AMA Journal of Ethics®

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics®

Illuminating the art of medicine

AMA Journal of Ethics. March 2018, Volume 20, Number 3: 211-223.
doi: 10.1001/journalofethics.2018.20.3.peer1-1803.

Peer-Reviewed CME Article: Original Research

  • Print
  • |
  • View PDF

Structural Competency and Reproductive Health

Structural competency helps physicians address reproductive health disparities through recognizing social determinants of health and social advocacy.

Margaret Mary Downey, MSW, and Anu Manchikanti Gómez, MSc, PhD

Editor’s Note: To claim one AMA PRA Category 1 Credit™ for the CME activity associated with this article, you must do the following: (1) read this article in its entirety, (2) answer at least 80 percent of the quiz questions correctly, and (3) complete an evaluation. The quiz, evaluation, and form for claiming AMA PRA Category 1 Credit™ are available through the AMA Education Center.


Reproductive health disparities—particularly those experienced by racial and ethnic minority groups—are considered a persistent public health issue in the United States. Frameworks that focus on social determinants of health seek to identify the forces producing these disparities, particularly social conditions that create vulnerability to premature death and disease. Such frameworks pose challenges to health care provision, as structural factors can seem immutable to health care professionals trained to treat individual patients. Here, we discuss the links between reproductive health disparities and social determinants of health. We then apply to reproductive health care the structural competency framework, developed by physician-scholars to encourage health care professionals to address health disparities by analyzing and intervening upon sociopolitical forces.


The World Health Organization (WHO) defines reproductive health as an integral component of complete well-being, noting that reproductive health indicates that people “have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if, when and how often to do so” as well as access to “safe, effective, affordable and acceptable methods of fertility regulation” [1]. Reproductive health care’s success in advancing this vision is mixed [2, 3], suggested by persistent reproductive health disparities in the US, particularly with respect to race, gender, and socioeconomic status. Women of color and low-income women fare worse than their white and higher-income counterparts in nearly every aspect of reproductive health, including access to prenatal care [4], maternal mortality [5], cervical cancer mortality [6], sexually transmitted infections [7, 8], access to services (including assisted reproductive technologies) [2], and education [4].

For clinicians trained to treat individual patients, the structural underpinnings of these reproductive health disparities pose practical and conceptual challenges. Structural competency is a framework developed by physician-scholars that seeks to address these challenges and to encourage health care professionals to recognize, analyze, and intervene upon the structural factors that impact health disparities. Here, we define “structural” factors as those that codify, in systems like medicine, law, or welfare, differential access to social, political, and economic opportunities [9]. Structural factors produce group-differentiated vulnerabilities to harm, including health disparities, as well as group-differentiated access to goods, services, and resources [10]. In response to persistent reproductive health inequities and to challenges reproductive health professionals face in adequately engaging the social determinants of health, this paper applies structural competency to reproductive health care.

The Social Determinants of Reproductive Health

No single factor accounts for the persistent reproductive health disparities in the US. Major health organizations, such as the Centers for Disease Control and Prevention (CDC) and the WHO, have embraced social determinants of health as an explanatory framework to highlight the role of unequal social conditions in creating and perpetuating avoidable differences in health [11, 12]. These social conditions include those created by laws, policies, and practices overseeing “where persons work, live, learn, and play” [13], such as those regulating health care professionals and wider spheres (e.g., zoning, educational systems, food access, courts, and labor markets) [14]. The CDC states that familiarity with social determinants of health data can help practitioners better recognize “root causes” [15], which health care professionals can miss if they only rely upon individual-level assessment and interventions [16]. Amidst calls for health care institutions to play a role in eliminating reproductive health disparities and in incorporating social determinants of health into practice [17], scholars argue that reproductive health care operates within paradigms that directly and indirectly create or exacerbate reproductive health disparities [2, 3, 18, 19].

These paradigms impede access to care and reify disparities for many women by limiting patient autonomy, perpetuating stereotypes about marginalized groups, and undergirding negative health care experiences that might curtail future health care seeking [2, 20]. Consider Madrigal v Quilligan, a 1978 federal class action lawsuit brought forward by Latina women coercively sterilized in a Los Angeles public hospital. A former medical student testified that Dr. Quilligan, the named defendant under whom she trained, connected poverty, overpopulation, and social benefits of racialized sterilization. Quoting Dr. Quilligan, Gutiérrez writes “poor minority women in Los Angeles County ‘were having too many babies,’ that this was placing a ‘strain on society,’ and that it was ‘socially desirable’ that the women be sterilized” [21]. Here, public health policies underlay the connections between individual patient characteristics (e.g., being Mexican, low income) and the perceived social danger of overpopulation. Beyond Quilligan, examples of health care practices and policies that replicate reproductive oppression and impede care for many women include the twentieth century’s forced sterilization of poor and working-class women, disabled women, and women of color [22] and the coercive sterilization of at least 148 women in California prisons between 2006 and 2010 [23]; long-acting reversible contraception (LARC) promotion targeting racial or ethnic minority and poor women without regard for the ways that this might invoke population control [3]; and state family cap policies that deny cash benefits to children born in families already receiving benefits [24].

Structural Competency as a Response to the Challenges of Addressing Reproductive Health Disparities

What should reproductive health care professionals take from these examples of reproductive oppression? First, reproductive health care professionals must realize that their field has played a role in exacerbating health disparities by serving as gatekeeper to services, resources, and technologies that facilitate or constrain reproductive choice [25]. These practices are not matters of individual bias or failure or of health care professionals acting as “bad apples” [14, 26]. Rather, the medicalization of wider social problems (e.g., poverty, racism, nationalism) vividly emerges in reproductive health care [27]. The (potentially) pregnant body is a site of systematized and heightened regulation and surveillance, particularly when those bodies are poor, disabled, immigrant, minority, and so on [27]. The medicalization of social problems has ethical implications for reproductive health care professionals, who must balance their pursuit of patient care and respect for patient autonomy, justice, beneficence, and nonmaleficence with the realities of institutional and structural discrimination experienced by patients. Indeed, research indicates that health care professionals do not feel equipped to understand or intervene upon structural factors, despite acknowledging the impact such factors have on their profession [28, 29]. Trained to treat individuals, reproductive health care professionals might contribute to the replication of problematic health care trends by ignoring structural barriers to care [30] because they and their institutions lack the skills and resources to identify, analyze, and imagine structural interventions.

Structural competency, an emerging paradigm in health care, seeks to address medicine’s overemphasis on the individual (e.g., biology, behaviors, characteristics) while addressing the hierarchies that produce unjust health conditions. Structural competency responds to dominant paradigms in health care education that neglect the ways in which access to the resources needed to make health changes and choices are influenced by unjust social determinants such as the differential treatment patients receive from health care institutions and professionals with respect to race, class, or immigration status, for example [31]. Developed by physician-scholars, structural competency is a means not only to analyze structural factors that impact health disparities but also to operationalize health care interventions to reduce health disparities, including in reproductive health [13, 32, 33]. Structural competency moves beyond cultural competency, which can reinforce racial, ethnic, linguistic, or other stereotypes by positioning these cultural groups as unsophisticated subjects and professionals as sophisticated or objective [34]. Structural competency offers a means to pursue ethical practice in a context of structurally produced health disparities without blaming the individual for health outcomes produced by upstream social conditions that are ultimately beyond his or her control.

Universities and clinics across the US have engaged with structural competency, offering conferences, trainings, and semester-long programs [28, 35]. A shift to structural competency is ultimately a hopeful one. To health care professionals, the social determinants of health can feel immutable; structural competency helps demystify health’s causal pathways and identify systematic ways to help patients.

Applying Structural Competency to Reproductive Health

Structural competency has particular utility in politically charged settings such as reproductive health care, where the day-to-day activities of health care professionals are highly sensitive to changes in the social, political, and economic spheres. Successfully treating patients while navigating these rapidly changing conditions requires understanding of the structures shaping these conditions. Metzl and Hansen outline five core elements of structural competency generally: defining clinical interactions in structural terms, developing an extra-clinical language of structure, rearticulating “cultural” presentations in structural terms, observing and imagining structural intervention, and developing structural humility [14]. Here, we apply these elements to reproductive health care.

Recognizing the structures that shape clinical interactions. Structural competency holds that recognition of structures shaping clinical interactions—including laws, funding mechanisms, and markets—is important, as it allows health care professionals to understand the wider spheres governing their clinical work. With that understanding, health care professionals can identify and correct missed opportunities to support their patients in navigating structural barriers to care. Abortion counseling services provide an instructive example of the structures shaping clinical interactions and their implications for health care and outcomes [31]. Owing to targeted state legislation that drains clinic budgets by forcing compliance with regulations beyond what is needed for patient health and safety [32, 33], many abortion clinics must meet patient need in minimal time. In turn, clinics cut services such as in-depth counseling, which provides space for patients to process their values and preferences related to abortion [36]. Furthermore, in-depth counseling can enhance quality of and access to care when it identifies structural barriers to health outcomes (for example, difficulties travelling to follow-up appointments among undocumented persons due to police checkpoints) [36]. A structurally competent approach to abortion care, incorporated into education and training curricula, would provide health care professionals with a framework to understand and analyze the social and political conditions that constrain the types of care available and influence clinical outcomes.

Developing an extra-clinical language of structure. An extra-clinical language of structure refers to incorporating terms and concepts from social, political, and economic theory into the health care encounter. Consider the case of promotion of LARC to prevent adolescent pregnancy. Although adolescent pregnancy is now recognized to be influenced by a complex set of factors—including education, housing, and employment—that pregnancy prevention alone cannot solve [37], Higgins argues that promoting LARC as if contraceptive efficacy were a panacea to structural barriers faced by young, poor women of color is unfair to patients and health professionals alike because it puts the onus on individual patients and professionals to solve a problem better addressed by more robust funding of education, housing, and employment programs [37]. In this context, language engaging social conditions (e.g., poverty) is ineffectual and does not reach the level of extra-clinical language suggested by structural competency, given that these arguments are not informed by the rich discussions of structural barriers in social, political, and economic theory. Drawing on structural competency, health care professionals might see how the absence of structural factors and social well-being in discussion of LARC locates the origin of social problems in the reproduction of poor adolescents. They could then be ready to discuss contraceptive decision making with their patients (and colleagues) in terms that go beyond clinical effectiveness, which is commonly promoted by physicians as the most important contraceptive consideration for women, although women often consider other aspects such as acceptability, values, and autonomy to be of equal or greater importance [30, 38]. A structurally competent perspective surfaces the ways that social inequities with respect to race, gender, class, and age are reproduced within clinical settings and in rhetoric about LARC, highlighting the need for alternative counseling approaches (such as shared decision-making models, which seek maximum patient input and use patient-directed language) [31].

Rearticulating “cultural” presentations in structural terms. Rearticulating “cultural” presentations in structural terms refers to understanding the structural factors producing differential clinical outcomes and presentations based on race or ethnicity and including these factors in any assessment and treatment plan. Health care professionals must consider the ways in which their knowledge base (e.g., research studies that refer to young, poor, or minority women as “at risk” for pregnancy and that replicate moralizing risk discourses [39]) and their professional norms explicitly and implicitly stratify women’s fertility based on stereotypes that are often framed as inherent to group “culture” [40]. One example is the stereotype that young, poor women of color are at risk for unintended pregnancy due to the controversial notion of a “culture of poverty” [41, 42] or “cycle of poverty” [43] that devalues education and other means of social mobility and promotes promiscuity. In rearticulating “cultural” presentations, health care professionals should analyze how patients’ decisions, feelings, and resources related to reproductive health might be influenced by differential opportunities to parent and exercise autonomy over childbearing options. Rearticulating cultural presentations in structural terms enables health care professionals to recognize stereotypes when they emerge in practice and to treat patients’ issues more accurately and acceptably [31].

Observing and imagining structural intervention. Observing and imagining structural interventions means health care professionals are both aware of key examples of thinking beyond the individual and capable of envisioning how they might apply them in practice. Reproductive health professionals can look to the past, present, and future to observe and imagine structural interventions. Women of color launched the reproductive justice movement in 1994, because they were dissatisfied with the reproductive rights movement’s narrow focus on “choice.” They openly challenged the exclusion of abortion access from health care reform and pushed for an intersectional understanding of reproductive oppression, particularly the forces that denied women of color the human right to have children and to parent with safety and dignity, as well as the right not to have children [44]. These activists paved the way for minority women’s leadership in health advocacy and in organizing successful campaigns against unjust policies and practices [45]. One example of reproductive justice in action is Black Women Birthing Justice, a San Francisco Bay Area collective that seeks to ensure, for black women, the right to birth with safety and autonomy—where, how, and with whom they choose. This organization works closely with local health providers and grassroots community groups to expand access to the range of pregnancy and postpartum care options for black women (e.g., Medicaid coverage of home birth, access to doulas and midwives of color, and access to trauma-informed, strengths-based breastfeeding support) as well as to increase the accountability of medical institutions to black pregnant women through community accountability boards [46].

In the current political climate, health care professionals might consider structural interventions such as training in how to resist collaboration with US Immigration and Customs Enforcement (ICE) and other policing institutions within their own clinics and at community-led direct actions [47, 48]. For example, citing erosion of community safety and public trust in local institutions, Planned Parenthood Mar Monte in California was one of 18 signers of a letter demanding that the Fresno sheriff immediately end a partnership between ICE and the police department, which had facilitated detainment and deportation proceedings of over 100 people [47]. Detainment and deportation can worsen reproductive health outcomes (e.g., increased risk for unintended pregnancy and sexually transmitted infections) by depriving patients of necessary reproductive care as well as subjecting undocumented women and families to disproportionate state violence and surveillance, thereby constraining their reproductive choices and experiences [49, 50]. Reproductive health care professionals might also consider following the example of movements such as White Coats for Black Lives, which leverages clinicians’ professional privilege to galvanize political support for the Black Lives Matter movement [51]. The Black Lives Matter movement and reproductive health equity are inextricable, given that police brutality and surveillance can be understood in the words of one physician as “particularly extreme forms of maternal stress” and might influence black women’s health outcomes or childbearing decisions [48]. As the political climate surrounding reproductive health intensifies, professionals are in a privileged position to advocate for structural interventions addressing not only the immediate reproductive health care needs of their patients but also the conditions that produce differential vulnerabilities in the first place. Structural competency allows for more appropriate interventions by aiding clinicians in recognizing and responding to the most salient structural contexts in the clinical encounter itself while also motivating clinicians and their health care systems to intervene in the extra-clinical determinants of health.

Developing structural humility. Structural humility is the capacity of health care professionals to appreciate that their role is not to surmount oppressive structures but rather to understand knowledge and practice gaps vis-à-vis structures, partner with other stakeholders to fill these gaps, and engage in self-reflection throughout these processes. Self-reflection allows health care professionals to better discern how structures are impacting them and their patients and identify systematic ways to help patients. By definition, structural issues cannot be addressed by an individual. Health care knowledge and interventions will always be partial. Engaging with this reality rather than clinging to professional status and expertise means that professionals will be better able to capture the complexity of their own experience as well as that of patients and other allies.

Although necessary, increased awareness of structural influences on health through more robust education and training will only take reproductive health professionals so far. Collective, coalition-based action to create lasting structural changes must follow reflection and awareness raising [14]. One example is taking a collaborative, movement-based approach to reform, such as the movement for single-payer health care [52, 53]. Reproductive health care professionals are well poised to argue for full access to reproductive health care (including abortion) in legislation that expands health care delivery [54], which would address social determinants of reproductive health by lowering financial barriers to the full-range of health care options patients need to achieve reproductive autonomy. In order to be fully visible and influential, they must do so alongside other health care professionals and advocacy groups such as Physicians for a National Health Program or National Nurses United [53]. Embracing structural humility, reproductive health care professionals must be careful not to dominate discussions or strategy at the expense of other stakeholders but rather cooperate and compromise as they move into spaces where multiple knowledges, identities, and priorities converge.


Structural competency represents a powerful framework for shifting the burden of eliminating health inequities from individual professionals and patients to institutions and systems, including health care, schools, and clinics. Structural competency training with a reproductive health focus might improve clinician sensitivity to social determinants of health, encourage generative self-reflection, and open opportunities for solidarity with patients. It might help health care professionals offer safer, more acceptable, and therefore more effective care. Given that reproductive health care professionals may work within “beleaguered” systems [55], structural competency is a means to empower these professionals to face occupational difficulties and organize for transformative change [56]. Because changes in structure cannot be achieved by individuals alone, structurally competent reproductive health care will take collective force, skill, and imagination but can ultimately play a key role in helping health care professionals to advance a vision of reproductive health as part of complete community well-being, to the benefit of patients and professionals alike.


  1. World Health Organization. Reproductive health. Accessed July 25, 2017.
  2. Harris LH, Wolfe T. Stratified reproduction, family planning care and the double edge of history. Curr Opin Obstet Gynecol. 2014;26(6):539-544.
  3. Gomez AM, Fuentes L, Allina A. Women or LARC first? Reproductive autonomy and the promotion of long-acting reversible contraceptive methods. Perspect Sex Reprod Health. 2014;46(3):171-175.
  4. Anachebe NF, Sutton MY. Racial disparities in reproductive health outcomes. Am J Obstet Gynecol. 2003;188(4):S37-S42.
  5. Centers for Disease Control and Prevention. Pregnancy mortality surveillance system. Updated November 9, 2017. Accessed December 7, 2017.
  6. Beavis AL, Gravitt PE, Rositch AF. Hysterectomy-corrected cervical cancer mortality rates reveal a larger racial disparity in the United States. Cancer. 2017;123(6):1044-1050.
  7. Hogben M, Leichliter JS. Social determinants and sexually transmitted disease disparities. Sex Transm Dis. 2008;35(suppl 12):S13-S18.
  8. Harling G, Subramanian S, Bärnighausen T, Kawachi I. Socioeconomic disparities in sexually transmitted infections among young adults in the United States: examining the interaction between income and race/ethnicity. Sex Transm Dis. 2013;40(7):575-581.
  9. Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995(theme issue);80-94.
  10. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212-1215.
  11. Centers for Disease Control and Prevention. CDC Health Disparities and Inequalities Report—United States, 2013. MMWR. 2013;62(3)(suppl):1-186. Accessed December 7, 2017.
  12. World Health Organization. Rio political declaration on social determinants of health. Published October 21, 2011. Accessed December 7, 2017.
  13. Centers for Disease Control and Prevention, CDC Health Disparities and Inequalities Report, 186.
  14. Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126-133.
  15. Centers for Disease Control and Prevention. Tools for putting social determinants of health into action. Updated February 22, 2017. Accessed November 29, 2017.
  16. Phelan JC, Link BG, Tehranifar P. Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;(suppl 51):S28-S40.
  17. Dehlendorf C, Rodriguez MI, Levy K, Borrero S, Steinauer J. Disparities in family planning. Am J Obstet Gynecol. 2010;202(3):214-220.
  18. Colen S. “Like a mother to them”: stratified reproduction and West Indian childcare workers and employers in New York. In: Ginsburg FD, Rapp R, eds. Conceiving the New World Order: The Global Politics of Reproduction. Berkeley, CA: University of California Press; 1995:78-102.
  19. Kimport K, Weitz TA, Freedman L. The stratified legitimacy of abortions. J Health Soc Behav. 2016;57(4):503-516.
  20. Gomez AM, Wapman M. Under (implicit) pressure: young black and Latina women’s perceptions of contraceptive care. Contraception. 2017;96(4):221-226.
  21. Gutiérrez ER. Fertile Matters: The Politics of Mexican-Origin Women’s Reproduction. Austin, TX: University of Texas Press; 2008:46.
  22. Stern AM. Sterilized in the name of public health: race, immigration, and reproductive control in modern California. Am J Public Health. 2005;95(7):1128-1138.
  23. Johnson CG. Female inmates sterilized in California prisons without approval. Reveal. July 7, 2013. Accessed December 7, 2017.
  24. Camasso MJ, Jagannathan R. The future of the family cap: fertility effects 18 years post-implementation. Soc Serv Rev. 2016;90(2):264-304.
  25. Beynon-Jones SM. Expecting motherhood? Stratifying reproduction in twenty-first century Scottish abortion practice. Sociology. 2013;47(3):509-525.
  26. Ginsburg FD, Rapp R, eds. Conceiving the New World Order: The Global Politics of Reproduction. Berkeley, CA: University of California Press; 1995.
  27. Bridges KM. Reproducing Race: An Ethnography of Pregnancy as a Site of Racialization. Berkeley, CA: University of California Press; 2011.
  28. Goldstein D, Holmes J; Harris Interactive. 2011 Physicians’ Daily Life Report.,&dl. Published November 15, 2011. Accessed December 7, 2017.
  29. Neff J, Knight KR, Satterwhite S, Nelson N, Matthews J, Holmes SM. Teaching structure: a qualitative evaluation of a structural competency training for resident physicians. J Gen Intern Med. 2017;32(4):430-433.
  30. Downey MM, Arteaga S, Villaseñor E, Gomez AM. More than a destination: contraceptive decision making as a journey. Womens Health Issues. 2017;27(5):539-545.
  31. Dehlendorf C, Krajewski C, Borrero S. Contraceptive counseling: best practices to ensure quality communication and enable effective contraceptive use. Clin Obstet Gynecol. 2014;57(4):659-673.
  32. Hansen H, Metzl JM. New medicine for the US health care system: training physicians for structural interventions. Acad Med. 2017;92(3):279-281.
  33. Metzl JM, Roberts DE. Structural competency meets structural racism: race, politics, and the structure of medical knowledge. Virtual Mentor. 2014;16(9):674-690.
  34. Kleinman A, Benson P. Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Med. 2006;3(10):e294. Accessed December 7, 2017.
  35. Knight K, Nelson N, Strong S; Rad-Med (Critical Social Medicine Working Group). Structural competency for the future of the Bay Area: developing structural competency and structural humility trainings. Panel presented at: Structural Competency: New Responses to Inequality and Discrimination in Health and Welfare; November 4, 2016; Berkeley, CA. Accessed December 7, 2017.
  36. Gould H, Perrucci A, Barar R, Sinkford D, Foster DG. Patient education and emotional support practices in abortion care facilities in the United States. Womens Health Issues. 2012;22(4):e359-e364.
  37. Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: perceptions of young adult women. Am J Public Health. 2016;106(11):1932-1937.
  38. Roberts DE. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York, NY: Vintage Books; 2017.
  39. Sisson G. Finding a way to offer something more: reframing teen pregnancy prevention. Sex Res Social Policy. 2012;9(1):57-69.
  40. Masters NT, Lindhorst TP, Meyers MK. Jezebel at the welfare office: how racialized stereotypes of poor women’s reproductive decisions and relationships shape policy implementation. J Poverty. 2014;18(2):109-129.
  41. Lewis O. The culture of poverty. Sci Am. 1966;215(4):19-25.
  42. Ladson-Billings G. “Makes me wanna holler”: refuting the “culture of poverty” discourse in urban schooling. Ann Am Acad Pol Soc Sci. 2017;673(1):80-90.
  43. US Department of Labor Office of Policy Planning and Research. The Negro Family: The Case for National Action. Washington, DC: US Department of Labor Office of Policy Planning and Research; 1965. Accessed January 18, 2018.
  44. Ross L, Solinger R. Reproductive Justice: An Introduction. Oakland, CA: University of California Press; 2017.
  45. Luna Z, Luker K. Reproductive justice. Annu Rev Law Soc Sci. 2013;9:327-352.
  46. Black Women Birthing Justice. #LiberateBlackBirth #RespectBlackBirth. Accessed November 28, 2017.
  47. Castillo A. ACLU urges Fresno County sheriff Mims to end collaboration with immigration officials. Fresno Bee. November 14, 2015. Updated November 16, 2015. Accessed January 18, 2018.
  48. Greenlee C. “It behooves you to understand why people are getting sick”: a Q&A about police violence and reproductive health. Rewire. March 21, 2017. Accessed August 7, 2017.
  49. Castillo S, Estudillo B, Oseguera E. Protecting reproductive health access + creating safe health settings for immigrant patient populations [webinar]. November 28, 2017.
  50. Sacchetti M, Marimow AE. Undocumented teen immigrant has the abortion she sought for weeks. Washington Post. October 25, 2017. Accessed January 18, 2018.
  51. Charles D, Himmelstein K, Keenan W, Barcelo N; White Coats for Black Lives National Working Group. White Coats for Black Lives: medical students responding to racism and police brutality. J Urban Health. 2015;92(6):1007-1010.
  52. Harrison AM. Medical students call for single-payer national health insurance. Acad Med. 2017;92(6):735.
  53. Woolhandler S, Himmelstein DU, Angell M, Young QD; Physicians’ Working Group for Single-Payer National Health Insurance. Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance. JAMA. 2003;290(6):798-805.
  54. Single payer healthcare offers best options for women [news release]. Boston, MA: Our Bodies Ourselves. June 15, 2009. Accessed January 18, 2018.
  55. Joffe C. The politicization of abortion and the evolution of abortion counseling. Am J Public Health. 2013;103(1):64.
  56. Pérez MZ. A new way to fight health disparities? Colorlines. July 15, 2014. Accessed October 18, 2017.

Margaret Mary Downey, MSW, is a doctoral candidate in the School of Social Welfare at the University of California, Berkeley, where she also completed her master of social work degree. Prior to attending graduate school, she practiced as a birth and abortion doula in Philadelphia at the Hospital of the University of Pennsylvania and Planned Parenthood of Southeastern Pennsylvania, respectively. During this time she also served as a research specialist at the University of Pennsylvania School of Medicine on several National Institutes of Health-funded projects in partnership with the Philadelphia Departments of Education and Public Welfare, supporting teachers and community-based clinicians in implementing evidence-based mental health services. Her current research interests are reproductive health and justice and the political economy of health.

Anu Manchikanti Gómez, MSc, PhD, is an assistant professor at the University of California, Berkeley, School of Social Welfare and the director of the Sexual Health and Reproductive Equity (SHARE) Program. For more than 15 years, Dr. Gómez has worked as a health equity researcher; she has conducted research both in the US and globally on diverse topics, including contraceptive use, abortion, HIV prevention, gender equity, transgender health, and violence against women and children. Dr. Gómez’s current research focuses on three areas: the measurement and meaning of pregnancy planning; understanding contraceptive decision making within social, relational, and structural contexts; and evaluating the impact of and evidence base for policies related to reproductive health.

#BlackLivesMatter: Physicians Must Stand for Racial Justice, October 2015

Culture and Moral Distress: What’s the Connection and Why Does It Matter?, June 2017

Forced Sterilizations of HIV-Positive Women: A Global Ethics and Policy Failure, October 2015

Is Lower Quality Clinical Care Ethically Justifiable for Patients Residing in Areas with Infrastructure Deficits?, March 2018

Physicians’ Social Responsibility, September 2014

When Should Screening and Surveillance Be Used during Pregnancy?, March 2018

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.