“You are free to choose, but you are not free…” Are women even free to choose?

I remember the first time I told my family that I don’t know if I want to have children in the future. My parents and grandmother were appalled at my statement, telling me that it was surely just a phase and that I would eventually want children. My dad even went as far as to say that I “owe” him children because he has supported my dreams, and I ought to support his dream of being a grandfather. Needless to say, the conversation came to an abrupt end, but my thoughts on the interaction have lingered for years. No one will say it outright, but girls are socialized from a young age to understand that our bodies are not our own. While men are allowed to aspire to be any number of things, women are expected to aspire first and foremost to motherhood. The social control exerted over women has multiplied in recent decades as the expansion of our definition of reproduction, combined with the nature of healthcare as an economic entity, have allowed for increased medicalization and politicization of women’s bodies.

Redefining Reproduction

Open any biology textbook, and you’ll find an overview of reproduction as a series of biological processes, with most of these processes occurring inside a woman’s body. Sociologists, however, seek to redefine reproduction as more than a biological series of events. Rene Almeling defines it simply: “Reproduction is the biological and social process of having or not having children” (Almeling 430). This definition, while seemingly simple, allows us to reconceptualize reproduction in a way that accounts for biological, individual, interactional, cultural, political, economic, structural, and historical factors that influence the decision of if/when someone will have children. At first glance, this expanded definition of reproduction is a good thing. It allows us to understand reproduction as a lifelong intersectional process, and this understanding could lead to the empowerment of marginalized women as they approach motherhood.

The expanded definition, however, has been utilized to increase social control over women. By expanding the definition of reproduction beyond a brief biological process, people in power are able to medicalize and politicize women’s bodies. Because reproduction is viewed as a lifelong process, we have seen the advent of “preconception health” as demonstrated by the CDC’s Show Your Love Campaign. Waggoner explains that this campaign conflates womanhood with motherhood, as women of reproductive age are expected to live in anticipation of motherhood regardless of whether or not they actually want children (Waggonner 942). The notion of preconception health has allowed medicalization to expand beyond childbirth–now, women’s bodies are medicalized as soon as they reach reproductive age, and they are told to live in a way that prioritizes fertility. Medicalization, as explained by Conrad, is a mechanism of social control, making the medicalization of women’s bodies synonymous with the control of women’s bodies (Conrad 211).

Contextualizing Medicalization

In order to understand the importance of increased medicalization in women’s lives, we must first understand healthcare within its larger economic and political context. Because healthcare is largely an economic entity in the Unites States, unlike other developed countries, access to and quality of healthcare are largely determined by the same social determinants that influence access to other capitalist goods. In a study on publicly funded prenatal care, Andaya found that race plays a larger role than any other social determinant when examining clinic waiting times and maternal mortality rates (Andaya 651). The systemic underfunding of public healthcare has caused non-white women to receive inadequate care, and this is almost a direct result of this country’s foundations in racism and slavery. Although slavery was abolished with the 14th Amendment, the remnants of it can be seen throughout America today. Most visibly, the remnants of slavery are seen in our prison system, but authors such as Bridges note how the carceral model extends into areas we would least expect. Bridges explains how the medicalization of women’s bodies extends past a simple notion of control for poor women in that their use of Medicaid allows for state regulation and surveillance over their bodies (Bridges 85). When I initially read this, I found it to be a bold and possibly over-exaggerated claim. Then I thought back to my time working at a maternity home.

While I was working at the maternity home, one of my responsibilities was to take the pregnant women and new mothers grocery shopping–a simple task, right? I could not have been more wrong. Because each of the moms relied on Indiana WIC, a program designed to provide nutrition to women, infants, and children, their grocery lists were predetermined by the Indiana Department of Health. Unlike those of us who are fortunate enough to selectively pick what we want to cook that week, the moms’ lists were specified all the way down to the brand of canned corn they had to purchase. When one mom complained of leg cramps, I suggested buying bananas, to which she informed me that she had already used up her fruit credits for the cycle. I was astounded.

This moment has bothered me for months, and after reading articles on the medicalization of women’s bodies as a means of increased control, I have come to realize that women’s bodies are truly no longer their own.

Pro-“Choice”?

We’ve all become familiar with the Pro-Life vs. Pro-Choice debate concerning government regulation of abortions. All of the current “choice” rhetoric around women’s bodies revolves around the abortion debate, but I argue that women’s choices have been limited more than we realize. In the previous example, we see that poor women who rely on state funding for prenatal care cannot even make choices about their diets. Furthermore, women who use Medicaid have significantly fewer options than women of greater privilege in that there are fewer available hospitals, providers, midwives, etc. to choose from. Even for women who do not require government financial support, their bodies are still controlled by bills such as Texas SB-8 that seek to overturn Roe v. Wade by implementing gestational bans on abortions. Although popular opinion supports a woman’s right to choose, lawmakers continue to introduce hundreds of bills each year to extinguish this right. We must question how many of these bills are actually influenced by a desire to protect “unborn children” and how many are meant to control women’s bodies and women’s sexualities. Additionally, the failure of such bills to exempt rape and incest cases promotes rape culture in which women are completely objectified and expected to do as told by men. A culture in which I “owe” my dad a grandchild simply because he said so.

References

Almeling, R. (2015). Reproduction. Annual Review of Sociology, 41(1), 423–442.

https://doi.org/10.1146/annurev-soc-073014-112258

Andaya, E. (2019). Race-ing time: Clinical temporalities and inequality in public prenatal care. Medical Anthropology, 38(8), 651–663.

https://doi.org/10.1080/01459740.2019.1590826

Bridges, K. M. (2008). Pregnancy, Medicaid, State Regulation, and the Production of Unruly Bodies. Northwestern Journal of Law & Social Policy, 3(1), 61–102. 

Conrad, P. (1992). Medicalization and Social Control. Annual Review of Sociology, 18(1), 209–232. https://doi.org/10.1146/annurev.so.18.080192.001233 

Waggoner, M. R. (2015). Cultivating the maternal future: Public health and the prepregnant self. Signs: Journal of Women in Culture and Society, 40(4), 939–962.

https://doi.org/10.1086/680404

Reproductive Inequality in the LGBTQ+ Community

The praxis of education, advocacy, ethics, and surrogacy form the LGBTQ+ issue of reproductive justice.

The accessibility of reproductive health and medicine is not an unfamiliar topic to many, but especially those who fall outside of the trope of a white nuclear family. The search for reproductive and fertility equality is not new to the LGBTQ+ community, who must navigate social stigmas, educational microaggressions, and limited access in the search for reproductive care and ability.

Photo from Out Magazine, “Why Reproductive Justice is an LGBTQ+ Rights Issue”

Social Stigmas

When asked to picture a family, it’s pretty easy to imagine the stereotypical mother, father, 2 kids (boy and girl), and a golden retriever. Their two-story house with a fenced-in yard is not too far behind, also. This is the stigma of a family. The perception of reproduction usually involves two cisgender, heterosexual adults, as this is the most common practice of reproduction. Commonality makes this image accessible. As such, stigmas of individuals who turn to external sources for reproduction, whether that be surrogacy, adoption, IVF, or others, are perceived to have a marked physical condition. There is a crack in the system, preventing the “normal” method.

LGBTQ+ reproduction advocates want to change the conversation. Infertility is not failure; rather, it is a circumstance of life.1 By taking away the shame of infertility, access to reproductive aid can be easier for all, not just those with same-sex partners. As such, infertility is not only a condition for those practicing heterosexual intercourse. Therefore, primary alterations in reproductive justice can occur through attention to rhetoric. Instead of assuming sexuality, gender identity, or reasons behind infertility, the first questions should be regarding specific couples’ fertility and reproductive needs. 

Furthermore, these needs go beyond initial fertility or pregnancy. These include, but are not limited to, access to reproductive health records, protection from microaggressions in medical settings, and equal access to parenthood for all partners. Barriers and stigmas to these needs include lack of recognition of partnerships, insurance coverage, and the privilege of reproduction. Babies are expensive to have, but even more expensive to have when fertility help is needed. 

Microaggressions in Education

Lots of these needs often exist in hidden information. The story of former Marine Miguel Aguilera is poignant; as a gay man, he was looking to take advantage of the fertility services covered by his VA health insurance. However, he learned that marriage to a woman was required for the services.2 This policy gatekeeps parenthood from those who do not meet the nuclear family. There is clear and undeniable discrimination due to the biology of both partners, along with a lack of respect for varying types of relationships. Captain Aguilera was also not made aware of the lack of insurance coverage up front, meaning that education regarding his options was limited. The ability to seek out having children is a privilege not afforded to all. 

Conversations regarding reproductive and sexual health also promote cisgender, heterosexual relationships, as that is the most readily provided information. The framework for queer reproduction is not taught in most early adolescence curricula. Therefore, LGBTQ+ youth are not able to find safety or recognition when learning about reproduction. Diversity of family styles is not promoted, but hidden.3

Some inequalities in education are more subtle. Research by the Guttmacher Institute found that women who identify as queer utilize less preventative screenings and reproductive health appointments, which could be due to misperceptions that they are at less reproductive risk.4 Though perceptions in this community may have a false sense of security or protection against STIs, the risk is still present and these infections can still cause reproductive difficulty down the road.

Access to Reproductive Care

Issues of stigma, education, and individual approaches to queer reproduction must be holistically taken into account with a cultural and systemic praxis of healthcare limitations. The United States regularly fails minorities in equality of care quality, access, and education. Care fragmentation, discrimination, and lack of legal equality all work together to make reproduction an action of privilege. 

Many LGBTQ+ individuals have found reproductive healthcare centers, like Planned Parenthood, to be safe havens for inclusive, welcoming care. Therefore, legal threats to the autonomy and ability of these centers is also a threat to queer reproductive counseling, care, and access.5 Relatedly, limitations of insurance to cover these healthcare centers and/or coverage of fertility/reproductive treatments makes creating a family all the more difficult for LGBTQ+ individuals and couples. Increased likelihoods of insurance denials, barriers, or lack of recognition of an individual or family creates struggles in family care, proper healthcare, and reproductive counseling. Limitations to insurance in reproduction are also places for concern later in life, especially when partner insurance may not cover another partner or children without biological relation. Therefore, the holistic interaction between social stigmas and cultural  practice act in direct form of oppression against reproductive access. 

Reproductive Justice

…reproductive justice recognizes that the legal rights are meaningless without ensuring practical access to reproductive health care…through activism, academia, research, and advocacy.”

Tam, “Queering reproductive access: reproductive justice in assisted reproductive technologies”6

The risk of parental or reproductive rights for any individuals, whether they are queer or not, places risk to the LGBTQ+ community. The political and legislative climate that centers around controversial reproductive healthcare access and freedoms is a constant give and take. Any ground gained is never comfortable, and any ground lost places all other areas of care on edge. The fundamental liberties of reproductive rights and accessibility must be equal, accessible, and socially-informed for the LGBTQ+ community, as regulating the definition of family is regulating the autonomy of individual identity. Reproductive justice is the framework for finding the hope amongst the discriminatory stigmas, education, and access. Inherent intersectional interaction of reproductive oppression makes each case individual; there is no better place to start than such praxis-based activism. 

Reproductive Justice Graphic, Piper Shine, April 2022.

References:

  1. Kaufman, David. “The Fight for Fertility Equality,” The New York Times. 22 July 2020, https://www.nytimes.com/2020/07/22/style/lgbtq-fertility-surrogacy-coverage.html
  2. Kaufman, David.
  3. Berg, Alex. “Why Reproductive Justice Is an LGBTQ+ Rights Issue,” Out Magazine. 19 February 2019, https://www.out.com/out-exclusives/2019/2/19/why-reproductive-justice-lgbtq-rights-issue
  4. Dawson, Ruth and Tracy Leong. “Not Up for Debate: LGBTQ People Need and Deserve Tailored Sexual and Reproductive Health Care,” Guttmacher Institute. 16 November 2020, https://www.guttmacher.org/article/2020/11/not-debate-lgbtq-people-need-and-deserve-tailored-sexual-and-reproductive-health
  5. Gonen, Julianna S. “Our Common Quest for Autonomy and Dignity: Reproductive Rights and LGBTQ Equality,” Alliance for Justice. 27 June 2019, https://www.afj.org/article/our-common-quest-for-autonomy-and-dignity-reproductive-rights-and-lgbtq-equality/
  6. Tam, M.W. Queering reproductive access: reproductive justice in assisted reproductive technologies. Reprod Health 18164 (2021). https://doi.org/10.1186/s12978-021-01214-8

Debates Around Surrogacy and Ethics

Over Spring Break, I was with my cousin who is studying abroad in France this semester. I asked her, “Is there anything that has been really surprising to you culturally in any of your classes?”. She replied with a story about how a week before our reunion, she was debating the ethics of surrogacy with her professor and other students in the class. She and her American friend shocked the professor and class with their acceptance of surrogacy and its prevalence in the United States, something that I believe is seen in a relatively positive light here, which clearly is different from French and European perspectives, at least based on this story. 

I was first introduced to the concept of surrogacy in 2011 while watching the TLC show “The Little Couple”, a reality show following the lives of Dr. Jen Arnold, MD, and her husband Bill Klein, as they navigate life with skeletal dysplasia. Due to her skeletal dysplasia, Jen’s doctors decided that it was unsafe for her to carry a pregnancy, and wanting a biological child of their own, the two decided to pursue surrogacy. The concept of surrogacy was a surprising and exciting one to me. I have a disability which may impact my ability to safely carry a child to term, so I have always viewed surrogacy as a way for people who are disabled and unable to carry a child themselves to have a child. It is also a way for LGBTQ+ couples to have a child who is biologically related to a parent, which is a wonderful thing. To me, it has represented the fulfillment of one of my biggest dreams in life and one of many people’s life goals through the generosity, sacrifice, and kindness of another woman.

Ethical Concerns

It was not until my medical ethics course last semester that I thought about the potential ethical concerns tied to surrogacy. There is debate around whether women can fully consent to surrogacy, psychological and emotional consequences for the surrogate, what to do if the parent decides they no longer want to care for the child, and the fact that it could reinforce women as “breeders”. There is also concern from some ethicists about commercializing reproduction, mostly based in fears of affecting a potential surrogate’s free choice to consent to carrying the pregnancy, which is a risky condition for anyone. There is fear among some that low-income women may be exploited by using their bodies to bear other people’s children, entering a situation that they would not otherwise because they are in need of more financial security. However, women who become surrogate mothers are being paid for their work, which is better than doing it for free, and it gives women another way to earn money. The motivation of money is not necessarily problematic on its own- but I do think that it is important to look at the overall context of the situation for the mother to make sure she understands what she is committing to and that she will be cared for both during the pregnancy and while recovering from birth. Any job has risks and benefits, so I think payment for surrogacy is ethical as long as the woman is being fairly compensated and her well-being is a priority. It is important that she has access to resources and support throughout her pregnancy.

International Commercial Surrogacy 

One alternative for American couples who can not afford a surrogate in America is to pursue surrogacy in another country. India banned commercial surrogacy in 2016, but from 2002-2016 when it was legalized, India was a hub for international commercial surrogacy due to low prices of fertility clinics and a high supply of low-income women who were willing to become surrogates.1

An important aspect to consider about international commercial surrogacy is the cultural context to determine if it is ethical or not. The United States and India differ in cultural attitudes towards pregnancy and surrogacy, and this is crucial information in this debate. Surrogate mothers in India “grapple with their new identity as participants in an industry that is morally contentious and constructed as deviant and unnatural in India”.2 This could take a psychological toll on the surrogate mother, which could make this experience more challenging. Additionally, for the time period when commercial surrogacy was legal in India, there was “minimum state interference with few laws regulating the procedures, the contract, or the womb mother-client relationship”.2

This creates further opportunities for exploitation and does not provide adequate protection for the surrogate mother.

Conclusion

While I do not think that international commercial surrogacy is inherently unethical, I do think it is important to consider the cultural context and the amount of regulations in place to protect the mother. Surrogacy in all contexts, whether domestic or international, should only be done if the surrogate mother is able to fully consent and is provided with support for her mental and physical needs while she is pregnant and recovering from birth.

Sources

  1. India’s new Surrogacy Regulation Bill falls short of protecting bodily autonomy and guaranteeing reproductive liberty https://blogs.lse.ac.uk/humanrights/2021/04/21/indias-new-surrogacy-regulation-bill-falls-short-of-protecting-bodily-autonomy-and-guaranteeing-reproductive-liberty/
  1. Global reproductive inequalities, neo-eugenics and commercial surrogacy in India, Amrita Pande

photo: https://unsplash.com/photos/dF8jzk6GdQc?utm_source=unsplash&utm_medium=referral&utm_content=creditShareLink

What Serena William’s pregnancy can tell us about black maternal mortality

The Grio (https://thegrio.com/2018/01/15/serena-williams-birth-facebook/)

In a 2018 Vogue article, international tennis star Serena Williams opened up about the near-death experience she had after her pregnancy. After delivering her baby via emergency C-section and feeling shortness of breath thereafter, Williams immediately assumed a pulmonary embolism due to a history of blood clotting. Despite telling a nurse that she needed a CT scan and IV heparin right away, she was met with dismissal. The coughing continued to the point where her C-section ripped open and required restitching. Only after fierce and arduous insistence on the part of Williams, a CT scan was finally performed, and as suspected, there was a blood clot in the lungs that was making its way to the tennis star’s heart.

William’s experience was disheartening to many black women. It revealed that not even an internationally recognized celebrity status and the ability to afford top-quality health care could protect against the neglect and dismissal that birth-giving black women encounter. It speaks more widely about the maternal mortality of black women in America’s healthcare system, the only explanation for which is racism.

Historical Origins

From the beginnings of the North American slave trade, white physicians were instrumental in the degradation and commodification of the black body. For example, in the antebellum South, the bodies of black enslaved persons were inspected by physicians to check for their “soundness” for buyers/sellers so that they could have the most productive laborers that would generate the most profit. Even after death, this commodification continued with black bodies used as cadavers in medical institutions.

In particular, white physicians had an interest in black women’s bodies and reproductive lives, partly because black women giving birth to children equated to more capital gain for the slave owners. However, despite this focus, infant mortality remained extremely high. Although the cause of this was the malnourished and laborious conditions that black pregnant women were subjected to, racist attitudes dismissed this phenomenon as affirmation that black bodies were inferior to white bodies.

As a result of this, it is impossible to ignore that black people, especially women, have had a painful relationship with white Western medicine. Medicine today is the result of exploitation and experimentation on black bodies, especially during the era of slavery. Medicine is fundamentally racialized and this continues on into the modern-day.

Black Maternal Mortality in the US today

Although the World Health Organization reported that maternal mortality was decreasing worldwide in 2017, it was noted that the US was one of two countries that actually experienced an increase in maternal mortality. The largest incidences of US maternal mortality were among black women, whose death ratio is 2.5 times that of white women.

A statistic that I find shocking is that “a Black mother with a college education is at 60 percent greater risk for a maternal death than a white or Hispanic woman with less than a high school education.” This strikes me the most because I think it is a clear example that no matter how much hard work a black woman puts in to try and improve her life circumstances, such as increasing one’s income and status to receive higher-quality private medical care as was the case with Serena Williams, it does not buffer against the effects of racism. This statistic to me clearly shows that there is no explanation but racism for such high maternal mortality.

Racism contributing to maternal mortality appears to manifest itself in two ways: racist attitudes and physiological effects on the body from racism.

Black women fall in between the intersection of sexism and racism. Therefore, black women especially are not respected by their providers. As in the case of Serena Williams, despite having the best knowledge of her own medical history and body, she was dismissed by the medical providers as “being crazy.” It was only after fierce insistence that she was able to receive the medical attention that she needed. Although white women/people may be seen as assertive and proactive in their health when advocating for themselves in the hospital, black women may be seen as pushy and demanding. Such stereotypes and racist attitudes may contribute to black women’s needs and voices being disrespected and ignored by medical providers, especially after childbirth, and the consequences of this may be fatal.

Furthermore, black women are at a greater risk for pregnancy-related deaths from heart/blood-related complications such as cardiomyopathy and hypertension. The effects of structural racism, such as low-quality housing, low income, and various other factors that contribute to poor health may cause high blood pressure and strain on the cardiovascular system which accumulates over a lifetime. Therefore, racism physically impairs the black body so that it cannot function optimally, resulting in complications in such things as childbirth.

Conclusion

The Serena Williams case was disheartening for many black women as it appeared that not even a woman widely perceived as powerful, assertive, and means to receive top-quality medical care could be safe from the effects of racism that contribute to high black maternal mortality. It is important to recognize and reflect upon the fact that the health system in the US has origins rooted in slavery and the degradation of black bodies which persists into the modern day. This is necessary to examine the ways structural racism has embedded itself in the US Healthcare System and the only way black maternal mortality can be sufficiently addressed.

Citations

(1) Lockhart, P.R. “What Serena Williams’s Scary Childbirth Story Says about Medical Treatment of Black Women.” Vox. Vox, January 11, 2018. https://www.vox.com/identities/2018/1/11/16879984/serena-williams-childbirth-scare-black-women.

(2) Maternal mortality in the United States: A Primer. The Commonwealth Fund. 16 December 2020. https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer.

(3) Owens D. C. and Fett S. “Black Maternal and Infant Health: Historical Legacies of Slavery,” American Journal of Public Health 109(10), (2019): 1342-1345.

Reproduction Problems in a Pandemic

Introduction

Pregnancy and reproduction can be a big challenge and burden for many women, and when it occurs at the same time as a pandemic, the challenge is even greater. The US ranks last for women’s healthcare among all wealthy nations in the world. This reflects “historical neglect of women’s health within the United States, which is a gender bias that continues to persist” [1] and is a result of many women lacking access to necessary care. In a pandemic, at a time of national crisis, there are even fewer resources and care offered to women who need them. The COVID-19 pandemic challenged pregnancy and child development in a variety of ways. The pandemic caused babies to have lower development scores, an increase in maternal mortality, and difficulty in the surrogacy process.

Pandemic Babies

Over 200 million babies have been born worldwide since the pandemic started. Originally, researchers were unsure of how these babies would be affected, but after studying, they have found that the damage has the potential to be lifelong. “The first three years of life are crucial for brain development” [2] and these infants have had a widely different experience than most. During the pandemic, people were isolated, limited interaction, and wore masks, and all of these things had effects on children. In an article called Modern Body, Modern Minds, it was argued that as times and environments change, so do our bodies. As evidenced in the town of Green River, “older residents argued that just as the community had changed and become more modern so too had the bodies, minds, and sensibilities of the younger generation.” [3] As the environments that these babies grew up in were impacted by the pandemic, their bodies began to be influenced and their development slowed.

The pandemic “caused a lot of stress — emotional, financial, and otherwise — for so many families.” [4] Mothers especially felt that stress as reported symptoms of anxiety and depression were much higher than in pre-pandemic years. Prenatal stress can cause changes in brain connectivity and development, and stress that continues after delivery can change the development of a child forever. If mothers are stressed “and that stress is coming out, your child can absolutely pick up on that.” [5] It is also dangerous that it can change the way you interact with your child. Babies need constant attention and need to be touched, held, played with, and talked to. Caregivers who are struggling with the mental effects of the pandemic may not be able to give that constant energy and attention.

Mother and her son using computer and making video call at home. [Drazen Zigic]

With pandemic lockdowns, interactions with anyone other than parents were extremely limited. “Babies on average are interacting with fewer people (and seeing fewer faces because of masks)” [6] and have had fewer words spoken to them on average than they did before the pandemic. When babies feel the stress of their mother and have fewer playdates and interactions, their brains don’t develop the way they should. The effects are showing as “babies born during the pandemic scored lower in gross motor, fine motor, and social-emotional development than babies born before the pandemic.” [7] The longer the pandemic continues, the more deficits the children will accumulate, but there is still time to steer them back on course.

Increase in Maternal Mortality

The United States has always had difficulties with maternal mortality; they rank last overall among industrialized countries. Causes of death can vary widely but typically hemorrhage during pregnancy and infection and weakened heart muscle postpartum are most common. To improve these outcomes, women’s health care needs to be improved before, during, and after pregnancy. Some of their key efforts must include “identifying higher-risk women earlier, enrolling women in insurance, and keeping them in care after childbirth.” [8

The large proportion of maternal deaths that occur after childbirth suggests that too many women are losing connections to health care after giving birth.

Eugene Declerq and Laurie Zephyrin

The unfortunate part is that during the pandemic, women were getting even less care than they were before. “The rate of women who died during pregnancy or shortly after birth increased significantly during the first year of the COVID-19 pandemic,” [9] and that is not a surprise. Hospitals were overflowing with COVID patients and turned away those who did not have emergency situations. Women were less likely to get their needed checkups and were very unlikely to be followed up with care after giving birth. With limited access to prenatal care, increased stress, and lack of support available before and after birth, it is easy to see why the number of maternal deaths rose by 14% in the first year of the pandemic. The virus caused more strain on healthcare workers and left less time for them to focus on the country’s maternal mortality crisis. As a result, the rates increased significantly.

Shortage of Surrogates

For couples who cannot conceive, surrogacy is a great and popular option. However, during a pandemic, this option becomes less available. “Commercial surrogacy is a multi-billion dollar industry across the world” [10] and countries like Ukraine, and formerly India, lead the charge. In the US total transactional costs can be upwards of $100,000, so families look for places like Ukraine to find a surrogate for one-third of that price. This can be convenient, but during a lockdown, families face many problems. For many families who started the process before the pandemic hit, they were eventually unable to fly to foreign countries to receive their kids. They were forced to wait multiple months and some surrogates even found themselves having to care for the baby they delivered. They also faced difficulties such as administrative challenges, extra anxiety, unexpected costs, and failure to obtain the paperwork needed to return home. All these challenges, among others like less access to care for the surrogate, lessened the incentive to become a surrogate or pay for a surrogate.

Entering surrogacy during the pandemic was unwise and did not offer many benefits. As a result, we now see “an approximately 60 percent decrease in potential surrogates.” [11] Wait times and fees have significantly increased because of this shortage. Vaccine debates also contribute to the shortage. Many families and surrogates may have differing opinions on vaccines. This severe shortage is creating a bidding war and seeing people wait over a year to be matched with a surrogate. Which was once an option for many couples, is now unfeasible for many.

Mother with her newborn baby in the hospital. [Rudi Suardi]

Conclusion

While women in the US face many healthcare challenges, especially during pregnancy, their struggles got even worse during the pandemic. After decades of efforts to improve maternal and infant health, the rates of maternal mortality and adverse birth outcomes remain very high. Throughout pregnancy, women’s bodies are supposed to be monitored and taken care of, but when a pandemic pushes that aside, negative outcomes will continue to occur. Weakened motor development for babies, an increase in maternal mortality, and a shortage of surrogates are just a few examples of the way the pandemic negatively affected women. These issues were even worse for Black women as the rate between Black and White maternal mortality continues to rise. It is a call to action for healthcare workers and government officials to rethink the way they approach women’s health. As the worst developed country in the world for women’s healthcare, something needs to change.

References

  1. D’Ambrosio, Amanda. “Report: U.S. Ranks Last for Women’s Healthcare Among Wealthy Nations.” Medical News, MedpageToday, 5 Apr. 2022, https://www.medpagetoday.com/obgyn/generalobgyn/98059. 
  2. McCarthy, Claire. “Pandemic Challenges May Affect Babies – Possibly in Long-Lasting Ways.” Harvard Health, 13 Jan. 2022, https://www.health.harvard.edu/blog/pandemic-challenges-may-affect-babies-possibly-in-long-lasting-ways-202201132668. 
  3. Ginsburg, Faye D., et al. “Modern Minds, Modern Bodies: Reproductive Change in an African-American Community.” Conceiving the New World Order: The Global Politics of Reproduction, University of California Press, Berkeley, CA, 1995, pp. 42–58. 
  4. McCarthy, Claire. “Pandemic Challenges May Affect Babies – Possibly in Long-Lasting Ways.” Harvard Health, 13 Jan. 2022, https://www.health.harvard.edu/blog/pandemic-challenges-may-affect-babies-possibly-in-long-lasting-ways-202201132668. 
  5. Barger, Theresa Sullivan. “Studies Show Developmental Setbacks in Pandemic Babies.” Discover Magazine, Discover Magazine, 18 Feb. 2022, https://www.discovermagazine.com/health/studies-show-developmental-setbacks-in-pandemic-babies. 
  6. McCarthy, Claire. “Pandemic Challenges May Affect Babies – Possibly in Long-Lasting Ways.” Harvard Health, 13 Jan. 2022, https://www.health.harvard.edu/blog/pandemic-challenges-may-affect-babies-possibly-in-long-lasting-ways-202201132668. 
  7. McCarthy, Claire. “Pandemic Challenges May Affect Babies – Possibly in Long-Lasting Ways.” Harvard Health, 13 Jan. 2022, https://www.health.harvard.edu/blog/pandemic-challenges-may-affect-babies-possibly-in-long-lasting-ways-202201132668. 
  8. Declercq, Eugene, and Laurie Zephyrin. “Maternal Mortality in the United States: A Primer.” Commonwealth Fund, 16 Dec. 2020, https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer. 
  9. Clark, Maggie. “Increase in Maternal Mortality during COVID Underscores Need for Policy Changes.” Center For Children and Families, Georgetown University Health Policy Institute, 25 Feb. 2022, https://ccf.georgetown.edu/2022/02/25/increase-in-maternal-mortality-during-covid-underscores-need-for-policy-changes/#:~:text=The%20rate%20of%20women%20who,than%20twice%20the%20national%20average. 
  10. Pande, Amrita. “Global Reproductive Inequalities, Neo-Eugenics and Commercial Surrogacy in India.” Current Sociology Monograph, vol. 64, no. 2, 2016, pp. 244–258. 
  11. Braff, Danielle. “Desperately Seeking Surrogates.” The New York Times, The New York Times, 2 Apr. 2022, https://www.nytimes.com/2022/04/02/style/surrogate-shortage-us-pandemic.html.

What Netflix Got Wrong About Abortion

Maeve, a 17 year-old high school student who has no home, no family, and no support system, becomes pregnant and wants an abortion. On her way to an abortion clinic, Maeve pushes past two anti-abortion activists and bonds with another woman in the clinic, a clean, bright space with modern equipment and professional staff who counsel her on contraceptives, offer considering adoption, discuss the abortion procedure, and respect her ultimate decisions. Sex Education, a Netflix TV show about high school students exploring their sexuality, spends an episode realistically representing a woman’s experience of abortion, an often taboo and stigmatized medical procedure.

“We didn’t want to sensationalize abortion,” says Emma Mackey, who plays Maeve, “and we didn’t want to make it this huge, dramatic decision” (Mcnamara, 2019). Mackey claims the episode is educational for clarifying abortion as standard, fast, safe, and usually without long-term consequences on the woman’s body and mind. But I would argue Maeve’s experience with abortion in this episode does not realistically represent the experiences of poor and/or minority women, who usually receive lower quality care in abortion clinics and encounter more barriers to access. 

Undervalued Woman

 According to the Guttmacher Institute, low-income women usually wait 2-3 days longer than high-income women between making an appointment and receiving an abortion. For women who live in states with waiting periods, which mandate women receive counseling and wait 24-72 hours before the abortion procedure, they often have to wait 7-8 days longer than women who live in states with no waiting periods (Jones & Jerman, 2016). Elise Andaya, a medical anthropologist who studies the organization of time in reproductive health care, argues long wait times become a vector through which women “encounter the lesser value assigned to their time, bodies, and labor” (Andaya, 2019).

Andaya makes these observations in a clinic at Beaumont Hospital, a public safety net serving primarily uninsured, Black and Hispanic women who work low-wage, service-sector jobs in New York City. Most women perceived the long wait times and the inconvenient appointments as a lack of institutional concern for their childcare obligations, work duties, or transportation difficulties. And most women spent less than five minutes with their provider. “Our visits are five minutes long because we can’t give more time than that,” says one provider, who describes the physical and emotional exhaustion in running from patient to patient (Andaya, 2019). Providers in abortion clinics, some which must be protected by security fences and bulletproof glass like this one, feel they do not have sufficient time to address all of their patients’ question and concerns, leading to miscommunication, conflict, and emotionally-charged situations that compound the stress of receiving an abortion. 

Another study by Khiara Bridges, a professor of law at UC Berkeley, criticizes requirements for health care providers to obtain and submit a detailed medical/social history documenting the abortion to the state (Bridges, 2008). Not only do these requirements take time away from patients’ visits but also intrude on patients’ privacy because they must report sensitive information. Bridges’ work draws upon Michel Foucault’s biopolitics model, which claims states can exert their power by administering, controlling, and regulating who can access health care services and under what conditions. Recent trends in state legislation lend support for the biopolitics model. American states introduced 2,090 bills concerning reproductive health in 2021. Of these bills, 633 restricted access to abortion, and state legislatures enacted a record number, 108 (Nash, 2022).

Reproductive Injustice

Such policies have consequences for women who access state-funded abortion clinics organized around the notion that poor and/or minority women possess “unruly bodies.” Bridges explains how state-funded health care prescribe “unruly bodies” surveillance and management by trained professionals because the institution assumes “unruly bodies” behave abnormal and thus cannot manage themselves. “[These policies] create two abortion circuits,” says Stuart Elden, a professor of political theory, “one, a restrictive experience for the poor; the other, private, liberal—and expensive” (Elden, 2016).

In light of Dobbs vs. Jackson Women’s Health Organization, the U.S. Supreme Court case about Mississippi’s law banning nearly all abortions after 15 weeks gestation, affluent women could travel to other states or countries to have an abortion while poor women must either have children against their will or risk aborting an unwanted pregnancy under unsafe conditions (Wilkinson, Onwuzurike, & Bartz, 2022). Some states cite adoption as an alternative, but this argument makes the “unruly body” fallacy in not considering the social, emotional, or economic effects associated with staying pregnant and surrendering a newborn to the state. Dr. Barbara Wilkinson, an OB/GYN at Brigham and Women’s Hospital, and colleagues summarize the issue with that argument nicely: “[It] treats pregnant people as vessels that can be manipulated rather than as fully autonomous persons” (Wilkinson, Onwuzurike, & Bartz, 2022).

The biomedical and legal climate for poor and/or minority women in American creates inequalities in access to abortion but also other reproductive health services, such as contraception, sex education, and culturally-competent prenatal care. Reproductive health inequalities originate from the 19th century when gynecologists developed new surgical techniques, such as the Caesarian section, through repeated experimentation on the bodies of non-consenting enslaved women and led investigations into the cause of infant mortality only after the U.S. and Britain banned the trans-atlantic slave trade, the main source of African captives for slaveholders (Cooper Owens & Fett, 2019). While many providers acknowledge the impact of structural racism on American health care, they seldom consider how structural racism influences their own biases and practices in caring for their patients.

Conclusion

I commend Netflix’s Sex Education for creating an episode to address some of the misinformation and stigmatization surrounding abortion. The episode’s overall message seems consistent with key results from the Turnaway Study: that women experience a mix of positive and negative emotions, the intensity diminishing over time; that the overwhelming majority of women feel abortion was the right decision for them five years later; that the most common reason for abortion is not being able to afford having a child. But I feel the episode overlooks the stark inequality in access and quality of abortion care among poor and minority women, many who think the health care system lacks concern for their bodies, many who feel the health care system surveillances and exploits them, by using Hollywood to set Maeve’s abortion in an affluent, private abortion clinic with minimal waiting and maximum compassion. 

By George Yacu

Bibliography

Andaya, E. (2019). Race-ing Time: Clinical Temporalities and Inequality in Public Prenatal Care. Medical Anthropology, 651-663.

Bridges, K. (2008). Pregnancy, Medicaid, State Regulation, and the Production of Unruly Bodies. Northwestern Journal of Law and Social Policy, 63-102.

Cooper Owens, D., & Fett, S. (2019). Black Maternal and Infant Health: Historical Legacies of Slavery. American Journal of Public Health, 1342-1345.

Elden, S. (2016, March 2). The Biopolitics of Birth: Michel Foucault, the Groupe Information Santé and the Abortion Rights Struggle. Retrieved from Viewpoint Magazine: https://viewpointmag.com/2016/03/02/the-biopolitics-of-birth-michel-foucault-the-groupe-information-sante-and-the-abortion-rights-struggle/

Jones, R., & Jerman, J. (2016, August 1). Time to Appointment and Delays in Accessing Care Among U.S. Abortion Patients. Guttmacher Institute, pp. 1-21.

Mcnamara, B. (2019, January 15). Netflix’s Sex Education Portrays Abortion Accurately. Retrieved April 10, 2022, from Teen Vogue: https://www.teenvogue.com/story/netflixs-sex-education-portrays-abortion-accurately

Nash, E. (2022, January 5). State Policy Trends 2021: The Worst Year for Abortion Rights in Almost Half a Century. Retrieved from The Guttmacher Institute: https://www.guttmacher.org/article/2021/12/state-policy-trends-2021-worst-year-abortion-rights-almost-half-century

Wilkinson, B., Onwuzurike, C., & Bartz, D. (2022). Restrictive State Abortion Bans — A Reproductive Injustice. The New England Journal of Medicine, 1197-1199.

Midwifery to Mortality: The Counterproductive Medicalization of Black Women in Childbirth


Black infants in America are now more than twice as likely to die as white infants — 11.3 per 1,000 black babies, compared with 4.9 per 1,000 white babies, according to the most recent government data — a racial disparity that is actually wider than in 1850, 15 years before the end of slavery, when most black women were considered chattel.

Linda Villarosa, New York Times. [1]

Introduction

Up through the twentieth century, black maternal care was largely reliant on the work of midwives, particularly in the segregated south. The shift to hospital-based childbirth in the late twentieth century brought with it a new wave of medical disparities between racial groups. On the surface, this transition would seem to be a node of progress for healthcare equity; in reality, however, the gap in childbirth outcomes between races has only widened since pregnancy in black women was medicalized.


Rooted in Slavery

Modern maternal medicine is rooted in slavery, and yet black women remain the victims of medical malpractice during childbirth at rates that dwarf those of white women. In the Antebellum South, particularly after the end of the slave trade, the survival of mothers and infants in slavery was prioritized since the children born to women in slavery were the sole source of new slave labor. Despite the incentive to ensure maternal and infant survival, the death rate of enslaved infants in 1850 was 1.6 times that of white infants [2]. That disparity has only grown as centuries have passed and childbirth has become more medicalized; today, black infant mortality is 2.3 times higher than mortality among white babies. Though maternal and infant care has never been equal across races, the shift to hospital-based births has failed to bridge the gap between races.

Along with the importance of maternal and infant survival as a means of preserving slave labor, the Antebellum South utilized black childbirth as an opportunity for medical experimentation. Consistent with the racist idea of black people as mere objects, white physicians and scientists essentially used pregnant slaves’ bodies as scientific property. In this way, “a slaveholding surgeon, François Marie Prevost, pioneered cesarean section surgeries on American enslaved women’s bodies through repeated experimentation” [2]. This invasive procedure has saved millions of lives since its development, but it is also linked to postpartum complications heavily correlated with maternal mortality.


Midwifery and Subsequent Medicalization

Midwifery played an important role in black communities of the rural south for centuries, until the medicalization of reproductive healthcare became commonplace. Black midwives such as Maude Callen, Onnie Lee Logan, Mary Francis Hill Coley, and Margaret Charles Smith are commended for their service to black women in the south, as heavily segregated hospitals often made it impossible for black women to seek medical care during childbirth [3]. Except for Maude Callen, who was an educated nurse-midwife, most of these granny midwives learned the practice by observing others and eventually obtained licenses to work as homebirth midwives. Despite the prevalence of hospital segregation due to Jim Crow Laws, the growth of privatized medicine accompanied a rise in maternal mortality rates due to a new reliance on general medical practitioners with inadequate obstetric education. Subsequent government intervention subjected both midwives and physicians to new state health regulations, requiring granny midwives to acquire permits through formalized training programs. By complying with these state demands, the black midwives used their experienced to demonstrate that “a well-trained lay midwife could deliver healthy babies even in the poorest conditions while acting as an intermediary between patients, nurses, physicians, and members of the local community” [4]. In this way, the significance of black midwives extended beyond their medical expertise as they provided security and empathy to women facing the intrusion of white men in the childbirth process.

Black and white image of Mary Coley, Martha Sapp, and a small baby. In the lower right corner Martha Sapp is laying in bed. She looks away from the camera at Mary Coley seated to her right. Coley is on the left side of the image, looks at the woman in bed and wears a white nurses' cap and a light-colored dress. In her lap she holds a small baby. On the table to the left of Coley are dishes and a pot full of liquid. The background of the image on the left side is in shadow.
Collection of the Smithsonian National Museum of African American History and Culture [4].

In the early 1900s, midwives attended 90% of African American births in the south, but that number declined to below 50% by the middle of the century [5]. This shift was largely due to widespread antimidwifery public health and legal campaigns, driven by the medicalization of childbirth. By translocating the birthplace from home to hospitals, healthcare officials believed that medical and social progress were taking hold. Alongside this movement, however, came disdain for the interruption that midwives played in the reproductive process, as physicians did not enjoy  competing “with midwives for patients nor [tolerating] the linkage of childbirth to empirically trained, usually unlettered black women” [5]. Therefore, the medicalization of black women in childbirth inevitably saw the decline of midwifery, particularly among the granny midwives whose expertise was rooted in tradition and experience as opposed to formal education.


Race-Based Disparities Today

Decades after black childbirth was translocated from home to hospitals, there still exist differences between the treatment of black and white women in the birth process. Although the cesarean section surgery was experimented on black women’s bodies with the purpose of improving white childbirth outcomes, black women are more likely to receive unplanned c-sections today than are their white counterparts. Between 2018 and 2020, 35.8% of live births for black mothers were carried out through cesarean deliveries, compared to only 30.9% of white births [6].

March of Dimes Infographic [6]

Higher cesarean section rates are correlated with increased maternal mortality rates, as there exist numerous complications associated with the invasive procedure. In general, women who plan for a vaginal delivery self-advocate against having a c-section, and therefore these statistics suggest that the wishes of black women are denied more frequently than are those of their white counterparts. The significance of this disparity goes beyond a patient’s wishes and recovery time; the gap is undoubtedly linked to the high black maternal mortality rate in the US.

According to the CDC annual report, the maternal mortality rate for non-hispanic black women in 2o2o was 55.3 deaths per 100,000 live births, a rate 2.9 times that of white women [7]. Despite the common attempt to explain this gap by stigmas of poverty or education status, the disparity stills exists when accounting for these confounding social factors. In fact, “a black mother with a college education is at 60 percent greater risk for a maternal death than a white or Hispanic woman with less than a high school education” [8]. The same inequality exists among infants born to black mothers. The babies of black mothers are more likely to die before their first birthday than are babies born to white mothers, regardless of the education or economic status of the mother [9].

ccf_20161021_reeves_1.png (768×552)
CDC Data Report – Infant Mortality by Race and Maternal Educational Attainment [9]

Conclusion

The racial gaps with regards to both infant and maternal mortality rates in the US are wider today than they were in the decades before the medicalization of black childbirth. The shift from home births to hospital births occurred alongside a decline in the practice of midwifery, and therefore black birthing mothers lost a support system vital to the laboring process. These disparities do not suggest that black women and infants had better outcomes before the medicalization of childbirth; they simply make it clear that hospital-based maternal care is white-centric and needs to be adapted to account for the individual needs of black women and babies.


Citations

[1] Villarosa, Linda. “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis.” The New York Times, The New York Times, 11 Apr. 2018.

[2] Cooper Owens, Deirdre, and Sharla M Fett. “Black Maternal and Infant Health: Historical Legacies of Slavery.” American Journal of Public Health, vol. 109,10 (2019): 1342-1345.

[3] Hill, Hanna. “Five Black American Midwives You Should Know: Black History, History of Childbirth.” Hanna Hill Photography, 2 Mar. 2022.

[4] Hunter, Ryan. “The Historical Significance of Doulas and Midwives.” National Museum of African American History and Culture, 24 Mar. 2022.

[5] Fraser, Gertrude J. “Modern Minds, Modern Bodies: Reproductive Change in an African-American Community” In Conceiving the New World Order, The Global Politics of Reproduction. University of California Press, 1995.

[6] March of Dimes, National Center for Health Statistics, final natality data. Last updated January 2022.

[7] “Maternal Mortality Rates in the United States, 2020.” Centers for Disease Control and Prevention, 23 Feb. 2022.

[8] “Maternal Mortality in the United States: A Primer.” Commonwealth Fund, 16 Dec. 2020.

[9] Reeves, Richard V., and Dayna Bowen Matthew. “6 Charts Showing Race Gaps within the American Middle Class.” Brookings, 9 Mar. 2022.

Pregnancy as Social Control

Pregnancy is an intense time in which the pressures of motherhood and societal expectations begin to take hold of expectant mothers. The readings and experiences documented in this unit portray the human struggle of pregnancy and birth. From doing anything to have your own children, including flying halfway around the world, to having to made agonizing choices about the future of your pregnancy, this unit really hit home in a lot of areas. One of the more interesting topics brought up in the discussion of pregnancy and childbirth is the idea of social control. Pregnant woman are controlled through a variety of mechanisms. Everyone from doctors, their families, their communities and society seems to want to have an input in how a pregnant woman lives her life. One helpful case study is how alcohol use during pregnancy is constructed. Below we can see an image encouraging mother’s to refrain from alcohol during pregnancy.

Image Source: Wade, L. ‘Social Control of Mothers’, Contexts, 10(1), pp. 76–77. (2011) doi: 10.1177/1536504211399060.

The image lists three healthy women with the text that “pregnancy is sacred.” Implied in this statement is the idea of pregnancy as important as some sort of religious ritual. There is an implicit understanding that women will want to protect and care for this sacred object. The top of the image implores women to be alcohol free. Although there is no safe amount of alcohol for a mother to consume, the impacts of alcohol on the fetus can be wide ranging. [2] Even in cases of fraternal twins, one twin can be severely impacted by fetal alcohol syndrome while the other has more mild symptoms, hinting at some sort of genetic cause. Ultimately, the medical establishment cannot say that drinking alcohol will always lead to Fetal Alcohol Spectrum disorders, and therefore they go with the broadest possible recommendation for no alcohol consumption. Many women who do decide to drink during pregnancy know the risk. In one study examining the attitudes of drinking during pregnancy, nearly all of the participants recognized the risk of Fetal Alcohol Spectrum disorders, believed that a few glasses would not make a difference. Furthermore, these individuals pointed to alcohol as cultural important and an important social element [3]. Individuals spoke of occasionally drinking a glass at Christmas, and other special occasions. However, the women also sharply highlighted the social pressures that they felt when they were observed drinking alcohol, and for some this perceived external pressure was enough to get them to abstain.

Stigma as Social Control

This leads us to another common method of social control which is stigmatization. As was stated above, the stigma and guilt associated with drinking while pregnant did lead some women to alter their behavior. Women report friends, family, and even strangers with stepping in as the “pregnancy police” in order to try and dissuade them from drinking. This stigma does not only happen during pregnancy, but in cases where Fetal Alcohol Spectrum disorder develops in children, the biological mothers are  frequently construed as bad parents, neglectful parents, child abusers, or addicts [2]. Despite the fact that the public has no idea about how much or how little alcohol the mother consumed, there is intense stigma directed towards the biological mothers of children with fetal alcohol spectrum disorders. There is moral fault directed towards these mothers which can lead to negative mental health outcomes. Additionally, researchers think about how this stigma can be directed inwards in a term known as self-stigma where the mother herself accepts the stigma. It is an interesting idea because it seems that strangers and members of the community feel much more comfortable stigmatizing and applying pressure and social control towards mothers. Pregnant women and mothers in general experience social control from their families, doctors and communities, and the case of Fetal alcohol spectrum disorders is no different.

Community as a Helpful Partner

However, I would argue that rather than directing efforts towards marginalizing mothers who drink or mothers with children who have Fetal Alcohol Spectrum disorders the community can be a helpful partner. The community can help the mother carry the burden. Perhaps at celebrations or events where alcohol consumption would be expected, individuals make an effort to abstain with the mother, rather than only rather than say no drinking. By giving the mother other people to rely on and to have other people who are not engaging in alcohol consumption might go a long way to reduce the isolation that mothers can feel when they feel that they are the only ones not consuming alcohol. An argument could be made that society through this stigmatization and pressure against pregnant drinking is trying to steer people towards correct decisions, and despite the control and burden it places on the mother, the CDC does say no alcohol during pregnancy. Communities always have had a keen interest in their children, and thus collective parenting and collective care for the young are practices in many communities. However, rather than directing the community towards applying guilt, stigma, moral pressure, and alienation, communities should work to better understand the struggle many pregnant women go through and work with them to achieve the health for both the mother and child. No mother wants to cause her baby harm and a collaborative approach rather than one based on stigma and guilt would seem to be the more effective in this circumstance.

[1] Wade, Lisa. “Social Control of Mothers.” Contexts, vol. 10, no. 1, Feb. 2011, pp. 76–77, doi:10.1177/1536504211399060.

[2] Roozen, S., Stutterheim, S.E., Bos, A.E.R. et al. Understanding the Social Stigma of Fetal Alcohol Spectrum Disorders: From Theory to Interventions. Found Sci (2020). https://doi.org/10.1007/s10699-020-09676-y

[3] Meurk, C.S., Broom, A., Adams, J. et al. Factors influencing women’s decisions to drink alcohol during pregnancy: findings of a qualitative study with implications for health communication. BMC Pregnancy Childbirth 14, 246 (2014). https://doi.org/10.1186/1471-2393-14-246

A War of Control

Fundamentally, reproduction is the means by which every living thing comes to be on the earth. Without it, plants, animals, humans, you, and I would simply cease to exist. However, as the human race has grown and developed, so has the concept of human reproduction. Today, with our complex political, social, and medical institutions, the concept of human reproduction is no longer just a biological process. Controversies and debates have arisen surrounding the meaning, ethics, and means of reproduction, deeply intertwining the deeply personal process of reproduction into politics, society, culture, and medicine, especially in the United States (1). As a result, reproduction in the United States has emerged as a highly medicalized and regulated process that exerts control over the decisions of women surrounding their reproductive health, removing autonomy and personal choice from their own pregnancies.  

Preconception Health

  

The withdrawal of autonomy and personal choice from a woman’s reproductive health starts very early in the reproductive process; that is before she is even pregnant. In 2004, the CDC launched the Preconception Health and Health Care Initiative, giving rise to a new paradigm in women’s reproductive health termed preconception health (2). Preconception health is the focus on the health of women during their reproductive years (ages 12-51) in order to improve and protect the health of future pregnancies and babies. The concept of preconception health and preconception campaigns launched by the CDC such as the “Show Your Love Campaign” target any fertile women as future reproductive agents, implying that all women are potential reproductive vessels and permanently prepregnant (2). The highly personal choice of a woman starting a family is removed as it is automatically assumed that she will become pregnant someday and needs to prepare her body for a healthy pregnancy. In addition, guilt and shame are projected onto women who do not follow the guidelines of preconception health campaigns as it is implied that they do not care about the health of their potential baby, further reinforcing women’s role in society as reproductive vessels.

Medical Births Here Only

When women do conceive and decide to start a family, their autonomy and personal choice are only further withdrawn and placed into the hands of doctors. Prenatal care in healthcare allows for continuous surveillance and regulation of women throughout their pregnancies in the form of weekly exams, ultrasounds, supplements, and more . At the time of labor, 98.4% of births occur in the hospital with ⅓ of babies delivered Caesarean due to hospital regulations surrounding induced labor, length of labor, and previous Caesarean history (3). Many times women will receive an undesired or unconsented Caesarean as the regulation of childbirth in the form of hospital policies surpasses her personal choice and autonomy in the decision, leaving women powerless during their own labor. Women are once again placed into the primary role in reproduction as only vehicles for childbirth. However, even with the high involvement of technology and medicine in childbirth, the United States has the highest rates of maternal mortality among industrialized countries (4). Furthermore, black women are 4 times more likely than white women to die from pregnancy; a statistic worse than it was 25 years ago (3). These maternal mortality rates reflect the ineffectiveness of our healthcare system in listening to the complaints and concerns of laboring mothers during and after childbirth. Even more so, the racial inequalities and discrimination present in society and in the realm of women’s reproductive health are exposed. Black women are subjected to increased societal stress from everyday racism in addition to implicit biases of doctors who may believe black women to be exaggerating their pain or culprits of their own illness during pregnancy (5). Overall, there is a failure of our healthcare system to take into account the autonomy and choice of women during childbirth, in addition to the racial disparities historically ingrained in the institution of medicine, leading to high maternal mortality among mothers in America.

Abortion

Some women who conceive will decide they want to terminate the pregnancy for a multitude of personal reasons. The topic of abortion in the United States has become highly controversial due to ethical debates among different groups in society. Today, abortion is legal in the United States, however, many states have their own strict regulations and requirements surrounding abortions (. This limits accessibility and availability of abortion to women who may have poor access to transportation, healthcare, education, and support. In addition, women risk receiving shame, hate, and social rejection for seeking an abortion in certain communities (6). While ultimately women are given the personal choice to terminate a pregnancy, regulations and social pressure push many women to carry out unwanted pregnancies. Recent trends indicate the potential for even tighter regulations and possible banning of abortion on the level of the law, leading to another aspect of reproductive health that women do not have a personal choice in. 

An Uprising?

Women’s reproductive health in America allows for surveillance, control, and regulation of women as reproductive vessels. Women are pressured into a permanent potentially pregnant role in which their future reproductive health is regulated and controlled by medical, social, and political institutions. Once pregnant, women are surveilled and subjected to doctors who control and manage the pregnancy until birth. However, evidence of potential resistance to reproductive surveillance and control over women’s pregnancies has arisen. A rise in at-home births using midwifery has occurred, demedicalizing childbirth and placing control of women’s birthing experiences into their own hands (7). Doulas have become more utilized among black women to guide them supportively through pregnancy and advocate for them during birth to minimize racial discrepancies in hospitals (3). Pro-choice groups are fighting against the criminalization of abortion to preserve women’s choices in their pregnancy. As we move through the 21st century only more of these resistances arise, leading to the question: will women one day win control of their reproductive health, gaining full autonomy and personal choice over their reproduction?

References

(1) Rene Almeling. “Reproduction.” Annual Review of Sociology, 41, (2015): 423-432, doi:10.1146/annurev-soc-073014-112258.

(2) Waggoner, M. R. “Cultivating the maternal future: Public health and the prepregnant self.” Signs: Journal of Women in Culture and Society, 40(4), (2015): 939–962. https://doi.org/10.1086/680404

(3) Villarosa, L. “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis.” The New York Times. 11 April 2018. www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html.

(4) Maternal mortality in the United States: A Primer. The Commonwealth Fund. 16 December 2020. https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer.

(5) Owens D. C. and Fett S. “Black Maternal and Infant Health: Historical Legacies of Slavery,” American Journal of Public Health 109(10), (2019): 1342-1345.

(6) Tolentino, Jia. “Interview with a Woman Who Had an Abortion at 32 Weeks.” Jezebel, G/O Media Inc., 15 June 2016, https://jezebel.com/interview-with-a-woman-who-recently-had-an-abortion-at-1781972395?rev=1466004781175

(7) Shapiro, S. M. .”Mommy wars: The prequel.” The New York Times Magazine. 2012 May 23. https://www.nytimes.com/2012/05/27/magazine/ina-may-gaskin-and-the-battle-for-at-home-births.html

Racist Undertones of Managing Black Women’s Reproduction

Almost all institutional structures that oppress marginalized groups of people and advance white men can be traced back to imperialization. Though it is a common belief that we have progressed past the racist foundations of many nations, one of the most apparent forms of modern control is the limitation of reproductive choice. Black women, in particular, have suffered the most from the medicalization of reproduction. Starting in the 1960’s with the rise of eugenics, birth control was advertised to politicians as a way to manage the Black population. Even now, Black women experience higher maternal mortality rates and are seriously negatively affected from being denied abortions. This complex past and present of limiting Black women’s reproductive freedom inherently shows how institutional racism preservers in reproduction. 

“Reproduction was not just a function, but the purpose of a woman’s life.”

Ann Stoler, when discussing the role of women during imperialization

Modern History Of Limiting Black Women’s Reproduction

Ever since the foundation of America and the doctrine of freedom for all, people in powerful positions have been working to create inequality between white citizens and citizens of color. Even seemingly helpful and feminist movements for progress were designed to restrict Black population and power growth. For example, birth control was seen as a revolutionary step towards equality “for how it allowed women to control their fertility and thus increase their educational attainment and participation in the labor force” (Almeling 427). I argue that this framework comes from a very western and privileged women’s perspective as it claims that women now have sole jurisdiction over their reproduction in regard to their educational and occupational goals. However, for women of color and poor women, their goals were limited by their social status and race. Even if they were able to control their reproduction, they were barred from many opportunities so that their womanhood still rested on bearing children. Birth control, in reality, stemmed from eugenic thought that aimed to limit the reproduction of these marginalized people. As Dorothy Roberts rightly points out, “birth control became a tool to regulate the poor, immigrants, and Black Americans” (Roberts 59). More so, Planned Parenthood was founded by Margaret Sanger who was fiercely aligned with eugenic theorists. To gain mass popularity, “eugenics gave the birth control movement a national mission and the authority of a reputable science” (Roberts 72). Whereas many women trust and depend on Planned Parenthood for reproductive help, it was strategically and politically created to further white supremacy and diminish the reproductive freedom of women of color. Instead, by being socially accepted, these forms of birth control enabled doctors to push contraception onto marginalized groups of women without the obvious accusation of being racist. 

Figure 1: Historical Rates of Maternal Mortality in the US (Commonwealth Fund)

Increase of Maternal Mortality Rates

With the invention of new technology and safer techniques, one would assume that maternal mortality rates would dramatically decrease, and stay consistently low, since the beginning of the 20th century. However, they have been increasing in recent years. This is due to the disproportionate increase of maternal mortality among Black women than white women. Research shows that “In the United States, pregnancy-related mortality is three to four times high among Black women than among White women” (Owens 1343). In addition, the CDC conducted a study in 2016 that concluded “Black infant mortality is 2.3 times high than mortality among non-Hispanic white babies” (Owens 1343). Both of these figures demonstrate how modern-day racism and microaggressions contribute to the deaths of Black women and infants. Black women are more likely to die from eclampsia during pregnancy due to high blood pressure and health complications related to living in a racist society. Furthermore, their babies and their health are not prioritized during birth because of institutionalized racism from the hospital and medical education systems. Although maybe not overtly racist, the current social and medical environments cause a higher risk of death among Black patients. Inherently, this parallels the goals of the eugenics movement partnering with the birth control movement to limit the reproduction of Black citizens and ensure the dominance of the white race.  

“I have learned that I can trust patients to know what they and their families need; no two people are ever exactly the same, and there is no one-size-fits-all approach that is right for every woman.”

Dr. Harris, an obstetrician-gynecologist who worked in an abortion clinic

Being Denied Abortions and the Negative Consequences

            There are many reasons that women wish to have an abortion, and all of them are valid. As mentioned in the quote above, women who want to terminate a pregnancy are doing so with themselves, their families, and their fetuses in mind. It is never an easy decision, but some women are not even allowed to make this choice. In the Turned Away Study, researchers surveyed women who were allowed abortions, and other women who were denied them because they were past the clinic’s gestational limit. In regard to financial stability, the study “shows that being denied a wanted abortion results in economic insecurity for women and their families, and an almost four-fold increase in odds that household income will fall below the Federal Poverty Level” (Turn Away Study 3). I recognize that this study does not incorporate intersectionality and other factors that may affect women so, I am assuming the following conclusions. However, given that Black people have the highest poverty rate in the United States (Federal Safety Net), I think it is fair to say that many of these women turned away from abortions and consequently suffered financial instability are Black women. Even when Black women don’t want to carry a baby to full term and give birth, their options are limited by clinic timelines. In turn, they suffer an impoverished lifestyle that disables them from succeeding in educational and occupational fields. Although being denied an abortion is seen as the opposite of pressured birth control and high maternal mortality rates during pregnancy, it still has the same effect. It continues to disadvantage Black women, and their new baby from an unintended pregnancy, by putting them in a generational cycle of poverty. Even though it doesn’t limit the Black population, it ensures they don’t threaten white supremacy by widening the racial divide of wealth and social status. The institutional management of Black women’s reproduction has roots in colonial racism and eugenic thought that transcends decades so that even today, they are disadvantaged in something that should be uniquely equal among all women: reproduction. 

References

Stoler, Ann. Making Empire Respectable: The Politics of Race and Sexual Morality in 20th-Century … https://www.jstor.org/stable/645114. 

“The Turnaway Study.” ANSIRH, 21 Mar. 2022, https://www.ansirh.org/research/ongoing/turnaway-study. 

“U.S. Poverty Statistics.” Federal Safety Net, 7 Apr. 2022, https://federalsafetynet.com/poverty-statistics/. 

Harris, Lisa H. “My Day as an Abortion Care Provider.” The New York Times, The New York Times, 22 Oct. 2019, https://www.nytimes.com/2019/10/22/opinion/abortion-clinic-doctor.html. 

Owens, Deirdre Cooper, and Sharla M Fett. “Black Maternal and Infant Health: Historical Legacies of Slavery.” American Journal of Public Health, American Public Health Association, Oct. 2019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6727302/. 

Roberts, Dorothy E. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. Vintage, 1999. 

Almeling, Renee. Reproduction. Department of Sociology, Yale University, 2015. 

Declercq, Eugene. “Maternal Mortality in the United States: A Primer.” Commonwealth Fund, 16 Dec. 2020, https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer.