Disparities in Reproductive Healthcare for Multiply Marginalized People
Pregnancy is unnecessarily one of the riskiest times in many people’s lives. While the demands of pregnancy on the human body are intense and the demands of childbirth even more so, many of the associated risks are within our control and are therefore exacerbated by bias and lack of adequate medical care. Many populations are at increased risk of medical abuse, assault, inadequate care, and even death during pregnancy and childbirth. Risks are even higher for multiply marginalized individuals such as nonbinary, Disabled people.
Socially, many people are raised to believe that pregnancy and childbirth are women’s issues, and this becomes even more prevalent in a society where LGBTQ+ rights are chronically under attack. In a society that believes that trans and nonbinary people should not exist, that they are predators, that they are unsafe for children to be around, it can be near impossible to access adequate medical care. It is even harder to find a provider to care for sexual and reproductive health because medical providers are ultimately products of the society in which they live. Prenatal care, pregnancy, exams, and childbirth can be traumatic experiences for trans and nonbinary people as they navigate experiences that may not align with their genders and may trigger dysphoria—even in cases of wanted pregnancies. Add to that the lack of education and training that providers have and their potential biases, the act of accessing care becomes even more traumatic and potentially damaging. This ultimately puts people at risk of avoiding prenatal care, having unassisted births, being assaulted during care, being misgendered during care, and even potentially dying.
Disability is a topic greatly ignored in sexual and reproductive health. This is largely due to the infantilization of Disabled people (yes, Disabled people—not “people with disabilities”) and the embedded eugenic beliefs that much of society carries about Disabled people. Beliefs that Disabled parents are not capable of being good parents (as proven by the fact that the vast majority of CPS investigations specifically target Disabled parents) (Slice, 2025). Beliefs that Disabled people are selfish for potentially passing on their disabilities and having Disabled children (ultimately buoyed by the belief that being Disabled is inherently bad or morally wrong). The reality is that Disabled people want to be parents, they deserve to be parents, and they are good parents. But they are often discouraged from intentionally becoming parents, encouraged to terminate wanted pregnancies, neglected when it comes to sexual education and healthcare, medically controlled throughout their pregnancies and births (if they can even find a provider willing to care for them), and forced to terminate or become sterilized or give up their children against their will and sometimes through the misuse of the court system (Slice, 2025).
The scientific eugenics movement in the United States has implications on every societal existing societal system in the country—inclusing our healthcare system. Eugenic thinking is a systemic issue that is hardwired into every single one of us, even if we are not aware of it. It underlies our questions about quality of life, continues to feed systemic racism, and causes judgements about low-income individuals choosing to build families. Americans certainly did not invent eugenic belief as while degeneracy theory was only formalized in the 1700s, “concept of segregating or condemning ‘depraved’ people is described in the Old Testament which indicates that this type of thinking has been in existence longer than social scientists or historians could possibly know” (Laffey, 2021). Degeneracy theory was popularized by the mid-19th century and "the term eugenics was coined by Darwin’s cousin Francis Galton in 1883” (Laffey, 2021). It is worth noting that “Galton’s theories were grounded in a belief in the genetic distinctions between races, as well as individuals” and were therefore driven not only by ableism, but also racism (Roberts, 1997). What originally began as a desire for selective breeding soon spiraled and “the eugenics movement in America...embraced the theory that intelligence and other personality traits are genetically determined and therefore inherited” (Roberts, 1997). During the eugenics movement, “states across the country forcibly sterilized thousands of citizens thought to be genetically inferior” including Black and Disabled people and the first American “law mandating compulsory sterilization on the basis of eugenics was enacted in 1907 through the advocacy of Harry Clay Sharp, a prison physician in Indiana” and the movement ultimately led to significant “political violence including the legal forced sterilization of over 64,000 individuals...to ‘prevent hereditary degeneration’” (Roberts 1997; Laffey, 2021).
It is not a stretch to claim that this history leads to the ongoing control of Black and brown bodies, current attacks on queer rights, and the systemic belief that Disabled people cannot and should not parent. In fact, Black communities have been targeted for the push of long-term birth control. For example, “Baltimore was the first city to distribute Norplant aggressively to teenagers” when they implemented a program in 1992 calling for “doctors, hospitals, and clinics to persuade their ‘high risk’ teenage patients to have the device implanted” and offering it in school clinics without parental consent (Roberts, 1997). These patients and students were overwhelmingly Black. Black people are disproportionately impacted by obstetric violence including assault and maternal and fetal death. When reproductive care is manipulative, intended to prevent reproduction, and poor in quality for Black and brown patients, they are more likely to have poor outcomes or to avoid prenatal or reproductive medical care altogether.
Further, the LGBTQ+ community is constantly under attack and these attacks are worsening. In 2025 alone, “the ACLU tracked 616 Anti-LGBTQ bills” in the United States (ACLU, 2025). Many of these bills have implications on reproductive healthcare “with LGBTQ patients experiencing health disparities across the lifespan because they face multiple, and often compounding, barriers to accessing appropriate care” (Dawson & Leong, 2020). These barriers include lack of integration in healthcare, discrimination, and lack of cultural competency, insurance barriers, and intersecting oppressions (Dawson & Leong, 2020). This lack of adequate care makes it difficult for queer people to access necessary reproductive care—whether they intend to become parents or not since LGBTQ+ people also have higher rates of younger, unintended pregnancies (Dawson & Leong, 2020). The reality is that LGBTQ+ people need reproductive care, but there is a lack of available care for them that is rooted in care rather than abuse and neglect.
Similarly, it is difficult for Disabled people to access adequate care. In fact, in a 2022 study by Dr. Lisa Iezzoni, “doctors admitted that they avoid taking on disabled patients...explained that the time allotted for appointments doesn’t provide enough room to make accommodations” and one provider even “complained about the cost of hiring a sign language interpreter” (Slice, 2025). It is not uncommon for Disabled people to be encouraged to have hysterectomies at young ages because doctors assume they are never going to have children, be refused treatment at fertility clinics, and have child protective services called on them for no substantial reason—making both having a child and raising a child unnecessarily difficult. While it is not uncommon for people to assume that Disabled people won’t, can’t, or don’t want to parent, “disabled people get pregnant at the same rate as nondisabled people” which makes it particularly alarming how insufficient care is (Slice, 2025). Disabled people have higher rates of interventions (including cesareans) and higher rates of complications (such as postpartum depression) due to this lack of adequate care—not due to their disabilities.
Given the abundance of evidence that the history of eugenics and overall trends of obstetric violence are disproportionately impacting patients of marginalized identities in receiving adequate reproductive and sexual healthcare, several steps are necessary in beginning to address these disparities (Pascucci). However, I would caution against any of these steps being considered solutions to systemic issues engrained in the very fabric of our nation. Culturally competent care is a necessary implementation which requires provider training in hospitals on DEIB (Diversity, Equity, Inclusion, and Belonging) work, caring for diverse patient populations, and Disability and Reproductive Justice. It is necessary for this work to be done from a top-down approach as significant, long-term change requires policy changes at the hospital level. The success of policy changes relies on buy in from all stakeholders from directors to CNAs.
In addition to provider training, many people—especially patients who face systemic oppression—would benefit from accessible midwifery care. Increasing the accessibility of midwifery care requires both policy and public outreach efforts. Currently, it is difficult to become a midwife, there are significant liability risks, and many people incorrectly believe (in large part due to the attack on Black granny midwives in the South and the medicalization of birth) that midwife-centered care is less safe than hospital care with an OB/GYN (D., A., 2024). Public outreach about the benefits of midwifery care would allow for an increase in demand, potential for more birth centers and holistic prenatal care, funding allocation, and greater awareness of midwifery as a potential career path. Funding efforts should be made other than help subsidize education for midwifery students as the cost of education can be a barrier. Additionally, education options for midwives are limited, especially in rural areas, and expansion of these options would allow more people to become midwives.
As a doula, I feel compelled to address the need for trained, informed doulas who specialize in care for inequities and systemic barriers to care. It is incredibly difficult to self-advocate in medical settings and significantly more so during labor. The presence of a doula significantly decreases the rates of intervention and unplanned cesaeran while also increasing the likelihood of patients perceiving their birth experience as positive, but birth work is signficantly more than holding someone’s hand through contractions. Trauma-informed doulas help to provide a grounding presence, support laboring clients in regulating their breathing and emotions, and empathetically acknowledge and address the ways in which trauma impacts clients in labor and birth (Moses, 2026). Additionally, advocacy-centered doulas show up to volunteer, speak out or in support of proposed bills, have a wide variety of resources available to their clients, and focus on client education (Graham, 2024). Increasing the number of doulas who have the education to support Reproductive Justice both in and out of the birthing room has the potential to vastly improve obstetic outcomes for all patients, especially patients facing oppression and marginalization.
Unfortunately, doula care is frequently inaccessible to those who would most benefit from it. There is a misconception that doula support is intended for middle and upper class white women. These people absolutely deserve the care of a doula; however, there is a significant gap in doula care for BIPOC, LGBTQ+, Disabled, and lower income birthing people. Therefore, I also find it crucial to develop public grants and funding efforts for these communities to be able to access doula services and childbirth education. One such effort is Massachusetts’s doula initiative, which is currently being expanded. In Massachusetts, birth and postpartum doula services are covered by MassHealth for doulas that register with the state. Additionally, Massachusetts is providing scholarships to doulas for training, offering a voluntary certification program, building a DPH doula training, and collaborating with hospitals and practices in the state to make them more doula-friendly (Massachusetts Department of Public Health, 2026). Programs like this increase the accessibility of critical support for the above mentioned communities and birthing people generally. Expanding existing programs and developing programs where they are not yet present would help to improve obstetric outcomes and counter the disparities in care faced by multiply marginalized birthing people.
References
Dawson, R., & Leong, T. (2020, November 16). Not up for debate: LGBTQ people need and deserve tailored sexual and reproductive health care. Guttmacher Institute. https://www.guttmacher.org/article/2020/11/not-debate-lgbtq-people-need-and-deserve-tailored-sexual-and-reproductive-health
D., A., (2024, May 30). Palestinian Occupation & the Medicalization of Birth: Limbs of the Same Beast. Birthing Advocacy Doula Trainings. February 25, 2026, https://www. badoulatrainings.org/blog/palestinian-occupation-the-medicalization-of-birth-limbs-of-the-same-beast
Graham, M. (2024, August 29). Aligning Birth Work to Activism: A Daily Practice. Birthing Advocacy Doula Trainings. February 25, 2026, https://www.badoulatrainings.org/blog /aligning-birth-work-to-activism-a-daily-practice
Hypermobile Ehlers Danlos syndrome (hEDS). Ehlers Danlos society. https://www.ehlers-danlos.com/heds/
Karthikeyan, A., & Venkat-Raman, N. (2018). Hypermobile Ehlers-Danlos syndrome and pregnancy. Obstetric medicine, 11(3), 104–109. https://doi.org/10.1177/1753495X18754577
Laffey, K. (2021). Disconnects Between the Disability Community and the Field of Education, 1–15.
Mapping attacks on LGBTQ rights in U.S. state legislatures in 2025. American Civil Liberties Union. (2025, December 29). https://www.aclu.org/legislative-attacks-on-lgbtq-rights-2025
Massachusetts Department of Public Health (DPH). (n.d.). Doula initiative. Mass.gov. https://www.mass. gov/info-details/doula-initiative
Moses, A. (2026, February 19). The Trauma-Informed Doula: Beyond Birth Plans and Into the Nervous System. Birthing Advocacy Doula Trainings. February 21, 2026, https://www.badoulatrainings.org/blog/the-trauma-informed-doula-beyond-birth-plans-and-into-the-nervous-system
Pascucci, C. (2023, February 11). Obstetric violence. Birth Monopoly. https://birthmonopoly .com/obstetric-violence/
Roberts, D. E. (1997). Killing the black body: Race, reproduction, and the meaning of liberty. Pantheon Books.
Saladin, K. S. (2024). Anatomy & Physiology: The unity of form and function (10th ed.). McGraw Hill LLC.
Slice, J. (2025). Unfit Parent: A Disabled mother challenges an inaccessible world. Beacon Press.
