Taylor Young has never wanted to be a mom. From the time the now 27-year-old began dating, she experienced persistent anxiety around the thought of getting pregnant in Ohio, a Republican-controlled state where Young felt her right to abortion was tenuous. 

In 2018, she discovered the childfree subreddit, an online forum on Reddit for people who do not have children and do not want them. In that forum, she learned about bilateral salpingectomy, a procedure that removes both fallopian tubes and permanently prevents pregnancy.

“I was 19 or 20, and I knew I probably wouldn’t be able to get it,” says Young, who didn’t meet the minimum age requirement to have a Medicaid-funded sterilization procedure at the time. “But it was something that was kind of in my back pocket.” 

In 2022, when a document suggesting the U.S. Supreme Court was likely going to overturn Roe v. Wade was leaked, Young, who now met the minimum age requirement, immediately made an appointment with her gynecologist for a bilateral salpingectomy. 

After observing the mandatory one-month waiting period, Young received the procedure. “[I had felt like] an animal in a trap,” she says. “But when I woke up from that surgery, it was just … indescribable peace.” 

Young is one of many people of reproductive age whose health care decisions have been influenced by the overturning of Roe v. Wade, the fundamental ruling protecting the right to abortion in the United States.

In the years since, the rate of permanent sterilization procedures for people between 18 and 30 has jumped, particularly among female-born people. During the 2024 election, abortion rights were a key ballot issue and several states, including Maryland and Colorado, enshrined the right to abortion into their state constitutions. 

Political promises to legalize abortion—a critical issue, but one topic in the much larger ecosystem of reproductive health care—have overlooked some of the discussions the country must have to improve reproductive rights for the millions of reproducing people in America. When we take a closer look at the quality of reproductive health care that most people receive, it’s clear that simply restoring Roe v. Wade isn’t enough.

“The populations with the best reproductive health care outcomes … have all of [their] basic and human life needs met,” says Dr. Regina Davis Moss, president and CEO of In Our Own Voice: National Black Women’s Reproductive Justice Agenda, a group that amplifies Black voices to advocate for reproductive equity. “That is why we have some of the worst outcomes when we compare ourselves to other industrialized countries.” 

Pregnant people in the United States are more likely to die during pregnancy, childbirth, or postpartum than any other high-income nation, even though more than 80% of maternal deaths are preventable. The maternal death rate is double for Black women, who statistically are less likely to have access to high-quality medical care. On average, giving birth in the U.S. can cost more than $18,500. 

Cost is a leading prohibitive factor for those who most need to access birth control, abortion, and other reproductive health care. But there are legal barriers to subsidizing reproductive health care services—such as the Hyde Amendment, which bans the use of federal funds for abortion with few exceptions—and in many counties, no one to provide them. An estimated one-third of American counties, for example, do not have a single birthing facility or obstetric clinician to deliver maternal care. 

So, what might reproductive health care look like in a reimagined America that puts equity first? There’s already a framework for it: reproductive justice, a critical feminist framework that advocates for the right to have children, the right not to have them, and the right to raise children in a safe environment.

A Quest for Overall Well-Being 

In 1994, a group of Black women activists coined the term “reproductive justice” to achieve, as Loretta J. Ross writes, “the complete physical, mental, spiritual, political, social, and economic well-being of women and girls, based on the full achievement and protection of women’s human rights.”

While reproductive justice promotes equitable reproductive health care for everyone, the idea was born out of the struggles that people of color—particularly Black women—have faced in the United States since slavery, when they were forced to bear children to work on plantations.

The framework acknowledges that Black women face poorer reproductive health outcomes—and aims to do something about it. “The reproductive justice framework analyzes how the ability of any woman to determine her own reproductive destiny is linked directly to the conditions in her community—and these conditions are not just a matter of individual choice and access,” Ross writes. “Reproductive justice addresses the social reality of inequality—specifically, the inequality of opportunities that we have to control our reproductive destiny.” 

There is a modern-day implicit bias in health care, says Davis Moss, that women as a whole can’t be trusted to make their own decisions about their bodies. For example, Black women commonly report that health care providers are not offering them the full range of contraceptive options.

“The subjugation, the control, all that has happened ever since the country was born,” says Davis Moss. “We’ve seen that happen over the years in our health care system, in segregated hospitals, all the way up to modern day in clinical care encounters.” 

Though Young’s bilateral salpingectomy, which can cost thousands of dollars without insurance, was fully covered by Ohio Medicaid, cost remains a prohibitive factor for many people accessing reproductive health care in the United States. 

Take contraception, for example. A 2022 KFF Women’s Health Survey, which interviewed more than 5,000 female-born participants, looked at how cost influences contraceptive choice. Researchers found that a quarter of those surveyed with insurance had to pay at least part of their birth control costs out of pocket. “Any time you have to make a choice about day-to-day expenses and a copay… you know, living expenses, keeping food on the table… that is going to have an impact [on health],” says Davis Moss. 

The survey also found that of those who were in their reproductive years, one in five women who were uninsured had to stop using a contraceptive method because they couldn’t afford it. That data is supported by a Commonwealth Fund survey of women in several high-income nations, which found that women of reproductive age in the U.S. were the most likely to skip or delay necessary care due to cost.

Solutions for the Future

In 2023, In Our Own Voice and more than 50 other Black women’s organizations published the Black Reproductive Policy Agenda, a playbook on how to improve reproductive justice for birthing people at the policy level. 

The report makes more than a dozen policy recommendations that Davis Moss calls “proactive, comprehensive, and life-saving.” Among them are making prescription birth control free, requiring states to provide maternity and newborn care for at least one year (the time frame in which most maternal deaths occur), and increasing access to doulas and midwives who advocate for patients.

Passing acts like the Equal Access to Abortion Coverage in Health Insurance Act would require the federal government to provide funding for abortion services. “That in and of itself directly impacts a large percentage of Black women of child-bearing age [who] are on Medicaid and Medicare,” says Davis Moss.

For people struggling to pay for contraception, with or without health insurance, the cost of an in-person abortion—the median price is $600—is somewhat unthinkable. Medication abortion, however, can be cheaper and more accessible. Such is the promise of telehealth abortion, a virtual way to connect with a doctor, receive a prescription, and take abortion pills in a supportive environment.

Increasingly more women in the United States are finding themselves living in maternity care and reproductive health care deserts—areas where there is limited or nonexistent access to prenatal, postnatal, maternity, contraceptive, or abortion services. Telemedicine can provide a range of services for people living in these areas at a fraction of the cost—the median price of a telehealth medication abortion is $150.

“Telehealth does a lot to remove barriers to access to health care,” says Dr. Ushma Upadhyay, a public health scientist at UC San Francisco who researches the impacts of telehealth abortion. “People who live in rural areas, young people, people who report facing food insecurity… in our research, they are the most likely to have said that telehealth enabled them to have an abortion.” 

But even with the advent of telehealth, both Upadhyay and Davis Moss say addressing racism is essential to establishing an equitable reproductive future. That’s one of the reasons the Black Reproductive Policy Agenda recommends funding anti-Black racism programs as a part of its agenda. 

“This is the reason those 12 Black women 30 years ago said ‘You can’t only focus on abortion,’” says Davis Moss. “It’s impossible to have one without the other.”

After getting a bilateral salpingectomy, Young feels relieved. Yet she still worries about what will happen with Medicaid and the Affordable Care Act—the resources she relies on to help her afford care for chronic health issues—under the Trump administration, and what that means for others seeking care.

“Thinking about if other women don’t have access, that breaks my heart, and from the abortion side […] it’s too much to bear,” she says, emotion tugging at her voice.  “I feel relieved I got [the procedure] done when I did. I feel safe.”