Gender is an important and often overlooked social determinant of health (Alcalde-Rubio et al., 2020). Factors related to gender include health system discrimination and bias, inequitable societal norms and practices, differential exposure to disease, disability, and injuries, and biases in health research.
Historically, women have been victims of bias and discrimination in medical diagnosis, treatment, and care. Compared to men, women are less likely to be diagnosed with a non-psychosomatic illness, have their pain treated, and have their symptoms taken seriously. Women were also excluded from clinical trials until the early 1990s.
Women are less likely than men to be referred for cardiovascular testing, and indigenous women in particular report perceived discrimination by clinicians as a reason for not seeking recommended cancer screening. Indigenous and non-white Hispanic women have been stereotyped as being non-compliant with clinical health recommendations, having risky health behavior, and difficulty understanding or communicating health information (Dirks et al, 2022).
There has been a long history of forced and coerced sterilization of women throughout the world. Throughout the early 20th century, countries passed laws authorizing the coerced or forced sterilization of those they believed should not be permitted to procreate. The practice targeted marginalized populations, including people diagnosed with a mental illness, disabled persons, racial minorities, poor women, and people living with specific illnesses, such as epilepsy. In the U.S., more than half of the 50 states had laws permitting the sterilization of people with specific physical illnesses, Native Americans, and African Americans (Patel, 2017).
Did You Know. . .
From the 1910s through the 1950s, and in some places into the 1960s and 1970s, tens of thousands—perhaps hundreds of thousands—of American women were detained and forcibly examined for sexually transmitted infections. The program was modeled after similar ones in Europe, under which authorities stalked “suspicious” women, arresting, testing, and imprisoning them.
Inside these institutions, the women were often injected with mercury and forced to ingest arsenic-based drugs, the most common treatments for syphilis in the early part of the century. If they misbehaved, or if they failed to show “proper” ladylike deference, these women could be beaten, doused with cold water, thrown into solitary confinement—or even sterilized.
Scott W. Stern, America's Forgotten Mass Imprisonment of Women Believed to Be Sexually Immoral, 2019
Health Inequities in Perinatal Care
Recognizing the need to humanize birth, the World Health Organization and leading maternity care scholars have incorporated respectful maternity care as a central tenet of high-quality care, regardless of birth setting, technology, or resources available in the country. Person-centered maternity care is defined as “care that is respectful of and responsive to women’s preferences, needs, and values and is a core component of quality maternity care” (Ibrahim et al., 2022).
The term “higher quality maternity care” describes perinatal care that is respectful and facilitates a level of autonomy preferred by the birthing person. In keeping with the self-identification of study participants, we employ the term “women” throughout this manuscript though we recognize that not all people who give birth identify as women and have varying gender identities and preferences for language (Ibrahim et al., 2022).
Black and Indigenous women in the U.S. are significantly more likely to die within a year of giving birth and experience disproportionately higher rates of severe maternal morbidity. Nearly half of these maternal events are preventable through improving quality of care. Inequities in the quality of preconception, prenatal, intrapartum, and postpartum care may contribute to racial disparities in maternal health outcomes. Notably, when mode of delivery is disaggregated by race, Black women in the U.S. have the highest rates of cesarean birth, despite similar predisposing factors (Ibrahim et al., 2022).
Improving maternal health and health equity is a key priority of the U.S. Surgeon General, and the U.S. Department of Health and Human Services. Racism and racial discrimination are linked to poor health, and specifically, negative birth outcomes for women of color and their infants. Mistreatment during pregnancy and childbirth has been associated with both short- and long-term adverse mental health outcomes that include pain and suffering, postpartum depression and post-traumatic stress disorder, fear of birth, negative body image, and feelings of dehumanization (Ibrahim et al., 2022).
Reproductive Justice
At U.N. conferences in 1994 in Cairo and in 1995 in Beijing, participants considered the status of women, population, and development. They adopted the principles of reproductive justice, i.e., that it is a fundamental right to be able to control the number and timing of childbearing. This requires access to family planning information, contraceptive services, and abortion. However, developing country surveys show that as many as a quarter of women who want to either delay or stop childbearing altogether lack access to contraception or have concerns about the safety and side effects of available methods (Speidel and Sullivan, 2023).
Reproductive justice calls for the right to have children or not have children, to choose their number and timing, and the right to live in supportive environments that provide reproductive rights, equal opportunities for women, education, fair wages, housing, and healthcare. Advocates warn against repeating the past coercive history of some family planning/population programs––notably mandatory birth limitation and forced abortions in China and involuntary sterilization in India and the U.S. (Speidel and Sullivan, 2023).
The concept of reproductive justice represents a significant shift from traditional notions of reproductive rights, specifically in its inclusion of the impact of contextual and structural factors on reproduction. As described by Ross and colleagues, “The ability of any woman to determine her own reproductive destiny is directly linked to the conditions in her community and these conditions are not just a matter of individual choice and access. For example, a woman cannot make an individual decision about her body if she is part of a community whose human rights as a group are violated, such as through environmental dangers or insufficient quality health care” (Fleming et al, 2019).
The recent Supreme Court ruling overturning Roe v. Wade has already affected pregnancy-related healthcare for many women. It has also impacted OB/GYN training in the states that have restricted or are poised to restrict abortion services. This means hospitals will no longer offer vital training used to manage miscarriages and other pregnancy-related complications.