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Conscience Magazine

Controversies in Reproductive Health

By Suzanne Poppema June 29, 2015

While there is excellent research in many disciplines about human reproduction, Reproduction and Society represents the only effort that I have seen to create a clear and comprehensive framework for understanding the controversies in reproductive health and place them logically within their much larger social context. Even as a physician who has been involved in reproductive healthcare my entire career, I found new ideas and points of view presented articulately within these pages. The editors draw from historians, journalists, activists and academics in sociology and medicine, all chosen obviously both for the content of their work as well as an ability to write about it engagingly. Joffe and Reich have created a powerful tool for engaging students and experts alike in thinking about all aspects of reproduction and of the social, economic and political issues that influence the men and women seeking to exercise their right to reproduce or not. It should be required reading for any student of human rights, gender issues, medical care and social justice, as well as physicians, lawyers, public health students, nursing students and/or sociologists. reproduction-and-society-joffe

The introduction sets the stage by pointing out that reproduction “is not simply a biologic process, but one laden with symbolic, political, philosophical, and ideologic meanings.” Here the editors also outline the themes that will recur throughout the book: a feminist perspective; a close examination of race and class issues in reproduction; an inspection of the institutional settings where reproductive services take place; connections to the reproductive and social justice movements; and a section on global issues with a major focus on the US.

Fertility Control and Society

In the context of contraception and sterilization, the editors point out that throughout known history, men and women have sought to control their fertility and determine family size. At the same time, those in power have recognized that fertility control is a most powerful tool for rulers. These attempts have led to coercive birth control, as well as the withholding of birth control methods because “particular reasons for promoting or rejecting birth control typically represent cultural, political and economic currents in a society and vary across time and place.” The very fact that fertility control allows women to be non-procreatively sexually active without a high risk of pregnancy can be socially destabilizing, presenting controversial new cultural norms.

Birth control has been part of the folklore of both primitive and advanced societies for millennia. Aristotle, Plato and other Greek physicians, Sanskrit and Islamic scholars, as well as the Chinese, Africans and others all had discussions about and methods for controlling fertility. An essay from the late feminist writer Toni Cade Bambera argues that, while not a panacea, oral contraceptives certainly give women control over some aspects of their lives and should not be dismissed as weapons of genocide against black women. There is also a quite shocking report on forced sterilizations performed on poor women of color in the US, showing the clear division between the way different classes and races experience reproductive health.

Abortion: A Historical Constant

The editors’ main point in the section on abortion  is that “abortion is a historical constant: whether legal or not, women have always sought abortion in every society for which there is a written record.” The five articles cover personal physicians’ stories, as well as a fascinating look at men’s perspective on the experience of abortion and a chilling discussion of the real-life effects of a judicial bypass system for minors seeking abortion in a state where parental permission is mandatory.

An excerpt from Joffe’s book Doctors of Conscience lays out the tensions between the institution of medicine, practitioners and women seeking help for an abortion. Her most compelling passages recount the experiences of true doctors of conscience who were brought face to face with the results of illegal abortion in the US, and how they became passionate advocates for their patients.

Lori Freedman’s contribution examines how the stigmatization of abortion has resulted in new and old practitioners being unable to provide abortion care at all, even though they are well trained and more than willing to provide the service. Tracy A. Weitz illustrates how this stigma has led to the new mantra (since 1990) of abortion as safe, legal and rare. She dismantles the implication that there are too many abortions and that, therefore, some must be “not so good” as others—and that abortion rights can be affirmed only in the context of reducing its use.

Willie Parker’s essay (written with Joffe) from the perspective of an African American physician is a heartfelt description of his determination to provide abortion care for the African American community. He includes a lovely paraphrase from Dr. Martin Luther King, Jr.: “Jeopardizing the reproductive health and rights of individual black women jeopardizes the collective well-being of the black community.”

Jennifer Reich interviewed 20 men from California involved with one or more unintended pregnancies and abortions with their partners, and her examination of their narratives is the only one of its kind. She produced a sensitive reflection of men’s cultural understanding of pregnancy, abortion and masculinity. It’s a fascinating read and an important addition to the scholarship in this area.

Global Reproductive Technologies

The editors organize the reproductive technologies section into three major themes: assisted reproduction technologies (in vitro fertilization, artificial insemination, surrogacy); social implications; and promise and perils. They explain the last part: “Like other areas of reproduction that we discuss in this book, assisted reproduction contains both liberatory and coercive possibilities.” All of these technologies are very expensive and far from always successful.

“Selling Genes, Selling Gender” shines light on both the commercialization of egg and sperm donorship and of the abundant gender biases included in these transactions, in which donors are chosen much more on social characteristics than biomedical ones. The examination of surrogacy in India is written with such nuance that it leaves readers less and less able to judge these women and their sponsors. While it is true that almost all Indian surrogates are from the garment industry (where they were overworked and underpaid), it is also true that surrogacy for many of these women gives them not only quite a lot of money but something even more important. They receive a sense of moral value: they have made a baby for someone, not simply a garment or other ephemeral object.

Disparities in Reproductive Health

Of major importance in the pregnancy and birth section is the fact that there are “huge disparities in positive pregnancy outcomes that exist along racial, economic, and geographical lines.” This is, not surprisingly, the longest of the sections.

Dorothy Roberts’ chapter, “Reproduction in Bondage,” while emotionally difficult to read, is a truly important glimpse into the lives of African American women who were enslaved. In the subsequent chapter, Francine Coeytaux, Debra Bingham and Nan Strauss present maternal mortality in the modern US as a human rights failure, pointing out the US stands at number 50 in global rankings of maternal mortality. While the world’s maternal mortality rate decreased by 34 percent from 1990 to 2008, the US rate doubled—a shocking statistic made even more shocking by how stratified it is along racial and class lines.

Also in the pregnancy and birth section, genetic counseling is shown to be rife with gender and social biases, even among competent and conscientious counselors. In keeping with the broader framework of reproductive justice, the book includes a frightening discussion of environmental toxins and their effects on many aspects of reproduction. These chapters also help identify often overlooked pregnancy issues, such as how does society deal with a woman whose pregnancy does not end in a live birth—where are the rituals for these experiences? In addition, the huge issue of liability for practitioners of obstetrics continues to be a major problem, resolvable only through institutional changes in malpractice insurance, hospital regulations and the courts.

The section on special populations targeted for reproductive control focuses on the fact that reproductive self-determination simply is not an option for many—especially disabled, immigrant, drug using and incarcerated women. Michelle Chen places us among migrant working women for whom, she writes, “the dignity of reproductive sovereignty is a privilege that the low-wage economy forecloses for millions of migrant women.”

In one of the most powerful articles, Lynn M. Paltrow discusses how women are slowly being relegated to a non-person status when pregnant by being excluded from the “community of constitutional persons.” The judicial system not only incarcerates many more women, but it also simply denies them any rights as women or mothers while in jail, even to the extent of forcing women to be shackled while in labor. Disabled women are too often viewed as asexual to begin with, so they cannot even begin to access the resources to help them prevent pregnancy or safely carry a pregnancy to term. It seems that for disabled and poor women, pregnancy is portrayed as a sign of moral weakness.

Cairo, Beijing and Beyond

After these in-depth looks at the past and present of reproduction, the book concludes with envisioning the way forward for the global reproductive rights movement. This begins with previous efforts on the international level, especially the 1994 International Conference on Population and Development in Cairo and the 1995 4th World Conference on Women in Beijing. These conferences exposed deep divisions, not only between traditionalists and modernists, liberals and conservatives, but also within the reproductive rights movement between the population controllers and the feminists urging the empowerment of women. This section reminds us that the liberatory vs. coercive elements of reproductive technologies are ever present and introduces a framework for reproductive justice that is most eloquently stated by Loretta Ross, a founder of Sistersong:

Every woman has the right to

Decide if and when she will have a baby and the conditions under which she will give birth

Decide if she will not have a baby and her options for preventing or ending a pregnancy

Parent the children she has with the necessary social supports in safe environments and healthy communities, and without fear of violence from individuals or intervention by the government.

Much more work is needed to grow the coalitions that will lead the world to truly accept Hillary Clinton’s insight: “Women’s rights are human rights.”

It is critical to read every one of the pages of this book, which has so much to teach about the complexities and interwoven issues in human reproduction. Reproduction and Society is an enormous addition to the scholarship of human reproduction across the many fields of academia and practitioners.

Reproduction and Society: Interdisciplinary Readings
Carole Joffe and Jennifer Reich
(Routledge, 2014, 334 pp)
978-0415731034, $40

Suzanne Poppema
Suzanne Poppema

is currently an advisory board member of the University of Washington Women’s Center. She was a founding board member of Physicians for Reproductive Health, a past board chair of the National Abortion Federation and is author of Why I Am an Abortion Doctor.