- There is a long history of coercive reproductive practices, including sterilization abuse, incentivized use of long-acting reversible contraceptives and resistance to remove them, threats to parenthood (including differential referrals to child protective services), and lack of safety in communities (including harmful environmental exposures as well as violence in multiple forms), all of which have been disproportionately imposed upon people of color, low income people, those with disabilities, immigrants, LGBTQ and incarcerated individuals. Sadly, this continues today, and impacts the way individuals and communities perceive family planning services (Thorburn 2005, Brandi 2018, UCSF Bixby BtP 2020).
- In the 1990s, 12 Black women founded the reproductive justice (RJ) movement (Ross 2017, Chrisler 2012) to improve institutional policies and systems that impact the reproductive lives of marginalized communities.
- The SisterSong Reproductive Justice Collective defines reproductive justice 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.”
- Public health guidelines should proactively help patients achieve their reproductive desires, but vary widely between states and countries. Given that coercive practices have historically devalued the childbearing of marginalized populations (Brown 2014), we must remain focused on providing care that is respectful of, and responsive to, individual patient preferences and values (Gomez 2014) and ensure that patient preferences and values guide all our clinical decisions (Institute of Medicine 2001). Our curriculum is informed by this history and this lens.
PROFESSIONAL ETHICS IN REPRODUCTIVE HEALTH
Prevention is increasingly recognized as the most effective means of ensuring health within populations and has received heightened focus by recent initiatives such as Healthy People 2020 and the U.S. Affordable Care Act. A comprehensive approach addressing patients’ preferences around pregnancy is an essential component of prevention within a public health framework (Taylor 2011, Levi 2011).
When assisting patients to achieve their reproductive desires, there are important expectations that fall on primary care providers. Contraceptive provision, pregnancy options counseling, and provision or referral to appropriate services for abortion and miscarriage are among the ethical responsibilities of healthcare providers. The availability of modern contraception can reduce but not eliminate the need for abortion.
The concept of pregnancy intention is complex, and not all unintended pregnancies are created equal. New research suggests that our current conceptual framework viewing pregnancy from a strict planned behavior perspective is limited, particularly among low-income populations and younger patients (Gomez 2019, Borrero 2015). Ambivalence, partner influence, and cultural perspective all inform how patients feel about pregnancy intention (Aiken 2016).
The significant political dissonance surrounding reproduction and sexuality is associated with limited funding, research, and guidelines for unintended pregnancy prevention. This in turn places a significant burden on patients and health systems. Additionally, it limits abortion training for interested providers.
COVID-19 AND ABORTION CARE
All aspects of healthcare have been impacted by the COVID-19 global pandemic, and abortion care is no exception. For example, some U.S. states introduced legislation attempting to further restrict abortion access by declaring it “non-essential”, “elective” or “not medically necessary”. The long-standing insistence on using the word “elective” to describe the majority of abortions, frames women’s equality and autonomy as expendable, and represents a moral rather than a medical judgment (Watson 2018). Yet abortion and reproductive health services have been more essential than ever during this public health emergency. COVID-19 responses and quarantines led to concerns of increased unintended pregnancies due to challenges accessing contraceptive supplies, rising income insecurity, and increased incidence of intimate partner violence including reproductive coercion (Bayefsky 2020, Todd-Gerr 2020).
Numerous national and international organizations strongly opposed responses that cancel or delay abortion procedures, and explicitly classified reproductive health care as an essential health service that must be accorded high priority in the COVID-19 response (Bayefsky 2020).
In addition to being disproportionately affected by the virus, low-income communities and people of color have also been disproportionately affected by such measures to restrict abortion and reproductive access. Central goals during COVID-19 have been facilitating reproductive autonomy, maintaining access to essential health services, and respecting social distancing as a public health mandate. These goals are not at odds with one another and can be simultaneously met (Karlin 2020). Telehealth has become a critical tool to achieve these goals in many settings.
In response to the pandemic, many providers pivoted rapidly towards innovative practice models streamlining diagnostic tests and minimizing contact between the patient and the healthcare system, using telemedicine and remote follow-up (Raymond 2020; see Chapter 4). It has been said in the U.S. that no-test medication abortion protocols have done for medication abortion in a couple months what years of research and discussion could not. It is likely that many of these changes will be long lasting.