Reproduction, Health, and Medicine: Volume 20

To explore the politics of gender, health, medicine, and citizenship in high-income countries, medical sociologists have focused primarily on the practice of legal abortion. In middle- and low-income countries with restrictive abortion laws, however, medical sociologists must examine what happens when women have already experienced spontaneous or induced abortion. Post-abortion care (PAC), a global reproductive health intervention that treats complications of abortion and has been implemented in nearly 50 countries worldwide, offers important theoretical insights into transnational politics of abortion and reproduction in countries with restrictive abortion laws. In this chapter, I draw on my ethnography of Senegal’s PAC program to examine the professional, clinical, and technological politics and practices of obstetric care for abortions that have already occurred. I use the sociological concepts of professional boundary work and boundary objects to demonstrate how Senegalese health professionals have established the political and clinical legitimacy of PAC. I demonstrate the professional precariousness of practicing PAC for physicians, midwives, and nurses. I show how the dual capacity of PAC technologies to terminate pregnancy and treat abortion complications has limited their circulation within the health system, thereby reducing quality of care. Given the contradictory and complex global landscape of twenty-first-century abortion governance, in which pharmaceutical forms of abortion such as Misoprostol are increasingly available in developing countries, and as abortion restrictions are increasingly enforced across the developed world, PAC offers important theoretical opportunities to advance medical sociology research on abortion politics and practices in the global North and South.

As maternal mortality increases in the United States, birth providers and policymakers are seeking new solutions to address what scholars have called the “C-section epidemic.” Hospital cesarean rates vary tremendously, from 7 to 70 percent of all births. Based on in-depth, semi-structured interviews with 47 obstetricians and family physicians in the United States, I explore one reason for this variation: differences in how physicians perceive and manage risk in American obstetrics. While the dominant model of risk management encourages high levels of intervention and monitoring, I argue that a significant portion of physicians are concerned about high intervention rates in childbirth and are working to reduce cesarean rates and/or the use of monitoring technologies like continuous fetal heart rate monitors. Unlike prior theories of biomedicalization, which suggest that health risks are managed through increased monitoring and intervention, I find that many physicians are resisting this model of risk management by ordering fewer interventions and collecting less information about their patients. These providers acknowledge that interventions designed to mitigate risks may only provide an illusion of control, rather than an actual mastery of risks. By limiting interventions, providers may lose this illusion of control but also mitigate the iatrogenic effects of intervention and continuous monitoring. This alternative approach to risk management is growing in many medical fields and deserves more attention from medical sociologists.

This chapter draws on qualitative interviews to examine how Bhutanese refugees interact with norms around mothering and childbirth. Since these women have birthed and reared children in Bhutan and/or Nepal, as well as in the United States, their stories help to explore how the implications of medicalization differ for individuals by race, class, and nation, with a unique cross-comparative lens. In particular, the respondents uniquely identify epidurals as an important medical intervention, simultaneously increasing their autonomy while subscribing to neoliberal mothering. This research furthers our understanding of neoliberal mothering and medicalization by showing a nuanced script that illuminates social processes, resistance, and internalization through an intersectional and cross-cultural lens.

Unassisted childbirth, also known as “freebirth,” is when a person intentionally gives birth at home with no professional birth attendant. The limited research on unassisted birth in the United States focuses on women’s reasons for making this choice. Studies suggest women are committed to birthing without a professional and that this choice is rooted in religious or natural-family belief systems. These studies do not adequately account for the ways a framework of “choice” obscures the role structural barriers play in decision-making processes. International research on unassisted childbirth finds that it is not always a first choice and may be a last resort for women who have had negative experiences with maternity care. More research on unassisted birth in the United States is needed to better understand if people face similar structural barriers. In this paper I examine how structural limitations of the US healthcare system intersect with values in decision-making processes about childbirth. Drawing on in-depth interviews with nine women who gave birth unassisted in the United States, I examine the women’s shared ideological commitments, negative experiences with health care, and barriers faced seeking care. I discovered that unassisted birth may not be a first, or even positive choice, but rather a compromise informed by ideological commitments and constrained choices. Structural barriers in the US healthcare system prevented women from having a professional birth attendant who they felt was acceptable, available, and accessible. I conclude by discussing the implications of these findings for debates about birth justice and health policy.

In the contemporary US, pregnant women must navigate competing ideas about their bodies, including expectations for weight gain. Given that there are few social spaces where women may gain weight without disapproval, pregnancy represents a period when women are allowed to put on weight. However, gaining weight means doing so within the context of the obesity “epidemic” and increased medical surveillance of the body. To explore how women navigate the medicalization of pregnancy weight, I draw on data from in-depth interviews with 40 pregnant and recently pregnant women. Findings indicate that women reframe the meaning of pregnancy weight as “baby weight,” rather than body weight. This allows them to view it as a temporary condition that is “for the baby,” while holding two concurrent body images – a pregnant and a non-pregnant version of themselves. Women also resist the quantification of their maternity weight, either by not keeping track or not looking at scales in the doctor’s office. Doing so prevented baby weight from turning back into body weight – a concrete and meaningful number on the scale. Such resistance to quantification is often accomplished with the help of doctors and healthcare professionals who do not explicitly discuss weight gain with their patients. These findings suggest that women rely on a variety of strategies to navigate the medicalization of pregnancy weight, and provides another lens through which to understand how and why women may make similar choices about other medicalized aspects of their pregnancy (or pregnancy experiences).

Popular self-help pregnancy literature suggests a “generational disconnect” between pregnant women and their mothers, emphasizing the incommensurate experiences of the two generations. Based on longitudinal, in-depth interviews with a diverse group of 64 pregnant women and 23 grandmothers-to-be, this chapter explores how different generations of women negotiate the idea of a disconnect and its implications for the medicalization of pregnancy. My findings showed limited support for the generational disconnect. Nearly all of the pregnant women I interviewed who were in contact with their mothers consulted them to assess issues related to pregnancy embodiment. Black and Latina women and white women with less than a college degree disregarded or even rejected the disconnect; they tended to frame their mothers’ advice as relevant. Their mothers attended prenatal care appointments and frequently expressed skepticism about medical directives. By contrast, I found that highly educated white women tended to endorse the generational disconnect when it came to matters related to pregnancy health behaviors – what to eat, how much to exercise – and their obstetric care. The mothers of these women not only largely supported the generational disconnect, but also bonded with their daughter over a shared appreciation for scientific understandings of pregnancy. Foregrounding women’s perspectives provides insights into meaning-making in pregnancy and the ways that mothers of pregnant women can both stymie and deepen medicalization of childbearing.

As biomedicine becomes increasingly enmeshed in modern life, biomedicalization processes have implications for reproductive policy, including abortion policy. Informed consent provisions have been a prominent trend in state-level abortion lawmaking in the United States in recent years. Modeled on the practice of securing informed consent for medical procedures, informed consent provisions stipulate the information a person must receive before they can consent to an abortion. Informed consent provisions purportedly require that this information be objective, scientifically accurate, and non-judgmental. Through an analysis of informed consent provisions in Texas abortion legislation from 1993 to 2015, this chapter explores how such provisions employ medical and biomedical tropes to frame regulations that restrict access to abortion care as ostensibly protecting women’s health and safety. I find that informed consent legislation in Texas selectively borrows from medical and biomedical lexicons, cites strategic empirical evidence, and co-opts medical techniques and experts in ways that encumber abortion access.

This chapter explores processes of stratification in reproductive healthcare and considers the ways in which mechanisms of inclusion/exclusion shape reproductive opportunities and experiences. First, I consider the process of “selective inclusion” among sexual minority women. This examination questions the schisms that exist within the sexual minority population in regard to their visibility and legibility in medical, scientific, and public health discourses and constructions of reproductive health. The second process I examine is that of “exclusionary inclusion” among substance using pregnant women who have been collectively deemed “bad breeders” by medical and state authorities and whose reproduction is explicitly monitored, regulated, and criminalized. The final process I discuss is “side-stepping inclusion” which describes the healthcare and consumer decisions of women who circumvent medicalized childbirth experiences by employing the services of a midwife for their pregnancy and birth care. This chapter examines how medicalization, biomedicalization, and de-medicalization dynamically work together to expand and delimit inclusionary processes, emphasizing the spectral and interconnected quality of these processes. By exploring various processes of inclusion that shape reproductive experiences of these disparate and differentially marginalized populations, this chapter provides a conceptual and critical meditation on the ways in which “respectable reproduction” is deployed in reproductive care. In considering these processes of inclusion and the ways in which they are co-produced by medical discourses and practices, scholars may more clearly grasp some fundamental mechanisms of stratification in reproductive healthcare and knowledge production.

This chapter examines symphysiotomy in twentieth-century Ireland as one example of a systematized obstetric violence that has characterized Ireland’s modern history. Expanding scholarly interpretations of state- and Church-inflicted abuse of women in the twentieth century, this analysis establishes the medical profession as a central actor alongside the twentieth-century state-Church coalition that regulated women’s reproductive lives and engaged in systematic repression. This chapter recognizes that Ireland’s history of reproductive abuse and coercion did not just involve contraception or abortion but also labor and birth experiences. In addition, it offers a more complete and complex interpretation of obstetric violence by highlighting the experiences of married women with wanted pregnancies; almost all research to date focuses on the experiences of unmarried pregnant women or unwanted pregnancies. This examination of symphysiotomy and obstetric violence in Ireland illuminates the ways in which religious, national, and medical power has been mapped on women’s reproductive bodies, particularly in the decades after independence in 1922. It also makes essential links between Ireland’s past and present, demonstrating that a careful analysis of the history of obstetric violence and the religious underpinnings of it are essential in understanding Ireland today. With this research, we also place symphysiotomy within the context of the global reproductive justice movement, asking how a reproductive justice framework – one that links reproductive rights with social justice – can help us interpret obstetric violence and address the wounds of Ireland’s past.

This chapter examines how women deploy gendered motherhood norms to publicly challenge abortion stigma. Drawing on a sample of 41 abortion stories from women living in Tennessee, I find that women evoke notions of intensive, total, and idealized motherhood in order to manage and challenge the stigma of an abortion. A large proportion of these stories were written by married mothers who emphasized their identities as good mothers and wives. A close qualitative analysis of these trends reveals two dominant forms of recasting abortion. First, abortion is framed as an extension of total mothering to spare an unborn baby from risky health conditions. Part of this includes casting abortion as an often-necessary choice in order for a woman to develop into the perfect mother for the benefit of her children – altruistic self-development. Second, abortion is construed as a form of maternal protection of current children to continue intensively mothering them. Both themes speak to women’s strategies for reframing abortion as a health practice to promote the well-being of children. These findings have implications for the study of medical stigma, reproduction, and the impact of gender ideals on women’s health choices.

There has been substantial interest in US cesarean rates, which increased from 5% of deliveries in the 1970s to nearly one-third of births by the mid-2000s. Explanations typically emphasize individual risk factors (e.g., advanced maternal age, increased BMI, and greater desire for control over delivery) of women giving birth, or address institutional factors, such as the medicalization of childbirth and the culture of liability leading physicians to practice defensive medicine. We focus here on another non-medical explanation – childbirth education (CBE). CBE is an important, underexplored mechanism that can shape women’s expectations about labor and birth and potentially lead them to expect, or desire, a cesarean delivery as a normalized outcome. We analyze data from three waves (2002, 2006, 2013) of the Listening to Mothers national survey on US women’s childbearing experiences (n = 3,985). Using logistic regression analysis, we examined both mode of delivery (vaginal versus cesarean), and attitudes about future request for elective cesarean among both primiparous and multiparous women. Despite previous research suggesting that CBE increased the likelihood of vaginal delivery, we find that CBE attendance was not associated with likelihood of vaginal delivery among either primiparous or multiparous women. However, both primiparous and multiparous women who attended CBE classes were significantly more likely to say they would request a future, elective cesarean. Furthermore, these effects were in the opposite direction of effects for natural birth attitudes. Our findings suggest that contemporary CBE classes may be a form of “anticipatory socialization”, potentially priming women’s acceptance of medicalized childbirth.

Within the field of medical sociology, there is an extensive body of literature on notable family transitions and stages in the reproductive cycle, such as getting married or becoming a parent, as they relate to mental health and well-being. However, the transition to becoming a completed family, that is, the process of determining or recognizing that one’s family is complete, is notably absent. In response to this empirical gap, this chapter presents findings from 114 semi-structured interviews with participants who reported having at least one child and who considered their family to be complete. First, the concept of “family completion” is introduced and conceptualized based on the qualitative considerations of participants and the contextual medical sociology literature. Then, thematic considerations around the process of family completion, related emotional preparations, and factors associated with mental health and well-being are explored. Findings suggest that family completion can be an important transitional period for parents and can be associated with emotional hardship for some individuals. Participants described experiencing conflict with their partner if they disagreed on the completion decision, frustration and sadness related to infertility, and/or feelings of loss or depression when completion was regarded as the end of a personal or familial life phase. This chapter concludes that creating a cultural context in which family completion is a recognized family transition period may spur intentional consideration among parents and promote the design of intervention services for parents experiencing changes in mental health or well-being.