MONTGOMERY, Ala. — Nailah Nicolas stood in the late-afternoon Southern sun at a park dedicated to three enslaved Black women who suffered torturous experiments to advance the field of gynecology.
Because of mistreatment and neglect of Black women by the medical profession, and society more broadly, the court’s imminent decision adds a layer of complexity to the continued struggle for equity in gynecologic and obstetric services — and to the divergent views on abortion.
Abortion care is opposed by some for religious reasons or regarded as a form of “genocide,” while others say overturning Roe would mark the latest effort to take away what generations of Black women have seldom had: control of their own bodies.
Nicolas fought for Black liberation as a college student in the late 1960s. As the years progressed, she recognized how the malignant forces of racism, sexism and classism intertwine in Black women’s battle for agency over their bodies.
She shudders to think of reverting to the secretive, shame-filled world she lived in before birth control pills were available to unmarried women and abortion was legalized nationwide in 1973, the year after she graduated from the University of California at Los Angeles. It was a time when sex, pregnancy, abortion — reproductive health in general — were in the shadows, even as hospitals dedicated entire wards to women suffering from complications of abortion because they did not have access to safe procedures.
“They never talked to us younger folks about it,” Nicolas, 71, said. “You almost had to be sneaky and listen to grown folk talk to grown folks.”
Nicolas became an activist, and alongside others, fought for more than the right to choose; they fought for the right to control what happens to their bodies, including having children on their terms and raising them in a safe and secure world that provides for the basic needs of parent and child.
She became a public school teacher as part of her mission and began to feel a broader cultural shift in the late 1970s when the curriculum expanded to fact-based lessons on reproduction, shifting away from moral deliberations.
“No storks. Medical books,” Nicolas said.
That Sunday at the Mothers of Gynecology Monument Park was a day of reflection on the progress achieved in overcoming the burdens and barriers Black women face in accessing not just abortions but also prenatal care and safe births — and the work still to be done.
The United States faces an ever-growing maternal health crisis that is especially deadly for Black women, who, along with Native American women, live shorter lives than many other Americans. Pregnancy and childbirth are among the leading causes of death of all teenage girls and women 15 to 44 years old, and Black women are three times as likely to die as a result of pregnancy as White women.
Nearly 2 out of 3 maternal deaths are preventable, research shows.
For the women like Alexis King who gathered at the park, medical racism and the disparities in gynecological care remain all too present. King struggled for eight years to find the cause of excruciating pelvic pain, mood swings, irregular menstrual cycle and excessive facial hair.
Her symptoms started immediately after giving birth to her second daughter in 2008. The 39-year-old had a tubal ligation and wondered if she was experiencing complications. One day, she doubled over with what felt like labor pains and was rushed to the emergency room, where she learned there was blood in her pelvic floor from a ruptured ovarian cyst.
Her doctor was blasé about the whole situation, she said, prescribing birth control pills to regulate her period.
“She never took what I was saying serious,” said King, a medical billing specialist from Birmingham. “It was traumatic.”
It wasn’t until she switched doctors that King was diagnosed with polycystic ovary syndrome, a hormonal disorder that causes the ovaries to develop fluid-filled sacs.
The new doctor performed two procedures that remove tissue from the uterus to help alleviate heavy bleeding, including a dilation and curettage — the same procedure used during surgical abortions — and endometrial ablation.
The specter of the court’s decision “worries me for my girls,” King said. “Them being limited in what they can do and what resources they might need is worrisome. We never know what life will bring.”
The Mothers of Gynecology Monument Park, a place of proud defiance and serene restoration, sits on the More Up campus, the future site of a conference center and resource museum.
“We overcome by the words of our what? Testimony,” Michelle Browder, the artist and creator of the park, told the crowd gathered at the monument.
Betsey stands 12 feet tall and wears speculums in her crown. Her pregnant form is made of discarded metal objects, much like Lucy (9 feet) and Anarcha, who has a gaping hole through the midsection of her 15-foot metal figure.
Less than a mile away, J. Marion Sims, the physician known as the “father of modern gynecology,” conducted surgeries without anesthesia on the three women and about seven other enslaved Black women in the 1840s. He was credited with curing what’s known as a “vesicovaginal fistula” — a hole that forms between the bladder and vagina after childbirth, cancer or surgery, causing incontinence — though his legacy in recent years has been scrutinized by scholars and debunked.
Browder urged the crowd to step into a small guard shack, a cathartic space decorated to rival the relaxation room at any spa, and record stories of the care received from the medical system.
“This is not just a piece of art,” she said. “It’s a healing. It’s history.”
Maternal health is informed by an accumulation of life events that start long before pregnancy begins, said Kanika Harris, director of maternal and child health at the Black Women’s Health Imperative, which works to improve the health and wellness of Black women and girls.
“This is about how you show up to pregnancy,” she said.
The shorter life spans of Black women — years taken by higher rates of maternal mortality — reflect hurdles piled one on top of another in a society where poverty and pollution often are concentrated in redlined neighborhoods but not affordable housing, grocery stores or reliable internet.
Black women confront racist stereotypes — lascivious, aggressive, “welfare queen” — that reduce them to caricatures, which affects their physical well-being and the medical care they receive. Health-care providers are more likely to dismiss Black pain and to negatively describe Black patients in electronic health records, studies have reported. And researchers have found that the unrelenting stress caused by racism wears the body down, aging it prematurely.
Ending legal access to abortion nationwide would “absolutely exacerbate this crisis,” said Rachel Villanueva, an obstetrician-gynecologist in New York and president of the National Medical Association, the nation’s largest and oldest national organization representing African American physicians.
“We already have a situation where women lack access,” Villanueva said. “States that did not have Medicaid expansion have some of the worst maternal outcomes.”
But there also can be financial barriers in states where Medicaid covers abortions. That’s especially true if a woman earns too much to qualify for the public health insurance program but not enough to afford the cost of an abortion, as one woman explained to University of California at San Francisco researchers who published a study last month examining how the enduring legacy of racism affects Black women’s access to and experiences with abortion care.
Researchers interviewed 23 Black women between the ages of 21 and 46 who had abortions. Most were parents living in the Bay Area. The report described a “complex web of painful injustices” that affected the women’s experiences with pregnancy, abortion and parenting.
About 18 percent of U.S. pregnancies end with an induced abortion, the Centers for Disease Control and Prevention reports. In 2019, more than one-third of abortion patients were Black women, whose rate of abortions was more than three times that of White women, according to federal figures, which did not include California, Maryland and New Hampshire.
Asking patients if they’ve ever been pregnant and the outcome of that pregnancy is part of understanding someone’s medical history, Villanueva said.
“It’s the same as asking when your last Pap smear was … not a matter of judgment,” said Villanueva, who like other reproductive health experts, worries that what they regard as a routine part of the doctor-patient conversation — abortion — could become increasingly fraught, deepening mistrust of the medical system amid the churning landscape of state reproductive politics, which, in some cases, would lead to punishing providers and delaying care.
“The narrative that a lot of groups like to dictate is: ‘People are careless. They’re just having sex. They have an abortion because they’re indiscriminate in what they do,’ ” she said. “We know that’s not the case.”
That’s the same argument King’s 16-year-old daughter, Amarie King, introduced in history class recently when the conversation turned to the imminent ruling on abortion rights.
“Like I was telling them: ‘You don’t know why she ended up pregnant and why she doesn’t want to keep the baby. People get raped all the time. Incest. It could be financial reasons,’ ” she said. “It’s not always what you think it is.”
Just like the reason she started taking birth control: to help mitigate severe cramps and heavy bleeding that accompanied her menses.
Polls show relatively few people have absolutist views on abortion rights, believing abortion should be completely illegal or legal — no exceptions. There are, however, certain situations in which the consensus is clear, according to a recent poll by the Pew Research Center: when a pregnancy threatens someone’s life or health.
Star Parker, founder and president of the Center for Urban Renewal and Education, a Black conservative think tank known by the acronym CURE, is among the 8 percent identified by Pew for whom there is no middle ground.
“We as a society need to explore much deeper how killing your offspring became health care,” said Parker, who sees the abortion debate as “a distraction” from the economic and social barriers that disproportionately keep Black people from getting medical care.
Parker said she believes there should be “a total ban” on abortions “regardless of the circumstances.”
“Situational ethics should not drive national policy,” she said.
A recent CURE report said the higher rate of abortion among Black women stems from predatory practices of an “abortion industry” that devalues Black lives. “If our goal is to improve access to beneficial healthcare for Black communities, abortion is not the way,” the think tank’s report says.
Like Parker, Louisiana state Sen. Katrina R. Jackson, a Democrat who is a member of the legislature’s women’s and Black caucuses, said she doesn’t believe outlawing abortion threatens the medical care Black women receive, including the ability to have candid conversations about previous abortions.
“I can’t subscribe to abortion being health care,” said Jackson, who recently sponsored legislation to increase penalties for providers of abortion under the state’s trigger laws. “I’m not willing to state that abortion is some sort of remedy. That would be putting Band-Aids where we need to be putting stitches.”
To truly improve health care for African American women and girls, research dollars should be spent determining why there are higher rates of diabetes, preeclampsia and fibroids in the Black community, Jackson said. And more should be invested in removing barriers to health care such as improving transit systems and expanding access to contraceptives and sex education, and ensuring Black women receive respectful care, Jackson added.
“Instead of focusing on providing funding and researching and addressing the issue of Black maternal health, people want to tell Black women abortion is what’s going to keep you healthy,” said Jackson, who told NBC News that abortion was “modern-day genocide” in 2019.
That year, Justice Clarence Thomas argued in an opinion that the eugenics movement opened the door for abortion rights. Social scientists have discredited eugenics, which was popular in the early 20th century, as a pseudoscience obsessed with the genetic fitness of White Americans.
It was an argument also found in the footnotes of the leaked draft decision overturning Roe in which Justice Samuel A. Alito Jr. wrote, “Some such supporters have been motivated by a desire to suppress the size of the African American population.”
Historians of the eugenics and abortion movements have called this argument a deeply flawed, willful distortion of history. Rana A. Hogarth, an associate professor at the University of Illinois at Urbana-Champaign who studies the medical and scientific constructions of race during slavery and beyond, said it was “extreme cherry-picking.”
Abortion is a personal choice, “not the state intervening and being like, ‘We’re going to forcibly sterilize you,’ ” which was a basic concept of eugenicists, Hogarth said.
It is a history with deep roots in Montgomery.
It was here in the 1970s that two young girls — Minnie and Mary Alice Relf, who were 12 and 14 — sued the federal government, exposing the widespread practice of the involuntary and coerced sterilization of thousands of Black, Native American, Puerto Rican and poor White women. Their mother was illiterate and signed with an “X” on a piece of paper she thought was authorizing her daughters to get birth control. They were surgically sterilized instead.
Standing before “The Mothers of Gynecology” and a panel that honors the Relf sisters, Joia Crear-Perry, an obstetrician-gynecologist and founder of the National Birth Equity Collaborative, a nonprofit group dedicated to eliminating racial inequities in birth outcomes, told the crowd: “People who are the descendants of the enslaved should never want anyone controlling our bodies. No matter your gender. No matter your race.”
Then, she told a story.
As a medical student at Louisiana State University in the mid-1990s, she was taught race-based medicine. One embryology professor told students there were three races — “Mongoloid, Caucasoid and Negroid” — as he taught about skin types. She was tested on the different pelvic shapes of Black, White and Asian women. And during training, Crear-Perry was taught that Black people had a different pain tolerance, a myth Sims propagated with his surgeries.
“So the physicians that you know that went to school in Mississippi, Alabama, Louisiana, where I’m from. … We were taught that by professors,” she said. “I had to unlearn that for myself.”
Crear-Perry’s story was top of mind as Nicolas and her daughter drove home that night. Her daughter brought up how Nicolas received neither anesthesia nor pain medication in 1991 when a doctor performed a biopsy of a uterine fibroid. Maybe, she wondered, he believed the myth about Black people’s pain. And now, Nicolas wondered about that, too.