A medical school essay.
Being able to make decisions over whether and when to bring new life into the world is a power. It is the power to determine, in part, the size and composition of future generations; society itself.
Due to this central and essential role in human societies, reproduction has always something that the power hungry have sought to control; whether this be by maintaining traditions of child and arranged marriages or by blocking contraceptive and abortion access.
Not only concerned with determining future populations, controlling women’s fertility has always been a useful way to keep women dependent and out of public life, thereby maintaining the power status quo.
Quite the opposite of ‘valuing life’ as many of those who support anti-choice policies claim, such actions and attitudes knowingly devalue women’s potential and humanity. In childbearing for women the stakes are high; not only physically, with pregnancy and childbirth still being major causes of mortality and injury (in 2015 830 women died due to obstetric reasons per day, WHO), but also educationally, economically and socially. Early and unwanted childbearing keeps girls and women in a vicious cycle of poverty, reliant on others financially and unable to escape further reproductive coercion.
Access to contraception and safe abortion enables women to escape not only from unwanted pregnancy, with it’s physical and psychological repercussions, but also transmission of disease and unsafe abortions, which cause 47,000 worldwide deaths per year according to the WHO.
Our relatively recent ability to control our fertility with the introduction of the pill has meant that women can take part in public life and control our own destinies in a way we never could before, but still today many women still face significant challenges when seeking to manage this fundamental aspect of their lives.
Coercion can take many forms and is present at all levels in society, from home life, to the public sphere, large organisations and Government.
Reproductive coercion is a term increasingly used to specify a type of domestic abuse and is recognised by the WHO as a real threat against women’s health worldwide.
It is defined as a male partner’s attempt to cause pregnancy in an unwilling partner through verbal pressure and threats or birth control sabotage (1). Once a woman is pregnant the partner may then try to control the outcome of the pregnancy by pressuring her into an abortion or trying to stop her from accessing one.
Perhaps due to it’s extremely personal nature, this form of abuse is not as widely discussed as other types of domestic abuse, though there are indications that it is actually quite common.
So common, in fact, that the American College of Obstetricians and Gynaecologists (ACOG) recommend routine screening of women and girls for signs of such coercion (2).
In California a survey conducted among over 1200 women aged 16- 29 using family planning clinics found that 19% reported experiencing pregnancy coercion and 15% reported birth control sabotage (3). Another survey at Brown University found a similar prevalence, and women experienced coercion regardless of socioeconomic status.
Unintended pregnancies have been found to be associated with intimate partner violence all over the world (for example: 4). A study on women in domestic violence shelters found that 77% reported birth control sabotage by their abusive partner (5).
Often such attacks on autonomy are normalised in popular culture, with the view that men should ‘have a say’ in abortion being quite common, for example. Some ‘men’s rights’ groups actively campaign for a legal say in women’s pregnancy outcomes. Additionally, many legal systems do not yet consider coercion into pregnancy an offence unless outright sexual violence is involved.
As the ACOG advise, it may need to become standard practice to use screening questions to check for this type of abuse, particularly in women presenting with unplanned pregnancies.
Whenever intimate partners display these controlling behaviours for the most part it is rightly condemned and recognised for the abuse it is; however, similar types of behaviour can be shown outside of a domestic setting and not condemned in the same way.
At a public level doctors and other healthcare workers may themselves try to stand in the way of women seeking contraception or abortion by holding a ‘conscientious objection’ to it.
Reproductive healthcare often appears to be an area of medicine where the autonomy of the patient is not absolute and their preferences are open to judgement in a way they are not in other areas of medicine.
This is all the more alarming considering the potentially serious impact of pregnancy and childbirth on a woman’s health.
In the UK such objections have been allowed by the GMC, and it is specified that the patient must be made aware that they can see another doctor and must be able to do so; however, disagreeing with a woman’s right to avoid pregnancy or childbirth raises serious questions about the doctor’s priorities and their view of women in general. Such beliefs appear to place women as secondary to their reproductive ability and not as patients in their own right.
The guidelines also say that objections must not be in any way discriminatory. It is difficult to see how objecting to women being able to control their fertility is not being discriminatory against women.
In the UK the 1967 Abortion Act includes a conscientious objection clause, however, the same problem arises. Why do these doctors believe that it would be acceptable to force continuation of pregnancy and childbirth on a woman? Why do they believe she should not have an absolute say in how her body is used by others?
Women’s reproductive health requirements need to be accepted according to reality, not the ideals of doctors. It is not clear why a doctor should be able to exert the same controlling tendency as a coercive partner as best they can and be protected in doing so.
There are several countries around the world that are known for enshrining reproductive coercion into law and this seems to be generally due to the influence of religion.
Up until relatively recently the catholic church held a great deal of power in Ireland. Many of it’s teachings (on the importance of female purity, of women as the origin of sin and the control of sexual expression by use of shame) created an society in which effectively women were considered to exist mainly for the purposes of having large catholic families.
This religious influence in the state meant that contraception was illegal until 1980 and laws regarding it’s sale weren’t properly relaxed until 1993.
Abortion too remains largely illegal and difficult to navigate for healthcare personal. The law states that women and foetuses have an ‘equal right to life’, while the recent ‘Protection of Life during pregnancy act’ (2013) technically allows abortion if a woman’s life is at risk. Introduced after the death of Savita Halappanavar in 2012, it has been described as unworkable and still far too restricted. By the time it was obvious Savita could die from her protracted miscarriage it was too late to save her, but intervention had been disallowed due to the presence of a foetal heartbeat.
In reality Irish women simply travel for abortions to the nearby UK if they can afford to do so, or they gamble with internet pills.
Horrendous abuses have resulted from a presiding ethos that treats women as secondary to their reproductive function.
Between 1944 and 1984 it is estimated that nearly 2000 women underwent symphysiotomies in Irish hospitals during childbirth without having given consent (6). It has been found since that these procedures were encouraged by the church because they did not limit the number of babies a woman could have, while a caesarean would (7). Victims were left in pain, with impaired mobility and incontinence and have experienced severe difficulty in achieving any acknowledgement or redress from the state.
Today, the effects of state interference in women’s health for ideological reasons can also be seen in South America. Despite the outbreak of the Zika virus catholic leaders defended the ban on contraception and abortion, showing a complete lack of respect for women and total unawareness of their own lack of qualification in making any decisions on the matter.
These countries all fail to meet the WHO recommendations for maternal health by denying women access to safe abortion, however a country like Ireland with it’s proximity to the UK is less likely to see the health effects of unsafe abortions than developing nations, where general medical care is also an issue.
The same kind of behaviour and entitlement that creates unequal power and abuse in relationships also creates hugely unequal societies when implemented by law. In addition, laws of this nature and doctors who agree with them actually support the attempts of coercive intimate partners.
Rape is a common occurrence in war. While previously it was considered ‘collateral damage’ of a conflict, it is now being recognised for the deliberate military strategy that it often is. A report by Medecins frontiers described the use of rape by the Serbs in Bosnia as part of an ethnic cleansing strategy and that’s it’s purpose was simply to genetically erase the community (8); that is mass rape with the intention to impregnate and force women to bear children.
Unwanted pregnancies are therefore of particular concern in women in war zones and amongst refugees. In addition to it’s clear role as essential healthcare, emergency contraception and abortion in such scenarios could rightly be considered as part of a defence against the ethnic cleansing aspirations of their attackers.
However, these women can face extreme obstacles in seeking healthcare. Aid may be difficult to reach, women can face stigma from their own communities as rape survivors and and the provision of emergency contraception and abortion has lagged behind other kinds of medical care.
Often this is also due to ideological reasons. The US’s Helms Amendment prevents American funds from going to programs that provide abortions, and as most international humanitarian medical organisations rely on US funding, an essential need of women and girls is frequently not met by aid efforts (9). In this way women’s health is not treated as a real concern in conflict areas due to the (religious) ideals of people on the other side of the world.
Medical Aid groups such as Medecins Sans Frontiers offer emergency contraception where they can and apply pressure where it is illegal, for example, in Honduras (10).
For doctors working in Aid work and emergency care the removal of barriers to essential medications should become a priority in order to truly meet the needs of patients.
For half the population the dignity of bodily autonomy is often treated as a fringe interest or something that can be negotiated and debated rather than an absolute necessity.
When a woman is left without the means to control her fertility, this is directly threatening to her health and well being and health professionals must therefore always resist the treatment of women as a means to a reproductive end, no matter where or who it comes from.
Ultimately, this is about power and if we recognise that crimes like rape are wrong because they involve the use of someone’s body against their will, with additional serious long term implications, then we must recognise that reproductive coercion is always wrong for the same reasons.