Why the cost of living crisis is a reproductive justice matterBMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p118 (Published 17 January 2023) Cite this as: BMJ 2023;380:p118
- Naomi Delap, director,
- Kirsty Kitchen, head of policy and communications
- Follow Birth Companions on Twitter @brthcompanions
The cost of living is soaring, austerity 2.0 looms, and the picture is bleak for mothers and children at the highest risk of mental and physical ill health because of their socioeconomic circumstances.
In November 2022, the MBRRACE-UK perinatal mortality report1 showed us that black babies living in deprived areas are twice as likely to be stillborn as white babies from the least deprived areas. Mothers who are black, Asian, living in deprived areas, known to social services, and those experiencing multiple disadvantages are more likely to die in pregnancy, labour, or the year after birth.1 Unsafe maternity staffing levels pose “unacceptably high levels of risk.”2 Health visitor numbers have fallen by at least 30%3 since 2015 and continue to fall. Mental health services are overwhelmed, and family support services have given way to a steep rise in late stage, crisis level interventions from the children’s social care system.4
The government’s failure to publish the long awaited health disparities white paper, which many hoped would represent a turning point, has deepened the sense of despair among those committed to tackling this emergency. Without it, individual sectors and services are left to do what they can to tackle the impact of huge, interconnected social and political problems in silos.
The Maternity Disparities Taskforce, for instance, will no doubt do its best to improve the outcomes of mothers experiencing deprivation and structural racism. But we know the roots of the social determinants of health are deeply entangled, and impossible to understand by looking at the ground immediately under our feet. Another approach is needed: a rights based focus to understand the inequalities affecting women’s reproductive rights in all their complexity. And, in response, a coordinated effort to create ambitious solutions that deliver justice.
Reproductive justice is not a widely recognised concept in the UK, but it should be. Originating from organisations led by and for ethnic minority women in the US, reproductive justice is a feminist framework through which to move reproductive rights beyond legal and political debates, to include the social, environmental, and economic factors that impact women’s reproductive choices.
Reproductive justice can be understood as four fundamental principles: the right to bodily autonomy, the right not to have a child, the right to have a child, and the right to raise a child in a safe and healthy environment. Every woman in our society should have equal access to these rights, but this is not the case.
In the UK, staffing problems in our maternity services are impacting disadvantaged women’s rights to have a child safely and with control over their own bodily autonomy.5 The rise in food and energy costs and the housing crisis will most severely impact poorer women’s ability to raise their children in safe and healthy environments. Our crumbling prison system is an unsafe and inappropriate environment for pregnant and birthing women, and mothers of infants. Now, staffing shortages mean some women are locked up for over 23 hours a day, unable to access therapeutic programmes, have family contact visits, or meet with their social workers. Local authorities operating under huge budgetary pressure are increasingly removing children from their mothers for reasons rooted in poverty, domestic abuse, and trauma. This is reproductive injustice writ large.
We know that low incomes, poor housing, poor air quality, poor education, exposure to racism, violence, trauma, and adversity all impact health. But we don’t understand the complex links between these problems and people’s mental and physical health outcomes. We don’t collect the right data in the right ways. We don’t prioritise the views and the experiences of those most affected.
The reason we don’t seek to understand these things better through numbers and voices is quite simply because some women, mothers, and babies are not valued as highly as others. Some are not valued at all. A cursory assessment of the way the hostile environment affects pregnant women seeking asylum illustrates this fact—destitute women are charged thousands of pounds for accessing maternity care in order to safely birth their babies.
Until we accept that the structures and practices of our society attach greater value to the rights of some pregnant women, mothers, and their children than others, we cannot hope to start to narrow the inequalities in health outcomes. Without a huge effort to disrupt them, cycles of disadvantage will continue unbroken across generations. That effort needs to be based on the reality, complexity, and basic universal value of those lives.
Commitment, compassion, and strong leadership from government are required to embed health equity in all policies, and end the onus on individuals to prevent or tackle ill health caused by the socioeconomic contexts they are forced to live in. Many aspects of our maternity, social care, criminal justice, and immigration systems currently expose women and mothers to huge risk, reinforce stigma and judgement, entrench power imbalances, and reproduce and perpetuate injustice. We must understand that many girls and women are burdened with adversity, trauma, and racism throughout their lives. We need to radically change our systems to recognise, mitigate, and directly tackle these experiences. We need to deliver true reproductive justice.
There are no conflicts of interest.
Commissioned, not externally peer reviewed