The Pillars of Equity

The political environment has shifted under the Trump-Pence administration and the anti-choice majority in Congress. Reproductive health and rights are under full attack through efforts to repeal the Affordable Care Act, restrict access to abortion, and confirm an anti-choice U.S. Supreme Court justice.

It is all the more important therefore to articulate the complex nature of women’s lives today and their role as key contributors to American society. Women’s economic contributions often depend on having access to comprehensive reproductive health services, as well as to education, jobs with livable wages, and workplace supports. In the U.S. political and public discourse, connections between women’s health and family economic stability are often obscured, ignored, or dismissed. The political debate is regularly reduced to either family planning or abortion, but reproductive health and rights encompasses a continuum of health services and legal protections that bolster all areas of their lives.

This report argues that reproductive health, rights, and justice must be integral to a successful, 21st-century economic agenda. The United States must acknowledge and focus on the mutually reinforcing ways in which reproductive health and economic empowerment help both women and the economy thrive. This report proposes policy recommendations for federal and state policymakers to help women achieve economic security and reproductive justice in tandem.

Current laws and public perceptions perpetuate stigma about reproductive health and rights. The country must change the conversation so that abortion is seen as an option—not just an exception—family planning is recognized as ineffective as a sole strategy for reducing poverty, and so that policy debates address solutions that consider both women’s economic and health needs. A new framework is needed that values reproductive health, responds to women’s economic challenges, and increases workplace opportunities for the modern woman and her family.

Reproductive health and rights are inextricably linked with reproductive justice. The five key pillars that should be at the core of an economic agenda to address the needs of women and their families are:

• Self-determination
• Access to comprehensive reproductive health services
• Affordability of care
• Parenting with respect and dignity
• Workplace and caregiving supports

Each pillar represents a key component that all women need to thrive and be healthy. These pillars are valuable individually but are also mutually reinforcing to anchor a policy agenda that meets the intersectional needs of working women.

This report argues that reproductive health, rights, and justice must be integral to an economic agenda that works for all. Rather than focusing solely on a narrow argument that access to contraception and abortion ensure economic opportunity for women, this report takes a broader, more comprehensive look at the mutually reinforcing ways in which reproductive health and economic empowerment help families and the economy thrive. This analysis is followed by a discussion focused on the five key principles listed above. Finally, this report proposes a policy agenda aimed at rejecting rollbacks that would reverse concrete progress in an environment hostile to women’s health and rights. The proposed policy agenda includes progressive measures at the intersection of economic justice and reproductive justice. These policy tools can be deployed at the federal or state level and include the following.

• Protect the Affordable Care Act, or ACA, so that millions of women can continue to benefit from no-cost access to well women’s care and other preventive services, such as contraception; breast feeding support and supplies; screening and testing for sexually transmitted infections, or STIs; and breast cancer screenings.
• Prevent roll backs of progress on reproductive rights, ensuring that abortion remains part of the full continuum of safe, legal medical care.
• Support the Title X Family Planning Program and ensure access to affordable health care for low-income, uninsured, and young people, as well as communities of color, across the country.
• Reject efforts that deny health care based on religious or moral objections.
• Expand Medicaid in order to help fill the coverage gap of approximately 3 million women who are currently eligible but uninsured.
• Pass the Equal Access to Abortion Coverage in Health Insurance, or EACH Woman Act, which would repeal the Hyde Amendment and other abortion funding restrictions passed through the appropriations process. It would also prohibit restrictions on private insurance coverage for abortion services.
• Pass the Women’s Health Protection Act, or WHPA, which would prohibit states from enacting dangerous restrictions on abortion care and interfering with the patient-doctor relationship.
• Pass the Health Equity and Access Under the Law, or HEAL, Immigrant Women and Families Act, which would restore Medicaid and Children’s Health Insurance Program, CHIP, coverage to immigrant women and families residing lawfully within the United States.
• Adopt strong workplace standards to improve job quality and give workers the resources and tools they need to live healthy lives. These include raising the minimum wage, guaranteeing all workers have access to paid family and medical leave and paid sick days, and promoting and ensuring pay equity.
• Promote affordable high quality child care that meets the needs of families and doesn’t jeopardize their economic security.
• Commission a study examining unequal access to women’s health care in order to connect health indicators with economic indicators and help address disparities in care.

Comprehensive state and federal policies, like those listed above, will ensure equitable opportunity for all.

Ensuring women’s full participation in the workplace and throughout society is crucial to the economic stability of women and working families, as well as to the efficient functioning of the economy.

In the United States, however, there has been a longstanding, deeply divisive struggle surrounding reproductive health.. Reproductive health care, particularly abortion access, is often omitted from the broader conversation about women’s economic needs. But women know that their lives cannot be broken into silos. Recent polling shows that voters viewed health care, the economy, and jobs as equally important during the 2016 elections.¹ In fact, health care is one of the top five issues for voters among jobs, government spending, terrorism, income inequality, and immigration.² In short, reproductive health and economic security go hand-in-hand, whether policymakers acknowledge it or not.

Many women struggle to maintain their economic security to the detriment of their health. Women make up the majority of workers in low-wage jobs, which are less likely to offer health insurance or workplace supports such as paid family and medical leave.³ But even when women have decent paying jobs with health insurance, they often struggle to find the time to take their leave and make use of their coverage. Additionally, increased restrictions on reproductive health at the state level interfere with the relationship between patients and their doctors.⁴ For instance, many states require abortion providers to counsel patients with inaccurate information, to perform medically unnecessary procedures, or to delay care.⁵ Worse, many of the states that severely restrict abortion access do not offer any additional workplace protections for pregnant women or new parents such as paid family leave, paid sick days, or pregnancy accommodations.⁶

An ambitious economic agenda must encompass reproductive rights, health services, and institutional supports in a broad way. It must protect their health, as well as their ability to plan their childbearing, support their families, and participate in the workforce. This comprehensive approach reflects the complexity of women’s lives and is essential for them to achieve their full potential. Reproductive health services help women and LGBT individuals become independent and control their own destinies. 

Reproductive health and rights have long played a role in women’s economic security and social advancement. Expanded accessibility of the birth control pill has helped millions of women chart their own course by being able to plan a pregnancy, determine their personal timetable for marriage, pursue an education, and embark on a career.

Comprehensive reproductive health services have improved women’s health broadly and increased the economic stability of countless families. Yet, in the political and public discourse, the connections between women’s health and family economic stability often have been obscured, ignored, or dismissed. This has occurred in three key ways:

• Policymakers have long singled out and treated reproductive health differently—and often more harshly—than the broader topic of health due to the abortion debate, regardless of the potential economic consequences
• Policymakers have used family planning ineffectively as part of a so-called strategy to reduce poverty without requiring a deeper investment in policies to promote economic stability
• Economists who advise lawmakers on policy solutions often view health differently from consumer of health care products.

These challenges are reflected in new laws and in public perceptions and stigma about reproductive health and rights.

Abortion as an exception

Reproductive health services include family planning, maternal health, preventive care—such as cancer screening—and abortion care.⁷ The public battles over reproductive rights, however, have historically centered on abortion access. As a result, there is a common misperception that reproductive rights are only about abortion access. Organizations and advocates alike have struggled for decades in this environment to balance their efforts pushing back against relentless attacks on abortion access, while also advocating more broadly for affordable contraception and the right to pursue motherhood on their own terms.

This has been most apparent in the legal arena where court cases have not just shaped reproductive health law but have changed the health care experience itself. In myriad cases, from the U.S. Supreme Court to the lower courts, reproductive health care options and patients’ ability to interact freely with their health care professionals have been altered because of special rules governing abortion care. For example, in Webster v. Reproductive Health Services,⁸ the Court ruled that states were allowed to restrict the use of state funds, public employees, and facilities from providing abortions. In Planned Parenthood v. Casey, the Court ruled that governments are allowed to impose restrictions on abortion services that do not pose an “undue burden” on those seeking care.⁹ These rulings not only contributed to the physical separation of abortion services from other kinds of reproductive  health services, particularly family planning services, but also meant that abortion care became more stigmatized and vulnerable to political attacks. Moreover, these and other cases reinforced the misperception that reproductive health care could be segmented into different components and dispensed in piecemeal fashion through legislative restrictions, rather than through consultation with doctors and health professionals.

These federal rulings and 30 years of state restrictions have shaped attitudes about abortion care. As a result, in 2016 many voters did not see restrictions on abortion services—such as the 24-hour waiting period, mandatory counseling, regulation of medication abortion, and parental notification—as unusual.¹⁰ But these policies actually harm the ability of people to receive all kinds of care. Treating abortion services differently from the broader range of reproductive health services puts all reproductive health at risk. An impact study conducted by Ibis Reproductive Health and the Center for Reproductive Rights found that states with the most abortion-related restrictions are also the worst at ensuring sexual and reproductive health in a broad range of areas, including STIs and HIV, domestic and intimate partner violence, cervical cancer, maternal health, and mental health.¹¹ Women can better control their lives when they have unfettered access to comprehensive reproductive health services, including abortion care.

Family planning as an ineffective solo strategy to reduce poverty

The first federal appropriation for family planning was made in 1965 to help low-income families as a part of President Lyndon Johnson’s War on Poverty program.¹² In 1970, Congress passed Title X of the Public Service Health Act, the only program to pay for family planning for low-income women.¹³ It was eventually expanded to other programs such as Medicaid, the State Children’s Health Insurance Program, or SCHIP, and block grants that support a network of family planning clinics across the nation.¹⁴ These programs successfully helped reduce unintended pregnancies, improve maternal health, and expand preventive care for low-income families. They did not stand alone, however, to resolve other systemic barriers—such as poverty, housing discrimination, and racism—that undermine low-income women’s economic opportunity.

More than a half-century later, Title X too often continues to be burdened by unrealistic expectations.¹⁵ Heralded for its cost savings to states and the federal government, the program is treated as a cure-all for the challenges that low-income women face. But research shows that contraceptive coverage alone does not alleviate poverty or lack of economic opportunities. For example, one 30-year study of 300 young mothers on the causes of generational poverty and teenage pregnancy found that contraception alone did not change their low socioeconomic status, the lack of educational and job opportunities beyond high school, or their social supports.¹⁶ As a result, when low-income women of color delayed pregnancy, for example, they often remained low-income.¹⁷

Policies that solely targeted teen pregnancy, such as comprehensive sex education, did increase access to contraception, but strategies focused on actually improving economic opportunities helped reduce poverty and teen childbearing rates.¹⁸ Thus, while investments in family planning services and Medicaid programs have made some inroads, complementary policies such as early childhood education programs, increased financial aid for higher education, efforts to raise wages, workplace supports, and addressing social inequalities are critical.¹⁹

Conflicting economic perspectives

Another challenge to crafting an economic agenda that embraces reproductive health, rights, and justice includes a basic understanding of how health affects economic outcomes. The discussion of health in the economic context often occurs in two ways: 1) health care as a contributor to the long-term growth of the economy because healthier people are more productive at their jobs, live longer lives, and work longer and 2) health care as an independent market with products, consumers, and profit.²⁰ But beyond these two concepts, health care also is essential to the quality of labor market opportunities for individuals, not just quantity of working hours and years. Employees and future workers must have comprehensive health care and good health in order to pursue education, have greater job mobility, build skills and different careers, and access job opportunities that make sense for them and their families. Yet the cost and availability of the full range of health care services for women rarely factor into the publicly discussed equation of what makes a fairer and more just economy.

For workers, the costs and availability of health care, namely reproductive health care, are critical to being able to make sound decisions about work, education, and their lives overall. Their ability to take advantage of workplace opportunities is directly linked to their ability to access reproductive health services and plan their families. Women’s early career choices, which often take place during their peak reproductive health years, affect their lifetime earnings and retirement security. A small body of economics research, for example, has looked at how access to reproductive health care—such as the availability of the pill—increased women’s economic opportunities when women were granted legal access to birth control at different times across states. Women were better able to invest in their careers, access higher education across more fields, and increase their labor force participation over the course of their lives.²¹

But too often economic policy is viewed as gender-neutral and, as it relates the interaction between economics and health factors, does not take into consideration gender differences such as the variation in the rates of particular diseases or the types of health services that are needed.²² As a result, the unique health needs of women are often omitted from essential conversations driving the economic policy decisions that will affect them well into the future.

Women lead complex lives and need access to policies that can help them respond to demands at home and at work and achieve economic stability for themselves and their families. Women frequently are still the primary caregivers for children and are more likely to have gaps in employment as a result.²³ Having the freedom to decide whether, when, and how to start a family affects their investments in education, career choice, career timeline, lifetime earnings, and retirement security differently than it affects men.

While access to reproductive health services alone does not guarantee positive outcomes, it is necessary to empower women to become economically secure. But more intentional efforts are needed to avoid oversimplifying women’s experiences, and to help ensure that any positive economic outcomes correlated with reproductive health care access actually translate into actions with broader effects, such as reducing health care costs and health disparities for low-income women.

Supporting access to reproductive health must be considered as an investment in the nation’s economic future. As such, federal and state policymakers should produce a framework that prioritizes reproductive health as a critical component of women’s economic challenges as well as their opportunities. 

Women’s lives are composed of intersecting factors that shape their ability to fully participate in society and have economically secure lives. The current political environment fails to reflect this nuanced understanding. Reproductive health services and legal protections are important, but they cannot resolve these economic challenges alone. As families struggle to make ends meet in today’s economy, women need the full range of economic supports such as paid leave, affordable child care, fair pay, and comprehensive reproductive health services.

What is needed is a shift to a reproductive justice agenda. Economic security is interconnected with reproductive justice, which is defined as the economic, social, and political power and resources for women to make healthy decisions about their bodies; sexuality and reproduction; families; and communities.²⁴ The phrase “reproductive justice” was coined by African American women in 1994.²⁵ It is rooted in the belief that systemic inequality shapes women’s decision-making around childbearing and parenting, particularly vulnerable women. Institutional forces such as racism, sexism, and poverty, influence women’s individual freedoms in society. Other factors—such as immigration status, gender identity, sexual orientation, and age—can also affect whether or not women get the appropriate care they need. All women deserve access to health services, but some people need supports beyond policy change and legal services. Justice, in this case, refers to cultural norms that value everyone and every community as human and worthy of respect.

The five pillars

Women’s health is not simply about the accessibility and availability of direct services, but also the social and economic conditions that allow women to be healthy and autonomous. These conditions are mutually reinforcing: Reproductive health, rights, and justice are necessary to ensuring economic empowerment. But just as importantly, economic empowerment is necessary for ensuring access to reproductive freedom for all women.

There are five pillars essential to an economic framework that fully integrates reproductive health:

• Self-determination
• Access to comprehensive reproductive health services
• Affordability of care
• Parenting with respect and dignity
• Workplace and caregiving supports

These pillars collectively represent a holistic approach to ensuring that all women have what they need to thrive and be healthy. Each pillar is valuable individually, but, taken as a group, the pillars are also mutually reinforcing to anchor a policy agenda that meets the intersectional needs of working women. This policy agenda centers on women’s health, not as the absence of disease or disparity, but as a driving force to ensure economic security.

Self-determination

Self-determination refers to a person’s ability to control her body, health, and resources in order to pursue opportunity free from violence or coercion.²⁶ It also refers to a woman’s ability to decide the number of children she will have, her family structure, and how she will parent.²⁷ Bodily autonomy is not simply a matter of biological reproduction but of one’s ability to work and form a family regardless of one’s gender or sexual orientation. A woman’s ability to work ultimately shapes her ability to take advantage of opportunities and seek economic mobility.

Reproductive and sexual health undergird a person’s ability to access other freedoms. A rights-based approach ensures that all people receive information about family planning, abortion, childbearing and sexual health education in a way that meets their unique needs. More importantly, when an individual receives information and services free from discrimination, coercion, or violence, it creates a ripple effect in their families and communities. The result is that all people can control their own lives, have healthier relationships, increase their self-esteem, and teach their children about health and wellness. Finally, self-determination is key to health equity. It places vulnerable people at the center of the allocation of resources as well as policymaking to ensure that everyone benefits. 

Access to comprehensive reproductive health services, including abortion care

Comprehensive reproductive health services include breast and cervical cancer screening; sexually transmitted infections, or STI, and HIV testing; pregnancy tests; birth control; abortion services; infertility specialties; mental health services; maternity care; addiction counseling; sex education; and counseling for victims of domestic and sexual violence.²⁸ These services are pivotal for women to be healthy throughout their lifetime, to control their fertility, and to increase their economic mobility. But the care must be available, accessible, timely, and affordable. Preventive care is considered the bedrock of women’s health, shaping women’s relationships with medical professionals for a lifetime.

Overwhelmingly, family planning is the primary reason women seek reproductive health care. Contraception is currently used by 62 percent of U.S. women of reproductive age.²⁹ The most common methods include the birth control pill and tubal ligation, but long-acting reversible contraceptives, or LARCs, are growing in popularity, as they are more than 99 percent effective.³⁰ While primarily used to plan and space pregnancy, contraception is also used for other health benefits such as menstrual pain and regulation, and to treat endometriosis.³¹

Pregnant women who want to bear children benefit from maternal health care, which refers to care provided during the pregnancy, childbirth, and post-partum.³² Prenatal care helps women reduce complications, protect fetal health, and plan for childbirth.³³ It also helps prevent negative health outcomes such as maternal morbidity, which has been on the rise for the past 25 years despite health advancements.³⁴

Low-income women and women of color are less likely to receive early prenatal care,³⁵ and a lack of care is associated with a higher rate of newborn death.³⁶ African American women are three times more likely than white women not to receive prenatal care.³⁷ But American Indian and Alaska Native women are the most likely to have late or no prenatal care.³⁸

Teens and women of color have higher rates of infant mortality.³⁹ For example, the infant mortality rates are two times higher for African American women than they are for white women.⁴⁰

Women who lack access to contraceptive care have an increased risk of unintended pregnancy, the leading cause of abortions. Of the nearly 3 million unintended pregnancies in the United States, 42 percent end in abortion.⁴¹ Unintended pregnancy rates for women, especially teens,⁴² have dropped; women at or below the federal poverty line, however, are still disproportionately likely to experience an unintended pregnancy. Indeed, low-income women are five times more likely to have an unintended pregnancy;⁴³ 49 percent of women who had abortions in 2014 earned less than $12,000 per year.⁴⁴ Additionally, studies have shown that at times, women who cannot access affordable abortion care  resort to self-induced abortion.⁴⁵ If the means or methods for self-aborting are unsafe, it can result in worse health outcomes.

Availability of services

Many women struggle to obtain health care because services are not located in a reasonable proximity to them. For example, more than 60 million rural women struggle to access general health care due to the limited number of doctor’s available outside of urban areas.⁴⁶ Women of color often experience a disparity in access to services due to lack of reliable transportation, communication barriers with medical professionals, historical distrust of medical institutions, or lack of insurance coverage.⁴⁷ Immigrant women face language barriers and often have concerns regarding immigration policies.⁴⁸ Teens and lesbian, gay, bisexual, and transgender, or LGBT, individuals face stigma and shame from doctors about their bodies, identities, and choices.⁴⁹

Furthermore, abortion remains the most highly restricted service in reproductive health care, in part because of its lack of availability. In 2011, for example, nearly 90 percent of U.S. counties did not have an abortion clinic; these counties were home to 38 percent of reproductive-aged women.⁵⁰ And in 2016 alone, 42 laws restricting access to abortion were enacted in the states.⁵¹

But state restrictions are not the only problem women face regarding access. The increasing number of religiously affiliated hospitals affects women’s health. These hospitals may use directives based on religious doctrine rather than medical standards, particularly for reproductive health care.⁵² Such directives prohibit doctors from providing services such as contraception, sterilization, infertility treatments, and abortion.⁵³ And because these institutions have an increased presence in low-income and rural areas with limited to no access to medical services generally, vulnerable women are being subjected to medical practices that would otherwise be illegal in secular medical settings.⁵⁴ This compromises women’s autonomy as well as violates standards of medical care.⁵⁵ 

Affordability of care

The passage of the Affordable Care Act has expanded health care coverage for more than 97.5 million women between the ages of 19 and 64.⁵⁶ It allowed states to expand their Medicaid programs, established state-based health insurance marketplaces, and improved employer-sponsored insurance plans.⁵⁷ Women are able to obtain a host of preventive services without a copay, such as contraception, annual gynecological visits, breastfeeding counseling, and STI screening and treatment.⁵⁸ Women are no longer charged higher premiums due to their gender.⁵⁹ More importantly, the ACA ensures that women have a continuum of coverage services throughout their reproductive lives.

Within the first year of its implementation, one-in-five women were covered including 25 percent of black women and 40 percent of Hispanic women.⁶⁰ Nearly 25 percent of young people between the ages of 18 and 25 were covered under their parent’s insurance.⁶¹

Unfortunately, too many women are still uninsured due to costs.⁶² And more recently, congressional Republicans introduced a replacement plan for the ACA that includes major cuts to funding for Medicaid, strips Medicaid reimbursements from Planned Parenthood health centers, greatly restricts private insurance coverage of abortion, and results in fewer people having health insurance.⁶³ Approximately 13 million women of reproductive age were uninsured in 2014.⁶⁴ With the proposed changes for dismantling the ACA, 11 million people, including senior citizens, people with disabilities, and low-income children, will be harmed.⁶⁵ This compounds the nearly half of all uninsured individuals who wanted insurance coverage but were unable to afford it in 2015.⁶⁶ This was especially true for women of color, immigrant women, and single mothers, who are much more likely to be uninsured.⁶⁷ As a result, these women are less likely able to use preventive services and receive a lower standard of care.⁶⁸

Between 2006 and 2010 nearly 9 percent of women paid for reproductive health services out of pocket.⁶⁹ Women without insurance coverage are more likely to forgo preventive care and face higher health care costs due to delayed care. They also have worse health outcomes due to their point of entry into the medical system.⁷⁰ This can result in higher rates of hospitalization for preventable conditions which lead to higher bills and medical debt.⁷¹ Uninsured medical needs can harm a family’s economic security, particularly those living on the brink.

The financial impact for women seeking abortion care can be economically devastating without insurance coverage. Low-income women with publicly funded health insurance, such as Medicaid, do not have coverage for abortion. This lack of care is due to the Hyde Amendment,⁷² an annually approved appropriations rider that prevents federal dollars from covering abortion except in cases of rape, incest, or life endangerment.⁷³ Currently, similar restrictions on federal funding for abortion also affect women in the military, Peace Corps volunteers, federal employees, federal inmates, Native Americans, and residents of Washington, D.C.⁷⁴ Since the passage of the ACA, states have passed Hyde-like restrictions imposed on private insurance plans, state health exchanges, and public employee health insurance plans.⁷⁵ Without insurance coverage, low-income women who are struggling to make ends meet further compromise their economic insecurity by paying for abortion care out of pocket.

Funding restrictions alone make abortion services unaffordable and inaccessible. States have adopted 344 abortion restrictions in the past six years, which have contributed to burdensome direct and indirect costs for women.⁷⁶ Abortion services cost between $300 and $1500 depending on location and the restrictions in the state.⁷⁷ Increasingly, many women must pay for lodging because of the distance between the clinic and their home. Women who are already mothers must consider child care costs.⁷⁸ Those who have jobs that do not provide paid leave may have to forgo pay for the time they take off to get services, which further limits their disposable income. In order to cover these costs, many women have delayed paying for basic utilities, food, and rent to afford this legal medical procedure.⁷⁹ Worse, a lack of resources can significantly delay an abortion procedure and increase the total cost of services.⁸⁰

Parenting with dignity and respect

Parenting with dignity is essential to an economic agenda that includes reproductive health, rights, and justice. Once children are born or adopted, resources such as housing, education, health care, and nutrition become as important as quality, affordable health services. Parenting with dignity entails having communities with social supports such as food security, high-quality education, public safety, public transportation, and freedom from violence.⁸¹ Young parents and LGBT families, in particular, need social supports to complete high school, move into the workforce, and parent without stigma.⁸² Providing for children requires more than a loving and nurturing home. Both the local community and broader society must play a role in producing healthy and happy families that strengthen our nation. 

Childbirth with dignity

Millions of pregnant women struggle to access maternal health services because of efforts to restrict reproductive health care. States that have not expanded Medicaid and have state abortion restrictions contribute not only to limited abortion care but preventive services like preconception care as well.⁸³ A report by the National Advocates for Pregnant Women revealed that more than 400 cases where post-Roe v. Wade restrictions were used to prosecute, police, or interfere with women’s pregnancies.⁸⁴  For example, women were unable to get drug treatment while pregnant, deliver their baby in the manner that they preferred, or to refuse a doctor’s advice regarding their care.⁸⁵

Incarcerated pregnant women particularly suffer from lack of access to childbirth with dignity.⁸⁶ Most women in jails or prisons are often denied information about their due dates and delivery location, as well as prevented from having family attend the delivery.⁸⁷ Despite the fact that 12 states have passed anti-shackling laws, many women are restrained with shackles and belly chains⁸⁸ during labor, delivery, and post-pregnancy.⁸⁹ Worse, they are often only allowed to spend 24 hours with their newborns after delivery.⁹⁰

Women need maternal health care and childbirth options that allow them to effectively parent. And they need a continuum of parenting supports from pregnancy throughout their child’s development into young adulthood. 

Freedom from violence

Sexual and domestic violence harm women’s reproductive autonomy and economic security. Both are also strongly associated with reproductive coercion, such as contraception sabotage, as well as forced pregnancy and abortion. Women of reproductive age are at the greatest risk for intimate partner violence.⁹¹ They are twice as likely to report physical or sexual abuse from an intimate partner to staff at a family planning clinic.⁹²

Violence often extends to the workplace. A 2005 survey showed that 21 percent of employed women considered themselves a victim of intimate partner violence.⁹³ As result, these women lost more than 7 days of work and 33 days of productivity at home.⁹⁴ Domestic violence survivors have more employment problems, such as a more employment gaps and increased health problems.⁹⁵ These challenges often give abusers more leverage over women and their decisionmaking.⁹⁶ Paid sick or safe days allow women to take time off of work without jeopardizing their economic security.

Workplace and caregiving supports

Workplace benefits and caregiving supports are still based on outdated ideas about family structures and income. While women have become a larger portion of the American workforce and household breadwinners, their roles as caregivers have remained the same. Workplace benefits and family policy have not modernized to support women’s dual roles as workers and family caretakers. This influences how women engage in the economy and make reproductive health choices.

We can understand how family responsibilities affect subsequent economic outcomes by looking at the difference in labor force participation based on number of children. The number of children a woman has affects her level of labor force participation, which in turn can affect her family’s economic stability. For example, childless women and women with one child work nearly 10 more hours a week than women with three or more children.⁹⁷ This trend particularly hurts working mothers, who are more likely to work part-time to balance child care needs.⁹⁸ Not only do part-time workers earn less overall because they work fewer hours, but they also earn less per hour than full-time workers, creating a part-time wage penalty.

Furthermore, a woman’s gaps in employment can cause lower earnings that are never recovered. The planning and spacing of children can help reduce these gaps and protect a woman’s lifetime earnings. Lower earnings compounded over time resulting in lower social security benefits can put women at greater risk for elderly poverty.⁹⁹ Planned childbearing helps women to better prepare for these transitions.

To provide sufficient workplace and caregiving supports, the country must come to terms with the modern lives of families as active members of the economy. The role of men and women as caretakers should also be considered. Workplace and caregiving supports include 1) access to high-quality early child care to support parents as they raise their children to be engaged members of society; 2) affordable higher education so they can achieve their own professional and personal goals; and 3) workplace benefits and protections—such as equal pay, paid leave, and caregiving supports—so women can balance work and family duties. Each of these workplace and caregiving supports must work in a tandem in order to give workers full access to economic opportunities and the freedom to raise their families.

Access to high-quality early childhood programs

Quality child care allows parents to prepare their children to learn how to think, reason, and interact with other children.¹⁰⁰ In a majority of families, all of the adults must work to contribute to the sustainability of the household. As a result, more than 11 million children under the age of five need child care.¹⁰¹ While costs vary from state to state, child care remains expensive compared to state median household incomes, particularly for single parents.¹⁰² In nearly every state, the cost of child care exceeds 10 percent of married couple’s median income and more than 40 percent for single parents.¹⁰³

Moreover, businesses report spending more than $4.4 billion annually on employee absenteeism due to their employees’ child care needs.¹⁰⁴ Investments in high-quality preschool and child care allow for the early education of children, parents the accessibility to work as needed, and families to care for their children without sacrificing their economic stability. Moreover, these programs can help low-income children and children of color start school with the skills they need to be successful. Due to disparate access to quality programs, too often these children start school already behind their more affluent peers.

Affordable higher education

Education is considered a key to economic mobility, but it also has health implications.¹⁰⁵ Income inequality prevents many families from making educational investments, which is highly correlated with health disparities. Parents with good health are better able to pursue education and in turn ensure their children are healthy and educated. Also, their children take advantage of more social opportunities as they grow into adulthood.¹⁰⁶ But it can be difficult for many low-income parents to invest time and resources into developing their talents as well as that of their children over the long term.

The long-standing correlation between reproductive health and education is compelling but different for young people of reproductive age who view birth control as essential to their financial security.¹⁰⁷ College education is necessary for one’s ability to get a higher skilled job and a secure future. And despite the need for higher education and the increase in women attending college, family incomes have not kept up with the rising cost of college tuition.¹⁰⁸ For low-income people there is often a conflict between the prospect of educating themselves and providing for the immediate financial needs of the family, regardless of whether they have delayed childbearing or their marital status.¹⁰⁹ This conflict can be particularly daunting for young women who find themselves earning significantly less than a man regardless of their chosen occupation¹¹⁰ and facing enormous student loan debt.¹¹¹ Over time, this means that working women have fewer resources to protect their reproductive health and their families’ economic security.

Workplaces that are responsive to women workers

Equal pay for equal work: Currently, a woman working full-time, year-round only earns 80 cents for every $1 a man earns.¹¹² The majority of the wage gap is attributed to factors such as occupational choice or segregation, differences in work experience given increased likelihood of time off, and union status, but nearly 40 percent of the gap is unexplained. Hispanic women, African American women, and American Indian women face even larger disparities, earning 54 cents, 63 cents, and 58 cents respectively of men’s wages.¹¹³ Women of color are more likely to enter into the labor force without a high school diploma or bachelor’s degree,¹¹⁴ forcing them into low-wage jobs where they are likely to struggle to obtain the hours they need to earn a living wage. As a result, the combined wage loss exceeds more than $490 billion a year for women working full-time in the United States.¹¹⁵

The wage gap is even greater for full-time working mothers, who earn only 71 cents for every $1 earned by working fathers—a so-called motherhood penalty that can prevent working mothers and families from obtaining basic resources such as food and housing along with child care services and medical care.¹¹⁶ Nearly 23 percent of breadwinning mothers bring home between 25 and 50 percent of the families’ earnings.¹¹⁷

Equal pay can ensure that women earn the same pay for the same job as men, as well as increasing the ability of low-income women to access health services, lift themselves out of poverty, and provide for their families.¹¹⁸

Different forms of paid leave: The United States is the only industrialized nation that does not guarantee workers paid maternity leave or paid family leave.¹¹⁹ Currently, only 14 percent of civilian workers have paid family leave through their employers and less than 40 percent have short-term disability insurance.¹²⁰ Far too many households struggle to take the time off that they need without sacrificing their income. Additionally, more than 40 million people do not have access to paid sick leave.¹²¹

A lack of paid family and medical leave or paid sick leave can force women to choose between staying employed and tending to their own health care needs or the needs of a loved one. Recent polling found that 43 percent of women who did not obtain health care did not do so because they lacked the time or the paid sick leave from work to access services.¹²² Additionally, providing paid family and medical leave and paid sick time has actually been shown to increase performance and productivity in the workplace.¹²³

Caregiving: Finally, working parents need workplace flexibility and policy supports to meet their caregiving responsibilities. Whether caring for children under the age of 18, elderly relatives, or family members with a chronic illness, millions of working families struggle to balance their time between work and home, as well as the enormous cost that can be associated with care. Caregivers for relatives who are not dependent children, the majority of whom are women, contribute enormously to the economy¹²⁴ as they sacrifice financially, physically, and emotionally.¹²⁵ Twenty-five percent of caregivers provide care for two or more family members and nearly half of all caregivers provide care for both a parent and a child.¹²⁶ Fulfilling these responsibilities often takes a toll on the health of working parents as well as their professional opportunities. As the workplace shifts to meet the needs of its growing workforce, we must rethink caregiving for American families struggling to make ends meet while facing increasing costs related to child care or other caregiving responsibilities.

A comprehensive agenda to strengthen women’s health and economic security must include policies that respond to the interconnected and diverse needs of women and their families. This means identifying steps that can be taken at the national and state levels to ensure that women can access the care they need and participate fully in the economy to move America forward. And while the political environment has already shifted under the new Trump-Pence administration and anti-choice majority in Congress—a shift where women’s health and rights are under attack—it is important to reject efforts to roll back women’s rights and stand strong in support of progressive policy changes that will help women thrive.

Actions to reject rollbacks

Congress must protect the Affordable Care Act. Under the ACA, millions of women have been able to access well women’s care and preventive services at no cost—including breast-feeding support, birth control, screening and counseling for domestic violence, and STI screening. Maternity care is required for all small group and individual health plans. The law also made it illegal to discriminate against women due to pre-existing conditions or charge them more for insurance coverage based on gender.¹²⁷ Access to affordable health care under the ACA has not only contributed to the health of women and families, but also their economic security. This means:

• Opposing any actions at the executive, congressional or state level intended to curtail women’s access to the full range of the ACA’s women’s health and preventive care services
• Opposing any actions to eliminate Medicaid expansion under the ACA or to decrease spending for the safety-net program through efforts to block grant its funding or institute per capita caps  

The president and Congress must not roll back abortion rights. Women in the United States have had the right to abortion for more than 40 years. Unfortunately, anti-choice politicians have tried to erode these rights by imposing draconian restrictions on coverage and funding for abortion, as well as the providers who serve them. This has led to a system of inequality where only women with means can afford to pay the out of pocket costs associated with abortion care or travel long distances if a provider isn’t within their city or town. It is imperative that a woman’s right to choose be upheld and efforts to erode access to abortion are abandoned in order for women to thrive in this country. This means:

• Rejecting efforts to limit or overturn access to abortion that are inconsistent with the parameters set forth by the U.S. Supreme Court and women’s constitutionally protected rights as upheld in the landmark Roe V. Wade decision
• Refusing to confirm federal judges at the U.S. Supreme Court or other levels who have been hand-picked to further a political agenda that would undermine women’s health, rather than interpret the applicable law impartially and fairly regardless of their personal views
• Opposing the expansion of the Hyde amendment and other measures targeting specific sub-groups of women to eliminate their access to abortion and effectively eviscerate their constitutionally protected rights

Congress must support Title X. Title X provides family planning services for low-income, the uninsured, young people, and communities of color across the country. Despite the implementation of the ACA’s contraception mandate, more than 4 million people access birth control, cancer screenings, and testing for STIs through Title X providers.¹²⁸ And while the need for Title X services has expanded in the past few years, federal funding for the program has decreased. Increased funding and the continuation of this vital safety net program is essential to ensuring that all people have access to family planning. Title X providers—such as Planned Parenthood, which serves nearly 1.5 million patients through the Title X Family Planning Program—must also be supported as they help meet critical health needs for underserved communities. This means:

• Opposing efforts to reduce funding and investments in Title X and related programs
• Rejecting proposals to deny funding to existing, essential Title X providers because they also offer abortion services with non-Title X funds

The president and Congress must reject efforts to deny health care based on religious or moral objection.  Under no circumstances should a person in need of reproductive health care be turned away or denied based on the religious or moral objection of a provider. This is especially true for women in need of emergency care, or those living in areas with limited access to health care. Reproductive health must be viewed through an economic and reproductive justice lens that recognizes the myriad of factors that impact overall health and the health of families, as well as the issues that impact access to care. This means rejecting efforts to pit religious and moral views against reproductive health by creating broad loopholes that put health at risk and deny people the services they need.

Affirmative progressive measures at the intersection of economic justice and reproductive justice

States must expand Medicaid. Currently, 19 states have not expanded their Medicaid programs.¹²⁹ As a result, 3 million women fall into the coverage gap due to eligibility requirements.¹³⁰ This barrier prevents women in need from obtaining comprehensive health services.

Congress must pass the EACH Woman Act. This legislation would repeal the Hyde Amendment and other abortion funding restrictions passed through the appropriations process. It would also prohibit restrictions on private insurance coverage for abortion services. By eliminating the Hyde Amendment, low-income women, federal employees, Native American women, Peace Corps volunteers, and residents of Washington, D.C., would have access to the full range of reproductive health services to help them thrive.

Congress must pass the Women’s Health Protection Act, or WHPA. This legislation would prohibit states from enacting dangerous restrictions on abortion care and interfering with the patient-doctor relationship. It would prohibit medically unnecessary procedures and clinic shutdowns, women’s ability to access medication abortion, and abortion bans prior to viability as deemed constitutional by Roe v. Wade.

Congress must pass the HEAL Act for Immigrant Women and Families. This legislation would restore Medicaid and CHIP coverage for immigrants, including women of reproductive age, who are authorized U.S. residents.

Congress must adopt strong workplace standards to improve job quality. Congress can take action to strengthen workplaces and give workers the resources and tools they need to live healthy lives. Policies focused on raising wages, ensuring access to quality and affordable health care services, eliminating gender discrimination, and providing paid time off for family or medical reasons.

• Raise the minimum wage. Increasing the minimum wage would allow the lowest paid women more resources to protect their health and support their families. Currently, the federal minimum wage is $7.25 per hour and $2.13 per hour for tipped employees.¹³¹ In every state, these wages result in millions of women living near or below the poverty line putting them at greater risk for being uninsured and unable to get consistent access to health services. To ensure that women better achieve economic security they must earn enough to pay for their basic needs as well as essential health services.
• Guarantee all workers have access to paid family and medical leave. Currently only 14 percent of civilian workers have paid family leave.¹³² The Family and Medical Leave Act provides for job-protected unpaid leave, but it is available to less than half of all workers.¹³³ Worse, most workers cannot afford to take it.¹³⁴ Paid family and medical leave law allow men and women to earn their pay while they leave to care for a new child, address their own serious medical condition, or care for a seriously ill family member.¹³⁵
• Promote and ensure pay equity and promote workplaces free of discrimination. Despite the fact that women make up larger numbers of the workforce, too many employers continue to pay women less than their male counterparts.¹³⁶ Strengthening equal pay protections is essential to promote greater transparency, eliminate pay secrecy, require employers to regularly disclose pay data to enforcement officials, tighten employer defenses, and ensure fair damages for legal violations.¹³⁷ It is also critical to make affirmative steps to combat other forms of gender discrimination in the workplace for women and transgender individuals, particularly those who are or planning to become parents. The Pregnant Workers Fairness Act would help ensure that women who are pregnant have access to reasonable accommodations that enable them to have healthy pregnancies and remain attached to the labor force.¹³⁸

The president and Congress must promote affordable high quality child care. Millions of families struggle to access affordable, high-quality child care. The United States needs a child care system that meets their needs and does not jeopardize their economic security. A High-Quality Child Care Tax Credit for low- and middle-Income families that is paid directly to the providers would assist working families.¹³⁹.

The president must commission a study examining unequal access to women’s health care. Health care disparities among low-income women and women of color is still a major issue in the United States. The president should direct the U.S. Department of Health and Human Services to examine the responsiveness of federally funded health care facilities in meeting the reproductive and maternal health needs of vulnerable women in local communities. The administration’s recommendations should instigate policy protections and solutions for meeting health needs, while also connecting with economic indicators such as equal pay. 

The political debate surrounding women’s health and rights is often reduced to either family planning or abortion, but in truth women’s health and rights include a continuum of health services and legal protections that bolster all areas of their lives. The right to have children, not have children, and to parent children safely is rooted in the information, resources, and power the individual woman has access to in her life.

Extracting reproductive health from an economic security agenda disrupts the potential for holistic services and policies that can help people obtain gender equality and health equity in the United States. A comprehensive approach requires a policy agenda that promotes self-determination, access to comprehensive and affordable services, parenting supports, and a responsive workplace. This ensures that women—regardless of location, income status, race, sexual orientation, or age—have access to the services and resources they need in a timely, culturally competent, respectful, and affordable way that will help contribute to their economic mobility.

An investment in reproductive  health means an investment in America’s promise of equality for all. That promise must be as adaptable and expansive as the roles women play in society. Policies and cultural norms must evolve so that women can participate freely in society and use all of their talents to strengthen families. Economic opportunities for women ensure that they can chart their own reproductive destiny and better achieve economic security. When all people are able to achieve their best economic opportunity, the entire national economy thrives and grows.

Heidi Williamson is the Senior Policy Analyst for the Women’s Health and Rights program at the Center for American Progress. Prior to joining American Progress, Heidi worked for the Alzheimer’s Association, SisterSong Women of Color Reproductive Health Collective and the Services Employee International Union, or SEIU. She has successfully led legislative and advocacy efforts in the South and helped the successful campaigns of more than 20 women legislators to office at the state and local level. She is a founding member of Trust Black Women Partnership, a strong network of African American women organizations and individuals, who mobilize to defend the human right to have a child, not have a child, and parent for African American women in the United States. Williamson is a graduate of Georgia State University, where she double majored in English and African American studies.

Kate Bahn is an Economist at the Center for American Progress. Her work has focused on labor markets, entrepreneurship, the role of gender in the economy, and inequality. In addition to her work on the Economic Policy team, Bahn has written about gender and economics for a variety of publications, including The Nation, The Guardian, Salon, and The Chronicle of Higher Education. She also serves as chair of the Executive Vice President and Secretary as well as the chair of the Communications Committee for the International Association for Feminist Economics and as moderator of the organization’s blog, “Feminist economics posts.” Bahn received both her doctorate and master of science in economics from The New School for Social Research, where she also worked as a researcher for the Schwartz Center for Economic Policy Analysis.

Jamila K. Taylor is a Senior Fellow at the Center for American Progress, where she serves as an expert on domestic and international women’s health, reproductive rights, and reproductive justice. Prior to joining CAP, Taylor was a senior policy advisor at Ipas, a global nongovernmental organization dedicated to ending preventable deaths and disabilities from unsafe abortion and helping women realize their sexual and reproductive rights. Taylor has more than 18 years of public policy and advocacy experience, working as the senior public policy associate for the Center for Health and Gender Equity, or CHANGE, as well as on HIV/AIDS policy and advocacy for The AIDS Institute, and on domestic abortion policy and advocacy for the National Network of Abortion Funds. Taylor holds a bachelor of arts in political science from Hampton University, a master’s degree in public administration from Virginia Commonwealth University, and a Ph.D. in political science from Howard University.