Q&A: Obstetrician-gynecologist advocates for reproductive justice for all

Last year, an 18-month bipartisan Senate investigation concluded that migrant women held at a privately-run Immigration and Customs Enforcement (ICE) detention facility in Georgia were subjected to unnecessary and unwanted gynecological procedures. The 108-page report was prompted by a 2020 whistleblower complaint alleging a years-long pattern of "aggressive and unethical" treatment of women.

Reproductive injustice is the denial of reproductive rights and choices to marginalized people, from lack of access to quality reproductive health care, to denial of abortion care and coerced sterilization.

In a commentary published in a special Obstetrics & Gynecology issue on racism and reproductive health, corresponding author Rose L. Molina, MD, MPH, a BIDMC obstetrician-gynecologist, researcher, and activist advancing health equity in pregnancy care, discusses how the situation in Georgia is not an aberration but part of a long-standing pattern of reproductive control within the U.S. immigration enforcement system. We asked Molina more about her work and how obstetrician-gynecologists (OBGYN) can be critical agents of change in promoting reproductive justice.

Why is it important to talk about reproductive justice?

In the paper, we reference a sterilization campaign in the 1970s in which ob-gyns coercively sterilized Mexican American women in response to an increase in Mexican immigration. Many of those people who were sterilized are still alive. Yet, without confronting the past and the systems that allow these atrocities to happen, the cycle repeats itself.

OBGYNs must create professional norms and systems for accountability regarding those who perpetuate abuses. We must denounce individuals as well as the systems that permit those practices to occur.

Many undocumented immigrants live in perpetual fear, especially when things like this happen. They hear that their mother, their sister, their friend got detained and didn't have access to contraception or had a surgery they didn't consent to, and then we wonder why people don't trust the larger health system.

As health care professionals, having that collective awareness and consciousness about the harms that our field has the power to perpetuate is really important. We need to bring that into our educational spaces and think about how that broader context shapes individuals' experiences—people who we may actually interact with in clinic or in the hospital.

We need to hold ourselves accountable, and we need to do it publicly. We have to commit to training the next generation, intentionally reflect on how these issues continue to play out generation after generation, and identify opportunities to interrupt cycles of reproductive injustice.

Has the profession had any success collectively advocating for reproductive rights so far?

Reproductive justice concepts are being integrated into medical education, and one example is a case-based curriculum that was co-developed with students and faculty at Harvard Medical School. One of the cases explores immigration barriers in the context of reproductive rights.

On a collective level, OBGYN's and their professional organizations can leverage their positions of power to advocate for federal and state policies that dismantle the structural harms of racism and xenophobia and advance reproductive justice and immigrant justice. For example, the American College of Obstetricians and Gynecologists successfully advocated to abolish shackling of pregnant people during childbirth in the carceral system.

If I am just one practitioner who wants to do better, what should my first step forward be?

My first suggestion is to think about immigration as a structural determinant of health. Do not just ask about immigration to ask about it, but ask because it's a really important factor in the health risks they endure and the access to services they need.

As a practicing OBGYN, I want to shed light on this hidden and excluded population that we, as a society, often don't think about. I have the unique opportunity to work in a federally qualified community health center, and I do see undocumented immigrants who come for the full spectrum of reproductive health care. But, I recognize that most OBGYNs don't practice in settings where they see this population, and if they do, the patients may not disclose their undocumented status.

In the context of a trusting patient-clinician relationship, asking about immigration status may allow for appropriate referral for social support services. One of the things that comes up a lot is insurance coverage. As clinicians, we should have a basic understanding of what is covered and what is not covered for the patients who come into our clinic.

Of course, we are not always going to be aware of every complexity in health care policy, but just having some awareness and sensitivity about this population and the challenges they face in navigating the health system is a first step.

In a second commentary on which I am senior author in this same issue, we address language barriers during pregnancy care and present a framework for enhancing communication and trust in obstetrics and gynecology.

Language is a critical lens for health inequities, and communication barriers undergird other structural drivers of inequities in reproductive health outcomes. I urge OBGYNs to prioritize improving care systems for patients experiencing language barriers. And while that certainly includes many undocumented immigrants, in 2015, approximately 25 million people, or 9% of individuals in the U.S. reported having limited English proficiency.

An additional 11 million people with hearing disabilities, including those who utilize American Sign Language, also require special considerations for effective communication. Language and communication barriers will continue to grow with immigration trends and the diversifying and aging population.

Why did you focus on the rights of this population?

I'm so passionate about this because I grew up 26 miles from the largest point of entry between Mexico and the United States. This bi-national, multi-cultural experience was really formative for me growing up. The way undocumented immigrants are portrayed in society at large can be extremely disrespectful and perpetuates negative stereotypes.

My hope is that we can simply look at this population in a different light than what we historically have. These are people who have usually experienced some of the most tragic and traumatic life events and demonstrated strength and resilience in their journeys. Many are in the U.S. seeking refuge, a better life, and opportunities that we as citizens were given simply because we happened to be born here.

Humanizing undocumented individuals is something that we should all strive for. Despite all the political rhetoric, seeing and honoring our shared humanity should not be controversial.

If you could get a message through to migrant detainees and other undocumented people, what would you say to them, as an ob-gyn?

For those who are immigrants, my hope is that you feel welcome, safe, heard, and understood when you seek health care services, particularly reproductive services, no matter your legal status.

People detained in the immigrant detention system is a very specific population that the general population may or may not feel a connection to, which indicates why it's important to humanize those who may not be seen or may not be heard.

Like the rest of us, people in detention live within the context and circumstances of their lives that not everyone understands, but we all have a story to tell. Particularly when it comes to health care, we should not put-up additional barriers to access the same high-quality care that every person deserves.