Most well-meaning efforts help enhance people’s quality of life. Sadly, in the case of young girls in Baltimore City, a well-meaning but flawed public health intervention impacted the ability of some young women to have a child and left a legacy of mistrust of the medical system for generations of young women and their families. When I first moved to Baltimore in 2008 to complete a Fellowship in Family Planning, I was not yet aware of the history of the local Black community and contraception, but that soon changed.
At the time, long-acting reversible contraceptive (LARC) methods were having a resurgence and research showed remarkable results in uptake and satisfaction when barriers, such as cost, were addressed. Given this positive feedback, I excitedly included counseling about these highly effective methods when talking to my patients about birth control options. However, I quickly came up against widespread resistance among many of my patients to having a contraceptive device inserted. This was in large part due to an initiative in the 1990s which spread skepticism of LARC devices among many people in my community. In fact, my patients told me that their mothers and aunties counseled against allowing any provider inserting a contraceptive device into their body.
A public health project in Baltimore City, the initiative asked medical providers to identify teens at risk for pregnancy and aggressively promoted implants to them. The purported intent of providing implants for young women and girls was to address Baltimore’s high teen pregnancy rate and to increase educational attainment.
Unfortunately, the same enthusiasm shown for placing the implants did not extend to the follow-up care necessary when people experienced side effects and complications, or simply wanted to have the device removed. As a result, many young women and girls suffered through side effects, and the fertility of some was impacted for years to come. The initiative, which often took place in school clinics, left many in the community with the impression that the project was designed to control the fertility of young, Black and low-income girls in the Baltimore community. This left a legacy of skepticism towards contraceptive devices and the medical system at large.
I have learned so much by listening to my patients and their stories about interacting with the healthcare system. I have also learned a great deal by reflecting on such harmful public health projects and on what it means when we think we know best, but do not center the people we're serving or seek to give them agency in their own health decisions. Simply blaming the medical providers who inserted the implant devices without appreciating the circumstances surrounding the implementation of the project and the sense of urgency to address teen pregnancy at that time is inadequate. Pursuing coercive policies to “help” young people plan and space pregnancies, without centering their wants and needs, ultimately only perpetuated systemic inequities.
Only a more holistic approach can fully address the social context and circumstances within which people make important decisions, including the decision about when and whether to have children.
The reality is that the challenges that Black, brown and low-income people face are informed by social determinants of health, which are “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.”
Thus, in the same way that safe and affordable housing, access to education, availability of healthy foods and access to health services can contribute positively to a person’s quality of life, so too can the opposite significantly and adversely influence health outcomes.
I have practiced medicine for almost two decades. By getting to know my patients, I understand their mistrust of the health care system given all that they have endured. We must do more to ensure that Black and brown lives are valued in our society and by the health care system. We must work to ensure that systemic and institutional racism are addressed in our communities and organizations.
We are encouraged by the legislative action of some states to address implicit bias in maternal health care and by commissions established to address racial inequities in maternal health. We are also encouraged by organizations, such as the American Public Health Association, and some cities and states that have named racism as a public health crisis. We must work to eliminate the Hyde Amendment, a discriminatory policy prohibiting Medicaid coverage of abortion care for 7.1 million people — a disproportionate number of whom are people of color. Finally, we must pass the Black Maternal Health Momnibus Act. All of these actions represent important steps to address the systemic public health challenges that impact access to quality reproductive health care for Black people and communities in the U.S.
This Black History Month, we celebrate the Black women who forged the Reproductive Justice Movement, which has provided a critical framework that has enriched the connection that I have with the communities I serve, and has made me a better physician and advocate. Every day I strive to live up to the principles of the reproductive justice movement, and will continue to work to bring them to life in my work as a physician and as CEO at Power to Decide.
In the 1990s, a group of Black women who thought the women’s rights movement was failing to address the unique needs of Black women and women of low income issued a public statement to members of Congress. The group, Women of African Descent for Reproductive Justice, made clear that “Reproductive freedom is a life and death issue for many Black women and deserves as much recognition as any other freedom.”
Over 20 years later, the same call to address racial disparities still rings true.
____Dr. Raegan McDonald-Mosley, MD, MPH, is the CEO of Power to Decide.