Expecting Motherhood? Stratifying Reproduction in 21st-century Scottish Abortion Practice

UK Abortion Law and Feminist Theory: Critiques of the ‘Normalisation’ of Motherhood

Qualitative studies of women’s experiences of abortion within the UK suggest that, while they are generally able to access the procedure, they sometimes experience very difficult interactions with the health professionals they encounter (Allen, 1985; Harden and Ogden, 1999; Kumar et al., 2004; Lattimer, 1998; Lee, 2004; Lee et al., 2004; Macintyre, 1977; Robotham et al., 2005). A consistent finding of this body of work is that most women decide to end their pregnancies before entering the clinic, and that they typically approach health professionals for information and support in accessing the procedure. Where such support is provided, women report positive experiences, but often describe feeling ‘over-counselled’ (Allen, 1985) and judged when they are questioned about their decisions.

Feminist theorists (Jackson, 2001; Lee, 2004; Sheldon, 1997) have linked the difficulties that women experience when requesting abortion to the gatekeeping framework through which the procedure is regulated in the UK. Currently, abortion is regulated through the 1967 Abortion Act, as amended by the 1990 Human Fertilisation and Embryology Act. This makes its legality contingent upon two doctors’ agreement that it is necessary on the grounds of a pregnant woman’s health or that of her foetus. This construction of abortion decision-making has been widely criticised (Boyle, 1997; Fyfe, 1991; Jackson, 2001; Lee, 2003, 2004; Sheldon, 1997) for its portrayal of femininity. By positioning the rationality of doctors as central to abortion decision-making, the law constructs women as irrational and incapable of judging the circumstances in which they should become mothers. Moreover, by depicting abortion as an exceptional, deviant act justified only by doctors’ assessments of ‘the individual circumstances (or inadequacies) of individual women’ (Sheldon, 1997: 42) it implicitly normalises motherhood.

While feminist analyses of UK abortion law concur about its problematic constructions of femininity, there are nonetheless important differences in the forms of critique which have been developed. For example, Jackson positions legal reform as the key issue, arguing that abortion law should be brought in line with contemporary medical law’s respect for the ‘guiding principle of patient self-determination’ (2001: 72). Drawing on Jackson, Lee’s (2003, 2004) concern is also with the letter of UK abortion law, specifically its failure to provide, ‘[A] clear and overt intention to view reproductive control as a “good”, that should be upheld and promoted in society’ (2004: 302).

However, as Smart (1989) argues, a narrow focus on legal change as an automatic solution to problems that affect women’s lives creates a number of further difficulties. Firstly, it reifies law’s account of itself, on which its claim to power rests, namely, that it is a ‘superior and unified field of knowledge’, rather than a ‘plurality of principles, knowledges, and events’ (1989: 4) enacted in specific contexts. Secondly, and following from its sociologically inadequate account of law, this approach fails to consider that the meaning of any new legislation will be determined by the specificities of its enactment(s) in practice (1989). Acknowledging these concerns, Sheldon (1997) articulates her critique of UK abortion law in slightly different terms. Notably, she emphasises the importance of exposing and addressing the gendered processes which have produced, and in turn sustain, law’s problematic constructions of women who request abortion. A related approach is adopted by Boyle (1997), who explores how psychology – as a discipline – has historically supported such constructions.

Nevertheless, through the analysis that follows, I reveal that even these, more nuanced, feminist critiques contain important limitations. Specifically, I suggest that their focus on processes of gendering has prevented them from engaging with the complexities of processes of ‘stratified reproduction’, and the ways in which these are entangled with the regulation of abortion provision in the UK.

‘Stratified Reproduction’ in UK Abortion Practice

In describing how women requesting abortion were represented in the debates that preceded the 1967 Abortion Act, Sheldon notes in passing that these representations ‘might productively be analysed in terms of class’ (1997:35). However, because her overarching concern is with processes of gendering, she does not engage any further with the implications of this significant insight. In contrast, the ways in which gender intersects with other stratifying practices of social classification in the regulation of abortion is central to Macintyre’s (1977) analysis of the processes via which single women reached particular ‘outcomes’ of pregnancy in 1970s Scotland. As part of her study she discovered that doctors’ expectations about the outcome of women’s pregnancies were determined by patients’ accounts of their anticipated marital status. In cases where women were planning to marry their partners, doctors treated motherhood as an inevitable pregnancy outcome. However, if questioning revealed that a woman was unlikely to marry, doctors became actively supportive of outcomes other than motherhood (adoption or abortion). In an extension of this analysis, Macintyre highlights that, in addition to referencing (anticipated or actual) marital status, doctors also utilised class, age and parity (number of children) in ‘attributing a desire to have, or not have, babies’ (1976: 190) to their patients.

Another, more contemporary, illustration of the perpetuation of stratified expectations about motherhood in abortion practice is provided by analyses of health professionals’ accounts of counselling in the context of prenatal diagnosis (Alderson et al., 2004; Statham et al., 2006; Williams et al., 2002a, 2002b, 2002c). A critical point demonstrated by this literature is that healthcare practice in this field has normalised the expectation that motherhood should be rejected following a diagnosis of foetal impairment (see also Ettorre, 2000; Farrant, 1985; Lippman, 1991; Shakespeare, 1998). However, of the 189,574 abortions conducted in England and Wales in 2010, only 1 per cent were conducted on the grounds of such a diagnosis (Department of Health, 2011: 3). In other words, although important, current sociological interest in the ‘high tech’ context of prenatal diagnostics means health professionals’ roles in the vast majority of abortion work – which does not occur within this context – has become a critically neglected topic.

‘Youth’

Given the regularity with which cultural anxieties about reproduction coalesce in the figure of the teenage mother during public policy debates (Carabdine, 2007; Kidger, 2004; Lawson and Rhode, 1993; Luker, 1996; Phoenix, 1991; Ward, 1995; Wilson and Huntingdon, 2006), it is perhaps unsurprising that health professionals also mobilised this figure to evidence the importance of the service that they provide. In some cases the extreme youth of those seeking abortion was presented as automatic evidence of its necessity, without any further explanation:

As Ward notes, in spite of the comparative rarity of the phenomenon, the case of very young pregnant motherhood – ‘babies having babies’ (1995: 147) – is often mobilised during debates about teenage pregnancy because of its rhetorical power to shock. Related discourses which position adolescents as automatically incapable of engaging in ‘adequate’ mothering behaviours because of their developmental age have been found to dominate health professionals’ accounts of antenatal care provision (Breheny and Stephens, 2007).

However, the majority of health professionals whom I interviewed did not rely on such ‘developmental discourses’ (Breheny and Stephens, 2007) when legitimating young women’s requests for abortion. Instead, motherhood and youth were presented as incompatible on the basis that the former would prevent young women from realising aspirations that would allow them to mother more ‘effectively’ in the future. On this basis, health professionals described abortion as a course of action that was rational for pregnant women at a range of life stages including and beyond adolescence:

I mean suppose it was somebody who was kind of young, in the middle of studies um pregnant by accident um really didn’t or really couldn’t cope with a child at the moment um really wanted a termination just to be, get it out the way and get on with their life […] That, you know there would be very little discussion, I would ask them whether they wanted to ask, ask me anything more about it. But if they didn’t […] I wouldn’t necessarily engage them in any further discussion about it. (GP17, female)

So young women who find themselves perhaps, they may have a stable partner, they may have had casual sex. Often if it’s been casual sex and they’ve found themselves pregnant, drink’s been involved so I just don’t think it’s very helpful to for us to be judgmental, you know, they’ve found themselves pregnant and it’s important to help them out […] And so these, this group of women is often at an early stage in their career, they just can’t see how fitting it um they haven’t got the finances to support the child, their relationship isn’t stable enough, they’re living in rented flat accommodation, they want to have developed their careers to a point where they could then support a child effectively. (GP9, female)

In constructing temporary constraints on young women’s ability to mother, GP9 cites the instability of the heterosexual relationships in which they are engaged and connects this explicitly to a state of economic uncertainty. This echoes the way in which the significance of a ‘stable relationship’ was portrayed more generally by interviewees: as evidence of the presence or absence of economic security. Such depictions contrast sharply with Scottish health professionals’ articulations of the meaning of heterosexual relationships and pregnancy in the 1970s (Macintyre, 1977), which centred on concerns with extra-marital reproduction. However, this difference – as well as the emphasis which contemporary health professionals place on the importance of young women’s attaining an education and a career prior to motherhood – makes sense in light of broader changes in UK policy discourse concerning ‘young’ motherhood. While the figure of the teenage mother has historically been used to signify concerns with extra-marital sex and the breakdown of traditional family structures, the advent of New Labour saw teenage pregnancy reconceptualised in terms of the ‘threat’ it represented to female participation in paid work (e.g. Carabdine, 2007; Wilson and Huntingdon, 2006).

‘Age’

When health professionals utilise women’s ‘youth’ to problematise motherhood, they automatically normalise motherhood that occurs ‘later’ in life. In some cases, this argument was made explicitly, with interviewees contrasting the example of patients whose youth rendered abortion an ‘obvious’ solution, with those whose age made its provision problematic:

And then of course it would depend on how old they are. If we were having this discussion with somebody who was 33 and they said yes they would want to have a child in this relationship but now isn’t the right time, I would then have an entirely different conversation about how, ‘Well 33 is getting on a bit and if you have this pregnancy terminated and then you can’t get pregnant subsequently and it does get harder as you get older, you know, why […] do this now and possibly consider getting pregnant next year or the year after. There often is no right time to be pregnant, it’s a difficult decision to make, to, to, that now is the time to be pregnant.’ But if somebody was 19 I wouldn’t have that conversation with them. (Consultant4, female)

When they suggest that, in contrast to teenagers, women in their thirties should be dissuaded from abortion, these doctors do not simply construct older women as more appropriate mothers than younger women. In both extracts, they also define a temporal window of opportunity beyond which the pursuit of motherhood can occur too late in a woman’s life. Although the reasons for this are left ambiguous in the first extract, in the second quotation, Consultant4 cites the time-limited nature of female fertility as the basis for her concern.

As Berryman (1991) notes, while the stigmatisation of ‘older’ motherhood is a relatively recent phenomenon, it now pervades medical literatures on childbirth which characterise conceptions that take place after age 30 as extremely risky endeavours. This process of stigmatisation is not confined to medical discourse. It is also visible in the media’s repeated portrayal of ‘selfish’ and/or ‘ignorant’ women who ‘delay’ childbearing in pursuit of their careers, only to find out that they have left it ‘too late’ and that they need to be ‘rescued’ by reproductive technologies in order to conceive (Campbell, 2011; Hadfield et al., 2007; McNeil, 2007; Shaw and Giles, 2009). As McNeil (2007) highlights, such portrayals fail spectacularly to acknowledge women’s awareness of processes of social stratification (for example, sexism in the paid workplace), which make it difficult, or indeed impossible, for them to bear children at an earlier point in time. Such discursive erasures were echoed in the accounts of several health professionals whom I interviewed, who, like Consultant4, portrayed older pregnant women as merely ‘ignorant’ of the time-limited nature of their fertility.

‘Parity’

An important subtext of the preceding sections was that, in delegitimising motherhood that occurs ‘too early’ (Phoenix, 1991) or ‘too late’ (Berryman, 1991), health professionals do not simply ‘stratify reproduction’ in terms of age. When they raise concerns about agreeing to terminate the pregnancies of women who may subsequently become ‘too old’ to reproduce, health professionals normalise biological motherhood as something which should be achieved (at the correct time) during the female life-course. This process of normalisation also takes place when health professionals suggest that younger pregnant women should be able temporarily to pursue aspirations other than motherhood, on the basis that this will enable them to mother more ‘effectively’ later in life.

The invocation of parity as an independent criterion for questioning or supporting women’s requests for abortion was another crucial means by which femininity and maternity became equated. As described previously, the absence of existing children, in combination with the identification of a patient as being ‘older’, was often problematised by health professionals. In the examples considered above, however, this process of questioning was articulated in relation to older patients’ expressed desire for future maternity. In contrast, in other cases, interviewees depicted childlessness (and age) as automatic criteria for questioning their patients’ attempts to prevent fertility, in the absence of a patient’s expression of interest in future maternity. For example, in describing the kinds of issues that she thought it important to talk about with women during consultations about abortion, one nurse suggested:

I mean it’s I suppose what you’re looking for is things like if somebody’s 40 and pregnant for the first time do you think it’s, you know it’s quite right to – you might raise with them well ‘Do you realise this might be your only chance of getting pregnant, are you sure this is what you want?’ (Nurse8, female)

To this dataset concerning the normalisation of women’s eventual maternity it is important to add a third figure that was routinely invoked by health professionals: that of the ‘older’ pregnant woman who has already borne children. A crucial feature of the way in which descriptions of this ‘type’ of patient were mobilised by interviewees was the sympathy with which their requests for abortion were depicted. This process is visible in the following extract, where a gynaecologist cites this situation as a rare instance in which (he claims) women are ‘genuinely’ emotionally distressed by the fact that they are requesting an abortion:

Um the majority of pregnancies that come via the termination clinic are accidents. So it’s just inconvenient […] There are the odd occasions […] where women are quite genuinely upset because for instance, they’re mid-forties, didn’t expect to get pregnant – bang got pregnant. Difficult lifestyle choice, family’s complete […]. (Specialist Registrar2, male)

In this extract, the abortion requests of women who have already ‘achieved’ motherhood are legitimated through a discourse of suffering, whereby ‘authenticity or genuineness is signalled by the agonistic difficulties of “making tough decisions”, of being seen painfully to ponder over antagonistic positions’ (Brown and Michael, 2002: 261). This interviewee constructs a clear distinction between such decisions and the ‘majority’ of requests for abortion, which he portrays as the result of the ‘inconvenience’ that pregnancy represents for women. As Boyle (1997) points out, such trivialisations of abortion are deeply gendered, simultaneously concealing the work involved in pregnancy, childbirth and mothering and devaluing any aspirations which women may have besides motherhood.

‘Class’

The construction of normative understandings of motherhood in relation to the ‘standard’ of middle-class women’s lives, and the corresponding devaluation of working-class women’s mothering, has long been recognised as a process through which patterns of social classification are perpetuated in the UK (Hey and Bradford, 2006; Skeggs, 1997; Tyler, 2008). For example, in her study of family planning clinic practices, Hawkes (1995) illustrates how staff characterised young working-class women’s requests for assistance with fertility as ‘irresponsible’ on the grounds that such patients were attempting to become mothers in circumstances other than the middle-class ideal. Likewise, health professionals interviewed for this study also reproduced idealisations of middle-class maternity through their accounts of abortion provision.

An implicit example of this process was highlighted in the preceding discussion, namely, the importance which interviewees ascribed to young women’s attainment of socio-economic stability via education and the establishment of a career and a stable relationship prior to motherhood. However, health professionals also engaged in a far more direct differentiation of the desirability of maternity on the basis of class. For example, at the outset of one interview, GP12 characterised his current practice as being located within ‘a very deprived area’, and listed a variety of reasons why his patients might request an abortion (including drug and alcohol use, involvement in sex work, large family sizes, clinical depression and/or youth) – none of which he problematised. In contrast, when I asked him explicitly if he ever encountered reasons that he found ‘problematic’ he said:

When I went on to explore what had happened to the couple in question, GP12 said that he had refused to refer them initially, and ‘couldn’t remember’ whether or not they had eventually been given access to the procedure. A notable feature of his account is the discursive device via which he positions a middle-class couple’s request to end a pregnancy as ‘irrational’. He constructs his negative reaction to this request as one that is grounded in professional, rather than personal, criteria by suggesting that it would be shared by a community of medical practitioners. He then reinforces the ‘objectivity’ of his position by contrasting it with what would constitute an ‘unfair’ judgment, namely one grounded in religion and a personal intolerance of abortion.

For the most part, however, health professionals were less confident than GP12 in positioning class as a legitimate criterion for differentiating between patients’ requests for abortion:

… there [are] you know, a lot of unemployment, poverty, drug dependence, violence […] all these things associated […] with deprivation and, poor educational achievement and so on and I certainly find it quite easy to think, yes, if a woman in those circumstances doesn’t want to bring another child into that sort of environment then […] I don’t have any difficulty with that decision if they’re struggling already. Although, I could accuse myself of being judgmental and paternalistic and what right have I got to take, to have any view on whether a child […] should or shouldn’t be born just because the circumstances in which they’re going to be born are going to be a lot more challenging than the circumstances into which I was born? […] And I probably, this, my view is probably shared by a lot of people that if the circumstances […] are likely to be very tough then it makes, you know this enormous decision to have a termination very easy […]. (GP19, male)

In recent decades, ‘the primacy of patient autonomy has emerged as a central theme within medical law’ (Jackson, 2000: 468) and an implicit prioritisation of this norm permeates GP19’s self-critical account of his ‘paternalistic’ sympathy for the majority of women in his practice population who request abortion. Nevertheless, while he is undoubtedly less confident than GP12 in describing the socio-economic circumstances of patients as a relevant issue in abortion decision-making, this hesitancy is ultimately undermined by his legitimisation of his approach as one that is ‘probably shared by a lot of people’. A similar process takes place in the following extract:

I can feel my sort of moral views or prejudices or whatever you like to call them coming through on the rarer occasions where a professional or successfully employed middle-class, well-educated patient, mother, woman comes […] And just wants the termination because it’s sort of inconvenient, you know, not […] the right time, doesn’t fit in with her plans. I’m certainly aware that in those circumstances I would try … I wouldn’t say ‘I’m not going to sign the form’ but I would probably then make a bit more, I would make a significant effort to get her to think through and make it clear, probably might make it clear to her that although I would sign the form I wasn’t in myself particularly supportive of her decision. Again that’s a judgment and some people might argue that I shouldn’t be doing that but that’s, that’s the way I work I think. (GP19, male)

As in many of the extracts considered above, women’s requests for abortion are positioned as ‘irrational’ through the depiction of pregnancy and motherhood as trivial matters of ‘inconvenience’. However, this account illustrates potently how processes of gendering intersect with other processes of stratification in the construction of women’s ‘rationality’. Irrational female subjects, for whom abortion is deemed to be merely ‘convenient’, are ‘classed’ and ‘aged’ explicitly through their portrayal as individuals who have established successful careers prior to pregnancy.

In the examples considered thus far, patients’ assumed socio-economic circumstances are used explicitly to ‘stratify reproduction’. More commonly however, health professionals constructed a more implicit distinction between the desirability of the fertility of different classes of women. Rather than critiquing middle-class women for requesting abortion, most interviewees focused only on their support for the abortion requests of those living in poverty. This more implicit approach is illustrated by the following extract, where GP8 explains the reasons for her involvement in family planning work:

Like most of the other health professionals that I interviewed, GP8 stressed that requests for abortion are initiated by patients, who have defined their pregnancies as ‘unwanted’ before they reach the consulting room. However, her account illustrates the discursive slippages which this term facilitates. While she begins by emphasising the link between the availability of methods of fertility control and patient health, it quickly becomes clear that the patient health she is referring to is that of the children who are the product of (what she defines as) a failure in fertility control. Moreover, her initial depiction of ‘morbidity’ in terms of its significance for children and their parents rapidly becomes a discussion of the burden which child ‘morbidity’ places upon the rest of society.