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Restrictions on reproductive bodily autonomy — the freedom to decide whether, when, and how to have a child, with whom, and under what circumstances — have long been leveraged to oppress and control persons and communities that are devalued by racist, classist, or ableist societies. On June 24, 2022, in the landmark Dobbs v. Jackson Women’s Health Organization decision, the U.S. Supreme Court revoked the right to abortion. Even though abortion is an essential component of comprehensive reproductive health care that has been protected in the United States for nearly 50 years, future access will be severely limited or denied in the 26 states that have banned or are likely to ban abortion care.
Decisions regarding the legal status of abortion and other reproductive health services reflect the status of civil rights for anyone with the capacity for pregnancy, but they have a particular resonance for Black and Indigenous people living in the United States, who have experienced reproductive oppression for centuries. The Dobbs decision rolls back fundamental rights for many people, and it is a direct assault on efforts to improve racial equity in health care. Indeed, abortion access is fundamentally a racial justice issue. We believe that clinicians, health care delivery systems, and policymakers should approach it as such.
The United States was built, in part, on racially differentiated policies toward reproduction. During the 256 years when slavery was legal, the country had a substantial economic interest in the fertility of Black people; increased fertility meant a larger labor supply and higher property value. Slaveholders therefore condoned rape of enslaved people, withheld from them knowledge about birth control, allowed gynecologic experimentation on them without anesthesia, and provided “incentives” to coerce them into reproducing. Abortion was an important tool leveraged by enslaved pregnant people to control their fertility and prevent future children from experiencing the horrifying and inhumane conditions of chattel slavery.
After emancipation and during the Jim Crow era, U.S. economic interest in Black bodies shifted. Once Black people were no longer a source of free labor, “eugenic” depopulation policies informed by White supremacist ideology began emerging in both government and clinical care. In 1927, the Supreme Court legitimized eugenic sterilization laws in Buck v. Bell, a case that has never been explicitly reversed. Forced sterilization, colloquially known as “Mississippi appendectomy,” was commonplace in the 20th century, with some estimates suggesting that as many as 70,000 people were involuntarily sterilized by government-sponsored family-planning programs.
Other racialized groups in the United States have also experienced reproductive injustice; for instance, between the 1930s and the 1970s, as many as one third of Puerto Rican women underwent forced sterilization, commonly referred to as “la operación.” Atrocities such as this are not confined to the past: in 2020, Immigration and Customs Enforcement forcibly sterilized female migrants in federal detention facilities who were seeking asylum at the southern U.S. border. Also, in the mid-20th century, Puerto Rican women were enrolled in clinical trials of hormonal birth control without their knowledge and used as test subjects for contraceptives that had not yet been approved by the Food and Drug Administration.
U.S. policy toward Indigenous peoples has promoted erasure by means of genocide, rape, family separation, boarding schools, language eradication, cultural assimilation, and reproductive exploitation. In the 1900s, many states passed laws allowing sterilization of the “feeble-minded,” which was practiced extensively on reservations and at government-run boarding schools, where Indigenous children who had been forcibly separated from their families were raised without connection to their tribal communities. In addition, tribal membership rules informed by eugenic concepts and U.S. government policy may infringe on reproductive freedom: to be a member of a tribe with treaty rights negotiated by their ancestors, many Indigenous people must demonstrate a minimum “blood quantum” from a particular tribe. Such requirements force Indigenous people to consider reproductive choices in the context of their potential children’s eligibility for tribal membership; children born as a result of rape or unwanted pregnancy may be denied enrollment in the same tribe as their birth parent, if the rapist or other parent does not have the requisite blood quantum from the same tribe. With every reproductive choice denied, Indigenous peoples and tribes move closer to erasure.
Systemic racism affecting reproductive health shows up today in maternal mortality statistics; Centers for Disease Control and Prevention data show that Black and Indigenous people are two to four times as likely as White people to die during pregnancy or around the time of childbirth. Abortion, which is now criminalized in many U.S. communities, is safer than pregnancy and delivery, especially for Black and Indigenous people. Recent estimates suggest that a nationwide abortion ban would increase maternal mortality by 21% overall and by 33% among Black Americans.
Racial and ethnic disparities in reproductive health outcomes follow from inequities in access to care. Owing to a wide range of factors (e.g., interpersonal racism, distance from health care institutions, health insurance status, employment benefits, state policies), Black and Indigenous people, immigrants, and rural residents have comparatively limited access to abortion care and other reproductive health services. In communities where people can no longer readily obtain contraceptives or terminate an unwanted pregnancy, access to prenatal services and obstetrical care is declining, with the steepest decreases occurring in communities — both rural and urban — that are predominantly Black, Indigenous, or Latinx. When people can’t prevent or terminate an unwanted or medically risky pregnancy, can’t easily access prenatal care, and live hundreds of miles from a hospital with an obstetrical unit, clinicians struggle to prevent tragedies and people’s health suffers.
As restrictions on abortion increase, racial injustice in health will persist and worsen. The adverse health effects of the Dobbs decision will fall hardest on patients, clinicians, clinics, health care systems, and communities in states with the highest maternal mortality and the biggest racial inequities in maternal and reproductive health. For example, Michele Goodwin has noted that in Mississippi, a Black person is 118 times more likely to die from carrying a pregnancy to term than from having a legal abortion. Indeed, Black and Indigenous people face disproportionate health risks when they become pregnant, and the places where these risks are highest are also those where it’s nearly impossible to receive or provide the health care patients may need to protect their life, their safety, or their family.
The Dobbs decision raises the stakes for clinicians, health care administrators, and policymakers who value racial justice in health. Reproductive health care restrictions exacerbate untenable racial inequities in health across the life span, not just during pregnancy. Abortion is health care, and the Guttmacher Institute estimates that one in four people with the capacity for pregnancy have needed or will need an abortion. Some patients who need abortions, racialized by a society that devalues them, may experience tragic consequences if they do not get the abortion they need. Clinicians can help by providing abortion care, supporting others who do so, and advocating for safe, dignified, humane reproductive health care services to be provided in their health care systems, to the extent allowed by state law.
The organization SisterSong 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.” Access to reproductive health services — including abortion — is essential for protecting the full humanity of anyone with the capacity for pregnancy. In the United States, the full humanity of Black and Indigenous people has long been denied. Indeed, statistics related to health, education, and poverty reveal the racism that underpins U.S. politics and policies. Generations have fought against these unjust tenets to ensure and advance civil rights, and the fight continues. We believe that clinicians have a professional obligation to champion policies that improve the lives of their patients and potential patients, including doing whatever is in their power to expand and protect abortion access. Abortion access is a racial justice issue, and it is today’s civil rights battle worthy of tenacious engagement by professionals in medicine, policy, and public health.
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