reproductive health – UAB Institute for Human Rights Blog

Eugenics: How the Remnants of a Bygone Theory Threaten Personal Liberty Over a Century Later

by Sumaira Quraishi

Trigger warnings: rape, invasive medical procedures, and medical malpractice.

Often, the Supreme Court of the United States is seen as a paragon of the American legal system and the national values it strives to uphold. At least, it used to be. While trust in the sanctity of the Supreme Court has recently been broken over controversial political issues, the Supreme Court is no stranger to making unfavorable and borderline unconstitutional rulings in cases brought before the justices at the time. While this is to be expected, with the court switching from conservative to liberal-dominant every so often, some cases seem to concern unalienable human rights that have been denied by the court, as expected of a supposed higher authority that is ultimately, and always will be, a product of its time. In 1927, Carrie Buck learned just how fallible the highest court in the American legal system could be when infiltrated with an ideology eventually perpetuated by the Nazi party during World War I.

Image shows Jewish prisoners in their barracks at the Nazi concentration camp Auschwitz. — Jewish prisoners at Auschwitz. Source: Yahoo Images.

The Birth of Eugenics

Surprisingly, and perhaps horrifyingly, eugenics was not the child of oppressive or violent regimes, but the culmination of centuries of scientific research and racism woven together and spread through communities worldwide during the early 20th century. Eugenics was a theory created to exterminate certain people who were not considered mentally fit, genetically clean, or conventionally attractive. The ones who decided the people that fit into these categories usually were ones in positions of power or influence in society: doctors, politicians, and scientists. Favored methods for perpetuating eugenics were forced sterilization, societal segregation, and social exclusion, all of which seem to be methods straight out of the time of slavery where eugenicists drew inspiration and justification for eugenics.

In the modern age, there is a laser-like focus on women’s rights to not have a child, and while this pursuit of maintaining women’s rights is justified, for many vulnerable men and women today the fight for the right to have a child is just as in need of attention. An old theory about the superiority of white, able-bodied people may seem like one to be thrown into the history books and mentioned alongside other conventionally shunned snippets of history in the modern discourse, however, eugenics never truly went away.

Eugenics Still Lingers

Overshadowing lives today as a phantom of the eugenics school of thought, a forgotten Supreme Court case in 1927 named Buck v. Bell led to the codification of sterilizing those deemed “feeble-minded” and genetically inferior by people in positions of power into law. Carrie Buck was a woman who resided in a mental institution and became pregnant after being raped, resulting in staff at the asylum taking acute notice of Buck. Doctors and directors at the asylum were firmly entrenched in the eugenics culture sweeping across America and firmly believed Buck should not be allowed to carry to term. These men took the stand that Buck should be forcibly sterilized to prevent her genes from being passed on, and the Supreme Court was in full agreement, with the justification for the ruling against Buck being that she had a history of mental illness back to one of her grandmothers and being sterilized would protect the goodness of society by keeping “feeble-minded” and “promiscuous” people from reproducing.

Not only is Buck v. Bell an appalling ruling that trod on the constitutional rights of Buck, but it also opened the door for forced sterilization procedures to continue without secrecy and, chillingly, has never been overturned. An old legal case from the 1920s may seem like something to be stored away in textbooks and forgotten, yet, eugenics practices in the form of forced sterilizations are happening today

In California between 2006 and 2010, almost 150 women in two different prisons were given hysterectomies without their consent or legal documentation authorized by the state, with 100 suspected cases of sterilization dating back to 1997 uncovered as well. Furthermore, in 2017 a Tennessee judge offered to reduce prison sentences by 30 days for any inmate who signed up to receive a birth control implant or a vasectomy. The latest case of eugenics rearing its head in American practices was in 2020 when it was revealed that hysterectomies were being performed illegally on women in the U.S. Immigration and Customs Enforcement (ICE) detention centers. These cases are not the only ones concerning the continued use of forced sterilizations to prevent incarcerated or institutionalized individuals from having the right to choose to have a child, with many more subject to the archaic practice who have yet to have their story told. These practices are considered morally reprehensible by the general public but can trace their roots to eugenic procedures approved by the Supreme Court in a case that was challenged but never overturned, and some laws approving the use of sterilizations are still in existence in states such as Virginia.

Image shows an empty cell area of a prison. — Prison. Source: Yahoo Images.

What Can Be Done

Fighting a system that has failed a large portion of the American population, and pushing for a Supreme Court ruling to be overturned when the nation’s political climate seems fit to burst with elections on the horizon can seem incredibly intimidating. These thoughts are not unfounded, but what government bodies forget is that their power comes from their people and constituents. Harmful practices can be challenged with public favor and fervor. Staying informed on what influences modern atrocities like Buck v. Bell and knowing that the majority of the population supports upholding the 14th Amendment protecting civil liberties keeps people motivated to improve the lives of their fellow Americans. Leaving Buck v. Bell as a precedent in U.S. law allows for unprotected groups of individuals who are incarcerated or institutionalized to be at heightened risk of human rights abuse, and while forced sterilization is morally reprehensible, the law does not currently outline sterilization as illegal since the Supreme Court ruling remains standing. Reaching out to local or state politicians is an option for those who want to appeal hurtful laws, and a less intimidating option is to join advocacy groups whose views align with your own.

For more information on another situation involving eugenic practices ruining the lives of nonincarcerated individuals, the case of a fertility doctor who artificially inseminated dozens of his clients with his sperm and remains free from jail can be found here.

The Future of Abortion Laws in the United States

The Texas Abortion Law, signed into law on May 19th, 2021, went into effect earlier this September, effectively banning abortions after the detection of fetal heartbeat. This law makes no exceptions even for victims of rape or incest.

Previous abortion bills introduced the state government and authorities to enforce abortion laws, but unlike anything seen before, Texas’s law awards the power to the citizens. Any private citizen in the country now has every right to sue anyone they suspect has had an abortion, took part in helping with an abortion, or in any way assisted an individual seeking an abortion in Texas. If the suit succeeds, the citizen will receive monetary compensation of at least $10,000. The intricacies of this law make it difficult to legally interpret since technically, abortion has not been criminalized.

History of the Heartbeat Bill

In 1973, the landmark Supreme Court case Roe vs. Wade federally legalized abortion in the first two trimesters of pregnancy but allowed states to ban abortion in the 3rd trimester. Since then, several state legislatures have passed so-called “heartbeat bills,” which criminalize abortions after fetal cardiac activity has been detected—usually at 6 weeks. However, this is only a flutter of electricity, and the heart forms only after 17-18 weeks. Most individuals do not even know that they are pregnant at this point, because birth control, other forms of contraception, or not tracking menstrual cycles can mask pregnancies until the 8th week.

Up until now, the Supreme Court has adamantly upheld Roe vs Wade, and every state abortion ban signed into law has been struck down in federal courts. In a historic decision, the United States Supreme Court ruled to let Texas temporarily implement its Abortion Law Although the decision was made in consideration of the difficulty interpreting the law by the Constitution, the hesitancy has been raising alarms all over the country.

During the Former President’s term, 2 conservative justices replaced the deceased Supreme Court Justices Ruth Bader Ginsburg and Antonin Scalia—tipping the balance of opinion from liberal to conservative. The new Supreme Court, with the power to influence landmark judicial decisions and history for the next century has many human rights and women’s rights activists seeing it as a threat to the well-being of the country. Reversing all or part of Roe vs. Wade will start an ethical slippery slope that some fear could lead to restrictions on contraception and women’s health services.

Historic Supreme Court building in Washington, D.C. pictured — Source: Unsplash; The Supreme Court Justices hear cases and make their decisions here at the Supreme Court in Washington, D.C.

Abortion as a Human Right

The United Nations affirms that access to safe and legal abortions is a fundamental human right. It is not only crucial to ending discrimination against women but also to protect women’s health. The United Nations Human Rights Committee (UNHR) states that restriction abortion bans violate basic “right[s] to health, privacy, and in certain cases, the right to be free from cruel, inhumane and degrading treatment.”

Despite the common misconception that abortion restrictions reduce abortions, they only increase unsafe abortions. Women and young girls use dangerous methods such as toxic chemicals, bodily harm, and relying on unlicensed abortion providers in their desperation to terminate a pregnancy. In fact, in the United States, the American College of Obstetricians and Gynecologists (ACOG) found that over 1.2 million women had unsafe abortions which resulted in nearly 5000 deaths, not including tens of thousands more left with long-term injuries and complications.

Depicts Abortion Rights protesters — Source Unsplash: Protestor holding up a placard stating “Protect Roe” in an October 2021 protest against Anti- Abortion Laws.

Women in Texas Now

The state has clearly indicated that the law is “not against women” but against abortion providers who are breaking the law.

Already, women in Texas are traveling out to liberal states such as California or New York to get their abortions. The influx of cases has overburdened providers in other states, but even still, those who make it out of state to receive an abortion at least have the option. The majority of women, however, do not have the means or funds to obtain an abortion in another state, so they turn to abortion pills to self-induce abortions. This method has its own problems. The pills can get stuck in customs anywhere from 2 to 30 days which adds to the anxiety of pregnant individuals, because the pills must be taken before 10 weeks of gestation to avoid life-threatening complications such as massive hemorrhaging.

Political Reaction

The Texas Abortion Ban symbolizes the modern bodily autonomy movement on a precipice. Based on the Supreme Court’s current balance, it is possible that Roe vs. Wade could be struck down within the next two years. One thing must be made clear though: overturning Roe vs. Wade means that abortion will only become illegal within states that have chosen to do so—not across the country.

However, another aspect to consider about the abortion rights debate is voice. Women and minorities are more empowered than four decades earlier and have the platform to fight for their beliefs. In fact, 77% of people want the Supreme Court to uphold Roe vs. Wade. If Roe vs. Wade is overturned, an unprecedented amount of public outcry will occur in every state to fight, once again, for the right to bodily autonomy that women have fought for decades.

Future

Later this year, the Federal Courts will hear Mississippi’s case to let their heartbeat law stand for 15 weeks. More conservative states will likely use Texas’s law to support their legislations. Thus, the outcome of these hearings will give the country an understanding of how the federal judicial system will respond to future abortion and women’s health legislation.

The Supreme Court’s ability to protect abortion rights is being tested, but according to the Los Angeles Times Editorial Board, the responsibility may be passed to Congress instead of staying with the courts.

In the Senate and House of Representatives sits a bill titled the Women’s Health Protection Act, which could provide universal abortion rights and remove the damaging restrictions women are subjected to for abortions. One of the goals of women’s rights activists is to see this bill passed in Congress, and the time has come for Congress and the Executive Branch to collaborate and alleviate any detrimental decision that the judicial system may make. The public can help with this goal by proactively voting for legislators that will turn bills into reality and supporting many nonprofit organizations and charities such as NARAL Pro-Choice American and Planned Parenthood through volunteer work or donations.

Reproductive Justice: Voices Not Just Choices

What Is Reproductive Justice?

Indigenous women, women of color, and trans people have long fought for the right to make decisions about their bodies. Coined in 1994, the term reproductive justice 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.”

One way to differentiate reproductive justice from reproductive rights is that the latter is the “legal right to access health care services such as abortion and birth control”. Initially, spokespeople of this women’s rights movement often included educated wealthy, middle class White women. This left marginalized communities and minority women who did not have easy access to their rights with minimized opportunities to voice their problems and experiences. This begs the question of what good are these rights, if they aren’t accessible. Built upon the United Nations human rights framework, reproductive justice is an intersectionality issue where reproductive rights and social justice are combined so the voices of LGBTQ+ people, marginalized women, and minority communities are uplifted.

Abortion as a Voice, Not a Choice

Choice comes from a place of privilege. The chance of deciding reproductive options is more easily accessible to middle class White women, while these same options are typically unavailable or restricted for poor, low-income women of color. These are the same marginalized women who historically bore the burden of unethical research in reproductive medicine from issues regarding the study of gynecology, to sterilization, and everything in between. For example, James Marion Sims, the father of modern gynecology, conducted medical procedures on enslaved Black women, which is unethical in more ways than one. No consent was given. A patient that has no knowledge of what is going on or what is being done to them cannot give consent. As an enslaved person, the patient was not seen as a human being, but rather as property, and therefore no consent was necessary. The medical procedure was purely experimental, and Sims’ likely had poor knowledge of what he was doing which made his actions torturous. Women like the patients Sims practiced on, women of color, women who were and are oppressed and marginalized, women with disabilities, and people of the LGBTQ+ community continue to be exploited, and it is important that their voices are heard now more than ever.

Source: Robert Thom, circa 1952. From the collection of Michigan Medicine, University of Michigan. Sims’ not only purchased Black women to conduct his inhumane experiments on, but he did so on the belief that Black women could not feel pain.

Often there are misguided notions that reproductive justice is just about abortion, and while access to abortions is a major component of the movement, the movement does not end there. Reproductive justice also goes on to include access to proper sex education, inclusive to all genders and sexualities, affordable contraception, and access to safe and healthy abortions. It’s not enough for abortion to be legalized. “Access is key,” meaning that the cost of the medical procedure is bearable. Medical expenses include travel to a medical provider, paid time off from work, prescription costs, dietary expenses, relocation, etc. all of which can cause difficulty in accessing care. As something that women of color, women with low incomes, and the LGBTQ+ community have brought to attention, reproductive justice is an umbrella that goes beyond the pro-choice versus pro-life debates. It calls into light that factors such as race and class in society affect each woman and LGBTQ+ persons differently. This means not every person has the choice to choose or not choose a pregnancy due to lack of access to services, stigma, or historic oppression, which is where the pro-voice movement intercedes.

The pro-voice movement is meant to “replace judgement with conversation” from both pro-choice and pro-life advocates. Abortion is an incredible emotionally and morally draining topic to converse on, and it’s a decision that should be void of politics and instead filled with empathy and compassion so an individual can make the healthiest choice and live their healthiest life. It is important to validate a person’s lived experiences and to acknowledge that they made the best decision they felt like they could with the resources available to them at the time.

Stigma Around Reproductive Health

There is lack of access to the topic of reproductive health due to incomprehensive sexual education in school systems. Access to this information, access to proper medical care, access to contraception and abortion “is a political, human rights and reproductive justice issue.” Some educational systems fail to mention how to obtain contraceptive methods, how to use them, and which methods are more suited for an individual. This lack of information and stigma around sexual education does not reduce the incidence of unsafe and “unprotected sex or rates of abortion.” In fact, lack of education around contraception and restrictive abortion practices leads to more unsafe abortions globally due to financial burdens as well as social and cultural stigma.

Source: Maria Nunes. An LGBTQ+ Pride event takes place in the Caribbean.

Another issue is heteronormativity which is the trend in sex education focusing “on straight, cisgender young people, but ignores LGBTQ+ youth.” These conservative views that do not cater to a whole population of young adults exacerbates this stigma around sexual and reproductive health. This leads to people feeling like they cannot ask questions due to fear of social repercussions or that their sexuality is abnormal. Not being provided with “information to address their health needs, leaves the LGBTQ+ youth at risk for sexual violence and unprotected sex,” making them more vulnerable to various sexually transmitted diseases, teen pregnancy, and mental health disorders. As important as it is it to address reproductive justice and reproductive health as a women’s issue, it’s even more important to know that LGBTQ+ people “can get pregnant, use birth control, have abortions, carry pregnancies, and become parents.” Part of fighting for and providing reproductive justice involves activism against controlling reproductive voices, and often controlling sexualities and gender expressions are synonymous with gatekeeping those voices.

Providing access to sexual and reproductive healthcare to LGBTQ+ people is one way to ensure that all communities are able to have information, resources, and the power to make their own decisions about their bodies, genders, sexualities, families, and lives. Access to reproductive healthcare can come in the form of gender affirming care and treatment for transgender, nonbinary, and gender nonconforming individuals. Having free access to reproductive education is a foundational piece within the reproductive justice movement. Talking about the framework around sex and reproductive justice is so much more than sex. It involves intersectionality and considerations of reproductive health regarding pregnancy, abortions, racial and class division and discriminations, maternal mortality rates, and environmental conditions. It’s about the dichotomies between oppression and liberation, individuality and collectivity, and most importantly choices and voices.

Source: Terry Moon for News and Letters. An individual in Chicago attends a protest in support for Planned Parenthood.

What Are Three Things I Can Do?

Understand that it’s not about being pro-choice or pro-life. Understanding abortion is about validating people’s stories and experiences. If you haven’t experienced abortion or don’t know of someone who has, the first step is to come from a place of compassion and empathy.
Know that reproductive justice goes beyond being a women’s issue. The same resources and information given to women need to be disseminated throughout the LGBTQ+ community.
Research organizations such as SisterSong, Planned Parenthood, and URGE to start your activism and make your impact.

Midwifery and Misconceptions

Living in a city with some of the most well-ranked hospitals in the nation, we sometimes take our access to healthcare for granted. The wail of an ambulance is a frequent annoyance to UAB students, but it’s a noise that many people are grateful to hear – especially those who live in rural areas with limited access to healthcare.

Midwife Lorina Karway is one of those people. Karway is responsible for helping thousands of Liberian women give birth safely. She often uses the light of her cell phone, held in her mouth, to deliver babies in a facility without electricity (UN Women). It’s not an easy feat to accomplish, but courage, intuition, and years of experience guide Karway to success. Childbirth is a common, natural process that veteran midwives handle skillfully, but complications do happen. When they do happen, it can be incredibly dangerous. The nearest hospital is over sixty miles away, and emergencies without swift action can have fatal outcomes. Midwives have successfully operated for centuries without hospitals, but medical equipment and clean facilities with electricity are immensely helpful in high-risk situations.

A smiling midwife holds a newborn baby bundled in a blanket. — “Cmdr. Protegenie Reed, a Navy midwife from Miami, Florida holds a newborn baby during Pacific Partnership 2015.” Source: Sgt. Valerie Epple, Creative Commons.

Midwifery still has a reputation for being illegitimate or unsafe relative to hospital deliveries, but midwives aren’t just second-rate doctors for communities without hospital access. “Skilled, knowledgeable and compassionate care for childbearing women, newborn infants and families across the continuum from pre-pregnancy, pregnancy, birth, postpartum and the early weeks of life,” is how the World Health Organization defines the holistic practice. Part of the negative reputation is because midwives tend to practice in areas where adequate services and equipment are lacking, creating the dangerous situations that Karway faces. Communities without access to healthcare still require some sort of healthcare, and midwives across the world bravely fill that gap.

Two midwives stand next to a curtain in a dim room with photos of babies on the walls. — “Midwives Hasina and Aya Begum wait inside the birthing centre in Koral slum, Dhaka, Bangladesh.” Source: Conor Ashleigh for AusAID.

The danger is not created by practicing midwives, but rather from the community’s lack of access to adequate local healthcare services that extend beyond a midwife’s capacities. A solution to this gap in service would enable midwives to deliver better standards of care, and to ensure midwives can collaborate with hospital assistance when required. Additionally, there is evidence that midwife-assisted births result in better care than births guided by obstetricians (Walters et al). The study by Walter investigates variation within hospitalized care, but similar conclusions were found in regards to remote midwifery. Cost analyses of prenatal and postnatal care from seven different remote aboriginal communities found that “midwife group care (MGP) was likely to be cost effective, and women received better care resulting in equivalent birth outcomes compared with the baseline maternity care” (Gao et al).

Policy solutions have not been aimed at uplifting midwives, but rather to create barriers and even criminalize. Midwifery was essentially outlawed in Alabama for the past forty years, along with a dozen other states. Even where legal, barriers were constructed make it difficult for up-and-coming midwives to obtain training, licensing, equipment, facilities, and adequate pay. This is bad for midwives, and detrimental to women in need of accessible maternal healthcare.

A woman in hijab stands in the middle of a classroom with six pupils in hijab. — “Community Midwifery Education Program.” Source: Aga Khan Foundation/Sandra Calligaro, Creative Commons.

According to the United Nations Population Fund (UNFPA)

Over 300,000 women and 2.7 million babies died in childbirth in 2015 alone.
Most of these deaths were preventable and caused by a lack of sufficient antenatal, delivery and post-natal care.
Almost ⅔ of all maternal and newborn deaths could be prevented by well-trained midwives.
Midwifery includes comprehensive reproductive health and community health practices.

Barriers faced by midwives include:

Social isolation / poor living conditions; 37% of midwives face harassment at work
Lack of professional development opportunities or support through regulation/accreditation
“Unequal power relations and gender inequality within the health system and within communities” (WHO).
“Private sector markets and medical hierarchy leading to medicalized births, which constrains opportunities for quality midwifery care” (WHO).

Human Rights Impact

Here are some reasons why it’s important to embrace midwifery as an alternative or addition to formal medical care:

Overlooking midwifery increases stigma. This makes it harder for women to access midwives – especially rural and/or low-income families cannot afford or cannot travel to medical centers.
Midwifery is a critical role in some indigenous traditions. Native women have the right to practice traditional knowledge and engage in their own culture. Legislation that stigmatizes or creates barriers for midwives will likely harm indigenous practitioners.
Women have the right to choose what kind of healthcare is best for them. Healthcare is never one-size-fits-all, and it’s important to invest in a variety of options for a variety of patient needs.
Midwifery needs to be an accessible and viable career path. Medicalization of birth and barriers to midwife accreditation essentially act as gatekeepers, forcing aspiring practitioners to attend costly medical school or, for those who can’t afford it, to abandon their dreams.

Midwifery is a quality alternative to hospitalized childbirth, but many don’t have the luxury to choose. When distance makes choosing hospitals impossible, midwives fulfill their communities’ needs for reproductive/maternal healthcare. Midwives should be empowered to provide adequate services whether in urban hospitals or rural facilities, with unhindered access to training, education, and opportunity. Per CEDAW, states have the obligation to provide “appropriate services in connection with pregnancy, confinement and the post-natal period.” Let us support midwives as they courageously provide services that no one else will. Let us encourage midwives across the globe to continue their work despite disdain, mistrust, and criminalization. Let us uplift and support midwifery to make the world a better, safer, more accessible place.

—–

Craven, Christa, and Mara Glatzel. “Downplaying Difference: Historical Accounts of African American Midwives and Contemporary Struggles for Midwifery.” Feminist Studies, vol. 36, no. 2, 2010, pp. 330–358. JSTOR, www.jstor.org/stable/27919104.

Parry, D. C. 2008. “We wanted a birth experience, not a medical experience”: Exploring Canadian women’s use of midwifery. Health Care for Women International, 29: 784–806.

Thomas, Samuel S. “EARLY MODERN MIDWIFERY: SPLITTING THE PROFESSION, CONNECTING THE HISTORY.” Journal of Social History, vol. 43, no. 1, 2009, pp. 115–138. JSTOR, www.jstor.org/stable/20685350.

Shaw, Jessica. “ The Medicalization of Birth and Midwifery as Resistance.” 20 Mar 2013.
Health Care for Women International. Volume 34, 2013 – Issue 6. www.tandfonline.com/doi/abs/10.1080/07399332.2012.736569?tab=permissions&scroll=top

When You Are Ready for the Baby Carriage: Black Maternal Health and Disparities

by MARTINIQUE PERKINS WATERS, Ph.D.

a maternity shoot — Source: Ariane Hunter, Creative Commons

I did something very interesting in my mid-twenties. I asked a few of my family members if they would be willing to be a surrogate if I could not have children. Now, let me preface this by saying I never had any kind of health issues and most women in my family conceived with no problem. My OB/GYN never mentioned irregularities, fibroids, or cysts. My graduate school research had nothing to do with women’s health so I was not inundated with facts and figures. Yet, here I was already concerned and worried (with no discussion of even a long-term future with my partner at the time might I add). My wonderful family, including my mother, tentatively agreed but I am sure were thinking “she has to be joking”. I had never been more serious; I wanted to have options. I did not know what would happen when my womanhood was called out on stage. As women, that is how so many of us define ourselves, right? This is what famed Developmental Psychologist Erik Erikson called generativity: deciding how we will contribute to future generations. In his theory, however, he felt that people usually did not start worrying about this legacy until middle age (or at the very least until a partner was on board), but here I was already thinking about my grandchildren.

About 5 years later, while I was teaching Public Health and Medical Issues in African American Communities, I discovered the documentary series, “Unnatural Causes.” Unnatural Causes delves into the relationship between social conditions and population health. When it came time to discuss health disparities as related to women’s issues, the episode “When the Bough Breaks” was perfect. One statement in the video astounded me: Black women with advanced degrees have worse birth outcomes than White women without a high school diploma. I nearly cried in front of my class. It not only took me back to my concerns in my 20s, but I had just found out I was pregnant with my first child. Would I, a Black woman with a PhD in her early 30s, not be able to carry full-term? Infertility issues, low birthweight babies, and high-risk pregnancies can absolutely influence any woman and family. However, research has uncovered unique circumstances that impact the maternal health of Black women.

Physical Factors

The 2006-2010 National Survey on Family Growth interviewed over 20,000 men and women about family life, pregnancy, infertility, general health, and reproductive health. Chandra and colleagues found non-Hispanic Black women were 1.8 times more likely to report fertility issues compared to non-Hispanic White women. This finding was true among married women as well. It is possible that uterine fibroids, benign tumors in the uterus, affect fertility. Reproductive Science is a relatively young field (compared to Obstetrics and Gynecology which date back to the 19^th century), therefore the relationship between uterine fibroids and infertility is far from definitive. However, race/ethnicity is a well-established risk factor for uterine fibroids with Black women developing uterine fibroids at an earlier age than White women. A recent analysis of couples in a reproductive medicine clinical trial found that Black women with uterine fibroids were more likely to miscarry before 12 weeks compared to White women with uterine fibroids. Researchers are trying to identify genetic causes but that will not help the thousands of Black women trying to conceive now.

Psycho-social Factors

Were you ever told babies do not grow in a hostile womb? I heard that at some point in life. During my first trimester, I learned this new information about health disparities in pregnancy outcomes and I was going through a career transition. I was stressed out. Stressors cause the body to release cortisol, which is a necessary hormone when you need to react during intense situations. However, long term exposure to cortisol weakens your immune system and puts you at risk for disease. There is a significant amount of data to support that high levels of cortisol (from continual exposure to stressors) throughout pregnancy can impact the development of your baby. At the same time stress, as a psychological and emotional reaction, is at the center of two of the most common psychological disorders: anxiety and mood.

Anxiety disorders often include fear, tension, nervousness, and dizziness whereas mood disorders often include a sense of hopelessness, fatigue, depression, and an inability to concentrate. Although pregnancy does not increase the likelihood that you will develop either disorder, whether stressed or not, undiagnosed psychological disorders prior to pregnancy can advance further because the symptoms go undetected due to similarities with the normal experience of pregnancy. Dealing with the stigma of mental health issues in the Black community will have to be for another time, different blog! What should a Black woman dealing with certain psychological and emotional symptoms, particularly as stressors, do? Best solutions to deal with stress: walk, yoga, cut out unnecessary activities, watch TV, journal, eat well, and countless other suggestions from books and websites about de-stressing your life. I will admit that I failed miserably in completely de-stressing but I did manage to incorporate a few suggestions over my pregnancy.

a pregnant Black woman sitting on a windowsill — maternity 5. Source: Ariane Hunter, Creative Commons

How can Black women deal with cultural, historical, and intergenerational stress…the kind of cumulative stress that comes from 400 years of slavery, racism, and discrimination? The pervasive stress that has entrenched itself in the Black psyche? Yes, it is absolutely in there, but it has not just remained in our minds as simple negative thoughts. If that were the case, we could have some sessions of cognitive therapy, learn to counteract those aversive thoughts, and stop perceiving the world as a threat. When one examines racial differences in health outcomes with all things being equal across the racial groups, for example money, education, health care access, and family life, health disparities are still present. Scholars have offered the historical trauma of Blacks throughout the course of US history as an explanation. Could racism not be another explanation for infertility? According to Prather and colleagues, it is the perfect explanation for the social conditions endured by Black women that ultimately influence sexual and reproductive health outcomes.

This is just the tip of the iceberg. There is additional research on the impact of lack of quality healthcare for Black women experiencing fertility issues. Differences in healthcare options affect the recommended treatment and patient understanding of alternatives. There are also observed racial differences in In Vitro Fertilization usage, with money most often the biggest deterrent. Low-income families are very likely unaware that there are grants available to assist with infertility treatment. These are macro-level factors that require changes in resource distribution, medical training, and public policy. And I ask again, how does it help the Black woman trying to conceive now?

As it turns out, I worried for no reason as I thankfully have two healthy and beautiful little girls. I want to ensure that my outcome continues to be the norm rather than the exception going forward. In my opinion, increased awareness of this problem in the Black community will cause a push for more research on racial disparities in fertility issues. Only then will we begin to see changes that will eventually trickle down to support for another young girl in her 20s wondering “can I conceive?”

Dr. Martinique Perkins Waters is an Assistant Professor in the Department of Behavior Sciences at the University of West Alabama. She obtained a PhD in Lifespan Developmental Psychology from UAB in 2010 and since then has taught a variety of courses for Psychology, African American Studies, and Public Health. For over 10 years, Dr. Waters’ research has broadly related to gerontology with specific interest in the social role of caregiving and how that impacts physical, mental, and emotional health.

What is Gender-Based Violence?

Growing up, I was resentful of the social freedoms my male friends naturally enjoyed. Unlike the parents of my male friends, my parents were very strict about things like curfews, not being outside at night alone, and avoiding certain neighborhoods. My dad would always say, “We trust you, but we don’t trust the people around you”. Although I was still resentful, I know my father enforced those stringent rules because he was trying his best to protect me from gender based violence (GBV). GBV is defined as violence towards an individual that is motivated based on his or her gender identity, biological gender, “or perceived adherence to socially defined norms of masculinity and femininity”. The term ‘violence’ encompasses physical, sexual, and psychological abuse along with coercion, threats and compromised liberty. Examples of GBV include sexual violence like rape, domestic violence, and human trafficking. Both men and women are affected by GBV; however it is recognized women and girls are at most risk for exposure due to the imbalanced power relations between men and women “which have led to domination over and discrimination against women by men … and that violence against women is one of the crucial social mechanisms by which women are forced into a subordinate position compared with men.”

Violence against women and girls is a prevalent human rights violation resulting in disproportionate negative consequences on females’ physical, mental and sexual and reproductive wellbeing including but limited to including, but not limited to: “i) fatal outcomes; ii) acute and chronic physical injuries and disabilities, iii) serious mental health problems and behavioral deviations increasing the risk of subsequent victimization and iv) gynecological disorders, unwanted pregnancies, obstetric complications and HIV/AIDS .”

International Womens Day Strike. Source: Molly Adams. Creative Commons

Some troubling statistics on GBV:

In 2014, a UNICEF study projected that ~120 million girls (almost 1 in 10) under the age of 20 have been forced to perform sexual intercourse or other sexual acts during some point of their lives.
Almost half of the women killed in 2012 were murdered by a family member or intimate partner.
Globally, the WHO estimates 35% of women worldwide have experienced either physical and/or sexual intimate partner or non-partner violence or sexual violence. Other national studies have estimated up to 70% of women experience GBV.
“Women and girls together account for 71 per cent, with girls representing nearly three out of every four child trafficking victims. Nearly three out of every four trafficked women and girls are trafficked for the purpose of sexual exploitation.”

Although a pressing issue, it wasn’t until 1992 when the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) formally adopted General Recommendation No. 19: Violence against Women (GR 19), which legally categorized violence against women a distinct form of discrimination. Likewise, it wasn’t until 1993 the United Nations General Assembly adopted the Declaration on the Elimination of Violence against Women (DEVAW), forming the first ever internationally-recognized definition of GBV. Both documents explicitly outline how GBV violates basic human rights mentioned throughout the UDHR such as the right to life, dignity, and health.

Health Effects of Exposure to GBV

Sexual and Reproductive Health
GBV is a major public health concern contributing to mass amounts of mortality and morbidity. Specifically, the relationship between GBV and HIV and other STIs has been recognized as an important pathway for the contraction and spread of such diseases. WHO states that, in some regions, women facing sexual partner violence are 1.5x more likely to contract HIV, and 1.6x more likely to contract syphilis. Here’s how:

First, increased vulnerability to HIV and STI’s stems from sexual violence such as rape. “Violence reduces victims’ abilities to influence the timing and circumstances of sex, resulting in more unwanted sex and less condom use, including situations where women are coerced or pressured not to use condoms.” For example, of the estimated minimum 250,000 women brutally raped during the Rwanda Genocide, 70% of those survivors tragically acquired HIV.

Second, another important pathway from GBV to HIV is men who are physically violent are also more likely to be HIV positive. Studies find violent men are more likely to engage in risky sexual behavior such as having multiple sex partners and utilizing transactional sex, increasing their chances of contracting and spreading HIV and other STIs.

Along with the spread of disease, women and girls experience unwanted pregnancies due to GBV. The WHO states that women with previous exposure to GBV are more likely to account having had a self-induced abortion. Globally, “80 million unintended pregnancies each year, at least half are terminated through induced abortion and nearly half of those take place in unsafe conditions.” A study analyzing the relationship between GBV and sexual and reproductive health among low-income youth in three Brazilian cities, supports WHO’s statement that women in abusive relationships are more likely to experience unwanted pregnancies. The study found adolescent females who became pregnant as teenagers were more likely to have been victims of controlling behavior or physical abuse compared to teenage girls whom have never gotten pregnant. Among the girls who got pregnant as a teenager during the study, “20% reported having suffered physical violence from a partner and 10% reported having been subjected to sexual violence from a partner, compared to 5% and 3% respectively of those who did not get pregnant as teenagers.”

Mental Health:

Along with physical harm, studies highlight women and children face serious mental health problems after enduring traumatic experiences with GBV. “Exposures to traumatic events can lead to stress, fear and isolation, which, in turn, may lead to depression and suicidal behavior.” According to the WHO, women abused by a non-partner are 2.3 times more likely to have alcohol use disorders and 2.6 times more likely to have depression or anxiety. A cross-sectional study based on the Australian National Mental Health and Well-being Survey in 2007 found that of the 4,451 female respondents, 1,218 (27.45%) of the women have experienced one of the four types of GBV analyzed in the study (IPV, stalking, sexual assault, and rape). Of the 139 women who experienced at least three types of GBV, the rates for mental disorders were 77.3% for anxiety disorders, 47.1% for substance abuse disorders, 34.7% for attempted suicide, and 56.2% for PTSD.

Right On. Source: Liz Spikel. Creative Commons

Potential Solutions to Address Gender-Based Violence

In light in of April being sexual assault awareness month, itself a form of GBV, it is essential to break through the culture of silence. Our health care system can be more active is addressing the prevention of GBV, and also the aftermath of GBV. First, providing survivors with mental health services such as counseling is critical for these women and girls to address their psychological trauma and progress with their lives. Mental health services are vital in providing survivors a voice to express themselves. Second, our health care system could potentially be a major stakeholder in identifying and stopping GBV.

“GBV is very common, but most health care providers fail to diagnose and register GBV, not only due to socio-cultural and traditional barriers, lack of time, resources and inadequate physical facilities; but even more so due to lack of awareness, knowledge and poor clinical practices with limited direct communication and failure to do a full physical examination, not to mention register and monitor the effectiveness and quality of care.”

Moving forward, there needs to be a systematic change within in the health sector. The World Bank, amongst other NGO’s, have provided approaches on how to address this issue. Some strategies to consider include, but of course not limited to:

1) Requiring GBV screenings during doctor visits to ensure early intervention
2) Train and educate health care personal about GBV to improve provider’s knowledge, medical services and attitudes towards GBV.
3) Providing survivors access to adequate infrastructure within hospitals which includes private counseling and examination rooms.

Women are approximately 50% of our global population, yet gender-based violence is one of the most prevalent and widespread human rights violations. Gender equity is an inalienable right protected in numerous human rights documents, however change will never be achievable until we break this vicious cycle of violence through education and strict policy changes. Ultimately, women have proven they are just as equally capable as men, and gender-based violence and discrimination over an uncontrollable biological factor is simply unjust.

Public Health Equity in Humanitarian Crises

In 1950, the office of the United Nations High Commissioner for Refugees (UNHCR), also known as the UN Refugee Agency, was created to help millions of Europeans who had fled or lost their homes during World War II. Since the creation of the UNHCR, the UN Agency for Refugees still remains the leading UN organization mandated to protect the basic needs and human rights of refugees. The unprecedented forced displacement of people, both internally and across borders, is one of the most persistent manifestations of humanitarian crises and conflict in the modern era. 65.5 million people around the world have been forced from their homes due to violence. Among the 65.6 million people, the UNHCR oversees more than 21 million refugees, over half of whom are under the age of 18. Presently, the rights of refugees are protected by the UN Convention Related to the Status of Refugees adopted in 1951, established from Article 14 of the Universal Declaration of Human Rights (UDHR). Article 14 of the UDHR recognizes the right of persons to seek asylum in other countries from persecution in their home country.

The long- and short-term effects of displacement on the masses of global refugees generate humanitarian crises for these persons. Humanitarian responses to crises focus on delivering equitable and quality public health interventions, an essential element of the larger operational framework of humanitarian aid. Public health encompasses a vast variety of components including: 1) reproductive health, 2) disease control, 3) maternal and child care, 4) psychosocial support, and lastly 5) sanitation. “Although the health needs during and after natural disasters and armed conflicts are similar, the differences arise from the political complexities of the latter, in which civilian populations serve as targets of war and human rights abuses aggravate health and protection needs” (Leaning, 2013). The main health consequences of armed conflicts are not conflict-related injuries and deaths. During humanitarian crises such as armed conflict, death is exacerbated by various direct and indirect factors, including common childhood illnesses such as diarrheal disease and severe malnutrition. The legitimate concerns of public health equity in the framework of refugees’ and internally displaced populations’ (IDPs) healthcare continues to be more complex and challenging.

Providing clean water to millions of people. Source: DFID, Creative Commons

Urban Refugees
Current global trends indicate a shift towards urban destinations for refugees and away from refugee camps. The UNHCR reports 60% of the global refugee population and 34 million IDP population live in urban environments. Urban environments provide social security for refugees. Unlike refugee camps, living in cities offers refugees the opportunity to live anonymously. Refugees residing in urban settings are not subjected to the limitations of a refugee status and camps. In urban settings, refugees have access to educational, advanced healthcare services, and employment opportunities which may not be available at refugee camps. Examples of this trend are Damascus, Syria and Amman, Jordan; both received more than 1 million refugees from Iraq alone. Furthermore, many refugees are not legally permitted to settle in urban centers, thus end up living in informal settlements and slums alongside the major urban areas. These informal settlements are typically outside the radar of government and humanitarian aid agencies, thus remaining unidentified and particularly at risk for human right violations.

Public health equity in humanitarian situations
From the public health perspective, it is much more difficult to keep track of people when they move to urban areas. This consequently makes healthcare delivery more difficult in terms of: 1) assuring refugees receive basic health care services, 2) coordinating patient referrals, 3) accessible and available health services and resources, and finally 4) managing the costs of health care services. UNHCR’s leading principles for public health assert health care services delivered to refugees by host countries should resemble and correspond with the services provided to citizens and residents in their country of origin. Minimum, yet essential, health care services must be maintained in all situations, including humanitarian disasters and mass forced migration. “This UNHCR guiding principle preserves a sense of fairness and equity between two contiguous groups of people who must, for a range of security and political reasons, be encouraged to live in this adjacency as harmoniously as possible for an indefinite period of time (Leaning, 2011).”

A coordinated system of health care delivery is more urgent in urban settings not associated with refugee camps or humanitarian relief. The urban displacement phenomenon has shifted the direction of care delivery systems to focus on establishing healthcare delivery systems supporting access to preventive health care services. Present systematic healthcare delivery issues requiring critical consideration include 1) the financing of health services, 2) access barriers to services due to unaddressed financial burdens, 3) cultural barriers, and lastly 4) and the integration of services for refugees within existing formal health systems.

Recently, UNHCR has begun to advocate for refugees to gain access to health insurance in their host country, especially in middle-income countries where healthcare systems already function for host populations. For example, in 2011, health insurance for Afghan refugees living in Iran was introduced. By June 2012, 347,000 refugees registered for health insurance. 40% of the Afghan refugees whom enrolled for health insurance were officially registered with the UNHCR. With health insurance, refugees have access to secondary and tertiary healthcare services for treatment of non-communicable diseases and other illnesses. Health insurance provides UNHCR registered refugees a second form of official documentation. Secondary healthcare services include consultant led-services with health care specialists. Tertiary care services include specialized consultative care delivered on referral from primary and secondary The Iranian government also benefits from providing health insurance to the country’s population by reducing the perennial risk of paying for the hospitalization of refugees. Refugee health insurance is successful in Iran because refugees have access to employment allowing some refugees the means to afford to pay premiums and co-payments. The UNHCR will support vulnerable persons if they cannot afford health insurance. Urban refugees need more representation and support services within the health sector.

Pēteris. Source: Pavão-Pavãozinho favela, Creative Commons.

Resource Allocation
Achieving public health equity in humanitarian crises is a complicated and challenging process. The majority of refugees do not live in refugee camps and their experiences as urban dwellers must be further investigated by academics and professionals alike. This trend holds for human societies in general; the world at large is experiencing rapid urbanization. In 1950, less than 30% of the world’s population lived in cities and towns. Presently, urban population has increased to 54% and is expected to reach 60% by 2030. Even though urban refugees have the ability to live anonymously and earn wages, living in an urban setting undermines refugees’ access to affordable and high-quality basic health care services. Future policy decisions and international aid programs regarding urban refugees must continue to adapt to the shifting demographic profiles of refugees, IDPs and the effects of global urbanization. Ultimately, public health equity problems the humanitarian community is attempting to confront can be categorized under two categories: resource allocation and decision-making. As humanitarian crises stemming from armed conflict become more common, investing in sustainable policy solutions for resource allocation in the health sector for forced migrants will prevent the suffering of these individuals on the low end of the welfare continuum.