An OB-GYN Unpacks the “Biological Clock,” Abortion, & Medical Pronatalism

PronatalismReproductive RightsSocio-Economic Justice

Feb. 4

In this illuminating episode, we talk with Dr. Kristyn Brandi, an Obstetrician-Gynecologist, proud abortion provider, and board chair with Physicians for Reproductive Health, where she debunks the “biological clock” among other pronatalist myths and discusses how the medical institution in one of many that fuels pronatalism. We also discuss what the overturning of Roe v Wade means in terms of safe abortion care for the already marginalized communities, including BIPOC, LGBTQ, people with disabilities, and those living in poverty, within the U.S.. We end the conversation by unpacking the dark history of reproductive control, including slavery, eugenics, and population control, and why centering reproductive autonomy through a deep understanding of Critical Race Theory (CRT), Reproductive Justice (RJ), and pronatalism, is essential to upholding reproductive rights and a sustainable environment.

MENTIONED IN THIS EPISODE:

Dr. Kristyn Brandi 0:00
I firmly believe in the tenets of reproductive justice - that all patients have the human right to be able to decide if and when to become pregnant and to parent the children in safe and sustainable communities. I cannot separate my ability to provide care as a physician from my lived experiences. I'm a cisgendered woman who could be harmed by restrictive abortion bans. I'm also a Latina, a daughter of Puerto Rican and Panamanian parents. I'm also a bisexual woman, and deeply identify with LGBTQ community, a community also in deep need of timely compassionate reproductive health care. People of low income, BIPOC folk, queer folk, people with disabilities, young people, people facing incarceration or detention and immigrants - who have faced many barriers to accessing care even before Roe was overturned - now face bigger hurdles. So I understand deeply how restrictions on abortion and outright bans impact marginalized communities because they are my community.

Alan Ware 0:56
Those are the words of Dr. Kristyn Brandi, who testified this past summer in the US Senate before the Health Education Labor and Pensions Committee, in a hearing titled Reproductive Care in a Post-Roe America. Dr. Brandi is an obstetrician, gynecologist, proud abortion provider, and board chair with Physicians for Reproductive Health. And in this episode, we will hear more from her about what a post-Roe America means for reproductive rights, especially for marginalized communities.

Nandita Bajaj 1:34
Welcome to The Overpopulation Podcast where we tirelessly make overshoot and overpopulation common knowledge. That's the first step in right-sizing the scale of our human footprint so that it is in balance with life on Earth, enabling all species to thrive. I'm Nandita Bajaj co-host and executive director of Population Balance.

Alan Ware 1:56
I am Alan Ware, co-host of the podcast and researcher with Population Balance, the first and only nonprofit organization globally that draws the connections between pronatalism, human supremacy, and ecological overshoot and their combined devastating impacts on social, reproductive, ecological, and intergenerational justice.

Nandita Bajaj 2:18
And before we move on to today's guest, we've got some listener feedback from an anonymous listener in New England, US. It's in response to our interview with Orna Donath, author of Regretting Motherhood. The listener says "I felt grateful for your discussion with Dr. Donath about the negative experiences of some mothers and parents in relation to having children. I was one of those people who, while I loved my baby, didn't love motherhood. I felt like my life had ended. People would gush, don't you love being a mother? And I would respond? No, I love my son, but I don't really love being a mother. The sleepless nights and boring days, and diaper changing and cracked painful nipples and mastitis and loss of my previous life were so hard for me. But this was too taboo to admit. I felt like saying these things out loud made me a pariah, or a freak. I was so resentful of all the things we aren't told.

Nandita Bajaj 3:20
Well, thank you so much for sharing your honest feelings about your experience with motherhood. I'm certain there are so many people who will resonate with your story. And also thanks to listeners like you, we now rank in the top 2% of all the podcasts globally. In addition to this podcast, we also run virtual educational programs at schools and conferences with a goal of empowering people to make liberated and responsible reproductive and consumptive choices. And we do all of this with a really small staff and we count on you to keep doing this important work, and we hope you'll consider supporting our transformative programs. And now on to today's guest.

Alan Ware 4:02
Dr. Kristyn Brandi is a medical doctor with a Master's degree in Public Health. She is an obstetrician gynecologist with a fellowship training in family planning, contraception, and abortion services. Dr. Brandi currently serves as the board chair of Physicians for Reproductive Health, sits on several subcommittees for the Society of Family Planning and is a founding member of Centering Equity, Racial, and Cultural Literacy and Family Planning. She has published research on contraceptive coercion by doctors to patients seeking abortion. Her master's degree concentration focused on health law, bioethics, and human rights, which she has focused her educational pursuits around abortion policy, contraceptive decision-making, and racial justice within medical education. She has been quoted in numerous articles on reproductive health and has written op eds around health care to such news outlets including the Washington Post.

Nandita Bajaj 5:00
Dr. Kristyn Brandi, welcome to the studio. It is so nice to have you here.

Dr. Kristyn Brandi 5:05
Thanks for having me.

Nandita Bajaj 5:06
We, of course, first learned about you through your interview in the film My So-Called Selfish Life, which of course is produced by our common friend, Therese Schechter, who's also the one who connected us with you. So big shout out to that great film, and also your appearance in the film. You were fabulous.

Dr. Kristyn Brandi 5:25
Oh thanks.

Nandita Bajaj 5:26
And there were some excellent points that you made in the film, one of which was this pronatalist myth that you debunk. It's also one of the most stubborn ones - that there is a biological clock ticking inside of us that's driving this cultural urgency and sensationalism around having children. Can you unpack that for us a bit?

Dr. Kristyn Brandi 5:49
Sure. I think there's been a lot of conflation between "women's biological clock", and whatever the social context is of having children. I was looking it up the other day. And it seems like this idea of a woman's biological clock came about in the 1970s or so, and it looks like there was a couple of different things happening in our culture that led to people kind of thinking about this idea. Some of it was people were just delaying pregnancy, and people were getting pregnant later and later in life and having less children. And this was also around the time of the first birth control pill being popularized. And so at the same time, there was a lot of advances around pregnancy care later in life. And they had found that people that get pregnant at the age of thirty-five or beyond, what doctors now call advanced maternal age, which I have problems with that term, we could talk about that later. But people that are over thirty-five that are pregnant have higher chances of things like genetic abnormalities, complicated pregnancies, risks to them, as well as their newborn. And so I think these two ideas kind of came together and created this concept of the biologic clock. And as I said, in the film, that's not a real thing. It's not something that says at thirty-five versus like, if you're thirty-four and one more day to your birthday. Your biology doesn't change, it's not something that flips on or flips off, it's just your assessment of risk, potentially. But there's nothing in your body that tells you, "You must get pregnant, and you must get pregnant at this time, at this age." There's no strict rules about that. And in fact, nowadays, about 19%, about one in five pregnancies are happening after the age of thirty-five. So it's something that people can do, should do, if that's what they want to do. But on the flip side, people shouldn't feel pressured to have a baby at a certain age because there's going to be something that happens if they turn, you know, a day older or a year older from that.

Nandita Bajaj 7:43
Right. And as you said in the film, that the biological clock, of course, there's it's based on the biological fact of diminished fecundity as women age. But the term has become this convenient trope that allows avoidance of earnest exploration of a woman's true desires in favor of kind of invoking this urgent and time sensitive imperative that you have to have a baby, otherwise something is wrong with you or your time is going to run out. And of course, we've also seen that if it was completely true, then we would see the fertility rates all around the world would remain the same and people would continue to have children until they couldn't. And like Therese's film showed, there's increasing number of people who are choosing to forego parenthood altogether. And like you said, people are delaying parenthood, or choosing other forms of family formation, as well. So I think this is something that needs to continually be debunked. There's a lovely quote from another feminist, Martha Gimenez, and she says, "The biological clock that some women claim to hear ticking, it's also a social clock, reminding them that whatever else may be going on in their lives, motherhood is their identity, the road to social acceptance and integration."

Dr. Kristyn Brandi 9:04
That's really lovely. And I think it does really reflect this idea that there are these two things that people are kind of put together and decided that, many patients come to me frantic, saying, like their biological clock is running out. And I have to tell them, like there's no evidence to support that there's something that you should be worried about. And while there are things like concerns about risks if you become pregnant later, or having issues becoming pregnant later, this is not the 1970s. We have a lot of technology, we have specialized fields of obstetrics that can take care of people that want to get pregnant later in their life or that have pregnancies that may be high risk because of their age and other risk factors. But at the same time, that internal feeling of that you're running out of time is really a social stigma. It has nothing to do with your biology. And there's so many things that we can do to help people make the families that they want to have, regardless of what that may look like.

Nandita Bajaj 9:56
Right. That's really lovely. And of course, this is one of the pronatalist myths that we hear culturally, but also within the medical institution where sometimes physicians will remind you that, you know, if you're in your thirties, have you considered that you're running out of time or your biological clock is ticking? And coming from a physician, that can be seen as a little paternalistic because they are in a powerful position of guiding you, medically. Are there other forms of pronatalism that you come across, either with your own patients or within the medical institution, with your own colleagues?

Dr. Kristyn Brandi 10:32
Absolutely, unfortunately. And I think you brought up a good one, that doctors and other health care professionals also perpetuate this idea of this biologic clock. And they do so, I think, I hope, with the idea that they want to protect patients from risk. And so they know that having pregnancies earlier may be safer for that individual person, they may want to encourage them to have a pregnancy if they want one to have it sooner. But that being said, you're right. It's very paternalistic, and it doesn't allow the patient to make the best decision for themselves and for their families. Other ways that I see pronatalism is when we talk to patients, at least in the obstetric field, it's never the question of do you want to get pregnant? Do you want to have children? It's often phrased in a way like, "When do you want your next pregnancy? Or when are you looking forward to getting pregnant?" It's kind of this idea of like, obviously, you're going to get pregnant in the future when that may not always be the case. And you're always planning for that next one, when you may not be.

Nandita Bajaj 11:28
So true. I even find that within the sexual and reproductive health and rights movement, there is this focus on reproductive health care, conflated with maternal care, as if people who do not want to or cannot have children do not need reproductive health care. As if reproductive health care must always lead to reproduction.

Dr. Kristyn Brandi 11:53
And we see that also in movements around abortion care. That we talk a lot about what I like to call the sad abortion, people that are pregnant and have circumstances where they end their pregnancy, which can be very traumatic, and it's a really hard decision for some. But I think we often center those voices because the person that wanted to be pregnant and something happened and they couldn't become a mother, that has a core value that I think much more people connect to, than the idea that I just didn't want to be pregnant, or this is not a good time. This is not good time for my income or my support system. That we've decided that those are not good enough reasons. And so we've seen on both sides of OB/GYN care, those wanting to get pregnant and those not wanting to be pregnant. And I think both spaces need to work on improving their messaging so that we're not centering motherhood.

Nandita Bajaj 12:37
So well said.

Alan Ware 12:38
You gave a good example of a woman with a baby without a brain at seventeen weeks, and she wanted an abortion and the rest of the staff kind of stigmatized her.

Dr. Kristyn Brandi 12:51
Yeah.

Alan Ware 12:51
And that was that your motivation to be able to perform abortion? To provide the whole spectrum of services.

Dr. Kristyn Brandi 12:58
It was. I mean, it's one of many stories that I've seen about people that come in with all kinds of circumstances around pregnancy. There wouldn't be a field of OB/GYN If pregnancy wasn't complicated. So I've seen so many stories of people that have had like really sad experiences around a pregnancy, a desired pregnancy, and because of the label of abortion, that their care is stigmatized. And in that particular case, I remember as a trainee that like none of the nurses wanted to go into the room, no one wanted to talk to her. And I was just so angry. This patient isn't any different than anyone else that I saw that day in my prenatal clinic, in labor and delivery. The patients I take care of that get abortions, also I take care of them for prenatal care. So it's all the same people. So it's just really frustrating sometimes. But I think internally also I tell that story because I think people care about that person more. They feel empathy toward that story in a way that feels different than the patient that I saw the other day that didn't want to be pregnant. And that is an okay reason too.

Nandita Bajaj 13:50
Right.

Alan Ware 13:51
So you focused your educational and advocacy efforts around abortion policy, contraceptive decision-making, and racial justice within medical education. And you're a founding member of Centering Equity, Racial, and Cultural Literacy in Family Planning. That organization, could you share what that initiative is about and what inspired you to start it?

Dr. Kristyn Brandi 14:14
Absolutely. And I think that it's a long list of things that I'm interested in, but I think there's a lot of intersection between these issues around people deciding if and when to become pregnant and the racism, classism, ableism that they faced. So Centering Equity, Racial, and Cultural Literacy in Family Planning is also called CERCLFP. It's an organization that is multidisciplinary, it's mostly doctors, but we have lawyers, other folks that are involved, that are using a combination of critical race theory and reproductive justice frameworks to dismantle both the interpersonal and structural racism that exists within healthcare structures, particularly around family planning and care. I'm a co-founder, I am a co-conspirator with many folks that are part of CERCLFP, we are a non-hierarchical collaborative. And so it's been a real honor and privilege to be part of that group. The reason why we started CERCLFP was because we ourselves as mostly BIPOC people that were providing abortion care or involved in family planning in some way, we felt excluded. And similar to reproductive justice frameworks where the original RJ folks didn't feel like they were part of like the reproductive rights movement, because there were so many other issues that weren't being addressed that we also felt that, you know, we care about family planning, we care about reproductive rights. But there's so many other issues around oppression that impact people's ability to get care and I don't think a lot of providers know about these things. And for people of color that have had to survive within the medical system, we've also faced oppression and bias and stigma. And so how do we also support people of color trying to do this work? That's kind of how we joined together to create this organization. And the main work we're doing is doing training programs, for institutions, for health care systems, teaching about some of these core tenants of CRT and RJ and thinking about how to apply them to health care. And that's all kinds of healthcare. So thinking about things like how do we educate the next generation of providers? How do we perform research in a way that centers our communities? How do we advocate? How do we build clinical spaces that are open for everybody? So there's a lot of different components, even though it's been a couple years since we started, it's still a lot of transformation and trying to figure out what we can do to be of best service to the needs of the people that we're serving.

Alan Ware 14:56
I've heard of one of the biases is the perception that Black people have greater pain tolerance, and therefore not prescribed pain medication at the same rate. Can you give us examples of other biases that you found in the research?

Dr. Kristyn Brandi 16:53
Sure, that's a good one. And something that's still challenging. And I think about that within reproductive health care, about how Black women are often not believed when they're in pain, often are deemed as drug seeking, and so are denied epidurals in labor or things like this, which is heartbreaking. I mostly serve Black and Brown communities in my clinical practice. So thinking of other examples, particularly around reproductive decision-making, that certain groups of people have lots of children and don't use birth control. And I think that stems from a history of reproductive control in Black and Brown communities, in Indigenous people, in people with disabilities. For example, people that have disabilities don't have sex, and so are not at risk for pregnancy. So that is a common misconception. And people are basing their counseling on that. So what can we do to help educate healthcare providers, healthcare systems, that these are just myths or bias, and how do we navigate that conversation and try to use it to transform healthcare to better serve our people?

Nandita Bajaj 17:56
And, of course, Critical Race Theory has not had a very good uptake within our educational system within the US. What kind of a response are you getting to both CRT and RJ principles within the medical institution? Is there support and sympathy within colleagues that aren't part of this specific group that you're leading?

Dr. Kristyn Brandi 18:20
I definitely think it's a mixed response. Again, people within health care are people. They are influenced politically, they have their own social views on things. I would say, particularly for people that are coming into medicine - younger people, medical students, residents - that they are very engaged. That they're very interested in how structures can change using these frameworks, and that they can see within their training that there are certain things that are clearly bias or clearly representing racism or other oppressions, and they want change. And so I think that keeps me going. And that is what fuels my passion for this work is trying to help the next generation of providers be able to provide better care. And along with that, better education, better research, all the components that we need to have in the health care system.

Nandita Bajaj 19:07
Yeah. And as of the recent Dobb's decision, the United States has abandoned a fifty year precedent of guaranteeing a woman's right to abortion. You are the board chair of Physicians for Reproductive Health, and you were recently invited to give testimony at the Senate hearing on Reproductive Care in a post-Roe America. The title was Barriers, Challenges, and Threats to Women's Health. So that is a great honor to be invited to represent the entire committee there. You said some incredibly powerful words and we'll post a link to the entire hearing as well as the transcript in our show notes. We would love to play a couple of clips, and then we'd love to just have you expand on your experiences about what you're saying in those clips.

Dr. Kristyn Brandi 19:56
Okay.

Dr. Kristyn Brandi 19:57
We know that in the United States you are fourteen times more likely to die in childbirth than you are to die of an abortion. And we know from the Turnaway Study that people denied access to abortion have a higher chance of facing poverty and having worse health outcomes compared to patients that were able to access an abortion. I am a pro-abortion doctor. And I say pro-abortion not to be antagonistic but to point out all the good that abortion can provide for people. Without autonomy, without decision-making ability, without access to abortion care, many people have challenging situations that can become even more painful or life threatening. And for those that do not want to be pregnant for any reason, the ability to have an abortion gives them the freedom to decide if and when to become pregnant. For some, abortion is liberation. There's a lot of good that comes from a people's ability to access abortion. And I want to celebrate that.

Nandita Bajaj 20:48
You covered quite a few things in there. Do you want to say a few words about your commentary there?

Dr. Kristyn Brandi 20:53
Sure. And I will say that testifying in front of the Senate was one of the wildest things I've ever done. Such a true honor to be part of that. And I was really glad to be able to deliver these words on that platform. I think the reason why I mentioned this statistic about dying in childbirth versus abortion is I think it's not very commonly known that abortion is incredibly safe and in fact, so much safer than childbirth and C-sections. I feel like it's something that's more socialized, people think about people delivering and having c-sections like a no big deal thing. That there's risks, but it's going to be fine. But abortion still has that legacy of back alley abortions where things were unsafe, and people died of abortion, but that's no longer the case. And so it's really important for people to know that abortion is incredibly safe, I like to say ridiculously safe, because it is so safe, compared to a lot of the other care that I can provide people. And that knowing that childbirth is more dangerous, it's really critical for people to understand that that should be a choice, if they want to sign up and have a child through a labor process, they should know what they're signing up for. And they should consent to that process. And if they don't, then they should have access to contraception and abortion. It's important, again, to recognize that it's all the same people that are making these decisions in this pregnancy versus another pregnancy, what they want that end to be. And that's not my choice. I don't think it should be political as far as who makes that choice. I think it should be the person and their family.

Alan Ware 22:22
I did see an article about the increased number of children that will be born in a lot of the banned abortion states with very little idea of these are often states that have low child welfare provision to begin with. So that's a negative side effect of this in a huge way.

Dr. Kristyn Brandi 22:42
Right, places where abortion is restricted is also the places that have less child welfare. When I teach this to medical students, I usually show them a map. And I show them this is the map of where abortion restrictions are currently in place. And then I show them another map, which looks like the same map. And this is the areas where maternal morbidity, mortality is the highest. It's all the same map, the same map that has higher teen pregnancy rates, that has less child welfare, has less Medicaid expansion. It's all the same map. And there's something to be said about that. Same thing around the new rules around mifepristone, which is the first of two medication abortion pills that the FDA just created new rules that said that you can now prescribe this medicine, which is something that we weren't able to do before, which is great news, and will really help expand access to people that need medication abortion. But same map, that map also includes all the states that even though the FDA said that you don't have to come in in person, and you don't have to go to a clinic specifically to get the pill, there's still state laws that require, in eighteen states, that you have to go in person and get the pill from this particular clinic and you can't get it prescribed by your doctor. So it's frustrating that map, but it's very clear, it's very obvious that all of these issues are interconnected. And we know where the work needs to happen.

Nandita Bajaj 24:01
You already started talking a little bit about the correlation you've been finding between the different aspects of that map. I'd like to play another clip from the same testimony hearing. And just to hear a couple of thoughts from you on that.

Dr. Kristyn Brandi 24:17
Okay.

Dr. Kristyn Brandi 24:17
I firmly believe in the tenants of reproductive justice, that all patients have the human right to be able to decide if and when to become pregnant and to parent the children in safe and sustainable communities. I cannot separate my ability to provide care as a physician from my lived experiences. I'm a cisgendered woman who could be harmed by restrictive abortion bans. I'm also a Latina, a daughter of Puerto Rican and Panamanian parents. I'm also a bisexual woman, and deeply identify with LGBTQ community, a community also in deep need of timely, compassionate reproductive health care. People of low income, BIPOC folk, queer folk, people with disabilities, young people, people facing incarceration or detention and immigrants who who have faced many barriers to accessing care even before Roe was overturned now face bigger hurdles. So I understand deeply how restrictions on abortion and outright bans impact marginalized communities because they are my community.

Nandita Bajaj 25:14
Another amazing statement.

Dr. Kristyn Brandi 25:16
I was really proud of that line.

Nandita Bajaj 25:17
It's beautiful. Can you talk a bit more about how abortion bans and restrictions on abortions specifically marginalize the people who are already living on the margins of society?

Dr. Kristyn Brandi 25:31
Thanks for that question. It's something that I think about a lot, because I hear the stories of people that have to travel, that are making the journey to get care. And all I hear are the barriers that people have to face to get that care. And when I think about people traveling out of state from other places to get to me in New Jersey, for example, I always think about like, those are the people that are lucky that they could fly, that they could drive, that they could take time off of work, that they have childcare. So it's always been an issue around equity for me in providing abortion care that I know not only do people that seek abortion come from these communities more often, people that seek abortion more likely are going to be BIPOC folk, more likely to be low income people. And that's due to a multitude of reasons. But those folks also are gonna have the biggest challenges in getting into health care. So whether or not they have insurance, whether or not that insurance covers abortion care, which many don't, including federal programs, and then the logistics of it, whether or not they can afford to take off a day of work, are they going to get fired, whether or not they have child care or support to be able to travel potentially hundreds of miles to the next state to get the care that they need. I've been thinking a lot recently about people that physically can't travel. So for example, people with disabilities have a really hard time traveling to get the care that they need in their local community, let alone having to go elsewhere, or people that are incarcerated. They're not going to be able to travel to get the care that they need. Or people that are undocumented that may have to face checkpoints to get to the next clinic. So it's a Venn diagram of all the people that are facing all of health disparities in our system in general, people that are marginalized, and the people that need abortion care. The Venn diagram is a circle. So it's something that I see all the time, and I'm really concerned about as access to becomes more and more restricted, how people will be able to get that care. I think, going back to the point earlier about what's going to happen to those votes. If people are unable to get care, many people that are pregnant will continue those pregnancies and deliver in those communities, which there's two crises happening at the same time. Many of those places are rural communities where they've lost their labor and delivery because there's no providers in those spaces. Many hospitals have closed because they've lost nurses. During the COVID pandemic, wards just closed and many of them were labor and delivery wards or prenatal care doesn't exist in that community, let alone abortion care. So there's a lot of issues around people that are marginalized getting the care that they need if abortion is what they need. And if they can't access that, how are they also going to get maternity care? And is that more dangerous for them in this moment, where black women are dying more in childbirth? There are so many things that are conflated together right now,

Nandita Bajaj 28:21
Definitely. And the stat from the Guttmacher Institute also shows that almost half of the pregnancies are unplanned. We know that out of the six million pregnancies in the US each year that are unintended, there's approximately a million unwanted children that are born. And as you said, the unintended pregnancy rates are highest among low income women, women who are cohabiting, women of color, young women aged 18-24. And it's this cycle of continued marginalization of people who are then giving birth to these children into families that are missing the material and emotional resources that are needed to flourish. They cause suffering for both the parent and the child that are put into that situation without consent. Right?

Dr. Kristyn Brandi 29:20
Right. And it's not just hypothetical, we have data from the Turnaway Study from the University of California, which followed people that either were able to access abortion or denied an abortion and found that people that were denied an abortion had a higher chance of facing poverty, higher chance of worse health outcomes, and higher chance of their children facing poverty. And so you're right, like this cycle is continuing. And I think if we're centering reproductive justice issues around how in order to become pregnant and continue pregnancy and parent in a way that's dignified, people need resources. It's not just like, "Are you healthy enough to have a baby? Yes, no." It's all the other things that people need to consider when they parent, and I think that it is dishonest of me to help people deliver babies and then hope that they'll be okay afterward. That the health care system, all systems really need to be focused on how can we help our communities do that work and help people if they want to parent, and also people that don't want a parent so that people are able to live out the families that they see best for themselves.

Nandita Bajaj 30:19
That's absolutely true.

Alan Ware 30:21
Now you practice mainly in New Jersey, and you've written about logistical barriers to obtaining a hospital based abortion in your state. And what did your findings indicate about the barriers, the implications, and how those could be minimized?

Dr. Kristyn Brandi 30:35
Sure. I tell everyone, I'm really fortunate to be able to provide care in New Jersey and also be part of research within the state. The question we had initially was, in a state that doesn't have really many to any abortion restrictions, are people still facing logistical barriers, barriers somewhere in the system, and how can we help minimize those barriers? And so we surveyed people that were coming from a independent clinic, an outside clinic, to a hospital based center, and why were they coming? How many weeks of care was delayed because they had to be transferred to a different place? And we found that even in New Jersey, people are facing limitations and barriers to care, particularly people that were low income and had a lack of transportation, that that was a really big barrier for people being able to access care. And we found that there was also a medical justification for delayed care. That people would go to an outside clinic, have certain risk factors that would make it not as safe to have their procedure done in a clinic versus a hospital based setting, and so would have to come to a hospital. And that delay, that extra time off of work, and transportation delays things more. And so even in a place like New Jersey, there are still people having delays of care. And that's in the "ideal setting". Imagine people that are also in a state where abortion is limited or restricted. If they also have medical risks, how are they going to not only get to the next clinic, but how are they gonna get to next hospital? How many clinics or how many hospitals are they going to have to go to to be able to get the care that they need? And so next steps are asking about patient experiences. What can we do to help minimize the delays in their care, what can we do to help their patient's experience be better? And also talking to providers, both people that are providing care in different settings, like in the clinic, in a hospital, and figure out how can we better coordinate this? Because it's a good model, not just for a state that doesn't have restrictions, but how do we communicate and coordinate care like we would any other care across state lines when people are having to come from one place to another. That's actually the safer way to provide care, but many people are worried about that because people may be worried about criminalization of communicating with a place where abortion is restricted. So it's complicated, but I think ultimately, that's what we need to do for patient safety.

Alan Ware 32:48
Yeah, I was looking at the map of the abortion ban states, and if you're in Mississippi, Louisiana, it looked like you'd have to go to St. Louis, if I was reading it right?

Dr. Kristyn Brandi 32:59
Yeah, I mean, right now Chicago is a hotbed for people getting care. Illinois right now is dead set in the middle of the Midwest.

Alan Ware 33:07
Yeah.

Dr. Kristyn Brandi 33:08
So lots of people were traveling to those spaces. And it really will depend. During the election in New Jersey, I was very worried about Pennsylvania. Because of Pennsylvania, which is right next to a lot of states that have bans, if that state fell, then all the stations are gonna come to New Jersey. And so it also may depend on the election that happens and what is happening locally in nearby states.

Alan Ware 33:29
And are there organizations helping women with those transportation costs and the cost of abortion itself?

Dr. Kristyn Brandi 33:36
There are. And so there are organizations called Abortion Funds that people can donate, and they're often volunteer run organizations. I'm part of the one in New Jersey that helps people pay for their actual procedure or their medication, whatever they need. There are other organizations like the Brigid Alliance that helped with the logistics, so they help with transportation, and hotels, and figuring out all the stuff around care, not necessarily the care itself. And those organizations have been doing that work for decades. But now more than ever are needed in this challenging time.

Nandita Bajaj 34:08
In one of your research papers, you looked at the incidence of contraceptive coercion by providers, that patients reported experiencing when they went to get an abortion. So that's an interesting phenomenon is there's already quite a bit of stigma around getting an abortion, but then you go to a place where you think it's safe and there might be additional kind of paternalistic suggestions from physicians. Can you share the findings of your research and how this coercion often manifested?

Dr. Kristyn Brandi 34:40
Sure, I was really surprised. I was looking to learn more about how people experience their contraceptive counseling around abortion, and particularly I had a suspicion of people that may be pressured into certain types of birth control because I often was the one that was not only providing abortion care, but also for whatever reason, taking out a lot of devices, implants, and IUDs after an abortion. So that's obviously suspicious, like what's going on here? So we interviewed people seeking an abortion and asking them about their whole experience about contraceptive counseling from beginning to end. And we found that one, people have very different experiences and what they call good or bad counseling. And what they consider good counseling is people that spent the time to talk about an array of options and help them deliberate between choices versus what they described as bad counseling, or people that just focused on one thing or a couple of things, and left out all the other options. Because people felt pressured that they didn't have as many options to choose from, people also felt particularly pressure to choose a certain type of birth control and most often, those are long acting forms of birth control, particularly the IUD. And then the last thing that was really challenging for me and a lot of the people doing this research was that people reported that the reason why they felt that their providers were pressuring them into things like the IUD was because they were motivated by abortion stigma, that they felt that their providers didn't want them to have another unintended pregnancy or another abortion. And so they were trying to pressure them into using a form that was more effective. And that was really hard to hear as the doctor that is trying to provide patient centered counseling. And it's unclear whether or not that's their own internalized stigma and kind of their interpretation of the conversation versus overt coercion and control during that conversation. But that is what patients are leaving the exam room with. And so it's really important, I think, for us to interrogate why that is, where does that come from, and I think we can talk about like the history of coercion and reproductive control. This was majorily BIPOC people that we interviewed. And so thinking about where this comes from, and then what can we do to be more patient centered in our counseling so people are getting the best care that they can?

Nandita Bajaj 36:45
Yeah, what would that conversation look like? What would that training looked like for physicians?

Dr. Kristyn Brandi 36:50
Sure, I think it's first important to explain what it wouldn't look like. And I've had this conversation and actually at a lot of different like medical conferences, or when I talk about contraceptive coercion. The way people have described contraceptive decision-making to me has been like, "Alright, I have a patient that has high blood pressure," often the conversation isn't, "Here are five different medicines I can give you. These are the pros and cons of each. Which one would you like to choose?" Often the conversation is, "I have a patient with hypertension, I'm gonna give them this medication, because that's the most effective. And if that doesn't work, then we'll try something else." And so people are applying that to contraception with the idea that unintended pregnancy is the disease we're trying to treat.

Nandita Bajaj 37:32
Right.

Dr. Kristyn Brandi 37:33
Which is really not the goal. That's not necessarily how our patients may interpret an unintended pregnancy. So we've kind of decided what's the problem, and we've also decided how to fix it. And so that's not patient centered. That's not necessarily centering what our patients need. And so I would encourage people that are thinking about how to make health care more patient centered, some of it is implicit bias training. Some of it is talking about how bias impacts our counseling, and particularly in this space, how does the history of racism, classism, ableism, the history of reproductive control in certain communities, how does that influence who we think today should and shouldn't get pregnant? And how is that thought impacting who I'm recommending more this IUD versus someone else? So really, it's having a conversation with someone and talking about not what are my goals as a doctor to protect my patient from risk and help them have better health, what are their goals? Why did they show up today to talk about birth control, if they even did. That's one thing, also making sure that this is something they wanted to talk about, versus they're here for an abortion, we need to have the checkbox conversation of alright, we talked about contraception, that's obviously linked, when it may not be for someone. And 50% of patients don't want to talk about contraception at the time of abortion. And so do we need even need to have this conversation? And if we are, what are the patient's goals? What did they need from me today? And how can I help with my medical expertise, giving the information that's going to help them make the best decision for themselves?

Nandita Bajaj 39:00
Right. That's a tricky one, in a way, right? Patients are looking to the physicians to provide some kind of expert advice. And at the same time, that power that physicians have can become a source of oppression. So how do you take that authority, the expertise that you have gained through skills and training, to continue to center the patient while also remembering that you do know more than the patient does in terms of expertise around health care? I can completely see how easy it would be to kind of cross that line.

Dr. Kristyn Brandi 39:42
Absolutely. And I've had many patients ask me, "What should I do? What birth control do you recommend?" Or because I'm a cisgender woman, they ask me what birth control are you on? Because they trust what I would choose for myself. But I'm not the same person that they are. And the way I describe it is that I am the expert in the medical information and the science and the risk. The preferences, that kind of stuff, that's on them. They are the expert in their lived experience. And so between the two of us, hopefully we will be able to share enough information together that will help them be able to make an informed choice versus me telling them what I think the best thing is. And I would argue that even though I think contraception is a good model to explain why we shouldn't be having directive counseling like this, that hypertension, that high blood pressure example I gave before, you can do that with that too. And maybe this is a model that all types of health care could follow. My role, I don't consider it a very prescriptive role. Sure, I can do the surgery, I can give them the medication, but that also creates gatekeeping. And so I see my role more as a counselor, that my job is to give people information, and then they use that information and whatever works best for them. And I hopefully can be able to provide them with the care that they have decided is best.

Alan Ware 40:52
You've also written about the factors that influence young women's decision to seek out reproductive health care support. And we'd love to find out more about what you found in that study, such as, what are some of the most common reasons for wanting to see a gynecologist for the first time?

Dr. Kristyn Brandi 41:10
Thanks for that. And this is actually the idea of a medical student of mine that eventually went into pediatrics that was very interested in this idea of when does pediatrics and family medicine transitioned over into gynecology? Like, when do you start going to a gynecologist and why? I think that also has a lot of great ties into the work I've done around autonomy and people deciding what's best for them. We found that many young people decided to switch in to see a gynecologist because of a link between that and sexual activity, for the most part. That people that were becoming sexually active, for whatever reason, either socially, in school, they decided that that milestone in their life of becoming sexually active requires them to go see a gynecologist whether that is the idea of starting becoming sexually active and getting sexually transmitted infection screening or starting a contraceptive to prevent pregnancy. And it's unclear still where that link comes from. We think it may be related to sex ed. And that's something that they were taught versus more likely something that they've heard word of mouth that that person is sexually active, they started seeing a gynecologist. Some of them also came because they wanted preventative screenings, that they wanted to make sure that their health was okay. Some came because they had an acute issue like they were pregnant, or they needed birth control, or they needed STD screening because they were worried that they were exposed. But a lot of it was around autonomy, there was not a pediatrician telling them to go see a gynecologist. That they themselves decided that it was something that they needed for their health. And I'm wondering, having done this research, what can we do to help better facilitate that for people? So one, kind of being clear about what we recommend is like, alright, you should go at the age of 12. Or you should go at the age of 10, or kind of what is the right age, what is the right situation where people should make that choice? And also to help pediatricians and other folks support people that need to make that transition for whatever reason. And also, again, empowering pediatricians to be able to do some of that work too. Which many of them do provide some form of gynecologic care, but many don't. And so what can we do to help you to transition care, or help them feel better about providing that care themselves to the patients they've had for years.

Alan Ware 43:12
And a lot of the young women, well, as you mentioned either they started sexual activity or maybe something they've heard in sex ed class. And as we know in the US, since we have local control of schools, and probably state control on sex ed curriculum, it's highly uneven across this country of what kids are not learning in schools.

Dr. Kristyn Brandi 43:34
Right? It's that same map.

Alan Ware 43:35
Yeah, the same map.

Dr. Kristyn Brandi 43:36
Same map that doesn't have sex ed available to them.

Alan Ware 43:40
So the Physicians for Reproductive Health that you're the chair for have been involved somewhat, right, in school sex education curriculum?

Dr. Kristyn Brandi 43:48
We've had, in the past, a curriculum that helps educate both people that were providing this care as well as people that were receiving this care around young adult reproductive health care issues. It's a program called RSC (Reproductive and Sexual Coercion). And we've transitioned that over to another organization, but still trying to do work around how do we tell people that maybe facing a problem, what exists out there, or just advocating that people can't have reproductive health care without good sex ed. And so that is a critical component of things that physicians should be advocating for.

Alan Ware 44:18
Have you had much luck working with school districts?

Dr. Kristyn Brandi 44:21
it's challenging. Like you said, like every school district is different. Every school deals like there's certain things that should be required and not required. And I would echo that we are seeing a lot more concerning things in a similar vein to abortion stigma and abortion care being regulated by politics, things like trans care, things like talking about LGBTQ folk in schools is becoming more and more challenging. And so I'm hopeful that people that are interested in abortion care also are interested in these issues and hopefully can help push so that all of this type of things that are in the space of health care shouldn't be something that is deemed as stigmatized and should be something that people are empowered access if they need it.

Alan Ware 45:02
Right, and all the good impacts that we've seen from comprehensive sexuality education, reducing rates of sexual activity and risk behaviors and transmitted infections and all of those good things.

Nandita Bajaj 45:14
We've kind of touched on a few times during this conversation that abortion stigma or abortion bans are both a form of reproductive coercion, what we're calling now the forced birth movement. And you've mentioned a few times that there has been a dark history of reproductive coercion, of course within the United States, but also globally, that has targeted marginalized communities, both India where I'm from Puerto Rico, where your family's from, have a history of authorities violating reproductive rights. Can you give us a brief overview of both the dark history of coercion within the United States, within the medical institutions, that you're familiar with, but also, in particular, what happened in Puerto Rico? There's, of course, the pill trials, as well as the involuntary sterilization campaigns, both of which really marginalized Puerto Rican women. We'd love to hear some of your thoughts on that.

Dr. Kristyn Brandi 46:15
Sure. And I could give a whole separate lecture and I do often for medical students about this history, because I think it's really important to understand that and how it ties into the way we talk to people now about their birth control options and becoming pregnant or not becoming pregnant. Our system in the United States is somewhat built on reproductive control. Often when I give this lecture, the first thing I talk about is slavery, because I think it is a really sadly, perfect example of reproductive control and action, where black women's bodies were literally bought and sold, and the reproduction bought and sold for the benefit of white men. And that lays the groundwork for our country and the eugenics movement where people were concerned about overpopulation, but really had the underlying messaging about who they were really worried about reproducing and not reproducing, and how that funded things like the sterilization movements, more people could undergo eugenic sterilization, so that doctors could just decide who they thought was deemed unfit to reproduce, and perform sterilization procedures without patient's knowledge or consent. And if we think about the parallels in our conversation today, it's the same folks that are now being marginalized in abortion care, and other forms of care. BIPOC folks, people with disabilities, people that are incarcerated, low income people. So we have a long history of that in the United States around sterilization. and Puerto Rico is also part of that, that Puerto Rico had, and continues to have one of the highest rates of its population sterilized in the world. And part of that was the history and now part of that has become a socialized feeling that, you know, my mom was sterilized, my mom had a tubal, so I should have a tubal, I should get my tubes tied. And so how do we break that down and help people make that decision if that's, that's what's best for them, but also recognize where that came from. And the other thing I mentioned was the pill trial, which the first birth control pill called the Enovid was tested in Puerto Rico before it was tested in the mainland US and done so intentionally. That people in the trial often didn't know that they were part of a trial, they just thought we could try this new pill to prevent them from getting pregnant, but didn't know that it was experimental, didn't know that there were potential side effects. And several women died during the study. And many people for a long time didn't know why. And if you look back at the notes of the researchers, it was done intentionally. There's a quote there that says, "If the poor, uneducated women of Puerto Rico could follow the full regimen, then people anywhere in the world could too." So it really gives you a sense of like where the researchers heads were at when they decided to do that there. And I would argue that we're still seeing patterns of this, that when the newer IUDs implants were developed, like Norplant, which is an old implant, we saw similar programs where there was a lot of pressure to use these in certain populations so that people could get more welfare benefits if they got Norplant inserted, or you'll get reduced prison sentences if they got a Norplant inserted. And so some of that is still lingering today. There are studies that show that providers do have preferences about who they recommend, particularly now, IUD implants as a new proxy for sterilization, and how that is super problematic, both for people that want to be pregnant and have pregnancies but also people that don't want to be pregnant. It's a really complicated conversation now about how can we encourage people to choose contraception, and particularly these long acting forms of birth control, knowing that their parents that their family members in the past have had those pushed on them. And many people are wary. They know that history and they don't want them because they're worried, they're scared, they're distrustful of us.

Nandita Bajaj 49:41
Right. Yeah, I mean, one of the parallels to what you're saying about this distrust, because we're working in the space of raising awareness about the dangers of, you know, human expansionism and population growth, both on human rights and ecological devastation which of course exacerbates social crises. We're also trying to raise awareness about the aspect of reproductive control that comes through things like abortion bans, and a lot of other pronatalist forms of coercion, whether it's based in nationalism, whether it's driven by xenophobia. There are lots of different reasons why reproductive control, whether it is to limit fertility or to increase fertility are still impacting the same groups of people. One of the things we noticed with both what happened in India, so India went through a very similar sterilization campaign in the mid-seventies, where about eight million, mainly men, but also women who were sterilized. And they were poor people who were incentivized, kind of, like you said, with incarcerated folks who were given incentives, if they accepted a certain type of pill, then their sentence would be reduced. It was similar with poor people who would get benefits for getting a sterilization. In situations like that, it's like a choiceless choice, right? You don't really have autonomy, you didn't really give consent. And so interestingly, when that happened in the seventies in India, which was a horrible thing, there's been a backlash to the point where the population issue has been silenced completely. And what we've been noticing is a different type of reproductive control has been allowed to reign supreme. And folks who are much more aligned with the right wing propaganda or nationalism or religious driven pronatalism are being empowered through the silencing of this debate. One of the things ironically, also, as you mentioned, what happened in Puerto Rico was voluntary sterilization has become socialized. It's now the most common form of fertility control that's used by women in Puerto Rico, and social feminists rightfully denounce those sterilization campaigns of the past as a form of genocide with its roots in colonialism. Interestingly, the same feminist movement is also critical of Puerto Rican women using voluntary sterilization now, to control their fertility, suggesting that they are somehow doing the work of colonialists. So there's an author historian of reproductive politics and a feminist critic, Laura Briggs, she's talked about how in doing so, these same feminists who really truly care about reproductive justice are strangely and unknowingly promoting pronatalism and nationalism, which has historically been associated with conservative Catholicism, the right wing, and anti-feminism. And it, of course, starts to get really murky and complicated.

Dr. Kristyn Brandi 53:00
Very messy. Yeah.

Nandita Bajaj 53:02
And I just wonder if you had any thoughts on this phenomenon. We've had Dr. Kimya Nuru Dennis, who's spoken similarly about how antinatalism against Black people has now turned into coercive pronatalism towards Black people, again, as some kind of a corrective measure to past reproductive injustice, without recognizing that coercive pronatalism is a form of reproductive injustice, and cannot be used as a corrective measure to say, well, you couldn't and now you should. So any thoughts?

Dr. Kristyn Brandi 53:41
I mean, there's a lot to unpack there. And I agree with you that it's challenging because I recognize that certain communities have irreplaceably been harmed by genocides, both overt genocides as well as genocides caused by reproductive control in these spaces. And it makes sense to me that people want to reclaim what's theirs and reclaim their population in a way of activism, in a way to help re-foster kind of rebuild what they've lost. But I think that is something that really holds on to pronatalism in its messaging of doing so, that it just negates the individual and negates this idea of like, what does that actual person want? Maybe they don't want five kids to help rebuild the system. And it creates this like communal responsibility that not only do you need to do this for yourself, you need to do it for the community, which creates additional pressure, just like we saw in other like nationalist movements. I'm trying to think as a physician, what is my role in that? And I think my role when I talk to patients is really understanding what is their goal, and how does that fit into the context, not only of like their family, their work, but also their community? What are their values about parenthood or the lack thereof? What can I do to help support them make decisions that are best for them? And not necessarily perpetuating that there's a right answer, because I think everyone is trying to, in the social movements, create a right answer of how many kids is appropriate for a family or having an agenda about reproduction that has nothing to do with that individual person. And my job always, I tried to center that individual person. And so that's my best answer of what I can do as a health care provider to help people that are facing a lot of social stigma in both directions in whatever environment they may be in. What is it that they need and how can I help them get there?

Nandita Bajaj 55:40
Yeah, I think that's such a crucial message of really putting the control back in the individual's hand. Having a counselor such as you is a nice opening for people to come into the clinic and understand that there is a different way of looking at things, that at least in one place the individual is really centered.

Dr. Kristyn Brandi 56:01
Right. And I think if I'm trying to provide health care with a Reproductive Justice focus, I do have to think about all those other impacts like environmental justice, economic justice, food security, housing security, and how that plays a role in people's decision to parent. And that exists in both directions. And I think we need to consider how those individually impact folks but also, what can we do on a broader scale to address a lot of those injustices so that people actually can live out their reproductive justice and decide if and when to become pregnant without the social constraint of worrying about the resources that they need.

Nandita Bajaj 56:35
Right. Yes. Do you have kind of any other comments in terms of how pronatalism might be included more within the reproductive justice framework? You know, we see pronatalism as a form of reproductive coercion, depending on the varying levels of pronatalism that we see the subtle, the tacit, to the more coercive like the abortion bans, and like the incentivization of childbirth - does it get enough play within the RJ framework?

Dr. Kristyn Brandi 57:06
I mean, I don't think it gets enough light in the Reproductive Justice framework, and rightly so. The people that created the reproductive justice framework were trying to think bigger than abortion or labor care, that they were trying to think about this bigger concept of what it is to parent or not parent. But I think that there are other questions we need to be asking ourselves about reproduction, broader questions about communities and how reproduction and communities impacts other things like the environment. But I think also, I really am focused on this idea of reproductive autonomy, and how pronatalism in any form is in direct conflict with autonomy. And I think also to consider that pronatalism is widespread within health care. One thing I didn't mention earlier was this idea that when someone is pregnant, it's a very common phenomenon in other health care spaces to not touch them, so to speak. When I was covering an emergency room, I we get lots of calls about people and they're pregnant, can they take Tums? Can they take Aspirin? Can we do surgery on them? This idea that pregnancy, somehow also makes you not a human and makes you a person that is carrying a pregnancy as another form of oppression that a pregnancy status, what we call pregnancy exceptionalism, that all of a sudden now that when you're pregnant, something is different about you in a way that we have to treat you differently, also creates oppression within the healthcare system. And I think a lot of that may be fueled by pronatalism, that we optimize pregnancy because we want to help people and promote motherhood. And so what can we do within the health care system to destigmatize pregnancy to allow people to be pregnant and also be a person and be a human and be able to do whatever humans do, regardless of their pregnancy status. I think that will help with abortion stigma, I think will help with pronatalism. It's another place of potential focus.

Nandita Bajaj 59:02
I completely understand what you mean about somehow that person kind of being seen as superhuman because they're carrying another human so much that they actually lose their own human status.

Dr. Kristyn Brandi 59:14
Yes, they lose their humanity by trying to gestate some other human, so.

Nandita Bajaj 59:17
Right.

Dr. Kristyn Brandi 59:18
Yeah.

Nandita Bajaj 59:19
I could easily spend another hour talking to you. I have so many questions.

Dr. Kristyn Brandi 59:23
I mean, this is stuff I'm really passionate about. So I'm really fortunate to be part of this conversation. So thank you so much for having me and talking about these things.

Nandita Bajaj 59:30
Thank you so much for what you're doing within the medical institution through trying to bring Critical Race Theory, trying to bring RJ principles, and also trying to dismantle pronatalism. We need a champion in every institution. You're such an incredible champion doing such great work and we're really grateful that you came and spoke with us.

Alan Ware 59:53
Yeah, thanks for all your work.

Dr. Kristyn Brandi 59:54
Thank you.

Alan Ware 59:55
Well, that's it for this edition of the Overpopulation Podcast. Visit populationbalance.org to learn more. To share feedback or guest recommendations, write to us using the contact form on our site, or by emailing us at podcast@populationbalance.org. If you feel inspired by our work, please considered supporting us using the donate button. Also to help expand our listenership, please consider rating us on whichever podcast platform you use.

Nandita Bajaj 1:00:24
Until next time, I'm Nandita Bajaj, thanking you for your interest in our work and for all your efforts in helping us all shrink toward abundance.