The Social Medicine Portal

Reproductive and Sexual Health

The Department of Family and Social Medicine hosts a Reproductive Health Fellowship. For information on this fellowship please contact Dr. Marji Gold. This posting, originally published in March of 2005, was prepared by Dr. Louisa Hahn, one the (now former) fellows:

Sexual and reproductive health have been defined in different ways depending on the political and social climate of the times. In the last few decades, most social and international organizations have recognized the merging of health and human rights. This means in part that the state cannot violate people’s rights to sexual health. Governments must also assure that no other organization or person violates those rights and create the conditions in which people are able to fulfill the right to sexual health.

The right to sexual and reproductive health used to be viewed mainly in negative terms (freedom from disease and disfigurement) but is now also viewed in positive terms (freedom to enjoy pleasure and fulfillment). The US Surgeon General, Dr. Satcher, in 2001, sought to establish that “sexual health is not limited to the absence of disease or dysfunction, nor is its importance confined to the reproductive years.” The World Health Organization defines reproductive health as a state of physical, mental, and social well-being in all matters relating to the reproductive system at all stages of life. Reproductive health implies that people are able to have a satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so. Implicit in this are the right of men and women to be informed and to have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth.

The choice for women of whether or not to go through pregnancy and childbirth is an important reproductive right. Looking through the lens of social justice (PDF), we know that the women most harmed by lack of safe reproductive choices are those without financial means or social connections. Moreover, when women can make their own reproductive choices, it opens up opportunities to them for education and employment. To make these life choices, women must have full access to family planning methods and abortion for unplanned and unwanted pregnancies.

Abortion is a simple, safe medical procedure that saves lives when it is available. The risk of death associated with abortion performed by trained professionals is approximately 0.6 per 100,000 abortions, and the risk of major complications is less than 1 percent. Almost 90 percent of abortions are performed in the first trimester of pregnancy (within the first 12 weeks after the first day of the last menstrual period), and fewer than 2 percent of abortions are performed after 20 weeks. Currently in the United States, there are two safe and effective methods of first trimester abortion: medical abortion and suction abortion. Medical abortion uses pills called mifepristone or RU-486 and misoprostol that essentially induce a miscarriage. Suction abortion is performed with a plastic cannula and hand-held syringe or vacuum. For a description of these procedures and their differences, go to: The Access Project or Brandeis Medical Center.

Women can find themselves with an unwanted pregnancy for many reasons. For many, effective family planning is out of reach. At least 350 million couples worldwide do not have access to information about family planning and the full range of contraceptives options. The contraceptive methods that we have to offer are often not easy to use and sometimes fail even when used perfectly. Between 8 and 30 million pregnancies each year occur because of contraceptive failure. And unfortunately, sexual coercion or rape is common around the world. Between 20% and 50% of all women and girls report sexual abuse, rape or sexual coercion. Women also choose to have abortions due to a variety of social and economic reasons that include: being unmarried, abandoned by their partners, being too young, unstable partnerships, having too many children to support already, and living in poverty.

Of the estimated 45 million pregnancies worldwide that are terminated by abortion every year, about 19 million involve unsafe procedures performed by women themselves, by unskilled providers, or in settings with inadequate medical standards. Approximately 68,000 women die from complications resulting from unsafe abortion and even more suffer from infections, infertility, and long-term damage to their reproductive tract. Unsafe abortion deaths account for 13% of all maternal deaths globally and over 25% in some countries. Evidence from countries where women have full access to safe services shows that these abortion-related deaths and disability can be virtually eliminated with appropriate policies and programs.

But even where it is legal, safe abortion is not always available. In many developing countries, health workers, doctors and nurses do not have adequate training or equipment. Some refuse to refer or perform abortions because they do not understand the laws or because they personally do not support abortion. And when women have complications from an unsafe abortion, adequate medical support is often unavailable, and family planning is not discussed. As one of his first acts as president, George W. Bush re-imposed the global gag rule (or the “Mexico City Policy”) on January 22, 2001. This policy restricts foreign non-governmental organizations from using their own, non-U.S. funds to provide legal abortion services in order to receive U.S. family planning funds. It also prevents them from lobbying their own governments for abortion law reform, and prevents them from providing accurate medical counseling or referrals regarding abortion services.

In the United States, abortion has been a legal right of women since the court case of Roe vs. Wade in 1973. The conclusion held that a woman’s right to an abortion falls within the right to privacy protected by the Fourteenth Amendment. The decision gave women the right to abortion during her entire pregnancy and defined different levels of state interest for regulating abortion in the second and third trimesters. Since then, the number of deaths in the US per 100,000 abortion procedures declined five-fold between 1973 and 1991.

Significant barriers still face a large number of US women seeking this service, including the determination of viability, cost and insurance coverage, waiting periods and parental consent laws, restrictions on medical abortion, provider unavailability, harassment, refusal clauses, anti-choice laws, and the fetal legal rights movement. Federally subsidized abstinence-only sex education, which has not been shown to decrease the rate of unintended pregnancy (and may increase it), has expanded and access to a full range of contraceptive options has been limited. Eighty-six percent of US counties have no abortion provider. There has been a steady decline in abortion providers over the past two decades. Only 12 percent of all Obstetrics-Gynecology residency programs require training in first trimester abortion and 91 percent of residents report having no experience with abortion procedures. Currently, almost half the pregnancies in the United States are unintended, and teen pregnancy rates are much higher than other developed countries, and even many developing countries. Women of reproductive age currently spend 68 percent more in out-of-pocket health care costs than men, primarily because of reproductive health-related costs.

The policies of the current administration have strengthened barriers to abortion both at home and abroad. Preserving women’s right to choose in the United States will require improved public and professional education, legislative and legal efforts, and advocacy by physicians and other health care professionals. To eliminate these negative outcomes for women, health care workers and activists need to work to ensure universal access to family planning services, especially for young people and women at risk of sexual abuse, rape and violence. Our communities need to be educated about unsafe abortion, social disparities in reproductive health, and their consequences, and work to reform restrictive laws and policies that deny access to family planning, health and abortion-related services.

For more information about organizations that advocate for reproductive rights and choice, visit these websites:

United States:

• National Abortion Federation
• Planned Parenthood
• Physicians for Reproductive Choice and Health
• Association of Reproductive Health Professionals
• Center for Reproductive Rights
• Abortion Access Project
• National Organization for Women
• American Civil Liberties Union
• Women’s Reproductive Rights Assistance Project
• Feminist Majority Foundation

International:

• International Planned Parenthood Federation
• Marie Stopes International
• Ipas
• International Women’s Health Coalition
• Center for Reproductive Rights Worldwide

See also Martin Donohue’s article Increase in Obstacles to Abortion: The American Perspective in 2004, published in the Journal of the American Medical Women’s Association.

— By Louisa Hann, MD, Family Planning Fellow in Family Medicine