A lot of the discussion about women’s choice and reproductive autonomy centers around the right to abortion. Although abortion access is critical to the freedom, autonomy, and health of people with uteruses, it’s important not to lose sight of choice constraints on other aspects of reproductive health. Here are a few issues that also require some serious attention.

Birth control
There are a lot of options on the market these days. From the pill to injections to NuvaRings to implants to IUDs, we can weigh our choices in terms of duration, convenience, and personal preference. However, cost is a major factor constraining choice for many women. Cost-sharing (when your health insurer pays only part of the cost and leaves you with the rest) for contraceptives was eliminated for people in the U.S. with insurance, which makes it easier to get the kind of birth control that is right for you, and not simply the one you can afford. 

But uninsured people are still constrained by cost—and birth control can get really expensive, whether it’s a monthly prescription cost or a huge up-front price for long-acting reversible contraceptives (LARC) like IUDs. A recent study shows that out-of-pocket costs seriously constrain choice of birth control, and leads less people to choose any form of birth control at all, as well as decreasing the use of LARCs. Aside from affirming bodily autonomy, facilitating free choice of birth control methods can decrease the rate of undesired pregnancies and abortions and reduce government spending on healthcare.

Birth control, again
This time, we’re talking about permanent birth control, like tubal ligation (“getting your tubes tied”) and hysterectomies (removal of the uterus). More young people, including those without children, are attempting to utilize permanent methods, but encountering strong resistance from medical practitioners. They are denied free choice because they “might change their minds” and want children or “meet Mr. Right” and regret their decision—even though research shows over 90% of women don’t regret sterilization after five years. And some people turn to hysterectomies to resolve issues of severe pain and discomfort, such as from endometriosis, but are turned away because the procedure would render them unable to have children. This, too, denies individuals the right to make free choices about their health and wellbeing.

Birth control, one more time for the people in the back
Ok, this time, we’re talking about the opposite problem—forced sterilization. First, here’s a quick overview of the history of forced sterilization in the U.S.: In 1907, Indiana became the first state to pass a law allowing the government to sterilize people who were mentally ill or criminals, which, at the time meant poor, mostly white, men viewed as sexually deviant. As the tubal ligation procedure became more widely available, states shifted their focus to women in mental hospitals and prisons. In 1927, the Supreme Court upheld the right of a state to sterilize “unfit” people (Buck v. Bell). In 1933, U.S. legislation became the model for the Third Reich’s sterilization program during the Holocaust. In 1937, Georgia became the last state to pass a sterilization law, at which point 32 states had such laws. In 1942, the Supreme Court decided that eugenic (controlling reproduction to increase “desirable” heritable traits) sterilization was not a valid state goal, but did not overrule Buck v. Bell (Skinner v. Oklahoma).

Eventually, states started to repeal these laws, but that didn’t stop sterilization drives. In the following decades and through the 70s, local governments continued to sterilize hundreds of thousands of people, mainly poor Black, Latina, and Indigenous women, under the guise of population control and promoting “personal responsibility.” These sterilizations were forced either because patients did not know what was being done to them, they were lied to about the permanence of the procedure, or they were coerced with threats of revoking welfare benefits. 

This history includes 7,600 sterilizations in North Carolina, 20,000 in California, and 3,406 Native American women across the country. That’s not counting the 37% of Puerto Rican women sterilized after the U.S. took control of the island. In 1974, the Supreme Court ruled that federal money could not be used for forced sterilizations and established standards of informed consent (Relf v. Weinberger). However, in 1978, a California District Court decided that the coerced sterilization of Mexican women—either by withholding pain medication during labor, providing consent forms only in English when the patient spoke only Spanish, or improperly obtaining consent while the patient was heavily medicated—was the unintentional result of miscommunication and language barriers (Madrigal v. Quilligan).

Thank goodness we’re past that, right? Not quite. The California Department of Corrections continued to coerce over a hundred imprisoned women to undergo tubal ligations until at least 2010. In 2009, 2017, and 2018, various state judges were reprimanded for coercing prisoners or probationers to receive long-acting or permanent birth control in exchange for lenience. As of 2020, Immigration and Customs Enforcement detention centers are being investigated for performing hysterectomies on undocumented women without consent. And even today, 31 states and D.C. have laws allowing the forced sterilization of disabled people. That doesn’t include the various ways in which people deemed disabled and subject to guardianship or conservatorships can be forced to take reversible birth control (à la Britney Spears). It’s important for all of us to remember that the freedom to choose birth control includes a freedom to choose no birth control at all, and that this freedom is still being threatened across the country.

Birthing Method
When it comes to giving birth, there are many ways to do it—“natural” or induced or by C-Section, with or without anesthetic, in a hospital or in a birthing center or in your home. And having those choices, being able to exercise some control over an emotional and unpredictable moment, is undeniably a good thing, particularly for mothers’ sense of autonomy and confidence. But some women, particularly women of color, experience less free choice. For instance, C-sections are liberally recommended by obstetricians, even when pregnant people don’t want or ask for them, and many women feel pressured to consent, especially if they have had a C-section in the past.

Having a vaginal birth after cesarian (VBAC) is possible, but many women, especially women of color, are discouraged or even prohibited from doing so. Many practitioners use a risk calculator to justify denying VBACs, even though the calculator includes race as a factor, automatically increasing the risk score for Black and Hispanic women. Even though a newer version of the calculator doesn’t explicitly include race, obstetric racism and race-based inequality is baked into the calculator and the way birthing options are recommended to or foisted on pregnant people. That said, women of all backgrounds report feeling pressured to consent to medical intervention during labor or being left out of decisions such as whether to undergo an episiotomy. The ability to exercise bodily autonomy at such a critical point like labor and birthing is a human right, and we should be vigilant for medical coercion.

There’s plenty more to say about reproductive freedom, but the upshot is: Our conversations about autonomy should acknowledge that reproductive freedom to choose is expansive. It means the freedom to choose whether or not to give birth, when to give birth, how to give birth, and any and all choices about the use (or not) of one’s reproductive organs. And as important as it is to be your own advocate as an individual patient, it’s also important to advocate for one another—“Injustice anywhere is a threat to justice everywhere” (MLK, 1963).