Essay Series 4.3: Comprehensive reproductive health care doesn’t exist for many women.

Comprehensive reproductive health care includes infertility treatment; safe and autonomous pregnancy, labor, and delivery; pregnancy prevention; abortion; and parental autonomy.²³⁴ Reproductive health care has evolved over time from being barbaric for women in the United States to many services being widely available up until 2022. In that year, the Supreme Court overturned Roe v. Wade, the case that had guaranteed women a right to control their reproductive care through abortion. Women are under threat in the United States in ways I never imagined possible. In many states, women face death, loss of fertility, stillbirths, and babies who die painful deaths shortly after birth due to their health care problems. Women are sometimes arrested when their pregnancies end prematurely via miscarriage.

This essay covers the struggle to get access to sex education, basic pregnancy prevention, abortion, and maternity and postpartum care. Rollback of progress started in 1981 and accelerated in 2022. These setbacks threaten women’s health and lives.

Sex Education

Sex education has been around for over 100 years in the United States. It started with discussions limited to having safe sex within marriage.²³⁵ Current abstinence-only sex education teaches much the same thing people were learning over 100 years ago.

In the United States, sex education is uneven and mostly inadequate.

1. Forty-two states require students to take a sex education course, and only 19 states require that the courses be medically accurate. Five of the 19 states only require medical accuracy for specific topics.

1. Thirty-four of the 42 states require that sex education include the topic of abstaining from sex.

1. Only 24 of the 42 states require education about sexual assault, and 21 require information about dating violence.²³⁶

These omissions are incomprehensible. Sex is an important aspect of human life, and children need access to comprehensive, accurate information about how their reproductive systems work, sexuality, and sexually-related violence.

The era of sex education focusing on abstinence began in 1981 with the passage of the Adolescent Family Life Act, which directed millions of dollars toward this effort. Numerous studies have found that abstinence-only sex education doesn’t delay when teens become sexually active or reduce the number of partners they have. Studies have found that students in these programs are less likely to practice safe sex than those who have had more comprehensive sex education.²³⁷

In 2009, President Obama signed into law the Teen Pregnancy Prevention Program, which prioritized comprehensive sex education; this program included discussion of abstinence. Between 2010 and 2015, about half a million teenagers participated in the comprehensive approach to sex education, and teen birth rates fell, in part, because of increased use of contraception.²³⁸

However, in 2017, under a Republican presidency, it was back to abstinence-only. This type of education gained the new label of sexual risk avoidance education. Along with the focus on abstinence-only has come a wave of parental rights and other groups seeking to ban teachers from talking about sexual topics and to ban books with sexual content in schools and even in public libraries.²³⁹

As a result, many young people can’t get good sex education, can’t talk to their teachers or other staff about sex-related topics, and can’t get any information about sexual issues from libraries.²⁴⁰ What these young people have left is the internet, which just about everyone can access.

The internet has websites that focus on sexual health. A 2015 study of the top 12 websites showed that of those that addressed pleasure, most just addressed sexual pleasure during masturbation. So, when children and young adults have questions about sexual pleasure, many turn to internet porn sites. These sites showcase humiliation and harm of girls and women. Researchers have found conflicting results about the impact of porn on young people, and much of the research has biases. No one knows if porn is addictive.²⁴¹

A reproductive health and justice reporter at The Guardian interviewed young people about where they learn about sex. She found that girls tended to learn about sex from fan fiction and social media, and boys from porn videos. Both sources have mainstreamed rough or painful sex where women receive pain when men pull their hair, spank, or choke them. Consent to this pain is not emphasized in porn. Choking was a common topic in the reporter’s interviews. In fact, adults under age 40 are twice as likely to have been choked during sex than those over 40. One survey found that 58 percent of women college students were choked compared to about 26 percent of men.²⁴² Choking can lead to disability and death.

Access to comprehensive sex education is difficult at best in the United States, and this country has gone back to the future. Children often can’t get good information, and the information they do get can be wrong or incomplete. The fight for access to good sex education resembles the fight for contraceptive care.

Contraceptive Care

Pregnancy can be a life-threatening condition, and the United States has the highest maternal mortality rate among wealthy nations. Pregnancy can also cause loss of fertility and disability. Human societies from at least the time of the Egyptians have attempted to control births. Old methods ranged from eating monkeys’ brains to the use of mercury, which is a toxic metal.²⁴³

Three birth control advocates in the United States were instrumental in improving women’s lives by giving them the knowledge of and methods for controlling their fertility. These women were Madame Restell, Margaret Sanger, and Katherine McCormick.

Madame Restell began giving advice about birth control and abortions (the latter covertly) in 1836. If women were pregnant and came to her early enough, she helped with abortions. If women were too far along in their pregnancies, Restell arranged adoptions for those women who couldn’t keep their children. When she started her work, it was legal. However, by the late 1800s, public opinion held that everything that interfered with giving birth, even using condoms, was considered killing a child.²⁴⁴

Margaret Sanger was a nurse who witnessed the impact of unwanted births. These included starving children, physically and emotionally exhausted mothers, and the death of women due to self-induced abortions. Sanger published The Woman Rebel, which focused on women’s rights and birth control. After only eight issues, publication stopped because of Sanger’s legal problems. She opened the first birth control center in the United States in 1916. She was arrested almost immediately for dispensing birth control advice and sentenced to 30 days in a “workhouse.” She continued to write about women’s need to control conception and was arrested several more times.^245,246 In 1921, Sanger founded the American Birth Control League, which was a precursor to Planned Parenthood.²⁴⁷ As a result of Sanger’s work, wealthy feminists and John D. Rockefeller funded a chain of birth control clinics.²⁴⁸

Sanger's accomplishments are complicated by her support of eugenics. This theory holds that supposedly desirable people should be encouraged to reproduce, and supposedly undesirable people should be prevented from having children through forced sterilization if necessary.

Katherine McCormick, a wealthy feminist, devoted herself and part of her wealth to funding the development of a birth control pill for women in the 1950s, after meeting a researcher Margaret Sanger knew. Sanger had started working with him to develop a birth control pill, and McCormick provided much of the project’s funds. McCormick’s role was crucial because pharmaceutical companies wouldn’t get involved in developing the pill.²⁴⁹

In 1957, the FDA approved Enovid, the first birth control pill to regulate menstruation, and in 1960, the FDA approved it for birth control purposes.²⁵⁰ The birth control pill changed women’s lives. They no longer had to rely on condoms, which men resisted; abstinence; or luck to avoid pregnancy.²⁵¹ Sexuality and fertility no longer had to be linked for women taking birth control pills.

Men’s Responsibility for Contraception

Society has pressured women and men to approach sex in different ways. Women are supposed to be the gatekeepers who say no to men, and men are always supposed to want sex. Fallout from sex is assumed to be the woman’s fault and her responsibility, including the resulting trauma, pregnancy, health problems, or child-rearing.²⁵²

As a result, reproductive health care discussions are all about women’s choices. One of the conversations that is largely absent from birth control is men’s role.²⁵³ This omission isn’t logical because women can’t get pregnant without men’s sperm.

Men need to be a central part of discussions about reproductive care and help prevent pregnancy and abortion by using condoms or getting vasectomies.²⁵⁴ Men need to accept as much responsibility as women already do for preventing unwanted pregnancy and, when pregnancy occurs, they need to financially support their children. The reasons include the following:

1. Generally, men are fertile all the time, and women release one egg a month that can be fertilized up to 24 hours after release. A woman’s fertility window can last up to 7 days each month because sperm can survive for up to five days inside a woman’s body. The timing of the egg’s release is largely unpredictable.²⁵⁵

1. Birth control methods that women control require medical appointments, prescriptions, and interventions or expensive surgery. With some methods, certain women risk pain, heavy bleeding, strokes, cancer, and heart attacks. The risks to women vary by method.²⁵⁶

1. Men have two major types of birth control available: condoms and vasectomies. Condoms are available without a prescription and are less expensive than birth control for women. Vasectomies occur in the doctor’s office with local anesthesia, health risks are low, and recovery time is short. Tubal ligations for women require general or spinal anesthesia and are done in hospitals or outpatient surgery centers. Vasectomies are much simpler and less invasive for men than are tubal ligations for women.²⁵⁷

People who are pro-choice or anti-abortion could agree that preventing unwanted pregnancies is preferable. And they could agree that men need to take responsibility for their sexual activities, especially pregnancy prevention, and they need to support any children they father.

Involuntary Sterilization

Eugenics is the idea that the human race can be purified by not allowing supposedly inferior people to reproduce and promoting reproduction among supposedly desirable groups.²⁵⁸ This concept led at least 30 states to pass related laws beginning in the early 1900s. These laws allowed governments to force sterilization on women and men these states deemed inferior.

Young women in institutions were a major target of these sterilizations, generally without their knowledge or consent. In 1924, Carrie Buck was living in the Lynchburg Colony for Epileptics and Feebleminded. Her foster family confined her there after she delivered a child as a result of rape. The institution required that she undergo sterilization. She appealed the order all the way to the Supreme Court. The Court ruled against her and affirmed the legitimacy of forced sterilization in 1927. That decision still stands. In 1933, the German Nazis passed their own forced sterilization law; they were inspired by U.S. laws.²⁵⁹

By the 1970s in the United States, at least 60,000 people were sterilized without their consent.²⁶⁰ By 1970, about one-third of Puerto Rican women had been sterilized, many without their knowledge or consent.²⁶¹

Abortions

Many women will get abortions, whether they are legal or not. Illegal abortions can be dangerous. In the mid-1960s, one in six pregnancy-related deaths in the United States was due to unsafe abortions.²⁶² Before 1970, estimates are that 200,000 to 1.2 million abortions occurred in the United States each year.²⁶³

It’s a myth that abortion has always been frowned upon or illegal. Groups that used to advocate for abortion rights now oppose them. Republicans supported abortion rights until the late 1970s. Southern Baptists also advocated for abortion rights. In 1971, their National Convention adopted a resolution supporting abortion in cases of rape, incest, severe fetal deformity, and damage to a woman’s physical and mental health.^264,265

In the United States, the Roe v. Wade Supreme Court decision made safe, legal abortions available to women nationwide in 1973. States had to allow women and their doctors to determine whether an abortion would occur. During the second trimester, states could regulate abortions for health reasons, and states could prohibit most abortions during the third trimester.²⁶⁶

In 2022, the Supreme Court eliminated the 50-year-old national right to an abortion in its decision in the Dobbs v. Jackson Women’s Health Organization case. This decision allowed states to regulate abortion, and many now prohibit abortion in most, if not all, cases, even when pregnancy results from incest or rape.²⁶⁷ In the 18 months following the Dobbs decision, researchers estimate that rape led to about 59,000 pregnancies in states that ban abortions due to rape.²⁶⁸

Women will get abortions and have for hundreds of years, despite prohibitions. Unsafe abortions or lack of access to them lead to disability and death for women. Men have no direct physical consequences when they cause pregnancy.

Maternity and Childbirth

This section highlights just two of the many risks that a woman faces during labor and delivery of a baby; those are pain and death.

Pain

The medical profession during the 1800s said women should endure pain during childbirth. A U.S. doctor said that women should experience labor so they would learn to love their babies. Also, the pain of childbirth was supposed to be god-given and, if women didn’t experience pain, they could turn into “sexually depraved beasts.”²⁶⁹

A Scottish physician named James Simpson pioneered the use of chloroform during childbirth for “civilized” (read White) women. Finally, when the English Queen Victoria used chloroform during delivery of her eighth child, this practice became acceptable for upper-income-class women.²⁷⁰

Enslaved Black women suffered more severely in the United States. For example, during the 1840s, a physician named James Marion Sims, who used to be called the “father of gynecology,” operated many times without using anesthesia on at least three enslaved women’s genital areas. Their names were Anarcha, Lucy, and Betsy. Anarcha endured about 30 operations over four years. Sims was trying to correct “fistulas,” which are holes in the vagina that result in leakage of urine or feces. Fistulas can occur as a result of delivering a baby. When Sims did the same operations on White women, he used anesthesia.^{271 272}

The epidural method of pain relief, which involves nerve blockage, didn’t become widely available until the 1960s. Currently, about 70 percent of births involve an epidural; sometimes this procedure doesn’t work.²⁷³

The pain doesn’t end with birth. In the United States, an estimated 25 percent of women return to work within two weeks of giving birth. They have not recovered from pregnancy or the birth process by then. And they are sleep-deprived and have limited ability to bond with their babies.²⁷⁴ This happens because parents aren’t guaranteed paid family leave, paid sick leave, or help with day care or preschool expenses. In many other Western countries, parents do get this kind of help.²⁷⁵

Maternal and Fetal Death

During the early 1900s, many women died due to childbirth. In 1910, an estimated 46 percent of the deaths of women aged 20 through 39 were related to childbirth.²⁷⁶ In 1915, 6 women died for every 1,000 live births, and 10 percent of infants died. The numbers were twice as high for non-White people.²⁷⁷

The 2024 maternal mortality rate was 17.9 deaths per 100,000 live births. The rate for Black women was 44.8 per 100,000 live births, significantly higher than White (14.2), Hispanic (12.1), and Asian (18.1) women.²⁷⁸ More than 80 percent of maternal deaths in the United States are preventable.²⁷⁹

Pregnant women can be arrested for feticide. Thirty-eight states have adopted feticide laws, which make it a crime when a pregnant woman’s fetus dies. The federal Unborn Victims of Violence Act of 2004 makes it a crime to harm or kill a fetus. Pregnant women have been and are being prosecuted under these laws, even for miscarriages.²⁸⁰ Miscarriages are a common end to pregnancy; 10 to 25 percent of pregnant women miscarry during their first trimester.²⁸¹

Reflections

I had perfunctory 1960s sex education in middle school. It was boring and provided little education and no information about birth control. It wasn’t until I was in college that I was able to get access to birth control and was able to read the ground-breaking book called, Our Bodies, Ourselves (1970), which provided comprehensive sex education.

I experienced severe pain during an abortion due to a miscarriage in Texas in 1981. I was on a very effective means of birth control at the time; however, most methods can fail. If the same event were occurring in Texas now, I could be forced to wait until the fetus died and hopefully avoid sepsis, which is a life-threatening blood infection.

Restrictions on comprehensive reproductive care hurt men too. I know of at least two men in my generation who married their pregnant girlfriends. Both told me they would have made different marriage and career choices if they hadn’t had children early in their lives. The same is even more true of women who can’t get access to the reproductive care they need because many men don’t take responsibility for the pregnancies they cause.

Many women’s lives are being lost or upended because anti-abortion laws fail to account for the mother’s health or mental health. Women are dying, infants with fatal birth defects are dying painful deaths, and women are losing their fertility or their ability to function.

How has your life or that of someone you know been affected by the gaps in the United States’ reproductive health care and the loss of the right to an abortion?