research on reproductive health

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Reproductive Health focuses on all aspects of human reproduction, including adolescent health, female fertility, contraception, and maternal health and all articles are open access.

Reproductive health is defined as a state of physical, mental, and social well-being in all matters relating to the reproductive system, at all stages of life. Good reproductive health implies that people are able to have a satisfying and safe sex life, the capability to reproduce  and the freedom to decide if, when, and how often to do so. Men and women should be informed about and have access to safe, effective, affordable, and acceptable methods of family planning of their choice, and the right to appropriate health-care services that enable women to safely go through pregnancy and childbirth.

Reproductive Health  has a particular interest on the impact changes in reproductive health have globally, and therefore encourages submissions from researchers based in low- and middle-income countries.

The challenge of the field is to evaluate current promising interventions rigorously, address emerging issues such as synthesizing ever-increasing research findings, and develop innovative dissemination and communication strategies.

The journal invites submissions on research in reproductive health, including social and gender issues, sexual health, country and population specific issues, assessment of service provision, education and training and also in a broader range of gynaecological and obstetrical topics related to reproductive health.

Reproductive Health provides a platform that helps authors to share their knowledge with a wider audience, and sustains a rapid process for submissions resulting in high quality publications. We further aim to contribute towards reducing the inequity in publications from low- and middle-income countries. Our audience is global and we intend to share research results in reproductive health from all parts of the world.

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Reproductive Health operates a trasnparent peer-review system, where the reviewers' names are optionally included on the peer review reports for authors. In addition, if the article is published, the reviewer reports are published online alongside the article under a Creative Commons Attribution License 4.0 . Previous versions of the manuscript and all author responses to the reviewers are available by contacting [email protected] .

The benefit of transparent peer review is that it increases transparency. In addition, published reports can serve an educational purpose in helping facilitate training and research into peer review.

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Citing articles in Reproductive Health

Articles in Reproductive Health  should be cited in the same way as articles in a traditional journal. Because articles are not printed, they do not have page numbers; instead, they are given a unique article number.

Article citations follow this format:

Authors: Title. Reprod Health [year], [volume number]:[article number].

e.g. Roberts LD, Hassall DG, Winegar DA, Haselden JN, Nicholls AW, Griffin JL: Increased hepatic oxidative metabolism distinguishes the action of Peroxisome Proliferator-Activated Receptor delta from Peroxisome Proliferator-Activated Receptor gamma in the Ob/Ob mouse.  Reprod Health  2009, 1 :115.

refers to article 115 from Volume 1 of the journal.

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Reproductive Health 's open access policy allows maximum visibility of articles published in the journal as they are available to a wide, global audience. 

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Reproductive Health offers a fast publication schedule whilst maintaining rigorous peer review; all articles must be submitted online, and peer review is managed fully electronically (articles are distributed in PDF form, which is automatically generated from the submitted files). Articles will be published with their final citation after acceptance, in both fully browsable web form, and as a formatted PDF.

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In addition, articles published in Reproductive Health may be promoted by press releases to the general or scientific press. These activities increase the exposure and number of accesses for articles published in Reproductive Health . A list of articles recently press-released by journals published by BMC is available here .

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Reproductive Health

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The Johns Hopkins Division of Reproductive Science and Women’s Health Research is devoted to advancing the health of women at every stage of their lives. Our multidisciplinary team draws strength from the expertise across Johns Hopkins to examine every facet of women's health. Our goal is to find better ways to treat illnesses and conditions that effect the lives of our patients, to contribute to the scientific community at large and to improve the health of all people.

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Featured Research Project Intercepting Ovarian Cancer

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WRHR (Women's Reproductive Health Research)

The Johns Hopkins WRHR program (JH-WRHR) recruits junior Ob/Gyn faculty who demonstrate strong potential to become productive and independent physician scientists to conduct innovative and significant women's health research. Leveraging the abundant resources of Johns Hopkins University, the growing capabilities and research resources of the Department of Gyn/Ob at Johns Hopkins, and the critically important milieu provided by the national NIH-supported WRHR program , we hope to help address the critical shortage of Ob/Gyn researchers.

Principal Investigator: Andrew Satin, M.D.

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The Reproductive Scientist Development Program (RSDP) is a multi-disciplinary, multi-institutional research career development program for Gyn/Ob physicians studying cell and molecular biology and related fundamental sciences. The RSDP is a consortium involving the current host institution, its sponsors and the many institutions around the country that train RSDP scholars.

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CDC’s Division of Reproductive Health focuses on issues related to reproductive health, maternal health, and infant health.

• For over 50 years, we have worked to improve the lives of women, children, and families through science, data, programs, and partnerships.

CDC supports national and state efforts to collect data and information to better understand health issues impacting reproductive, maternal, and infant health. CDC also works with partners to translate research into practice. This increases quality of care and informs prevention approaches. CDC provides technical assistance and training to help improve male and female reproductive health, maternal health, and infant health. A key part of our work is assessing the drivers of health disparities. This informs efforts to improve equity in care and outcomes.

CDC also works with partners to translate research into practice. This increases quality of care and informs prevention approaches. CDC provides technical assistance and training to help improve male and female reproductive health, maternal health, and infant health.

What CDC is doing

Through key investments, CDC promotes optimal reproductive and infant health and quality of life. By ensuring women get the right care at the right time, we can ensure we are making a difference.

Strategic Areas of Focus

These strategic areas of focus are priority topics for CDC's Division of Reproductive Health efforts. They are not inclusive of all work, but help to measure progress in key areas.

Maternal Mortality and Complications of Pregnancy Identify, review, and monitor maternal deaths and complications of pregnancy to prevent them.

Infant Morbidity and Mortality Provide epidemiologic and programmatic subject matter expertise in infant (0-12 months) morbidity and mortality, with special emphases on sudden unexpected infant deaths.

Chronic Disease Prevention among Women of Reproductive Age (WRA) Advance evidence-based guidelines, policies, and practice related to chronic disease prevention among WRA to improve pregnancy outcomes and improve women's health through the life course.

Reducing Teen and Unintended Pregnancy Advance evidence-based practices, policies, and programs related to reducing teen and unintended pregnancies, focusing on improving access to and use of quality family planning services.

Global Reproductive Health Provide technical assistance for activities to reduce maternal and neonatal mortality and severe morbidity in high mortality settings, primarily through program monitoring and evaluation, and building in-country capacity.

Science to Practice Identify and implement effective strategies for promoting the translation of science to practice and policy to impact population health outcomes.

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Reproductive Rights, Reproductive Justice: Redefining Challenges to Create Optimal Health for All Women

The World Health Organization (WHO) defines reproductive health as the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes. Reproductive Justice is the complete physical, mental, spiritual, political, social, and economic wellbeing of women and girls, based on the full achievement and protection of women’s human rights. While these concepts are similar, the latter was an approach that grew out of the need to better articulate the language and realities of women of color as it related to sexual and reproductive health issues. The current U.S. reproductive health agenda is polarized to a choice or abortion issue without any alignment to other issues that predominantly impact women of color within the reproductive health framework. This article acknowledges the history and challenges of reproductive health and rights, while offering a non-polarized, more inclusive ethical course of action, using an optimal health approach with new alliances for the reproductive justice movement today.

Introduction

The 1994 International Conference on Population and Development (lCPD) in Cairo and the 1995 Fourth World Conference on Women in Beijing (FWCW) debated and redefined focus within the reproductive health arena. The Platform for Action and the Beijing Declaration (documents) from the conferences created an enabling national and international political environment for reproductive health. They altered the language about population and family planning issues to include human rights and intensified the interest and participation of non-governmental organizations (NGOs), governments and institutions worldwide in reproductive health issues ( The First World Conference on Women, 1995 ).

Including NGOs made certain that strategies were derived from consistently “listening to the voices of those closest to the ground and most importantly ensuring that programming was relevant and sensitive to community conditions and cultural norms” ( Seibert, Stridh-Igo, & Zimmerman, 2002 ).

Before attending the ICPD, a group of black women in Chicago coined the term reproductive justice, defined as the complete physical, mental, spiritual, political, social and economic wellbeing of women and girls, based on the full achievement and protection of women’s human rights ( Ross, 2007 ). This was done out of the need to better articulate the language and realities of women of color as it related to sexual and reproductive health issues and rights. Following this, in the late 90s, the Ford Foundation funded a collective of women of color –led NGOs, called SisterSong, the cornerstone for reproductive justice programming. Twenty years later, this concept or broad lens is still limited in its use to guide programming and advocacy efforts within the reproductive health arena.

Today, the U.S. reproductive health agenda is polarized around choice on abortion issue without any alignment to other issues within the reproductive health framework. This paper highlights a brief history of reproductive rights and the challenges faced as these rights evolved into the reproductive justice movement. It goes on to encourage the reproductive justice movement to adopt an even broader framework of optimal health steeped in theories that advocate for women to embrace their feminine power, a more inclusive and ethical fit for women’s health. This new framework will generate a new movement that will create fresh language, identify new allies, foster nontraditional partnerships and strengthen the capacity of the reproductive justice/optimal health movement so it fully reflects the voices of all women.

Reproductive Justice Context and History

During the 1950s and 60s, philanthropic and international development organizations focused mainly on population and reproduction. Efforts were made to better understand the causes, characteristics and consequences of the population growth trends facing developing countries. Demography was developed as an independent discipline (establishing centers for graduate study) and research was supported in reproductive and contraceptive development. Broad discussions on population policies and assistance were held to better define the design and delivery of family planning programs overseas.

The 1980s involved funding model projects to provide education and facilitate safe, affordable and effective contraceptive use and abortion services if necessary. The focus was on disadvantaged women who chose to have children safely and ensure the safe and healthy development of all children (maternal and child health programs). There was also an increased emphasis on factors influencing the demand for family planning with regard to women’s development, cultural references in developing effective population policies and increased efforts on migration/refugee issues.

The 1990s saw a conceptual shift from family planning to reproductive health and a women-centered, rights-based focus. Within this decade organizations helped emphasize the cultural and economic factors affecting reproductive health (high fertility, poor maternal health and STD/AIDS spread). They also paid special attention to disadvantaged women in developing countries through their reproductive life cycle, supported efforts against STDs/AIDS, and addressed the special needs of adolescents. The main feature of this new focus was to strengthen social science research and training to expand knowledge about the socioeconomic factors affecting reproductive health.

Funding was provided for projects that helped women articulate and act on their reproductive health needs both within the family and at the community and policy levels. This support also promoted public discussion aimed at developing ethical and legal frameworks for reproductive health appropriate to the culture and traditions of different societies. The late 1990s saw the inclusion of sexuality as integral to reproductive health.

The 1994 ICPD in Cairo shifted the emphasis from governmental aims to limit population growth to individual decision-making in reproductive health. The narrow definitions and scope of family planning programming (pregnancy and contraceptives) were expanded holistically to include an individual’s comprehensive needs (reproductive intent, contraceptive availability, client choice and satisfaction). Along these lines the inherent holistic concept of choice was reaffirmed to include freedom to decide when and whether to have children. A woman’s reproductive health was now placed within the structure of reproductive rights and empowerment i.e. accounting for power imbalances and the degree to which women’s choices are constrained. Women played a vital role in national development and had the right to control their fertility. They had the right to participate in providing direction in the formulation of policies that impacted the political, social and economic realms of their health and therefore their existence ( United Nations Population Fund (UNPF), 1994 ).

This conference and the FWCW the following year, expounded on principles that redefined sexual and reproductive health and rights programming for all women around the globe. New principles of thought, along with altering the language around population and family planning issues to include rights, helped to intensify the interest and participation of non-governmental organizations (NGOs), governments and institutions worldwide in reproductive health issues ( The First World Conference on Women, 1995 ).

Unfortunately, in the United States the globally endorsed action plan did not frame sexual and reproductive health and rights programming. Instead, efforts remained fragmented and unidirectional, i.e. pro-choice.

The subsequent meetings, ICPD (1999) and Beijing Plus Five (2000) discussed progress and obstacles to implementation of the initial action plans. Both conferences highlighted that action was still needed to guarantee women their human rights. Steps were required to implement much of what was written. There was still limited demonstration of the understanding of a women’s reproductive health and its link to other issues that affected her health, rights and empowerment.

The important advances resulting from the Plus Five experiences included more female activists as members of government delegations than ever before. Another was the agreement that all forms of violence against women would be treated as a criminal offense, including marital rape. Governments re-affirmed the indicators and time-bound targets on sexual and reproductive health and stated that adolescents especially girls should also have access to sexual and reproductive health services including sexuality and life skills education.

In 1997 the Ford Foundation funded an initiative on reproductive health. Sixteen (four African American, four Asian American/Pacific Islander, four Latina and four Native American) U.S. community based organizations (CBOs) led by women of color were supported in an attempt to promote research and advocacy on reproductive tract infections (RTIs) faced by women of color ( SisterSong, 1997 ).

RTIs were chosen because of their contribution to the major health problems of women. Often undiagnosed until more severe complications arise, these preventable and treatable infections are responsible for the mortality of thousands of women each year through their association with cervical cancer, unsafe deliveries and septic abortions. The high rates of RTIs are also associated with interrelated socio-cultural, biological, and economic factors including poverty, low social status, low levels of education, racism, rapid urbanization, etc. The synergistic effects of these factors are known to reduce women’s decision-making power over their own sexuality and constrain their ability to seek quality reproductive care, thus contributing to poor reproductive health.

The initiative called The Women of Color Reproductive Health Collective or SisterSong (Loretta Ross, Dazon Dixon Diallo leading grantees) was a three-year effort to support these organizations to identify common concerns and needs and develop a plan of action for prevention and early treatment of RTIs within their communities. It also focused on identity and ethnicity and its intersections/linkages as to how women approach health and reproductive issues. The 16 organizations represented the different facets of reproductive health programming (prevention, HIV/AIDS services, midwifery, substance abuse, human/health rights advocacy, self-help care, and reproductive rights). The Collective through shared learning served as an enhanced voice to bring awareness and action to improve the reproductive health of women of color.

The Collective highlighted the need to recognize health and reproductive health as human rights issues impacted by social, political, cultural and economic factors. This broad definition of reproductive rights was revealed at the ICPD and FWCW and had been repeatedly voiced by women of color in the U.S and globally.

This broader concept now called reproductive justice was not an opposing one to the present day pro-choice/reproductive rights movement. In fact, it was inclusive. This renewed definition served to repeatedly highlight that the health and rights of women could never be analyzed without taking into consideration the «holistic» reality of a woman’s existence.

Reproductive justice is defined as the complete physical, mental, spiritual, political, social and economic wellbeing of women and girls, based on the full achievement and protection of women’s human rights ( Ross, 2007 ; Ross, Solinger, 2017 ).

The Women of African Descent for Reproductive Justice in Chicago coined this definition in June of 1994, before the ICPD in Cairo (Loretta Ross and Toni M. Bond organizers). Recognizing that the current reproductive rights movement led by middle class white women was not inclusive of minority, low income, and other marginalized women, this group of African American women started the movement of Reproductive Justice. Reproductive Justice began when the group published a statement with over 800 signatures in the Washington Post and Roll Call. Thus, acting as a catalysis for Sister Song ( SisterSong, 1997 ).

To date, SisterSong is the only national coalition in the U.S. consisting of women of color organizations working to ensure reproductive justice for communities of color” ( SisterSong, 1997 ). SisterSong believes that they have the right and responsibility to represent themselves and their communities, and the equally compelling need to advance the perspectives of women of color. They know that they can do more collectively than they can do individually. Headquartered in Atlanta, they are a blend of both young and experienced activists, academic and community scholars, grassroots and national organizations ( SisterSong, 1997 ).

Recently, two additional movements that have brought attention to women’s reproductive issues are the #MeToo movement, and the Women’s March. The #MeToo movement was founded in 2006 by Tarana Burke to help survivors of sexual violence find healing, particularly black women and girls and other young women of color from low economic communities. What began as a hashtag to spread awareness became popularized when several celebrities began to use the hashtag and spread word about the movement via their social media pages. An important turning point of the #MeToo movement came when men, and members of the LGBTQ+ communities shared their experiences. The goal of the #MeToo movement is to reframe and expand the global conversation around sexual violence to speak to the needs of a broader spectrum of survivors ( MeToo, 2006 ).

The Women’s March began on social media. Teresa Shook stated that a pro-woman march was necessary in reaction to Trump’s presidential win. In 2017, the first full day of President Donald Trump’s presidency hundreds of thousands of people gathered in the nation’s capital for the Women’s March on Washington. On the same day, many other women and supporters of the march gathered in other cities and states. The Women’s March centered around eight principles–ending violence, ensuring reproductive rights, LGBTQIA rights, workers’ rights, civil rights, disability rights, immigrant rights, and environmental justice ( Women’s March, 2017 ).

While these movements have brought awareness to those who identify as women and those effected by women’s issues, they do not address that comprehensive reproductive health care and sexual and reproductive rights are «vital human and social assets within a broader developmental agenda to reduce poverty and injustice» ( Ford Foundation, 2001 ). The agenda, defined by SisterSong highlighting the importance of the reproductive justice movement, is often overlooked in the mainstream media. Unfortunately, the agenda and access to these assets still are impacted by the inter-relationship of race, culture, gender, class and political factors thus the continuous neglect of women of color and others from low socioeconomic backgrounds.

Reproductive health and rights have become a well-established field both domestically and internationally. Key national and international organizations (i.e., International Planned Parenthood Association, NARAL-Pro Choice America, Center for Reproductive Rights, National Abortion Federation) help to form a widespread network of activism that has contributed to the visibility and progress of women’s health by engaging in political advocacy, advocating for funding appropriations and demanding increased and improved reproductive health programming. Despite these well-established networks and programming efforts there are still challenges to overcome.

Leading reproductive health organizations in the U.S. have minimally or not at all incorporated reproductive justice into their programming. They have continued to not effectively engage women of color in representation, leadership development or promotion, programmatic design, implementation or evaluation. Many of these organizations believed and argued that women of color were complacent on issues related to their reproductive health and rights. These fail to recognize that although organizing around reproductive health issues have been difficult for these women there has been long standing activism in communities of color on these issues even within the abortion rights movement. Even when women of color become involved with these organizations, they invariably fail to have a significant influence on the organizations’ agenda because it speaks to mainstream needs ( Bond, 2001 ).

There remains institutional limitations within well-established reproductive health organizations around cultural or racial/ethnic diversity. While many of these organizations have been funded over the years to diversify and have women of color in leadership roles, there has been limited success in this effort. Many have placed their focus on board representation. This does not guarantee the adequate level of diversity on the professional staff level where programmatic focus, strategic planning, evaluation and networks are concentrated.

In order to counter the adversity of the challenges, strategies need to be derived from consistently “listening to the voices of those closest to the ground, enabling self-defined needs to guide decisions, and most importantly ensuring that programming is relevant and sensitive to community conditions and cultural norms” ( Seibert, Stridh-Igo, & Zimmerman, 2002 ). The reasons are obvious. Those closest to the issues have the solutions and must advocate for those solutions thus creating social change. However social change can only occur through strong ethical leadership supported by strong organizations with visions, missions, capacity, strategic partnerships and alliances that reflect all members of the community.

In 2013 GuideStar (the largest source of up-to-date information on nonprofits) presented an article entitled “New Rankings Announced: Top 25 National Reproductive Health, Rights and Justice Nonprofits.” These were organizations identified as having an impact on multiple levels. Of the 25, four were using a reproductive justice lens to influence their work and four were led by a woman of color (SisterSong, National Latina Institute for Reproductive Health, National Network of Abortion Funds, and Forward Together) ( Morrow, 2013 ).

This report also offers insights from experts on issues within the nonprofits (i.e. impact, other organizational strengths,) and how to improve them. SisterSong received favorable comments for leadership, innovativeness, networking, justice and equity. But under organizational areas of improvements, the comments included: “needs technical assistance, not stable in finances and staffing/operations.” All too familiar repeated statements made about CBOs’ capacity especially those led by women of color.

Today when using GuideStar to search for “reproductive rights” nonprofits the yield is 3,387 organizations. If the search uses the words “reproductive justice” 1,234 organizations are identified. If the exclusion criteria, “only organizations that have provided data on diversity, equity and inclusion”, is applied the results yield, 42 organizations for reproductive rights and only 12 for reproductive justice.

Today, the U.S. reproductive health agenda both nationally and locally, largely because of the efforts to overturn Roe versus Wade, remains polarized to a choice or abortion issue without any alignment to other issues within the reproductive health framework. Women of color have often voiced that the mainstream reproductive rights framework, which addresses legal issues, is mainly one-dimensional with no consideration for the broader issues within their communities (e.g. limited or no access to health services especially prenatal care, Medicaid expansion, hysterectomies, pregnancy-related deaths, poverty, interpersonal violence, STDs/AIDS, environmental injustices, mental health issues, etc.) which impact their reproductive health and rights on a daily basis.

A more recent display of extreme infringement on women’s reproductive rights and justice are the impending abortion laws adopted in multiple states such as Alabama, Georgia, Ohio, Missouri and Mississippi. Each passed abortion bans for nearly all-reproductive scenarios with limited exceptions (if the pregnant person’s life is at risk, or if the abortion is before six weeks of pregnancy (“heartbeat bills”)). While these bans are fundamentally unsound, unsafe and unethical, this extreme agenda pushed by ill-informed and buffoonery politicians disregards the entire paradigm of why women seek abortions in the first place (i.e., rape, incest, emergency life threatening conditions, etc.).

Unfortunately, many of these efforts are initially generated in states within the existing Bible Belt and extremely conservative religion theology undermines the bans. These states, and others considering adopting similar policies, have large powerful conservative religious populations and politicians. This is another clear example of how religion has been used repeatedly as a means of controlling, disempowering, and dominating women and girls for centuries.

Health is the physical, mental, spiritual and social wellbeing of an individual and access to it is a human right. Thus, services such as abortion, the method by which one can choose not to reproduce is embedded within a woman’s right to access health services and is a fundamental human right However, for it to have become the central and only theme of reproductive health represents an extremely myopic view of a woman’s human right to comprehensive reproductive health care. This approach although targeting power imbalances does not consider the degree to which women of color choices are constrained.

Bell Hooks, a black feminist, expounded on this when she wrote in 1999: “highlighting abortion rather than reproductive rights as a whole reflected the class biases of the women who were at the front of the movement.” ‘While the issue of abortion was and remains relevant to all women, there were other reproductive issues that were just as vital which needed attention and might have served to galvanize the masses.” ... “Ongoing discussion about the wide range of issues that come under the heading of reproductive rights is needed if females of all ages and our male allies in the struggle are to understand why these rights are important. This understanding is the basis of our commitment to keeping reproductive rights a reality for all females” (Hooks, 1999).

Today the approach termed “reproductive rights” or “reproductive justice” continues to conjure up preconceived thoughts and beliefs that have become even more polarized. Unfortunately, due to this polarization, individuals instantly take a stance for (choice) or against (prolife) this vital health issue with limited knowledge and understanding.

A New Ethical Course of Action

The few women-led organizations that have adopted a reproductive justice framework for their programming efforts are laudable. They are more likely to develop the interventions or strategies needed to shift the continuous burden of poor health outcomes among women and girls especially those of color. Unfortunately, due to limited complete data and escalating poor health outcomes, it is obvious that they cannot keep doing the same thing nor do it alone. Women’s health and wellness is an overpowering issue.

Therefore, to minimize the effects of losing any more ground and capitalizing on the opportunities, a new course of action or promising next steps would be to broaden the reproductive justice framework and embrace and advocate for “optimal health” for all women and girls regardless of socio-cultural or economic limitations.

Optimal health defined by the late John T. Chissell, MD is the “best possible emotional, intellectual, physical, spiritual and socio-economic aliveness that one can attain” (Chissell, 1998). It is a continuous journey versus a destination. In his work, Dr Chissell offers an Afrocentric approach or playbook to achieving optimal health that is relevant today. Dr Chissell’s definition of optimal health is similar to that for reproductive justice and offers an expanded focus with steps. This expanded focus can enhance the existing reproductive justice framework, amplify the language and shift the paradigm to one of total wellness while offering steps for action.

Focusing on optimal health as the next level of the women’s reproductive justice movement would eliminate polarized language, silos, unidirectional programming, selective funding efforts and the myopic focus of mainstream organizations that still haunts the reproductive justice movement. A new broadened framework will produce new dialogue, engender innovative solutions, foster new partnerships and strengthen existing ones. This new agenda termed “optimal health justice” or simply “heath justice” advocates for complete wellness.

This framework will be grounded in two major theories. The first is Womanism. Created by Alice Walker, Womanism is defined as – “... the opposite of frivolous, the cultivation of community, the demand of love- ...a woman who LOVES herself unconditionally or a form of feminism that emphasizes women’s natural contribution to society” ( Walker, 1983 ).

The second is the theory of the “divine feminine.” The divine feminine is defined as – “one’s powerful inner energy that represents the feminine side of self or consciousness. It is energy that is- present, loving, nurturing, creative, intuitive, kind, empathic, community focused, collaborative, flexible, sensual (in touch with feelings versus thinking or intellect)” ( Cromwell, 2017 ).

Both schools of thought offer an innovative and even broader framework for action. Together with all women and their allies these theories will aid and sustain a movement that will target the social, political, economic, spiritual and cultural factors that perpetuate poor health outcomes among all women and girls living in the U.S.

New thoughts and frameworks nurture new partnerships. Possible new allies and nontraditional partners for sustained action of this optimal health framework is the religion and spirituality domains. Noted earlier, religion is and has been closely aligned with conservative political ideology that is often anti-choice, lacks understanding of and is non-supportive of comprehensive reproductive health care. But this new framework must consider religion and spirituality as necessary allies. Women and girls operate within these arenas and they too have poor health outcomes.

Spiritual wellbeing is an integral component of an optimal health model. The faith community, both traditional (e.g. Black Churches), and non-denominational (e.g. Buddhist, Interdenominational entities) can clearly speak in support of this new approach and not sanction opposing rhetoric or unprecedented extreme bans on essential health care (i.e. abortions). Progressive and conservative religion/spiritual voices must be encouraged and welcomed thus ensuring inclusivity, sustainability and success ( Goodstein, 2007 ).

Visibly calling for and collaborating with males or partners in a movement targeting women and their optimal health is delicate but essential. The role of men and partners must be defined and welcomed. They may highlight missing keys to multiple insights, solutions and interventions. Women do not exist in isolation. They thrive in healthy relationships with others in communities. Having strategic input and involvement from those they are in relationships with would be innovative. Also partnering with male dominated institutions (e.g. Teamsters Union, 100 Black Men, etc.) would be even more innovative ( Funk, 2007 ).

Other strong nontraditional partners to foster new relationships with could include 1199 Hospital Workers, Teacher Union, Social Workers, Nurses, American Medical Association (AMA), National Medical Association (NMA), Black Lives Matter, etc. Each could contribute to strengthening the movement and ensuring it is sustained and successful.

This broader framework will need a new paradigm of research involving researchers and community practitioners working in concert with the community (a Communiversity) to evaluate and support capacity building assistance within cultural contexts. Reinforcing the sustainability and institutional capacity of community-based organizations involved in this new movement will entail offering capacity building assistance that includes relationship building, board development, program implementation, linking local strategies to national efforts, evaluation, training, organizational growth/development/adaptability and funding.

Due to the threats to women’s health and rights under the current conservative political climate there could not be a more pertinent time to support reproductive justice efforts by broadening the focus and engaging in optimal health justice advocacy. Forging a new paradigm by embracing an optimal health approach and partnering with new and nontraditional allies (i.e., religion, spirituality, men, others) can only build and reinforce the capacity for a stronger, more inclusive and effective optimal health justice movement for all women and girls. Inclusive involvement is essential to nourish this new ethical framework, propel relevant advocacy efforts, reinforce its capacity and sustain it to ensure its success on the local, state and national levels.

Authors’ Note

The opinions expressed in this article are those of the authors alone. They do not reflect the official opinion of any institutions that the authors serve. The authors have no financial conflicts of interest.

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Open Access

Peer-reviewed

Research Article

Parity and post-reproductive mortality among U.S. Black and White women: Evidence from the health and retirement study

Contributed equally to this work with: Cheryl Elman, Angela M. O’Rand, Andrew S. London

Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing – original draft

* E-mail: [email protected]

Affiliation Duke University Population Research Institute and Center for Population Health and Aging, Duke University, Durham, NC, United States of America

Roles Formal analysis, Funding acquisition, Methodology, Visualization, Writing – original draft

Affiliation Department of Sociology and Duke University Population Research Institute and Center for Population Health and Aging, Duke University, Durham, NC, United States of America

Roles Formal analysis, Investigation, Methodology, Writing – original draft

Affiliation Department of Sociology, Aging Studies Institute and Center for Aging and Policy Studies, Maxwell School of Citizenship & Public Affairs, Syracuse University, Syracuse, NY, United States of America

• Cheryl Elman, 
• Angela M. O’Rand, 
• Andrew S. London

• Published: September 19, 2024
• https://doi.org/10.1371/journal.pone.0310629
• Peer Review
• Reader Comments

Population health research finds women’s mortality risk associated with childlessness, low parity (one child), and high parity (6+ children) in a U-shaped pattern, although U.S. studies are inconsistent overall and by race/ethnicity. Parity, however, is contingent on women’s biophysiological likelihood of (in)fecundity as well as voluntary control practices that limit fertility. No studies have empirically examined infecundity differentials among women and their potential contribution to the parity–post-reproductive mortality relationship or the race/ethnic-related mortality gap. We examine 7,322 non-Hispanic Black and White women, born 1920–1941, in the Health and Retirement Study, using zero-inflation methods to estimate infecundity risk and parity by race/ethnicity. We estimate proportional hazards models [t 0 1992/1998, t 1 2018] to examine associations of infecundity risk, parity, early-life-course health and social statuses, and post-reproductive statuses with all-cause mortality. We find Black women’s infecundity probability to be twice that of White women and their expected parity 40% higher. Infecundity risk increases mortality risk for all women, but parity–post-reproductive mortality associations differ by race/ethnicity. White women with one and 5+ children (U-shaped curve) have increased mortality risk, adjusting for infecundity risk and early-life factors; further adjustment for post-reproductive health and social status attenuates all parity-related mortality risk. Black women’s parity–post-reproductive mortality associations are not statistically significant. Black women’s post-reproductive mortality risk is anchored in earlier-life conditions that elevate infecundity risk. Results suggest a need to focus upstream to better elucidate race/ethnic-related social determinants of reproductive health, infecundity, parity, and mortality.

Citation: Elman C, O’Rand AM, London AS (2024) Parity and post-reproductive mortality among U.S. Black and White women: Evidence from the health and retirement study. PLoS ONE 19(9): e0310629. https://doi.org/10.1371/journal.pone.0310629

Editor: Emily W. Harville, Tulane University School of Public Health and Tropical Medicine, UNITED STATES OF AMERICA

Received: January 2, 2024; Accepted: September 3, 2024; Published: September 19, 2024

Copyright: © 2024 Elman et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Study data cannot be shared publicly because they include Restricted Data pertaining to study participants' dates and places of birth. Data are available from Health and Retirement Study Administrators with a Restricted Data Application and approval by the Health and Retirement Study Executive Committee for researchers who meet the criteria for access to confidential data. Contact Information: HRS Restricted Data Application Processing, Survey Research Center, P.O. Box 1248, Ann Arbor, Michigan 48106-1248. To apply for data access use: https://hrsdata.isr.umich.edu/rda/rda-application-vdi or https://hrs.isr.umich.edu/data-products/restricted-data/ ".

Funding: The first two authors received research project support from an NICHD Population Dynamics Research Infrastructure Program award to the Duke Population Research Center (P2C HD065563) and an NIA Centers on the Demography and Economics of Aging Program award to the Duke Center for Population Health and Aging (P30 AG034424) at the Duke Population Research Institute. The third author received research project support from an NIA Centers of the Demography and Economics of Aging award to the Center for Aging and Policy Studies in the Aging Studies Institute at Syracuse University (P30 AG066583). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NICHD or the NIA. The funders of this study had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Women’s reproductive careers—including the number of children they bear (parity) and the life-course timing of their childbearing—contribute to post-reproductive mortality risk among midlife and older survivors. While early studies reported different strengths and directions of parity—post-reproductive mortality associations, the most recent European Census- and population registry-based studies report associations manifesting as J- or U-shaped curves [ 1 – 6 ]. These patterns signify that the reproductive statuses of childlessness, low parity (one child), and high parity (generally 5+ or 6+ children) are associated with elevated post-reproductive mortality risk. Studies of U.S. women, however, have not resolved inconsistent findings of: weak or no parity-mortality associations [ 5 , 7 ]; elevated mortality risk with higher parity [ 8 ]; a protective effect of higher parity on mortality [ 9 ]; and variable directions of associations across groups defined by race/ethnicity [ 10 , 11 ]. Additionally, most European studies and U.S. studies that pool Black and White subsamples report an inverse relationship between age at first birth and mortality [ 5 , 7 , 12 – 14 ]. However, U.S. studies that sample or stratify by race/ethnicity find that a younger age at first birth can be health-protective for Black women [ 10 , 11 , 15 ].

Inconsistent U.S. parity—post-reproductive mortality findings are not well-addressed in the literature and may reflect selectivity in childlessness status due to infecundity and other selective processes. In this paper, we refer to (in)fecundity as the (in)ability to reproduce, and refer to fertility or observed parity as the number of (live) children born [ 16 ]. Infecundity refers to the physiological incapacity to bear live children. Childless women (zero observed births) pose a problem in parity—post-reproductive mortality studies because they are a heterogeneous group: they might have been sorted into nulliparity due to their own biologically-based infecundity or other factors, such as voluntary control of childbearing, nonmarital celibacy, or spousal infertility [ 16 – 20 ]. This problem may underlie inconsistent U.S. findings: it is under-appreciated that pre-1940s birth cohorts of U.S. Black women had both higher fertility rates and higher childlessness rates than White age peers, with the latter partially attributable to poorer reproductive health and infecundity [ 20 – 23 ]. To better understand the parity—post-reproductive mortality relationship, we examine fertility as a process, where observed parity is contingent on women’s differential probabilities of (in)fecundity (their biophysiological likelihood of bearing children) associated with early-life-course factors, including health and social environments [ 17 , 18 , 24 ]. Social environmental factors are also associated with race/ethnicity-related health inequities [ 25 ]. Consequently, selectivity in childlessness due to infecundity may differentially shape parity—post-reproductive mortality associations and contribute to race/ethnic-related differences in associations net of other social determinants of health, parity, and mortality.

Using data from the 1992–1998 waves of the Health and Retirement Study (HRS), we follow 1920–1941 birth cohorts of non-Hispanic Black and White women through 2018. We first use zero-inflation count models to examine women’s probability of membership in a latent infecund class. We then use proportional hazards models to examine the associations between women’s probability of infecundity, observed parity categories, and all-cause mortality. In analyses focused on parous women, we examine the associations of timing variables—age at first birth and premarital birth—with all-cause mortality. In all analyses, we examine race/ethnic-related differences in these associations, accounting for infecundity risk. Because social and health selection processes occurring over the life course contribute to the parity—post-reproductive mortality association [ 7 , 19 , 26 ], we sequentially adjust for place-of-birth factors, early-life-course health and socioeconomic statuses, and adult (post-reproductive) socioeconomic, marital, and health statuses in the nested proportional hazards models we estimate.

Factors contributing to parity–mortality associations

The childbearing context.

The characteristics of populations, including their historical settings, contribute to observed parity—post-reproductive mortality associations [ 23 ]. For example, an early meta-analysis of 31 studies of women by Hurt and colleagues found one strong relationship among otherwise inconsistent ones [ 26 ]. In twelve of thirteen historical cohorts studied, mortality was highest among childless and low-parity women and declined with parity; contemporary birth cohorts, in contrast, more often exhibited U- or J-shaped parity-mortality curves. Subsequent meta-analyses also report U- or J-shaped curves in recent but not older birth cohorts [ 27 , 28 ]. Different associations by birth cohort partly reflect changes in childbearing contexts. The historical birth cohorts in Hurt et al.’s study [ 26 ] were high-fertility populations exposed to high rates of infant mortality. In this context, childless women were more likely childless involuntarily and not because of conscious, voluntary control of childbearing that could threaten community (and personal old-age) survival, religious beliefs, and/or other societal norms. Populations that do and do not practice fertility control are distinctive and observed parity—post-reproductive mortality associations likely differ on this basis [ 19 , 26 ].

This distinction has implications for U.S. parity-post–reproductive mortality research. Most U.S. studies sample early- to mid-twentieth century U.S. birth cohorts. Women in these historical birth cohorts shared atypical marriage and childbearing patterns; many could have given birth between 1946–1964, thereby contributing to the historical Baby Boom. Unlike women in contemporary birth cohorts, they more likely married, married prior to age 25, preferred to bear at least one child, had higher completed fertility, and primarily gave birth within marriage [ 7 , 29 ]. Indeed, one advantage of studying historical populations marked by a high prevalence of early marriage and marital childbearing, is that the parity—post-reproductive mortality relationship is less likely to be masked. Another advantage is that the potential selectivity surrounding marital childbearing that occurs in contemporary birth cohorts is minimized [ 7 , 12 ].

Yet, U.S. studies have overlooked U.S. childbearing contexts—and associated reproductive behaviors—that diverged by Census region and race/ethnicity. For example, the marital fertility rates of Black and White women in the American South, through the early 1900s, resembled levels found in populations that do not voluntarily control their fertility (i.e., natural fertility populations) [ 21 ]. Comparatively higher southern fertility rates then persisted to the 1940s [ 30 ]. Fertility control practices, however, diverged more by race/ethnicity than region [ 21 , 22 ]. Southern White women by 1900, like White women in all U.S. regions, show evidence of fertility control by both limiting marriage (nuptiality) and marital fertility [ 21 , 29 ]. Southern Black women compared to all White women, to the 1940s, more likely married, remarried, had higher fertility rates, and less-likely limited marital childbearing [ 20 , 21 , 22 , 31 ]. Their reproductive practices reflected their distinctive childbearing contexts: about 95% of U.S. Black women in 1900 (dropping to 75% in 1940) lived in the South and larger family sizes benefited their predominantly agricultural, but not land-owning, household economies [ 32 , 33 ].

Yet, Black women born between 1880 and 1940 had remarkably higher rates of childlessness than White age peers. A crossover in childlessness rates first occurred in mid-1880s U.S. birth cohorts: about 22% of White and Black women had remained childless by midlife, although Black women’s rates were rising and White women’s rates were declining [ 34 – 37 ]. About 20% of White women in the 1909 birth cohort remained childless, falling to about 6–7% in 1924–1929 birth cohorts [ 36 , 37 ]. In contrast, about 30% of Black women in 1909 to 1924 birth cohorts remained childless, falling to about 15%—twice the level of White women—in early 1930s birth cohorts [ 35 , 36 , 37 ]. A second crossover emerged in the 1942 birth cohort (approximately) as White women’s childlessness rates rose to surpass Black women’s rates, producing a reversal in the U.S. race/ethnic-related gap in childlessness [ 35 , 36 , 37 ]. It is important, however, that forces underlying childlessness rates differed by historical period and race/ethnicity. The initial 1880s crossover and new race/ethnic-related gap reflected Black women’s poorer reproductive health [ 17 , 22 , 33 , 34 ]. The 1940s crossover and reversed race/ethnic-related gap reflected Black women’s falling childlessness rates due to improving health [ 17 , 22 ] and White women’s rising rates, due to greater adoption of conscious fertility control and two-child fertility and childlessness norms [ 29 , 37 , 38 ].

Studies that examine parity progression further suggest divergent race/ethnic-related fertility control patterns in 1880–1940 U.S. birth cohorts. They reveal that the higher fertility-higher childlessness pattern in 1880–1940 birth cohorts of Black women manifested as a fecundity threshold, such that parous Black women able to have at least one child more likely had a next birth with each succeeding birth (i.e., no evidence of stopping at a particular parity) [ 34 , 35 ]. In contrast, parous White women in the same birth cohorts were less likely to have a next birth with each succeeding birth (i.e., evidence of stopping or voluntary limitation) [ 34 , 35 ].

These period, Census region, and race/ethnic-related differences in fertility patterns provide evidence that biophysiological in conjunction with social-environmental factors anchor parity—post-reproductive mortality associations [ 1 ]. The latter factors shaping childbearing contexts include: economic development and related factors that improve survival environments [ 6 , 39 ]; shifting policies and norms about women’s education, work, and family formation [ 27 , 40 ]; structural and regional race/ethnic-related inequalities [ 25 ]; and societal norms about childbearing limitation [ 38 ]. We address these factors further, below.

Biophysiological factors

Disposable soma and other evolutionary frameworks motivate much parity-mortality research. Researchers posit that the greater biological impetus to reproduce, rather than to maintain physiological fitness, comes with a biophysiological cost or trade-off: higher parity should shorten, and lower parity lengthen lifespans [ 41 ]. Although evolutionary pressures are difficult to empirically isolate in human studies, there is evidence of this expected trade-off in studies using multi-generational data within homogeneous (elite) populations [ 41 ]. Some contemporary Census-based studies also report this expected trade-off [ 12 ], while others do not [ 2 , 42 ]. However, meta-analytic studies find childlessness and lower parity associated with shorter, not longer, lives—the opposite of the expected trade-off—in historical high-fertility, high-mortality populations [ 26 ]. Recent studies examining this trade-off in the context of modern, higher living standards, reduced infectious disease, and reduced risk of early-life mortality—better survival environments—also yield inconsistent results [ 6 , 39 ]. In such contexts, however, more highly-resourced populations should be better able to overcome biophysiological constraints [ 6 ].

Importantly, interpretation of all findings from these studies is complicated by the inconsistent inclusion of nulliparous women across analytic samples; their exclusion can obscure left-hand portions of J- or U-shaped distributions. Studies also elide differences in childbearing contexts, especially their influence on the prevalence of voluntary limitation practices [ 19 , 26 ]. No study empirically distinguishes involuntary and voluntary childlessness and therefore, by default, all studies combine the infecund and the voluntarily childless, if they include the childless at all. Together, these factors may account for a lack of an expected trade-off pattern. As such, a default selective “healthy pregnant woman effect” may underlie observed historical population patterns: only reproductive-aged women with the physiological resilience to have reproductive ability and survive exposure to infectious diseases, malnutrition, and other health risks, including actual childbearing, reach higher parities and post-reproductive age [ 12 , 19 , 26 ].

Social environmental factors

Maternal depletion frameworks highlight the reproductive versus biophysiological/ metabolic trade-off but conceptualize maternal childbearing as resource-depleting or resource-neutral, not resource-enhancing. Maternal resource repletion between births or after the completion of childbearing is possible, albeit variably contingent on community, social, and familial resources [ 43 , 44 ]. Generally, it occurs more in resource-rich and healthful environments than in resource-poor and/or high-reproductive-risk environments [ 43 , 44 , 45 ].

Additionally, and of special relevance to our study, repletion is least likely when women’s reproductive careers are embedded in lifetime trajectories of structural disadvantage that produce chronic physiologically stressful conditions [ 45 ]. Critically, higher childlessness rates in 1880–1940 birth cohorts of U.S. Black women reflected childbearing contexts marked by greater exposure to infectious and nutritional diseases and environmental health risks, such as poor housing quality, compared to White age peers [ 22 , 23 , 34 ]. Southern Black childbearing-aged women had twice or higher mortality rates from southern infectious and nutritional diseases, such as malaria and pellagra, and from tuberculosis and venereal diseases [ 17 , 46 – 48 ]. Among survivors, the cumulative effect of these exposures across the life course, amidst structural racism as practiced in the Jim Crow South [ 49 , 50 ], would significantly impair health, including processes of maternal repletion.

Social determinants of health [ 51 ] and “weathering” frameworks focus attention on the embodiment of social disadvantage. Weathering conceptualizes the emergence of global health deficits (i.e., not limited to reproduction) as a lifelong process of: accumulated and accelerated childhood physical maturation, embodied as the early onset of menarche [ 52 ]; high rates of pregnancy complications associated with poorer maternal and fetal health [ 15 ]; premature aging associated with high chronic disease prevalence rates at midlife [ 53 ]; and reduced longevity [ 11 , 54 ]. Weathering implicates social and biophysiological mechanisms, including disadvantaged family origins, individual experiences of adversity, and low socioeconomic status in adulthood [ 11 ]. In most U.S. reproductive health studies, even with these factors controlled, race/ethnicity—and by this we mean unmeasured factors associated with race/ethnicity [ 25 ]—remains significant [ 10 , 11 , 14 ].

Studies testing social integration perspectives find parity-health and -mortality relationships influenced by and through social networks of support, including families of origin, spouses or partners, adult children, and fictive kin [ 3 , 7 , 9 , 27 , 55 ]. The identified mechanisms by which kin support is beneficial include financial and instrumental help and/or emotional support [ 43 , 55 ]. For example, greater longevity among couples with higher fertility may reflect influences of long-term companionship, social integration, and support from adult children [ 9 , 55 ]. Greater risk of post-reproductive mortality among the childless may reflect social norms that privilege women as mothers over the life course, inclusive of social and/or economic supports at the end of life [ 40 ]. Alternatively, it may be that the health behaviors of those with higher-fertility become more health-protective with increased childrearing experience [ 9 ]. Statistical controls for social factors, among the parous, can substantially attenuate or reduce parity—post-reproductive mortality associations to non-significance [ 40 , 55 ]. However kin support—and the need for support—likely varied by whether childlessness resulted from involuntary versus voluntary (i.e., planful) circumstances.

Influences of socioeconomic and health factors on parity—post-reproductive mortality associations reflect social selection as well as social causation. Families of origin differ in their capacity to provide education, foster health, provide nutritious foods, and socialize children about life roles, including parenting and the expected timing and sequencing of marriage and childbearing [ 38 , 40 ]. Some of the factors noted above (e.g., childhood poverty, poor living standards) are likely associated with both childlessness and high fertility, albeit though different mechanisms. They also are likely to vary in relation to race/ethnicity. While early parity-mortality studies did not always theorize or adequately measure social and health selection [ 7 , 26 ], current studies that adjust for these factors find that selective processes cumulatively exert their influence from childhood through adulthood and account for a portion of the parity—post-reproductive-mortality association [ 1 , 5 , 7 , 11 ]. These studies advance our understanding of the links between parity and mortality, but no study has examined whether health and social selectivity that is sufficiently severe to preclude childbearing is a contributing factor.

Research aims

The mortality risk of childless women may exceed that of all other women [ 26 , 27 , 28 ]. However, studies often sidestep this issue, as a result of study design, by excluding nulliparous women from their analyses. No study to date has examined the possibility of heterogeneous associations between involuntary and voluntary childlessness and post-reproductive mortality, or whether a consideration of involuntary childlessness can contribute to our understanding of race/ethnic-related differences in parity—post-reproductive mortality associations.

The current study has three aims that address these issues. First, we examine women’s probability of infecundity (i.e., involuntary childlessness) in a sample of non-Hispanic Black and White women born between 1920 and 1941. A first hypothesis is that:

• Hypothesis 1 : We expect to find that Black women have a higher probability of infecundity, but, at the same time, an equal or higher mean number of births relative to White women.

Second, we examine whether women’s probability of infecundity plays a substantively important role in parity—post-reproductive-mortality associations, net of the childhood and adulthood socioeconomic and health contexts that prevailed for Black and White women in these historical birth cohorts. Specifically:

• Hypothesis 2 : We expect to find a U-shaped parity-mortality association such that infecundity risk, low parity, and high parity, relative to 2 births, are positively associated with mortality.
• Hypothesis 3 : We expect to find that the life-course timing of childbearing is associated with mortality such that premarital birth, and younger and older age at first birth, elevate mortality risk.

Finally, U.S. scholars have long argued that poorer health and living standards contributed to higher Black than White rates of early twentieth-century childlessness [ 17 , 23 , 34 , 35 ]. We examine whether race/ethnic-related differences in parity—post-reproductive mortality associations remain after adjusting for the probability of infecundity, and selected variables measuring women’s childhood and adulthood health and socioeconomic statuses.

• Hypothesis 4 : We expect to find that race-related differences in mortality risk are only partially explained by parity and its timing, such that Black women will have greater post-reproductive mortality risk than White women.

Material and methods

Data and sample.

We use the Health and Retirement Study (HRS), a nationally representative longitudinal study of U.S. adults. The first wave, conducted in 1992, interviewed persons born between 1931 and 1941 (ages 51–61 years); second and third waves were fielded in 1994 and 1996, respectively. A companion study conducted in 1993, the Study of Asset and Health Dynamics of the Oldest Old (AHEAD), interviewed persons born in 1924 or before; a second wave was fielded in 1995. In 1998, HRS and AHEAD cohorts were merged, and the Children of the Great Depression (CODA) cohort, born between 1925 and 1930, was added. HRS and AHEAD cohorts oversampled Black adults and the 1992 screener used to generate the initial HRS and AHEAD cohorts oversampled Florida residents. HRS and AHEAD response rates were 81.1% in 1992/1993, 90.7% in 1994/1995, 86.9% in 1996, and 83.8% in 1998 [ 56 ].

This study’s main HRS data source is the RAND Longitudinal 1992–2018 (Version 2) database (hereafter RAND). The RAND provides harmonized responses for selected measures across all HRS and AHEAD waves. We linked the RAND to two HRS databases, the Cross-Wave Geographic Information (State) Restricted Data File (1992–2020) and the Exit Date of Death Restricted File (1992–2020), to obtain participants’ states of birth and dates of death, respectively. We additionally linked the RAND to the: RAND Family Respondent File (1992–2014); RAND Detailed Imputation File (1992–2020); HRS 2020 Tracker File; and CORE-Demography files in each of the 1992, 1994, 1996, 1998 HRS and 1993, 1995 AHEAD waves. We limited analyses to women who self-identified as non-Hispanic Black or White, were born between 1920 and 1941, and entered the sample between 1992–1998. The lower birth cohort bound (1920) avoids population health anomalies associated with the U.S. influenza epidemic (1918–1919) and the upper bound (1941) avoids the 1940s race/ethnic-related shift in childlessness [ 35 , 36 ].

We linked the RAND data to Eriksson et al.’s [ 57 ] Revised Infant Mortality Rates and Births for the United States, 1915–1940. Eriksson et al.’s (2018) database provides better historical estimates of live births (denominators) than available in vital statistics data, although it uses unaltered infant deaths (numerators) taken from vital statistics data. We use Adjustment 4 that accounts for migration and other sources of lumpiness in birth rate data across states/time. We linked the IMR for each participant’s year and state of birth to her record using the appropriate birthplace Federal Information Processing Standards (FIPS) code provided in the HRS Restricted Geographic Information File. We excluded from the analytic sample women lacking a state FIPS code and women with missing data on early-life-course marital statuses and baseline health conditions (see S1 Table ). The final analytic sample includes 7,322 women (unweighted). The Duke University Institutional Research Board approved this study’s protocol (#2019–0641).

Dependent variables

We obtained the first dependent variable, number of Children Ever Born , from the RAND. The HRS asked participants about their number of live births at intake interviews (HRS 1992–1998; AHEAD 1993–1995). About 6% of the sample had missing values for the RAND harmonized variable; we used a second variable, participant’s number of Own (living) Children , taken from the RAND Family Respondent File, to fill in missing values and flagged this substitution in the count regression models we estimated. The final distribution of the Children Ever Born variable had ten outliers; to address this, we assigned women with 10 or more children a value of 10.

All-cause mortality.

We followed participants to December 31, 2018, using the HRS Restricted Mortality File (RM), 2020 Tracker File, and RAND in-wave status variables to determine survival, death, and attrition statuses. Fifty-nine percent of participants died over the follow-up period; we consider those alive on the follow-up date to be right-censored. About 9% of participants left the sample prior to this date. From Tracker-File data, we assigned each attritor a date of death or date when last known to be alive and treated those observations as right-censored (see Analytic Strategy below).

Primary independent measures

Observed parity and timing indicators..

Using RAND Family Respondent File (1992–2014) data to determine Age at First Birth , we subtracted the age of each participant’s self-reported oldest own child at the intake interview from the participant’s age at the intake interview if both were reported. (This database provides information only about each participant’s oldest and youngest currently-living child with whom they were in contact at the intake interview, not all children born.) If an oldest own child’s age was missing at the intake wave, we used the oldest own child age reported in the next available wave, subtracting it from the participant’s age at that wave. Consistent with Henretta [ 7 ], we considered women 20 years of age or younger at first birth to have an Early Age at First Birth and women with first births after age 35 years to have a Late Age at First Birth . We considered women whose age at first birth was less than their marital age to have had a Premarital Birth . Notably, HRS/AHEAD women were not queried about cohabiting unions; a cohabiting union pre-dating a reported first marriage may have produced reported children. Also, RAND Family data on children’s ages are not uniformly reliable [ 7 ].

Adjustment measures

Demographic characteristics..

Participant Age is year of age at the intake interview, taken from the HRS 2020 Tracker File. Race/Ethnicity , self-reported, is non-Hispanic Black, with non-Hispanic White as the reference.

Birthplace characteristics.

We examined parity-mortality associations in the context of birthplace health environment, as indicated by the Infant Mortality Rate (IMR) in each participant’s state and year of birth. The IMR is a robust measure of population health, aggregate income level, and living standards [ 11 ]. When participant IMR was missing due to non-reporting birth state, we imputed state/year values from 20 imputed datasets [ 58 ]. We used a dichotomous variable to indicate participants Born in the South (as defined by the U.S. Census). Birth in another U.S. region is the reference.

Childhood socioeconomic and health status.

RAND harmonizes mother and father educational status indicators across waves. Parent education for AHEAD cohorts referenced parent(s) having an 8 th grade attainment level or not. To maintain HRS/AHEAD consistency, we distinguished, for all participants, Parent Education categorically: father attaining 8 th grade or higher, missing, with attaining less than 8 th grade as the reference. We filled in missing values with mother’s attainment relative to completing 8 th grade.

Participants in the 1998 HRS wave reported health status to age 16, ranging from excellent (1) to poor (5). We constructed categorical Self-Rated Childhood Health , with categories of poor/fair and missing; good/very good/ excellent health is the reference.

Number of Living Siblings , harmonized in the RAND from intake interviews, is an ordinal indicator of each participant’s mother’s reproductive fitness (i.e., biophysiological factors) and participant’s childhood socialization about normative family size (i.e., social environmental factors).

Marital histories.

Marital Duration , in years, is obtained from a RAND harmonized variable reporting the duration of a woman’s longest marriage. Age at Marriag e denotes, in this era, the normative initiation of exposure to the risk of pregnancy. HRS and AHEAD developed different algorithms to query participants about marital histories. At the baseline interview, about 72% of women in our sample reported a single marriage, 26% reported a higher-order marriage, and 2.9% reported being never-married. To construct Age at Marriage for the first-married, we subtracted each participant’s year of birth from their year of marriage, if reported. If year of marriage was missing, we subtracted baseline Longest Marital Duration (given in years in the RAND) from the interview year to derive year of marriage; we then subtracted year of birth from this value. For those in higher-order marriages, we used the earliest reported year of marriage in women’s intake records and subtracted year of birth from this value. For AHEAD widowed/ divorced/cohabiting participants, we used the reported year that their marriage ended and its duration in years to derive Age at Marriage . Preliminary analysis of the joint distributions of Age at Marriage and Children Ever Born indicated that almost a third of the 212 never-married women had children and nearly 20% had two or more children. HRS/AHEAD women were not queried about non-marital unions, known to be associated with model variables of race/ethnicity, social class, health resources, and birth timing. Rather than exclude them, we assigned never-married women the mean Age at Marriage for the sample, flagging the substitution in the Children Ever Born count analyses. Sensitivity analyses that (1) used age at marriage categories including never-married and (2) excluded all never-married women produced the same substantive results as those we report in the paper.

Adult socioeconomic status.

Most U.S. women born before 1941 completed education prior to the onset of childbearing. However, the 1960s U.S. Manpower Act and economic growth fueled a boom in adult education, including for middle-aged women whose children had aged out of the home [ 59 ]. We consider completed Education at the intake interview as adult socioeconomic status; we used a RAND harmonized education measure to form categories of less than high school and greater than high school, with high school graduate/GED serving as the reference category. We additionally created measures of baseline Household Income (logged) and Home Ownership , a dichotomy, using RAND Detailed Imputation File data. Preliminary analyses of mortality included baseline household wealth, but inclusion of this measure did not improve model fit. Thus, we do not adjust for household wealth.

Adult health status and health behaviors.

A variable, Number of Medical Conditions , taken from the RAND, indicates whether participants at intake interviews ever had physician-diagnosed high blood pressure, diabetes, heart disease, stroke, lung disease, cancer, or arthritis. We also adjust for health behaviors [ 60 ]. Ever Smoked , observed at the intake wave, is a dichotomous variable indicating whether a woman ever smoked. Alcohol Use was ascertained by different questions across intake waves. We coded heavy drinking as having 3+ drinks/day for HRS 1992 and AHEAD 1993 participants and as drinking 5 or more days a week for HRS 1994–1998 and AHEAD 1995 participants.

Analytic strategy

Table 1 reports sample characteristics as proportions for categorical variables and means and standard deviations for continuous variables. All statistical analyses in Tables 1 – 5 report significance tests based on 95% confidence intervals.

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Fertility count models and infecundity risk

The first dependent variable in our study, Number of Children Born, is a count. Count regression methods are recommended for modeling count dependent variables as they have non-normal distributions. A first-choice model, a Poisson count model, assumes relative homogeneity in a study population (assumes that count equation variance is equal to its mean), although study populations’ characteristics might vary. Statistical tests of Poisson model fit to the data allow this assumption to be rejected. If so, (e.g., if there is a great deal of error variance or dispersion in the Poisson model), a next step is to estimate a negative binomial count model that relaxes the Poisson variance-equal-to-the-mean assumption.

Preliminary analysis of our sample showed that 10.5% of Black women and 8.6% of White women had zero births. We knew that, in theory, childlessness (zero births) among sample women might have reflected prior biophysiological (infecundity) or voluntary limitation processes. Moreover, if two different underlying processes (infecundity versus childbearing control) had produced zero births, two different groups of childless women would be present in our sample. The childless women from different groups could “inflate” the zeros in the fertility count. A negative binomial count model, used to relax the assumption of population homogeneity, might still not provide an adequate or best fit to the data.

That different underlying processes can produce different groups of childless women poses the problem of distinguishing the infecund from voluntarily childless nulliparous women. Fertility studies address this problem by additionally testing fit to the data of zero-inflation Poisson (ZIP) and zero-inflation negative binomial (ZINB) count models [ 61 , 62 ]. These models estimate the sample women’s probabilistic membership in one of two possible latent groups: an “always-zero” or infecund group and a group where women might have zero births but do not statistically fall into the always-zero profile [ 61 – 64 ]. Specifically, zero inflation models estimate a count of women’s observed number of children born as a function of two distinct processes: (1) a logistic (or probit) process that distinguishes a possible latent, always-zero group of probabilistically infecund women; and (2) a count process that estimates the parity distribution among probably fecund women, also allowing for zero births [ 62 , 63 ]. Zero-inflation models allow evaluation of the hypothesis that there is a latent always-zero (i.e., infecund) class of women in the data.

Using Proc Genmod, in SAS 9.4, we modeled women’s Number of Children Born as a function of: age; age at marriage (polynomial), marital duration [ 64 ], and number of siblings and race/ethnicity. We initially used Poisson count models. Finding considerable dispersion, we additionally examined negative binomial and ZIP and ZINB models. We compared, across regression models, model fit to the data using: ratios of Pearson chi-square and deviance scores to degrees of freedom to test overdispersion; and Clarke tests to determine the presence/absence of a distinct latent always-zero class of probabilistically infecund women. We also examined overall model fit and parsimony of fit by using plots of predicted count distributions against the observed count and BIC scores, respectively. To preview findings, the ZINB functional form best fits the data and identify women with a statistically high probability of selection into an always-zero parity class. In the sample, the correlation between the probability of selection into an always-zero parity latent class and an observed zero parity (childless) category is .27; the R 2 (% of variance explained) is 7.3% (0.27 x 0.27 = 0.073). After standardizing the distribution (mean = 0, SD = 1), we exported each woman’s probability of being in an always-zero parity class as a variable, Infecundity , and included Infecundity in the proportional hazard models to examine its association, alongside the association of observed parity, with all-cause mortality.

Mortality: Proportional hazards models

In estimating all-cause mortality, we modeled sample attrition as a cause-specific competing risk, treating it as right-censoring. We first conducted preliminary tests of the proportional hazards assumption for all model variables in the full sample and in the race/ethnic-specific subsamples by examining: (1) correlations between Schoenfeld residuals for each variable and the ranked order of failure time among those who died; and (2) interactions of each variable with time. Both tests indicated non-violation of the proportional hazards assumption, except for race/ethnicity (pooled sample) and both linear and categorized age (pooled and race/ethnic-specific samples). Further examination of full-sample mortality equations also revealed statistically significant interactions of race*linear age and race*categorical age.

Due to evidence of nonproportionality by race/ethnicity, linear age, and age group, we adopted age-stratified proportional hazards models to examine mortality in the full sample of women and in race/ethnic-specific subsamples. A graphical analysis of age group log-log curves generated from the equations in pooled and race/ethnic-specific samples indicated that the age-group strata were approximately proportional [ 65 ]. S2 Table reports full-sample results using best-fit linear age model adjustments instead of age-group stratification; parity—post-reproductive mortality findings do not substantively differ from age-stratified models.

In full-sample ( Table 3 ; full results in S3 Table ) and race/ethnic-specific analyses (Tables 4 and 5 ; full results in S4 and S5 Tables, respectively), we further differentiated parous plus nulliparous women (all women) from parous women. In all-women analyses, we tested parity—post-reproductive mortality associations using Infecundity probabilities and observed parity categories of 0, 1, 3, 4, 5, and 6+, with 2 births as the reference category for observed parity. In parous women analyses, we tested parity-mortality associations using the observed parities of 1, 3, 4, 5, 6+, with 2 births as the reference, and included early age of first birth, late age at first birth, and premarital birth. We report the results of likelihood ratio statistical significance tests for observed parity categories, as a group, in all models.

In the full sample of women ( Table 3 ), age-stratified Model 1 examines observed parity only. Age-stratified Model 2, for parous plus nulliparous women, examines women’s probability of Infecundity and observed parity. Age-stratified Model 5, for parous women, examines the main effects of the life-course timing and observed parity variables. It is also important to adjust parity-mortality associations for health and socioeconomic selection processes that operate over the life course and are associated with both parity and mortality [ 7 , 11 ]. Accordingly, age-stratified Models 3 and 6 adjust for race/ethnicity, birth place, and early life-course health and socioeconomic statuses. Models 4 and 7 further adjust for adult socioeconomic, health, health behavior, and marital statuses. We followed this same procedure in race/ethnic-specific analyses (Tables 4 and 5 ).

Information about children ever born, harmonized in RAND, was directly reported by HRS/AHEAD participants. In contrast, the RAND Family Respondent File ascertained participants’ number of in-contact, alive children from household and participant records. As HRS/RAND data do not report children surviving in the context of children ever born, and RAND Family data do not report deaths/death dates of children who died prior to HRS/AHEAD at baseline, there is a measurement gap: given the universe of children ever born, we only have information about surviving children in late-life (RAND Family Respondent File). This gap suggests that, among parous women, age of oldest child in RAND Family data may be mis-stated. This could introduce error in age at birth findings, contingent on whether even earlier-born child(ren) had died/lost contact (i.e., were not present in the RAND Family roster). In a sensitivity analysis (see S6 Table ), we examined possible measurement error in age at first birth variables used in Models for parous women. We created a Flag variable that differentiated number of children ever born and number of own alive, in-contact children in late-life. The Flag = 1 applied if women’s number of children born differed from their number of in-contact, living children in late-life or = 0 if the number of children matched . We found that statistical results (the size and significance of hazard ratios) for age at first birth variables did not change when Flags were included in Models. All models in this study use cluster-robust sandwich standard errors due to birth-state clustering (state FIPS).

Descriptive statistics

Table 1 describes the analytic sample. The sample is 17.4% Black and has a mean age of 61.39 years. The mean number of children born is 3.07; 9% of women were childless and almost 11% had borne 6 or more children. Parity distributions differed by race/ethnicity; more Black women were childless (10.5% versus 8.6%), gave birth to 1 child (12.2% versus 9.4%), or had 6+ children (25.3% versus 7.8%). Additionally, Black women more likely had a first birth at age 20 or less (64.6% versus 49.0%) and a premarital birth (53.2% versus 37.5%).

Count model

Table 2 presents ZINB estimates of Number of Children Born . The count model (top of the column) displays results as beta coefficients and exponentiated incidence rate ratios (IRRs). The count model finds that an older age at marriage—which would reduce exposure time to the risk of pregnancy within marriage—is associated with lower parity although marital age was less influential at older ages as indicated by the negative polynomial term. A squared term for marital duration does not improve model fit. Black women, net of other measures, have higher fertility; their expected number of children is 40% higher than White women’s expected number of children (Black beta exp .34 = 1.40). The estimated marginal mean number of children for Black women (i.e., least square mean based on all estimated effects in the count model) is 4.11; the estimated marginal mean for White women is 2.91 (not in Table). Women with higher-parity mothers (i.e., with more siblings) had more children, perhaps reflecting reproductive fitness and/or greater childhood exposure to religious or social norms predisposing to larger family sizes and/or avoidance of fertility control practices [ 40 ].

The zero-inflation portion of the ZINB model (Always-Zero Model) estimates women’s probability of selection into a latent always-zero class. Black women’s probabilities are twice that of White women’s: the mean predicted probability is 0.029 for White women and 0.074 for Black women (not shown in Table 2 ). Age and marital age represent biological parameters of reproductive physiological maturation [ 61 ]. Older age and older age at marriage are associated with a higher probability of always-zero class membership, although, again, marital age was less influential at the oldest ages as indicated by the negative polynomial term.

The models in Table 2 , taken together, suggest a fecundity threshold where Black women, compared to White women, have a higher probability of always-zero class membership and higher parity if fecund (Hypothesis 1). The ZINB model best fits the parity distribution in our sample and identifies a latent class of women at high risk of infecundity. We incorporate women’s probability of always-zero latent class membership, Infecundity , into our mortality analyses to account for zero-category heterogeneity in examining observed parity—post-reproductive mortality associations.

All-cause mortality, full sample models

Table 3 reports age-stratified proportional hazards estimates of all-cause mortality. Full model findings are available in S3 Table . In Model 1, the observed parity HRs pertaining to 0, 1, 4, 5, and 6+ births are all statistically significant, relative to a 2-birth reference. In Model 2, the Infecundity HR is associated with higher mortality and HRs for observed parities 1, 4, 5, and 6+ remain statistically significant; the 95% CI of the observed 0 birth category includes 1. Model 3 adjusts for birthplace region, IMR, childhood self-rated health, and family-of-origin socioeconomic variables; the Infecundity HR is statistically significant and approximately the same observed parity pattern holds, although the 4-birth category is only marginally significant. With the inclusion of post-reproductive-age adult health, marital, and socioeconomic statuses, parity—post-reproductive mortality associations are not statistically significant as a group. Consequently, we find only partial support for Hypothesis 2 although, notably, Infecundity remains significant in Model 4.

Parous women with one birth and with 6+ births (Model 5) have significantly elevated mortality risk relative to the 2-birth reference group, adjusting for timing variables. Observed parity indicators do not reach statistical significance as a group in Models 6 and 7 after adjusting for childhood and adulthood statuses, respectively. Regarding timing variables, an early age of first birth is statistically significant in Model 5, and in Model 6 with adjustment for childhood variables, but is not statistically significant in Model 7. However, in partial support for Hypotheses 3, the positive association between premarital birth and mortality remains statistically significant, adjusting for childhood and adulthood statuses (Models 5–7).

Overall, mortality risk is significantly elevated, with and without adjustment, among women with higher probabilities of Infecundity and among Black women. The parity—post-reproductive mortality relationship for all women (Models 1–3) and parous women (Model 5) exhibits a U-shaped distribution prior to adjustment for resources and statuses measured among survivors at post-reproductive ages.

All-cause mortality, race/ethnic-specific models

Preliminary analyses revealed evidence of age*race/ethnicity interactions (see S2 Table ). Thus, we examine parity and timing associations with mortality in race/ethnic-specific subsamples. Tables 4 and 5 present the results of age-stratified proportional hazards models for Black and White women, respectively. In Models 1–4 of Table 4 (Black parous and nulliparous women), observed parity categories do not reach statistical significance as a group, although Models 1 and 2 suggest a U-shaped pattern in the observed parity distribution at the extremes of observed zero and 6+ children. In Models 2 through 4, Infecundity is significantly associated with elevated mortality risk. However, against expectations (Hypothesis 3), timing variables in Models 5–7 (Black parous women) do not reach statistical significance.

In Table 5 Models 1–3 (White parous and nulliparous women), observed parity variables are statistically significant as a group and exhibit a U-shaped distribution. In Model 3, HRs for 0, 1, 4, 5, and 6+ births are statistically significant, adjusting for Infecundity , birthplace, and early-life-course selection factors. In Model 4, observed parity HRs do not reach statistical significance as a group with adjustment for adulthood variables. In Models 5 and 6 (White parous women), an early age of first birth, premarital birth, and having one-birth, relative to a 2-birth reference group, are associated with higher mortality, although the observed parity variables, as a group, are only statistically significant in Model 5. Full Model 7 finds partial support for Hypothesis 3: only premarital timing retains statistical significance.

Fig 1 illustrates Black:White observed parity—post-reproductive mortality associations taken from Tables 4 and 5 . For White women (Panel A), the unadjusted Model and the Model that adjusts for Infecundity risk only are U-shaped; the Infecundity risk adjustment only reduces the observed zero parity HR, while other observed parity HRs overlap the unadjusted HRs. This suggests that Infecundity primarily differentiates mortality risk among the childless. Further adjustment for childhood and adulthood variables in the fully adjusted model flattens the U-shape; parity categories are not statistically significant as a group ( Table 5 ).

For Black women (Panel B), in Models unadjusted and only adjusted for Infecundity risk, U-shapes suggest elevated mortality risk at parities 0 and 6+; with adjustment for Infecundity risk, the HRs decrease for observed parities zero and one and increase for observed parities 4, 5, and 6+. However, the observed parity categories for Black women are not statistically significant as a group ( Table 4 ).

https://doi.org/10.1371/journal.pone.0310629.g001

This study examined the parity—post-reproductive mortality relationship and race/ethnic-related differences in this relationship attributable to women’s differential biophysiological and social likelihoods of bearing children. We distinguished a nexus of biophysiological and social-environmental forces by focusing on the childbearing contexts of historical birth cohorts and used count regression methods to estimate women’s expected Number of Children Born , as well as their probability of membership in a latent always-zero parity class ( Infecundity ). As the ZINB equation best fit the data ( Table 2 ), a first main finding is that infecundity was non-random and identifiable among Black and White women in the HRS sample that we studied. Considering both portions of the ZINB equation together, Black women had a higher mean Number of Children Born and higher Infecundity risk than White women. These results provide evidence for Hypothesis 1.

We next estimated age-stratified proportional hazards models to test the associations between Infecundity risk, observed parity, and mortality in a pooled-sample of Black and White women ( Table 3 ) and in race/ethnic-specific samples of Black and White women (Tables 4 and 5 , respectively). Our second main finding is that a higher risk of Infecundity was always statistically associated with higher mortality risk for Black and White women, in pooled and race/ethnic-specific models. No adjustments to these models fully attenuated the mortality risk associated with higher Infecundity risk. In addition, observed parity—post-reproductive mortality associations in Tables for all women, Black women, and White women were U-shaped in models that did and did not adjust for Infecundity risk; this third finding provides partial support for Hypothesis 2.

Notably, marked race-ethnic differences also exist in observed parity—post-reproductive mortality associations. The associations did not reach statistical significance, as a group, in Black women’s models ( Table 4 ). By contrast, in the sample of White women, a statistically significant U-shaped distribution of parity—post-reproductive mortality associations ( Table 5 ), relative to a 2-birth reference, was present in models that did and did not adjust for Infecundity risk and early-life-course measures (i.e., Models 1, 2, and 3). Only the adjustment for resources and statuses, measured at post-reproductive ages, reduced observed parity—post-reproductive mortality associations, as a group, to non-significance (Model 4). Thus, a fourth main finding is that parity—post-reproductive mortality relationships differed by race/ethnicity in the birth cohorts we studied.

Why might this be so? Parity–mortality studies generally elide childbearing-context differences involving population fertility control practices [ 26 ] and survival environments [ 6 ]. Most U.S. Black women in pre-1940s birth cohorts—85% in the HRS sample—were southern-born, hence exposed to Jim Crow-era survival environments where “race,” a socio-legal organizing principle, allocated access to schools, health care, and occupations other than agriculture [ 48 , 49 , 50 ]. In our study, Black women exhibited a parity—post-reproductive mortality pattern ( Table 4 , Model 1) resembling that found in other historical birth cohorts, of higher mortality among the childless [ 26 , 27 , 28 ]. Further differentiation of “zero births” (Model 2) revealed that the higher mortality was associated with Infecundity (poor reproductive health). Black women in pre-1940s birth cohorts had high fertility as well ( Table 2 ) because the southern racialized economy tied their children’s economic value to agricultural field work more than education [ 23 , 33 , 48 ]. Black women’s poorer reproductive health and higher fertility was further linked to their children’s poorer survival odds [ 23 ] as high child mortality rates can foster precautionary avoidance of fertility control [ 66 ]. But, while Black women bore more children than White women, and their parity categories formed a U-shaped pattern ( Fig 1 ), the categories were not statistically significant as a group ( Table 4 ). We speculate that, because some infecundity (inability to reproduce) might have occurred after childbearing commenced (after a live birth) [ 16 ], Black women—due to poorer reproductive health—likely experienced infecundity risk with each birth, reducing their likelihood of reaching higher parity while suppressing the high-parity statistical risk of mortality. In the U.S. context, Black women would be more subject to “healthy pregnant women” selectivity, where healthier women were fecund, gave birth, and—because higher fertility amidst poor health and/or less repletion still carries its own health risks—survived to have a next child.

In contrast, White women’s U-shaped parity—post-reproductive mortality patterns, prior to adjustment for adult resources, resemble those found in contemporary birth cohorts ( Table 5 , Models 1–3) [ 25 , 26 , 27 ]. More striking, White women who had survived to post-reproductive ages had a low-parity peak in mortality risk at one child. This suggests that, subject to comparatively better survival environments over childbearing years, White women more likely achieved a first birth in spite of lower overall fertility ( Table 2 ). Their expectations of better child survival odds could promote fertility control practices. Additionally, White women’s better post-reproductive survival environments (e.g., higher living standards) statistically reduced both lower- and higher-parity post-reproductive mortality risk ( Table 5 , Model 4), net of Infecundity , although Infecundity remained significantly associated with post-reproductive mortality.

Population-level studies of early twentieth-century southern Black women link their poor reproductive health to extremely high rates of disease, poverty, and lack of medical care [ 17 , 46 , 67 ]. In the analyses based on the pooled sample ( Table 3 ), we find that nonparous and parous Black women have a 25% increased risk of mortality (Model 4) and parous Black women have a 22% increased risk of mortality (Model 7). Hence, a fifth finding is that the association of Black ancestry with post-reproductive mortality is not fully explained, despite adjustments for: Infecundity ; observed parity; and health and socioeconomic selectivity in childhood and at study enrollment in adulthood (Hypothesis 4). The persistent significance of race/ethnicity in fully adjusted models suggests additional, yet-unmeasured structural forces contributed to Black women’s higher rates of post-reproductive mortality, including cumulative exposure to the Jim Crow-era policies marked by racial discrimination, residential segregation (geographic place), and limited access to health-supportive social services and institutions (e.g., hospitals, institutions of higher education) [ 24 ].

Our study benefits from linking the RAND-harmonized HRS files to many other HRS-related databases. As a result of these linkages, we were able to examine women in the same historical birth cohorts with different reproductive practices and differentiate their lives across a wide range of life-course statuses associated with fertility and mortality (e.g., childhood background, education, later-life home ownership status). The data facilitated our ability to capture early-life-course selectivity in the same historical birth cohorts at the “front end” of parity-related mortality risk—i.e., the higher mortality risk associated with nulliparity and very low parity. Additionally, the prospective nature of the RAND allowed us to track participants for an average of 18.6 years, which is longer than most other U.S. parity—post-reproductive mortality studies. Combining the RAND with Vital Statistics data allowed us to examine: birthplace IMR, associated with community living standards and public health policies; socioeconomic selectivity early and late in life; and marital resources and health at survey baseline.

However, despite its strengths, this study cannot track selective processes influencing mortality that might have occurred during women’s reproductive years. Because of the age-eligibility criteria for enrollment in the HRS, our findings are conditional on women’s survival to midlife. Among fecund women, survival of a pregnancy enables progression to a higher parity category. This selective process evokes a default “healthy pregnant women effect,” which is most visible in high-mortality, high-fertility populations [ 25 ]. We know that early twentieth-century reproductive-age mortality was higher for Black than White women in the birth cohorts included in this study [ 64 ]. Consequently, our models likely under-estimate mortality risk among parous Black women. Other indirect evidence of reproductive period selection involving Black women is that their expected number of children is 40% higher than among White women—if they were fecund. Of course, having additional children required surviving prior pregnancies, which similarly evokes the default “healthy pregnant women effect” [ 25 ].

While our models contribute to understanding of the parity—post-reproductive mortality relationship by measuring selectivity in the transition to having at least one child (i.e., Infecundity ), due to the design of the HRS, we are unable to take selectivity in the survival of pregnancies among parous women into account. We cannot directly measure the mortality risk that surrounds having an additional child because we only observe women during the post-reproductive period. Disposable soma [ 12 , 21 , 25 ] and maternal repletion [ 44 ] scholars warn that examining current or completed parity in a sample of women can mask the parity-mortality relationship; information about infecundity and maternal mortality risk surrounding parity progression is omitted. To better understand the parity-mortality relationship, future data collection and research should concentrate on the formative influences of early-life exposures on women’s reproductive health and parity progression in reproductive careers. Studies of weathering processes that more fully measure the social determinants of health are needed.

Despite these limitations, our findings address an important gap in this research area. It is common practice in U.S. (and most extant) studies to include an observed birth category of zero births, or omit the category entirely and examine parous women only. However, as we show, women faced different contexts of selection into childlessness and their probability of selection affected their later mortality risk, net of other variables.

Much about the parity—post-reproductive mortality relationship remains unknown. The results of this study suggest directions for future research. For example, we control for number of medical conditions in adulthood in the models of all-cause mortality. However, no study to date has addressed the specific, prospective dynamics at the nexus of infecundity, parity, and the likelihoods (pathways) of individual medical conditions, their cumulation by later-life, and mortality. Clarifying these relationships will require better data collection to allow for more detailed consideration of the etiologies of these conditions and their associations with women’s parity and pregnancy histories, as well as their associations with mortality. Clarifying the relationships between infecundity, parity, and the likelihood, onset timing, and/or prevalence of individual medical conditions, and the pace of their accumulation, is especially important considering Black American women’s earlier trajectory of health decline [ 11 , 50 ].

Continued research on the social and biophysiological determinants of infecundity is warranted. Additionally, the onset of health deterioration earlier in the life course more directly overlaps the reproductive years of Black than White women and reflects—among current as well as historical birth cohorts—lack of equitable access to societal resources, including health care [ 68 ]. The results of this study indicate directions for ameliorative health policies, including the need to institutionalize universal, maternal care services that provide an added fourth trimester of post-delivery care. Past studies stressing maternal depletion, and current studies that locate most maternal mortality among today’s Black women in the post-partum period, all point to the need for post-delivery care to detect and remediate reproductive health problems [ 68 ]. Additionally, greater translational application of current weathering/reproduction research is warranted. In addition to a need for universal, expanded reproductive care, there is need to restructure it, with less segregation/siloing of care outside of primary care in order to optimize maternal health prior to a first pregnancy and provide on-going monitoring of longer-run sequelae of pregnancy [ 69 ].

Finally, our results highlight the importance of biophysiological and social environmental factors and how they combine to shape the parity—mortality relationship. Our results emphasize that the interweaving of diverse factors produce different fertility processes, reproductive outcomes, and differential mortality risk, also associated with race/ethnicity, in a manner indicating health disparities. It is important that future work examine race/ethnicity-related reproductive health disparities and the historical childbearing contexts that generate them.

Supporting information

S1 table. sample construction and data flow..

https://doi.org/10.1371/journal.pone.0310629.s001

S2 Table. Full age-adjusted proportional hazards models: All-cause mortality, black and white women.

https://doi.org/10.1371/journal.pone.0310629.s002

S3 Table. Full age-stratified proportional hazards models: All-cause mortality, black and white women.

https://doi.org/10.1371/journal.pone.0310629.s003

S4 Table. Full age-stratified proportional hazards models: All-cause mortality, black women.

https://doi.org/10.1371/journal.pone.0310629.s004

S5 Table. Full age-stratified proportional hazards models: All-cause mortality, white women.

https://doi.org/10.1371/journal.pone.0310629.s005

S6 Table. Reproductive timing sensitivity analysis: Stratified proportional hazards models: All-cause mortality, black and white women.

https://doi.org/10.1371/journal.pone.0310629.s006

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National Institute of Environmental Health Sciences

Your environment. your health., reproductive health, what is niehs doing, further reading, introduction.

Reproductive health refers to the condition of male and female reproductive systems during all life stages. These systems are made of organs and hormone-producing glands, including the pituitary gland in the brain. Ovaries in females and testicles in males are reproductive organs, or gonads, that maintain health of their respective systems. They also function as glands because they produce and release hormones.

Reproductive disorders affect millions of Americans each year.

Female disorders include:

• Early or delayed puberty.
• Endometriosis, a condition where the tissue that normally lines the inside of the womb, known as the endometrium, grows outside of it.
• Inadequate breastmilk supply.
• Infertility or reduced fertility (difficulty getting pregnant).
• Menstrual problems including heavy or irregular bleeding.
• Polycystic ovary syndrome, ovaries produce more male hormones than normal.
• Problems during pregnancy.
• Uterine fibroids, noncancerous growths in a woman’s uterus or womb.

Male disorders include:

• Impotence or erectile dysfunction.
• Low sperm count.

Scientists believe environmental factors likely play a role in some reproductive disorders. Research shows exposure to environmental factors could affect reproductive health in the following ways:

• Exposure to lead is linked to reduced fertility in both men and women. 1
• Mercury exposure has been linked to issues of the nervous system like memory, attention, and fine motor skills. 2
• Exposure to diethylstilbestrol (DES), a drug once prescribed to women during pregnancy, can lead to increased risks in their daughters of cancer, infertility, and pregnancy complications. 3
• Exposure to endocrine-disrupting compounds , chemicals that interfere with the body’s hormones, may contribute to problems with puberty, fertility, and pregnancy. 4
• Karen Clay, Margarita Portnykh, Edson Severnini. Toxic Truth: Lead and Fertility. 2019. NBER Working Paper No. 24607. [Accessed online 25 June 2019] [ Available Karen Clay, Margarita Portnykh, Edson Severnini. Toxic Truth: Lead and Fertility. 2019. NBER Working Paper No. 24607. [Accessed online 25 June 2019] ]
• U.S. Environmental Protection Agency (EPA). 2019. Health Effects of Exposures to Mercury. [Accessed June 25, 2019] [ Available U.S. Environmental Protection Agency (EPA). 2019. Health Effects of Exposures to Mercury. [Accessed June 25, 2019] ]
• American Cancer Society. 2019. DES Exposure: Questions and Answers. [Accessed June 25, 2019] [ Available American Cancer Society. 2019. DES Exposure: Questions and Answers. [Accessed June 25, 2019] ]
• Endocrine Society. Impact of Endocrine-disrupting Chemicals on Reproductive Systems. [Accessed June 25, 2019] [ Available Endocrine Society. Impact of Endocrine-disrupting Chemicals on Reproductive Systems. [Accessed June 25, 2019] ]

NIEHS conducts and funds research to understand environmental factors that may affect human reproductive health.

Heat exposure during pregnancy – NIEHS-funded researchers studied more than 400,000 pregnancies and found that both long- and short-term maternal heat exposures during pregnancy are associated with increased risk of severe maternal morbidity . The Centers for Disease Control and Prevention lists 21 different indicators of this medical condition that unexpectedly occurs after labor and delivery. The prevalence of severe maternal morbidity has continued to increase in the U.S. despite improvements in improvements in prenatal care coverage and quality.

Heavy lifting or shift work and decreased fertility – Two occupational factors for women – lifting heavy loads or working non-daytime schedules – are associated with fewer eggs in their ovaries, which could indicate decreased fertility. 5

Chemical exposure and assisted reproductive technology – Exposure to high levels of flame retardants 6  and plasticizers 7  may have a negative impact on the outcomes of in vitro fertilization (IVF), a technology used to help people get pregnant. The researchers found that women with higher levels of these chemicals in their urine had lower levels of ovary cells necessary for reproduction, and fewer successful pregnancies and live births.

Soy formula and menstrual pain – Girls who were fed soy formula as infants are more likely to develop heavy menstrual bleeding 8 , severe menstrual pain 9 , endometriosis 10 , and larger fibroids 11  later in life.

Vitamin D and uterine fibroids – Women with adequate levels of vitamin D are less likely to develop uterine fibroids than those with inadequate levels. 12

Uterine cancer – Women who used chemical hair-straightening products were at higher risk for uterine cancer compared to women who did not report using these products, according to research from The Sister Study that included more than 33,000 women. The researchers found that women who reported frequent use of hair-straightening products, defined as more than four times in the previous year, were more than twice as likely to go on to develop uterine cancer compared to those who did not use the products. Uterine cancer is relatively rare and accounts for about 3% of all new cancer cases. But it is the most common cancer of the female reproductive system.

Sperm quality – A comprehensive study, which included systematic review and meta-analysis, found sufficient evidence of an association between higher insecticide exposure—organophosphates and methyl carbamates—and lower sperm concentration in adult males. People can be exposed to insecticides through residential, occupational, and recreational sources.

NIEHS-supported researchers found prenatal exposure to air pollution (PM2.5) may shorten the distance between the anus and genitals, or the anogenital distance. Anogenital distance is a way to gauge reproductive health related to hormone levels, such as testosterone. Shorter anogenital lengths in newborn males are an indicator of lower testosterone activity in the womb, which may have implications for fertility and semen quality in adults.

• Mínguez-Alarcon L, Souter I, Williams PL, Ford JB, Hauser R, Chavarro JE, Gaskins AJ; Earth Study Team. 2017. Occupational Factors and Markers of Ovarian Reserve and Response Among Women at a Fertility Centre. Occup Environ Med 74(6):426-431. [ Abstract Mínguez-Alarcon L, Souter I, Williams PL, Ford JB, Hauser R, Chavarro JE, Gaskins AJ; Earth Study Team. 2017. Occupational Factors and Markers of Ovarian Reserve and Response Among Women at a Fertility Centre. Occup Environ Med 74(6):426-431. ]
• Carignan CC, Mínguez-Alarcon L, Butt CM, Williams PL, Meeker JD, Stapleton HM, Toth TL, Ford JB, Hauser R, EARTH Study Team. 2017. Urinary Concentrations of Organophosphate Flame Retardant Metabolites and Pregnancy Outcomes among Women Undergoing in Vitro Fertilization. Environ Health Perspect 125(8):087018. [ Abstract Carignan CC, Mínguez-Alarcon L, Butt CM, Williams PL, Meeker JD, Stapleton HM, Toth TL, Ford JB, Hauser R, EARTH Study Team. 2017. Urinary Concentrations of Organophosphate Flame Retardant Metabolites and Pregnancy Outcomes among Women Undergoing in Vitro Fertilization. Environ Health Perspect 125(8):087018. ]
• Hauser R, Gaskins AJ, Souter I, Smith KW, Dodge LE, Ehrlich S, Meeker JD, Calafat AM, Williams PL; Earth Study Team. 2016. Urinary Phthalate Metabolite Concentrations and Reproductive Outcomes among Women Undergoing in Vitro Fertilization: Results from the EARTH Study. Environ Health Perspect 124(6):831–839. [ Abstract Hauser R, Gaskins AJ, Souter I, Smith KW, Dodge LE, Ehrlich S, Meeker JD, Calafat AM, Williams PL; Earth Study Team. 2016. Urinary Phthalate Metabolite Concentrations and Reproductive Outcomes among Women Undergoing in Vitro Fertilization: Results from the EARTH Study. Environ Health Perspect 124(6):831–839. ]
• Upson K, Harmon QE, Laughlin-Tommaso SK, Umbach DM, Baird DD. 2016. Soy-based Infant Formula Feeding and Heavy Menstrual Bleeding Among Young African American Women. Epidemiology 27(5):716-25. [ Abstract Upson K, Harmon QE, Laughlin-Tommaso SK, Umbach DM, Baird DD. 2016. Soy-based Infant Formula Feeding and Heavy Menstrual Bleeding Among Young African American Women. Epidemiology 27(5):716-25. ]
• Upson K, Adgent MA, Wegienka G, Baird DD. 2019. Soy-based Infant Formula Feeding and Menstrual Pain in a Cohort of Women Aged 23-35 Years. Hum Reprod 34(1):148-154. [ Abstract Upson K, Adgent MA, Wegienka G, Baird DD. 2019. Soy-based Infant Formula Feeding and Menstrual Pain in a Cohort of Women Aged 23-35 Years. Hum Reprod 34(1):148-154. ]
• Upson K, Sathyanarayana S, Scholes D, Holt V. 2015. Early-life Factors and Endometriosis Risk. Fertil Steril 104(4):964-9761. [ Abstract Upson K, Sathyanarayana S, Scholes D, Holt V. 2015. Early-life Factors and Endometriosis Risk. Fertil Steril 104(4):964-9761. ]
• Upson K, Harmon QE, Baird DD. 2016. Soy-Based Infant Formula Feeding and Ultrasound-Detected Uterine Fibroids Among Young African-American Women With No Prior Clinical Diagnosis of Fibroids. Environ Health Perspect. 124(6):769-75. [ Abstract Upson K, Harmon QE, Baird DD. 2016. Soy-Based Infant Formula Feeding and Ultrasound-Detected Uterine Fibroids Among Young African-American Women With No Prior Clinical Diagnosis of Fibroids. Environ Health Perspect. 124(6):769-75. ]
• Baird DD, Hill MC, Schectman JM, Hollis BW. 2013. Vitamin D and the Risk of Uterine Fibroids. Epidemiology. 24(3):447-453. [ Abstract Baird DD, Hill MC, Schectman JM, Hollis BW. 2013. Vitamin D and the Risk of Uterine Fibroids. Epidemiology. 24(3):447-453. ]

NIEHS Research Efforts

• Calorie Restriction, Environment, and Fitness: Reproductive Effects Evaluation (CaREFREE) – A study, conducted at NIEHS, that investigates how nutrition, fitness, and environmental factors affect women’s menstrual cycles.
• Environment and Reproductive Health (EARTH) Study – Conducted by grantees in Massachusetts, analyzes the effects of environmental contaminants on male and female fertility and pregnancy outcomes.
• LifeCodes – A pregnancy cohort, led by Brigham and Women's Hospital in Boston, providing samples and data from more than 5,000 pregnancies for research projects such as investigating the association between environmental exposures and spontaneous preterm birth. It is one of the nation’s largest pregnancy cohorts and specimen banks.
• Pregnancy And Childhood Epigenetics (PACE) – A consortium of researchers at NIEHS, and around the world, that studies how environmental exposures in early life affect pregnancy outcomes and child health.
• Reproductive System Disorders – NIEHS supports research that is developing a fuller understanding of the relationship between exposures and risk of reproductive health problems. For example, grantees are studying the effects of arsenic exposure on birth outcomes; ties between dioxin exposure and endometriosis; and the role endocrine disruptors might play in sperm chromosomal abnormalities.
• Study of Environment, Lifestyle, and Fibroids (SELF) – A study conducted at NIEHS that uses ultrasound screening to identify risk factors for uterine fibroid development in African-American women.

Stories from the Environmental Factor (NIEHS Newsletter)

• Early-life Exposures, Assisted Reproductive Technologies Can Alter Gene Expression, Says Falk Lecturer (November 2023)
• Risk for Female Reproductive Cancer May Increase After Early-life Exposure to Endocrine-disrupting Substances (November 2023)
• Exposures Affect Men’s Biological Clocks, Too (June 2023)
• Scientific Excellence, Mentorship Go Hand in Hand for NIEHS Researcher (June 2023)
• Anne Marie Jukic wins NIH Bench-to-Bedside award (January 2021)
• Early embryos develop successfully through molecule called tankyrase (June 2020)
• Humphrey Yao elected to board of Society for the Study of Reproduction (May 2021)
• On the road again: NIEHS shines at the Endocrine Society’s annual conference (July 2022)
• Researchers Identify Cells Involved in Development of Genitalia (July 2021)
• Preterm Birth, Prolonged Labor Influenced by Progesterone Balance (April 2021)
• Replacement Chemicals May Put Pregnancies at Risk (February 2020)
• Pregnancy Hypertension Risk Increased by Traffic-related Air Pollution (January 2020)

Fact Sheets

Cosmetics and Your Health: NIEHS Research Findings

Environment and Health A to Z

Reproductive Health in Females and Males

Press releases.

• Preterm Birth More Likely With Exposure to Phthalates (July 11, 2022)
• Menopause and the Environment (2024) - NIEHS grant recipient Jodi Flaws, Ph.D., provides a brief overview of menopause and discusses her research that examines how exposure to phthalates may affect women’s reproductive aging. She also describes gaps in what we know about menopause and how research can inform clinical care to help women manage and treat their symptoms during the transition to menopause.

Additional Resources

• Common Reproductive Health Concerns for Women – Information and educational materials for women and health care providers provided by the U.S. Centers for Disease Control and Prevention (CDC).
• Journal of Women's Health Maternal Morbidity and Mortality – In the U.S., women are more likely to die from complications related to pregnancy or childbirth than in peer nations, and many health inequities are present among those who die. This special issue offers a research road map to help end this public health crisis. It showcases the work of NIH including NIEHS, other federal agencies, and the scientific community.
• Polycystic Ovary/Ovarian Syndrome – The NIH Office of Research on Women’s Health published an informational booklet on PCOS, an endocrine disease affecting millions of women that is often missed during medical examination.

Related Health Topics

• Bisphenol A (BPA)
• Cosmetics and Your Health
• Endocrine Disruptors
• Women's Health and the Environment

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Reproductive Health

Understanding and promoting reproductive health has been a key research theme for NICHD since it was founded. Research conducted and supported by the institute continues to broaden available knowledge about the spectrum of reproductive health issues that affect all people.

NICHD continues to expand its research to improve reproductive health, including studies of the basic biology of typical and atypical reproductive system development, the mechanisms and management of gynecologic disorders and their timing, options that allow all people to manage their fertility, social and environmental influences on reproductive health, and identification of biomarkers for reproductive aging.

Visit any one of the following health topics to learn more about the institute's research efforts to related to reproductive health.

NICHD Health Topics Related to Reproductive Health

Bacterial Vaginosis

Contraception and Birth Control

Endometriosis

Fragile X-Associated Primary Ovarian Insufficiency (FXPOI)

High-Risk Pregnancy

Infertility and Fertility

Labor and Delivery

Maternal Morbidity and Mortality

Men's Reproductive Health

Menstruation and Menstrual Problems

Pelvic Floor Disorders (PFDs)

Pelvic Pain

Polycystic Ovary Syndrome (PCOS)

Pre-Pregnancy Care and Prenatal Care

Pregnancy Loss (Before 20 Weeks of Pregnancy)

Preterm Labor and Birth

Primary Ovarian Insufficiency (POI)

Puberty and Precocious Puberty

Sexually Transmitted Diseases

Urinary Tract Health

Uterine Fibroids

Women's Health

Reproductive health

We support and promote reproductive health research. We cover the full range of clinical subspecialties in women’s healthcare. These include:

• maternal-foetal medicine
• benign gynaecology (including fibroids, menstrual disorders, and endometriosis)
• urogynaecology
• reproductive medicine
• gynaecology
• family planning
• post-reproductive medicine

On this page:

Areas of focus, national specialty lead, funding opportunities / funding calls, associate principal investigator (pi) scheme, help with research.

Our research areas of focus include:

• birth defects
• developmental disorders
• low birth weight
• preterm birth
• reduced fertility

Katie Morris is the CRN National Specialty Lead for reproductive health.

See the latest  funding opportunities for reproductive health research

If you’re a healthcare professional, you could be eligible for our  Associate PI Scheme

Through the Clinical Research Network (CRN), you can get help with:

• planning and delivering your research to achieve the greatest impact
• recruiting patients for your study
• costs for your study, if you are eligible. This could include money for extra staff, facilities or equipment

Find out more about the  Services to support study delivery

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NIHR researchers investigating ways to reduce health risks in maternity care have shown that a single dose of antibiotic after assisted childbirth can nearly halve the risk of maternal infection.

Preventing cerebral palsy in premature babies

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Research into the prevention of miscarriage showed that progesterone could increase the chance of having a baby for women with early pregnancy bleeding and a history of pregnancy loss. NICE guidelines now recommend progesterone treatment which could prevent more than 8,000 miscarriages each year.

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Gloria Sarto Reproductive Health Equity Symposium

The first UW Women’s Health and Health Equity Research Lecture and Symposium grew out of the pioneering vision of Dr. Gloria Sarto and Dr. Gloria Johnson-Powell in 2005. Since then, hundreds of people have shared their research addressing persistent gender, racial, and health disparities through presentations and posters at the event.

Dr. Sarto passed away on June 8, 2024. To celebrate the 20th anniversary of the Symposium and Dr. Sarto’s immeasurable impact as an advocate for health equity, we are honored to announce a new name for this important event: moving forward, the UW Department of Obstetrics and Gynecology will host the annual  Gloria Sarto Reproductive Health Equity Symposium.

This meeting will remain a crucial connection point for health care professionals, population health experts, and community advocates who are dedicated to advancing health equity. We can think of no better way to honor Dr. Sarto’s enduring legacy than to name this event in her honor.

Keynote Presentation:

Endometrial Cancer: Interventions to Address a Growing Public Health Crisis

Charlotte Gamble, MD, MPH

Attending Surgeon in Gynecologic Oncology Department of Obstetrics & Gynecology, Georgetown University School of Medicine Georgetown Lombardi Comprehensive Cancer Center Washington Cancer Institute MedStar Washington Hospital Center

2024 Gloria Sarto Reproductive Health Equity Symposium Agenda

Ellen Hartenbach, MD Chair and Professor, Department of Obstetrics and Gynecology Ben Miller Peckham, MD, PhD, Chair in Obstetrics and Gynecology

Toward a Unified Conceptualization of Abortion Access Jenny Higgins, PhD, MPH Director, Division of Reproductive and Population Health; Director of UW CORE; Professor, Department of Obstetrics and Gynecology and Department of Gender & Women’s Studies [email protected]

Adolescent Request for Online Access to Medication Abortion Before and After the Dobbs vs. Jackson Women’s Health Organization Decision Dana Johnson, PhD Health Disparities Research Postdoctoral Fellow [email protected]

LARC Removal and Contraceptive Coercion Leigh Senderowicz, ScD, MPH Assistant Professor, Department of Gender & Women’s Studies and Department of Obstetrics and Gynecology [email protected]

From Micro to Macro: A Collaborative Effort to Understand the Role of the Cervix in Preterm Birth Alex Christensen, MS PhD Candidate, UW-Madison Department of Medical Physics  [email protected]

Place Matters: The Foundation for Neighborhood Health Education Jeanne Erickson Executive Director, Foundation for Neighborhood Health Education Inc.

Presentation: Endometrial Cancer: Interventions to Address a Growing Public Health Crisis

Endometrial cancer is one of the only cancers that has rising mortality rates in the United States over the past decade, now overtaking ovarian cancer in terms of lethality. It also has one of the widest racial disparities in survival of all cancers in the United States, with Black patients experiencing a 20% lower 5-year survival rate compared to White patients, and having double the mortality rate. Studies have focused on the individual risks conferred from molecular pathways, treatment injustices, or social determinants of health, yet the complex interplay between these factors, and how they drive this survival disparity remains unexplored. Even fewer studies have examined interventions that can successfully address these massive inequities. In this talk we will examine the state of this public health crisis and gaps in necessary research moving forward.

Dr. Charlotte Gamble is a gynecologic oncologist at MedStar Washington Hospital Center in Washington D.C. with her faculty appointment at Georgetown University School of Medicine. Her research has focused on health services delivery, specifically on outcomes for patients who receive gynecologic cancer care at safety net hospitals. She is currently studying barriers to and facilitators of care for patients with endometrial cancer in Washington D.C. She is an active member of the Society for Gynecologic Oncology, the National Medical Association, the American College of Obstetricians and Gynecologists, and the American Society of Clinical Oncology. She is a board member of the patient advocacy group Endometrial Cancer Action Network for African Americans.

Dr. Gamble obtained her Bachelor’s of Science in Brain Behavior and Cognitive Sciences at the University of Michigan. She earned her Medical Doctorate at the University of Michigan Medical School, and her Masters in Health Policy and Management from the T.H. Chan Harvard School of Public Health. She completed her residency in Obstetrics & Gynecology at Duke University and her Fellowship in Gynecologic Oncology at Columbia and Weill Cornell Hospitals in New York City.

Presentation: Make No Bones About It: Osteosarcopenia in Women With Gynecologic Cancers

Women with cancer experience bone loss secondary to cancer treatment. Cytotoxic chemotherapy, premature oophorectomy, radiation and hormonal therapy are all associated with bone loss in women with cancer. Despite this risk, few data exist regarding longitudinal bone loss in this population. Available data suggest up to half of women undergoing treatment for gynecologic cancer experience nearly 100,000 women per year are diagnosed with gynecologic cancers. Women with gynecologic cancer are at risk for premature bone loss secondary to near universal ovarian removal (oophorectomy) and other cancer-directed therapy. Compared to other cancer types, however, data regarding bone loss among those with gynecologic cancers are substantially limited and available data have been generated among cohorts with non-gynecologic malignancies. Consequently, guidelines for routine bone mineral density (BMD) screening among cancer survivors widely cite studies performed in patients with breast and prostate cancers. Available data highlights a deficit of data regarding bone loss among those with female pelvic cancer compared to other cancer types. Though limited, available data report women with gynecologic cancer are at significant risk of increased bone loss secondary to premature menopause, chemotherapy, and pelvic radiotherapy. Additionally, the interrelated physiology of bone and muscle loss (increasingly recognized as the syndrome of osteosarcopenia) and the importance of this upon quality of life remains virtually ignored in cancer survivors. This talk will summarize available data regarding osteosarcopenia in those with gynecologic cancer and highlight ongoing prospective clinical research in this area.  

Janelle Sobecki, MD

Assistant Professor (CHS), Gynecologic Oncology

Building Interdisciplinary Research Careers in Women's Health  (BIRCWH) Scholar

Dr. Janelle Sobecki is an Assistant Professor (CHS) in the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology at the University of Wisconsin School of Medicine and Public Health. She is the Disease-Oriented Team leader of gynecologic oncology clinical trials for Carbone Cancer Center and is the medical director of the Women's Integrative Sexual Health (WISH) program at UW Health. Her primary research interest is improving the quality of life for gynecologic cancer survivors, particularly in the areas of bone and sexual health. She is a scholar in the NIH-funded Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Program at the University of Wisconsin-Madison and is a recipient of the GOG Foundation New Investigator Award. Her currently funded research is prospectively investigating the risk of osteosarcopenia in women undergoing treatment for gynecologic cancers. 

Evolution of A Community Engaged Approach to Support Justice Impacted Pregnant and Postpartum Women

The incarceration rate of women has grown faster than that of men for several decades. About 80% of these women are of childbearing age. According to the Sentencing Project, between 1980 and 2016, the number of women incarcerated in American jails and prisons increased by more than 700%. Approximately five million children (7% of all U.S. children) have experienced the incarceration of a resident parent in their lifetime. A large proportion of women are incarcerated for non-violent drug-related and property offenses, which are often linked to substance use disorders.

Our research questions were formed during a retreat of community members, including formerly incarcerated mothers, tasked with advancing prison birth justice in Wisconsin. The evolution of our community/academic partnership is outlined by four projects. We will delve into our shared work and how and when we deviated from shared goals.

Jill Denson, PhD, MSW, APSW

Director, UW-Madison Prevention Research Center

Dr. Jill Denson is a research assistant professor at the UW-Madison School of Medicine and Public Health. She serves as director of the UW Prevention Research Center, engaging researchers, community members, and translational partners in expanding community-based prevention research and health promotion to improve the health of women, infants, and families. Dr. Denson is passionate about maternal and child health, sexual and reproductive health, and health equity, with a focus on examining how social and structural drivers affect health outcomes. Dr. Denson’s research interests are rooted in collaborating with community partners to address health disparities through community-engaged research. She is particularly interested in building robust community partnerships, and centering the voices of those who are marginalized through capacity building and innovative research strategies.

Cheri Branham, BSW Certified Perinatal Educator and Doula

Certified Peer Support Specialist

Cheri Branham has her bachelor’s degree in Social Work. She is also a Doula, Certified Peer Support Specialist, Family Recovery Coach, and has been a justice reform advocate for many years. After giving birth while incarcerated in 2014 due to a crimeless revocation and a lack of treatment options, Cheri dedicated her life to improving conditions for incarcerated pregnant individuals and expanding services to allow family reunification. She believes no one should have to go through birth while incarcerated alone. Cheri has experience working with many different work experiences, giving her a unique set of skills that allows her to provide one-on-one support and project monitoring and development at a larger capacity. Cheri shares her story with the hopes of bringing awareness to how pregnant incarcerated individuals are treated and the need for change in our carceral system. She has also devoted her time to seeing Wisconsin have a successful Prison Doula Project, following the work of Prison Doula Projects across the United States. This past year she hosted a pilot of the "Pregnancy and Beyond" curriculum in Brown County Jail where the evaluation process showed many positive outcomes. She was connected to Dr. Denson, who graciously offered to begin researching these subjects and involve Cheri in the process. This included Group Concept Mapping to design a Doula Project for the Wisconsin Prison Birth Project, as well as "Where Do The Babies Go?" to identify where the babies of incarcerated pregnant people go after birth. She believes this work is a significant need in Wisconsin and looks forward to continuing this work inside facilities with the University of Wisconsin Research Prevention Center as a partner in this work. 

Katie Sampene, MD Clinical Associate Professor Division of Academic Specialists in Ob-Gyn

History of the Symposium:

The Symposium grew out of the pioneering vision of Dr. Gloria Sarto and the late Dr. Gloria Johnson-Powell.

Dr. Gloria Johnson-Powell  (1936-2017), the first African American female professor at Harvard, joined the University of Wisconsin-Madison faculty in 2001 as Professor of Psychiatry and Pediatrics, Associate Dean for Cultural Diversity, and Director of the Center for Cultural Diversity and Health Care. Dr. Johnson-Powell had remarkable influence in highlighting the importance of social equality as it impacts health equality.  She labored all her life to seek equality for all, through her research, writings, and work within communities.   

In 2003, Dr. Johnson-Powell and Dr. Sarto received NIH funding to establish a comprehensive center to investigate the role of biological and social factors on disparate health outcomes, primarily among minority ethnic and racial populations.  The first Symposium was held in 2005.

Dr. Gloria Sarto  has championed the health of women in innumerable ways throughout her professional career. As a physician, she personally treated many women and delivered their babies; as a department chair, she taught and mentored many students, residents, and young faculty; and as a national voice for women’s health, she continues to influence public policy, educational curricula, and national research initiatives.

Past Symposium Keynote Speakers:

• 2023: Denise Howard, MD, MPH ( video )
• 2022: Vanessa Northington Gamble, MD, PhD ( video )
• 2021: Elizabeth Howell, MD ( video )
• 2020: Erica Marsh, MD ( video )
• 2019: Tiffany Green, PhD ( video )
• 2018: Sheri Johnson, PhD
• 2017: Haywood Brown, MD ( video )
• 2016: Melissa Gilliam MD, MPH ( video )
• 2015: Florence Haseltine, MD, PhD
• 2014: David Grimes, MD, FACOG, FACPM ( video )
• 2013: Vivian Pinn, MD ( video )

October 10, 2024

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Health Sciences Learning Center Room 1325 or Zoom

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Email: [email protected]

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September 23, 2024

Ipas research in Kenya reveals how the climate crisis undermines reproductive health

As climate change intensifies, its impact on sexual and reproductive health and rights (SRHR), is becoming increasingly concerning. However, there has been limited research on how this crisis specifically affects SRHR services and the health of vulnerable communities.

To bridge this gap, Ipas Africa Alliance partnered with the Pastoralist Community Initiative and Development Assistance (PACIDA) and the Samburu County Government to assess how the climate crisis is affecting SRHR services in Samburu County, Kenya. The findings reveal the urgent need to strengthen the resilience of both health systems and communities in the face of climate change.

Pictured above: Janet Lemerimuka working in her kitchen garden that she created through the PACIDA project. Learn more

The study specifically explored how the climate crisis influences the need for SRHR services within the community health system, focusing on the adaptability and resilience of health services in Samburu County. Extreme weather events like droughts, intense heat, and flooding are disrupting the delivery of essential SRHR services.

“Heatwaves, floods, and droughts—worsened by climate change—are forcing pastoralist communities in Samburu to adapt in ways that directly affect their health, and SRHR is no exception,” says Sally Dijekerman, Ipas’s senior research scientist. She explains that as communities migrate further from health facilities in search of water and pasture, access to contraception and SRH services diminishes, leading to increased rates of STIs/HIV transmission, unintended pregnancies, and pregnancy complications.

A health facility manager in East Samburu also noted, “Many miscarriages happen during drought because people are migrating, and women experience back pains from walking long distances, which eventually leads to miscarriages.”

Climate change affects everyone, but not equally

This research is among the first to examine the effect of climate change on men’s SRHR, particularly male pastoralist warriors, known as Morans. Although climate change affects everyone, it does not do so equally. Alongside women and girls, Morans face significant challenges, including increased exposure to STIs/HIV, conflicts, and delayed initiation ceremonies, which, in turn, delay marriage.

The study highlights the need for targeted strategies to support both men and women as they navigate the impacts of climate change on their health and well-being.

It also underscores the critical need to integrate climate action with SRHR initiatives in Samburu County. While communities are slowly adjusting to the immediate impacts of droughts and floods, the health systems are ill-equipped to provide consistent, high-quality SRHR services.

Women in the study reported adverse health outcomes due to the burdens of migration and extreme weather. One female participant shared her story: “I lost my baby because I was overworked during the drought. The hospital advised me to stop working, but I had no help, and the work had to be done.”

What needs to happen

To address these challenges, the study participants—including community members and health providers—made the following recommendations:

• Institutionalize climate resilience into health systems planning & policies for long-term solutions
• Sensitization & training about climate change adaptation strategies & alternative livelihoods for everyone, including community members and health providers
• More partnerships between health systems, communities, and organizations
• Health education & more frequent outreach: integrated across partners & health topics, targeting men with family planning education
• Increase accessibility of health facilities / SRHR services, including more outreach, transportation, & Morans (young men) trained as community health workers
• Providing sanitary pads & soap to address hygiene issues
• More provider training & sensitization on SRHR & climate change

Case Study: Mary’s* journey through drought and pregnancy

* A pseudonym has been used to protect her identity

Mary, a 25-year-old woman from East Samburu, experienced an unintended pregnancy during a period of severe drought. After completing secondary school and working at a local shop, Mary became pregnant. The harsh economic conditions and lack of support made her consider terminating the pregnancy, but she ultimately decided to carry to term.

During her pregnancy, she had to walk 20 kilometers to fetch water, which caused significant back and stomach pain. At four months, she began attending prenatal checkups, but her local clinic lacked the necessary equipment to perform certain tests. She was eventually referred to a hospital in Wamba, where she was advised to stay close to the facility due to the likelihood of needing a C-section. While her mother stayed with her for a month, Mary struggled with missing her family and the difficulty of managing her pregnancy during such a challenging time.

Now, Mary supports herself and her child by selling mandazis and washing clothes. She dreams of having two more children but, given the poor economy, believes that now is not the right time.

The climate crisis and SRHR: detailed findings

Drought, floods, and extreme heat—symptoms of the climate crisis—are creating conditions that undermine the health and well-being of Samburu communities. The findings reveal that climate change affects SRHR through several pathways, including:

• Economic hardship: More school dropouts, increased sex work, and the loss of traditional livelihoods
• Migration: People moving in search of water, pasture, and income opportunities face increased risks of SRHR-related issues, such as unplanned pregnancies and STIs
• Increased conflict between and within communities: Scarcity of resources leads to raids and violence, impacting community security, particularly for women and girls
• Worsening hygiene: Access to clean water and sanitation is disrupted, leading to poor menstrual hygiene and increased health risks for pregnant women
• Reduced healthcare access: Health services, particularly SRHR services, become less accessible as communities migrate or are hindered by poor infrastructure
• Worsening access to water, sanitation, and hygiene (WASH): Flooding interrupts healthcare seeking; Increased heat exposure of pregnant women while collecting water; malnutrition & dehydration; lack of clean water to bathe in, worsened menstrual hygiene
• Changes in sexual activity: Increased migration contributes to extramarital affairs, unprotected sex, the spread of HIV/STIs, unintended pregnancy; unintended/teenage pregnancy and Sexually Transmitted Infections – due to increased unprotected casual sex (extramarital affairs and transactional sex) and inaccessibility to family planning
• Changes in marriage and traditional practices: Forced & child marriage was used as a coping mechanism for the worsening economy, e.g. restocking animals or feeding family; delayed circumcision  or initiation ceremonies for morans until rainy season

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Securing adolescent health and well-being today is vital for the health of future generations - WHO

Increased investment is urgently needed to address evolving health risks and meet the mental and sexual and reproductive health needs for the nearly 1.3 billion adolescents (aged 10-19 years) globally, according to a new scientific publication released by the World Health Organization (WHO).  Adolescence is a unique and critical stage of human development, involving major physical, emotional, and social transitions, and is a pivotal window for laying long-term foundations for good health.

“Promoting and protecting the health and rights of young people is essential to building a better future for our world,” said Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. “Conversely, failing to address the health threats that adolescents face – some longstanding, some emerging – will not only have serious and life-threatening consequences for young people themselves, but will create spiraling economic costs for societies. That makes investing in services and programmes for adolescent health both a moral imperative and an economic no-brainer.”

The publication was launched at an event on the margins of the United Nations’ Summit of the Future . It highlights a number of troubling trends in adolescent health observed over the last decade, pointing to the urgent need for action.

At least 1 in 7 adolescents globally now suffer from a mental disorder, for instance, with particularly high rates of depression and anxiety.  Anaemia among adolescent girls remains prevalent, at levels similar to those in 2010, while close to 1 in 10 adolescents are obese.  Sexually transmitted infections (STIs) including syphilis, chlamydia, trichomoniasis, and genital herpes that commonly occur among youth are rising, and if left untreated, can have lifelong implications for health.  

Meanwhile violence, including bullying, affects millions of young people worldwide each year, with devastating impacts on their physical and mental health.

Concerningly, attempts to roll-back adolescents’ access to sexual and reproductive health care and comprehensive sexuality education have escalated amidst a growing backlash against gender equality and human rights. Restrictive age of consent policies are limiting their access to STI and HIV services. Such measures can marginalize young people, reduce health-seeking behaviour, and lead to lasting negative health impacts.

The study emphasizes other broader fundamental challenges to the future of adolescents including climate change, conflict, and inequality.

The authors also highlight that gains are possible with the right investment and support.  For example, adolescent HIV infections have declined, due to coordinated and persistent efforts in this area. Adolescent pregnancy and harmful practices such as female genital mutilation and early marriage have reduced. In addition, many positive trends in health outcomes are linked to more time in school, especially for girls; since 2000, the number of secondary-school-age children out of school decreased by nearly 30%.

Against this backdrop, the findings make a strong case for investing in adolescent health and well-being, with attention to foundational elements including education, healthcare, and nutrition.  The authors call for enacting and implementing laws and policies that protect adolescent health and rights, for health systems and services to be more responsive to adolescents’ unique needs, and for the prioritization of youth engagement and empowerment across research, programming, and policymaking.

“Adolescents are powerful and incredibly creative forces for good when they are able to shape the agenda for their well-being and their future,” said Rajat Khosla, Executive Director of the Partnership for Maternal, Newborn and Child Health (PMNCH), which co-hosted the event where the publication as launched. “Leaders must listen to what young people want and ensure they are active partners and decision-makers. They are critical for the world’s future social, economic, and political stability, and if given the platform they need, they can help make a better and healthier world possible for everyone.”

Earlier this year, world leaders committed to accelerate efforts to improve maternal and child health , including adolescent health, at the World Health Assembly.  Implementing these commitments, as well as those reflected in the UN’s Pact for the Future, will be critical to protecting and promoting the health and well-being of current and future generations.

Notes for editors 

The publication was released at a high-level event convened on the margins of the UN General Assembly. It was hosted by the Governments of Chile, Colombia, and Ireland along with the UN’s Human Reproduction Programme, PMNCH and WHO in collaboration with: FP2030, Guttmacher, International Association for Adolescent Health (IAAH), Johns Hopkins Bloomberg School of Public Health (JHUSPH), Plan International, UNESCO, UNFPA, Women Deliver, and YieldHub.  

The Summit of the Future takes place on September 22 and 23, 2024, seeking new consensus around how the international system can evolve to better meet the needs of current and future generations. 

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September 25, 2024

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Study reveals natural disasters jeopardize women's reproductive health

In research published in Brain and Behavior , investigators found increased rates of menstrual irregularities in women living in areas affected by the 2023 earthquake in Turkey.

In the study, 309 women of reproductive age living in regions declared as disaster areas completed online forms nine months after the earthquake. Responses revealed an increase in menstrual irregularities from 14.3% before the earthquake to 44.8% after the earthquake. Risk factors for menstrual irregularities included post-traumatic stress symptoms, chronic diseases, and smoking.

The findings reveal that reproductive health can be significantly affected in the aftermath of natural disasters, and they highlight the importance of addressing mental health in post-disaster interventions to mitigate these effects.

"Traumatic events like earthquakes can disrupt not only physical but also hormonal and psychological balances, which can directly affect women's reproductive health," said corresponding author Sibel Kiyak, RN, Ph.D., of Necmettin Erbakan University.

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