⁵ is another step that could be taken to help ensure that residents learn, apply, and master these important competencies.

Next, clinical application of RJ principles in practice, as with any other important clinical skill, comes through experience with patient care and appropriate precepting and modeling by faculty. As educators, we can teach and model patient-centered care ³⁸ that incorporates RJ principles during didactic sessions, iterative precepting, and clinical supervision of learners. A patient-centered model of care includes discussing and demonstrating care that respects patient values and viewpoints and follows patient guidance on reproductive health decisions, including contraceptive, family-building, pregnancy, postpartum, and abortion care while also providing appropriate clinical guidance to patients. As clinician-educators, we can reinforce that patients know best about their bodies, families, and communities—including their decisions about pregnancy and childbearing; this stance is especially important for racial and ethnic groups and other communities that have been historically denied reproductive autonomy. ²³, ³⁹ Furthermore, we must model and provide patient-centered care for all patients, not just those deemed by the health care system to be “responsible," “intelligent," and/or “well-educated." We can model supportive and respectful care that not only elicits, but also centers patient preferences and choices with respect to SRH throughout the lifespan and for the duration of our relationship with the patient. ³⁹ As educators, we must examine our biases first in order to subsequently impart to our learners important principles, such as listening to and trusting patients, and to provide evidenced-based, unbiased, noncoercive, desired information that reflects RJ principles ⁴⁰ (Table 2). Moreover, educators can provide support and allyship for learners who may experience or witness behavior from other health care professionals (including other faculty/clinicians/staff) that is in direct opposition to RJ principles, such as the use of racist or demeaning language. We can identify common anti-RJ behaviors that learners may have witnessed and possibly even adopted as we work toward strategies for change. ³⁴, ⁴¹

Lastly, as family medicine educators committed to RJ, our job is to model and teach our learners, namely family medicine residents, how to make systemic changes that keep our patients as healthy and safe as possible. The Dobbs decision not only foreshadows that maternal and infant mortality rates will increase dramatically, ⁴² but also that pregnant people will be criminalized more than ever regardless of pregnancy outcomes, both of which will disproportionately impact racial and ethnic minorities. ³⁰ We can strive to protect pregnant individuals and families from criminalization and racialized child separation. For example, we can model and teach learners how to protect patient information about abortion and early pregnancy loss from state surveillance and criminalization, perform urine drug testing during pregnancy only with informed consent and right of refusal, ⁴³ and apply standardized tools and self-reflection questions when assessing for child abuse. ⁴⁴ As clinicians and educators, we can choose not to criminalize our patients and to resist being agents of the harmful penal system. ⁴⁵

Family medicine educators are tasked with incorporating multiple competencies into residency training; understandably, changing or adding competencies can seem daunting. However, concepts such as social determinants of health and health inequity initially were resisted yet were eventually applauded as integral to our specialty and to understanding disease causation, patient behavior, and improved health outcomes. Similarly, the RJ framework can and should be integrated throughout family medicine curricula to incorporate, support, and uplift the provision of SRH for greater equity and justice. To move toward change, family medicine educators will need to gain historical and contemporary knowledge about our country’s legacy of reproductive violence and oppression. We then can work as teams of educators and learners to deliver high-quality, patient-centered, justice-based, equitable care to our patients. We must, therefore, include the voices of those most impacted by injustice and inequity, namely our patients and their communities. ⁴⁶ It is time for us to answer the call directly from the communities we care for by incorporating RJ into clinical care and education. Our communities have given us the tools to envision new paradigms of SRH delivery, allowing us to teach and model clinical care, advocacy, and scholarly activity with our learners to achieve true equity and justice for all. Learning about RJ is not sufficient; we also must challenge and change the current dynamic of family medicine education for the next generation of learners.