The reproductive decisions women make in their lifetimes are very intimate and personal. Decisions about contraception or whether or not to have children can be complicated. Yet those decisions can greatly affect women, their families and ways of life. Researchers are working to better understand reproductive decision-making and how to best support women in their reproductive rights.
Reproductive rights involve a whole spectrum of issues. They include the decision to have children, to family planning and contraception, abortion and assisted reproduction (help from a specialist to become pregnant), just to name a few. Reproductive rights are a part of human rights, says Sonya Borrero, MD, associate professor of medicine, University of Pittsburgh School of Medicine, and director, Pitt’s Center for Women’s Health Research and Innovation.
“We need comprehensive health care to ensure those human rights,” she says. “All individuals have the right to decide if, when and with whom they would like to have children.”
Part of Dr. Borrero’s research has been focused on understanding some of the influences that might shape or complicate pregnancy decision-making, especially when the decisions do not conform to social norms. These influences can include relationship and family dynamics, financial status and many other factors. As a part of her research, Dr. Borrero started collecting stories from women in Pittsburgh about their reproductive decision-making. She realized that pregnancy is not always a yes-or-no decision for some people. The decision can be very complicated.
She says, “As a health care provider, we often have these ideas about how people ‘should’ be reproducing—for example, you should be in a stable financial situation, you should not be a teenager, etc. From a public health perspective, situations like economic instability or pregnancy in teens are associated with poorer outcomes. But these ‘shoulds’ aren’t necessarily a part of how men and women are evaluating reproduction in their own lives. For some folks, having a child even in the midst of job instability may also feel like the right time. As health care providers, our job is to inform women about all their options and any risks and help ensure that they are able to make decisions that line up with their values and priorities. We want to meet women where they are and then work with them to get where they want to be.”
Dr. Borrero and colleagues have developed a set of questions they think all women of reproductive age should be asked by their health care providers. The questions were designed to support women and their choices in nonjudgmental, patient-centered ways. The PATH (Pregnancy Attitudes, Timing, and How important is pregnancy prevention) set of questions are:
1. Do you think you would like to have children someday?
2. If so, have you thought about when that might be?
3. How important is it to you to avoid pregnancy until the time you think you want to have children?
By discussing women’s thoughts about reproduction, health care providers can align their reproductive counseling with any concerns or goals women may have.
One particular focus of Dr. Borrero’s is on women’s decision-making about sterilization (getting one’s “tubes tied”), a permanent method of birth control. Dr. Borrero is developing a patient-centered and patient-directed decision-support tool for women on Medicaid who are making decisions about sterilization. The United States has a history of forced sterilization. In the 1970s the Department of Health and Human Services created regulations around sterilization for women on Medicaid. These regulations were meant to protect against people being uninformed or forced to undergo the procedure. The heart of these regulations is a 30-day waiting period for federally funded sterilization procedures. The majority of these procedures are done after childbirth. The waiting period has become a barrier for women wanting sterilization. Sometimes women deliver before the 30-day waiting period is up or sign the consent too late in their pregnancy. Sometimes women forget to bring the consent form with them while in the hospital to deliver.
“Because these women have to comply with a waiting period,” says Dr. Borrero, “they aren’t able to exercise the same level of reproductive freedom as women who have private insurance and don’t have to wait. The hope is that the tool provides accurate and unbiased information that helps ensure that women are making informed decisions about sterilization that line up with their goals and values. This tool could potentially replace the waiting period and honor the spirit of the regulations (which was to protect women) without creating unnecessary barriers.
Access to reproductive health services is another part of the rights spectrum. Women who are looking for medical help in becoming pregnant can be limited by the cost of assisted reproduction. Inequities also exist for women are simply looking for access to reproductive health care. And one of the largest reproductive health care providers in the country, Planned Parenthood, is at risk of being defunded.
“There’s data showing that there are health consequences to defunding Planned Parenthood,” says Dr. Borrero. “Planned Parenthood provides essential health services that no other health care system at this time can replicate. We learned that from Texas. Texas essentially excluded Planned Parenthood from its Medicaid program in the past couple of years. We’ve seen how that has been harmful to women’s health. We’ve seen a drop in the number of women using effective birth control, not continuously using it and a rise in unintended pregnancies. Federally qualified health centers are struggling to meet the primary care needs of patient. They cannot also train health care providers in full, high-quality reproductive services.”
Ensuring access to the entire reproductive rights spectrum is more than an issue of women’s health.
“Reproductive health decisions affect women, individuals and families,” says Dr. Borrero. “There are economic and social impacts on children and families when women cannot determine their own reproductive choices.”
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