Restrictions on reproductive care perpetuate inequity and put maternal and child health at risk around the world. Education and high quality care can support reproductive autonomy.
The ability to make decisions about having a child can shape the rest of a person’s life.
While raising children can bring profound joy, pregnancy can carry substantial health risks and financial burdens. In the United States, there are nearly 33 maternal deaths for every 100,000 births, according to 2021 data from the Centers for Disease Control and Prevention. This rate is more than twice as high for Black mothers and nearly double for those in rural areas. Around 12% of births are in counties with limited or no access to maternity care.
The cost of giving birth and raising children in the U.S. is among the highest of any high-income country, yet many parents have few resources for employment leave or economic support.
These factors don’t just affect individuals. Without autonomy to control when and if they have children, people face poorer health and worse social and economic outcomes, which has a broader ripple effect on families and communities.
Limitations around contraception access, safe abortion services and high-quality reproductive care are not a challenge for the U.S. alone. These restrictions impact health and increase inequity around the globe, according to Sian Curtis, PhD, professor of maternal and child health at the Gillings School.
“We know that countries with more restrictive reproductive health laws have poorer reproductive health outcomes,” she explained. “The World Health Organization estimates that about 287,000 women die every year from pregnancy or birth complications, and many more experience other negative health consequences. The lifetime risk of dying from these conditions is massively different between countries, and it’s an indicator of many kinds of inequalities and structural injustices.”
Limits to reproductive care can impact children, as well. Globally, around 5 million children under age 5 die every year — rates that Curtis says could be improved by birth spacing, high-quality prenatal and delivery care, and access to child health services.
Pregnancy itself can carry complications that range from exacerbating existing health conditions to putting a strain on economic security or physical safety.
“There are circumstances where it’s better for a person’s health not to be pregnant, whether that’s physical health, socio-economic health or mental health,” said Alice Cartwright, a doctoral candidate in maternal and child health at the Gillings School. “People should have full, affordable access to contraceptive options, but we’re never going to be in a situation where everyone is using contraception that’s 100% effective all the time.”
Cartwright is a former project director with Advancing New Standards in Reproductive Health (ANSIRH), the research program at the University of California San Francisco that conducted the Turnaway Study.
That study found that people in the U.S. who were forced to carry unwanted pregnancies to term not only risked possible complications but were also less likely to receive advanced degrees and more likely to stay in relationships with abusive partners. They were also four times more likely to fall below the federal poverty level, a status that further contributes to health hardships for parents and children.
These outcomes are preventable.
A public health response to these challenges must consider the cultural and historical contexts through which decisions and restrictions around family planning occur. One strategy is to train health providers, religious leaders and community advocates to have non-judgmental conversations about reproductive health and consider how factors like health care access, intersectional identity, social values and family dynamics impact reproductive autonomy.
“There are layers of stigma around these conversations that are tied up in norms about morals, about gender, about religion,” Curtis said. “One way we can address this is through values clarification and attitude transformation exercises, which get people to think about how others approach these issues in a constructive and empathetic way.”
“There are dire consequences when physicians are forced to practice not based on medical training or scientific evidence but rather on legal considerations.”
— Amy Bryant, MD, MSCR
Well-designed public health approaches make space for these conversations and support people in making fully informed decisions about pregnancy. Part of the work is recognizing how legal restrictions and structural barriers like systemic racism and gender bias contribute to poorer health outcomes.
In the U.S., restrictions on reproductive services increased immediately after the Supreme Court’s ruling on Dobbs v. Jackson. Unfortunately, data from the Guttmacher Institute show that these restrictions make it more likely that people in need of reproductive care, including abortion, will be harmed, criminalized or face life-threatening circumstances.
“There are dire consequences when physicians are forced to practice not based on medical training or scientific evidence but rather on legal considerations,” said Amy Bryant, MD, MSCR, associate professor of obstetrics and gynecology at the UNC School of Medicine and adjunct associate professor of maternal and child health at the Gillings School. “Medicine is very individualized for each patient. When we’re told by non-medical forces that all options can’t be available, it can be really damaging.”
Efforts to restrict and defund reproductive health providers do more than limit abortion. Unclear legal restrictions may also limit access to the full spectrum of pregnancy and miscarriage care if physicians are unsure how to interpret legislation, especially for underserved populations already at higher risk of poor maternal health.
Cartwright says the U.S. is still in the early days of understanding how much miscarriage and abortion care could be denied in states with differing abortion restrictions, but it’s important to address common misconceptions.
“Close to 90% of abortions happen in the first trimester,” she said. “The risk of complications is magnitudes lower than with childbirth. And the people who are getting these procedures are trying to make the decision that’s best for their lives.”
While the growing legal restrictions on reproductive services in the U.S. are cause for public health concern, Bryant sees room for optimism. She believes there are also more conversations happening that help the public understand the need for autonomy around all health decisions.
“People often don’t understand that this could have implications for them and their loved ones,” said Bryant. “As we see more of the consequences, I think people will see that it could have an impact on their care, too.”
Curtis also has found optimism in global trends. As more countries engage in open and empathetic conversations around reproductive care, many are integrating a full range of high-quality services into reproductive health and effectively reducing maternal deaths.
“Person-centered and respectful care can give people the ability to control a significant portion of their own lives,” she said, “and that can make a difference in so many ways.”
