Medicalisation,depoliticisation and reproductive stratification: lessons from Canada's Muskoka Initiative

Medicalisation and technocratisation

Medicalisation refers to ‘the process by which medical definitions and practices are applied to behaviours, psychological phenomena, and somatic experiences not previously within the conceptual or therapeutic scope of medicine’ (Davis, 2010, p. 211). Medicalisation has typically been associated with a focus on biomedical symptoms, and a corresponding neglect of the underlying social, economic and political factors that shape these symptoms and their root causes, known broadly as the social determinants of health (Birn, 2011; Clark, 2014). Acknowledging the impact of social determinants of health means examining how factors such as poverty, gender inequality, racism and environmental degradation shape health outcomes; how these factors are themselves produced; and why they impact certain groups more than others (Raphael, 2016). When medicalisation works to ignore or decentre these elements (MacDonald, 2019), it can act as a form of depoliticisation that aligns with and reinforces a broader technocratisation of both health and development. This broader technocratisation positions global development as a series of relatively straightforward, technical problems that require technical expertise and solutions rather than as a set of complex political problems that require systemic change and deconstruction of global and local matrices of power (Ferguson, 1990; Li, 2007). Both technocratisation and medicalisation can function as forms of depoliticisation, obscuring rather than highlighting the political systems in which problems of global development, including global maternal health, are embedded and through which they often arise.

The technocratisation of global development creates a particular field of action for development interventions, which focus on issues such as building capacity, improving infrastructure and increasing the delivery of services (Li, 2007). While these development interventions work to make existing systems more efficient, they tend not to consider political contexts and the power relations that shape them as appropriate targets of intervention (Ferguson, 1990). While technocratisation may appear to inoculate outside actors against critiques that by undertaking development projects they are interfering in the politics of ‘underdeveloped’ countries, technical problems cannot be removed or separated from their political context. Instead of truly depoliticising development, technocratisation thus reinforces the status quo, leaving the systemic causes of underdevelopment and poverty unexamined and unaddressed whilst reifying the knowledge and authority of development experts to act on developing world populations (Mitchel, 2002; Li, 2007). I argue that medicalisation, by framing health as a series of biomedical problems that can be solved by technical experts, contributes to and constitutes a particular iteration of technocratisation that both relies on and reinforces a broader depoliticisation of development.

Examining the Muskoka Initiative through the lens of medicalisation and technocratisation necessitates acknowledgement of the particular ways in which pregnancy and childbirth have been constructed as problems of medical intervention. Feminist scholars have analysed how pregnancy and childbirth underwent a process of medicalisation in North America and Europe, in which they moved from the private domain of women-centred midwifery to the masculinised sphere of professional medicine and were re-constituted as conditions requiring medical management (Paterson, 2011; Shaw, 2013). Contraception and abortion have similarly been theorised as sites of medicalisation, having moved from the feminised sphere of midwifery to that of medicine and, in particular, medical surveillance (Mclaren, 1978; Tone, 2012). While some of this feminist scholarship critiques medicalisation as inherently disempowering, positioning women's bodies as the subjects of (masculinised) medical authority (Cahill, 2001; Parry, 2006), it is crucial to acknowledge that women both pursue and resist medicalisation in nuanced ways, and shaped by their intersecting identities and social positions (Brubaker and Dillaway, 2009; Johnson, 2016). Gary (2002) thus argues that feminist critique of medicalisation should focus not on rejecting medicalisation but on interrogating how medicalisation operates as a form of oppression in relation to specific individuals and communities. In this article, I use the concept of medicalisation to demonstrate how maternal health has been made ‘technical’ through the Muskoka Initiative's obscuring of the social determinants of health and how medical expertise is used to promote reproductive norms and behaviours that work to govern reproduction in the Global South.

Biopolitics and neoliberal governance of reproduction

I understand the reification of technological and medical expertise within the sphere of development as a crucial component of how global development acts as a site of biopolitical governance. In analysing the Muskoka Initiative, and maternal health interventions more broadly, as a form of biopolitical governance, I draw on Foucault's (1990) theorisation of biopower as the form of power that aims to govern human life. Biopower is operationalised through the complementary poles of anatomo-politics, which functions by disciplining individual bodies, and biopolitics, which operates by regulating the population as a whole (Foucault, 1990). Foucault identified sex as the ‘pivot of the two axes’ of biopower; that is, as the site wherein anatomo-politics and biopolitics meet, and through which individual bodies are disciplined in order to maximise the well-being of the population (Foucault, 1990: 145). Feminist scholars have further expanded this claim, examining how the maternal body also operates at this axis, being disciplined and regulated as a means of managing and optimising the well-being of the population (Weir, 2006; Moore, 2013). Morgan and Roberts name this process ‘Reproductive Governance’, defined as ‘the mechanisms through which different historical configurations of actors – such as state institutions, churches, donor agencies, and non-governmental organisations – use legislative controls, economic inducements, moral injunctions, direct coercion, and ethics incitements to produce, monitor and control reproductive behaviour and practices’ (2012: 243).

Foucault (1990) distinguishes biopower from sovereign power, the latter being understood as a repressive form of power best epitomised by a sovereign's ability to punish subjects through death. In contrast, biopower is both repressive and productive, compelling subjects to abstain from certain behaviours as well as to engage in others. Furthermore, while sovereign power is imposed from a central actor, biopower is relational and diffuse, exercised through a variety of institutions and permeating all aspects of our public and private lives (Foucault, 2004). Foucault encapsulates these various sites and technologies of power in the concept of governmentality, which denotes ‘the way in which one conducts the conduct of men’ (Foucault, 2004: 184). Of particular relevance to my analysis are neoliberal modes of governance, which rely largely on processes of self-regulation, including through discourses of risk. Within neoliberal contexts, the understanding that the role of the state is primarily to ensure citizens’ freedom rather than to administer their lives limits (though does not do away with) the use of direct, repressive force (Peterson and Lupton, 1996). Instead, neoliberal governance operates largely through self-governance, by which individuals activate their own agency to regulate themselves and their behaviours in accordance with established and accepted norms (Peterson and Lupton, 1996; Li, 2007). Because neoliberal subjects are expected to act rationally, in pursuit of their own self-interest, self-governance thus operates largely through the normalisation of certain choices and behaviours as serving our self-interest, and others as undermining it. This includes through discourses of risk, in which risks are understood as external factors that individuals can protect themselves from through rational and responsible decision making (Polzer and Power, 2016).

As Ruhl explains, the neoliberal model of risk differs from the social insurance model of risk, as in the former ‘collective responsibility is replaced by [a model] in which individuals are ultimately apportioned responsibility, even for things (crime, health, job training) which are social in their scope’ (1999: 102). This understanding of risk puts the onus on the individual to manage risk through rational decision making, and hence ensure their own health and safety. As such, neoliberal risk discourse, like discourses of medicalisation, tends to act as a form of depoliticisation that draws attention away from the systemic factors that shape vulnerability to risk, as well as our capacity to respond to it (Polzer and Power, 2016). Furthermore, discourses of medical risk act as a technology of governance, compelling citizens to achieve health by adhering to those behaviours that medical experts have identified as ‘healthy’, and avoiding those deemed unhealthy or risky (Peterson and Lupton, 1996). Medicalisation can bolster the circulation of risk discourse as a technology of governance, strengthening the authority of medical expertise and hierarchising the need to manage biomedical risk over addressing the social and political systems through which risk is inequitably produced.

Significantly, repressive power may still be enacted against subjects who are understood as unwilling or unable to exercise self-regulation (Weir, 2006), and/or who are understood as a risk to the majority of the population (Foucault, 2003). Yet this use of direct power on populations has been limited for global development institutions, given that they do not typically have access to the sovereign power of the state (Li, 2007; Morgan and Roberts, 2012). Instead, neoliberal global development has tended to rely on self-governance to achieve its goals, including by ‘educating the desires and reforming the practices of the target population’ (Li, 2007). I argue that one way in which this education of desire is enacted is through appeals to medical expertise, and, in particular, to dominant understandings of medical risk. Understanding how medicalisation works with discourses of risk to govern reproductive behaviour, including by reinforcing reproductive norms deemed risk adverse, highlights the ways in which interventions that appear technocratic or apolitical can nevertheless operate as sites of governance, producing inequitable effects.

Reproductive justice and stratification

The third theoretical lens through which I analysed the discourse of maternal health in the Muskoka Initiative was that of reproductive justice. Reproductive justice can be understood as both a political goal and a theoretical lens that deconstructs and expands on dominant choice-based frameworks for understanding and advocating for reproductive rights. It explicitly considers the social and political contexts in which reproductive decisions are made, including how these contexts are shaped by interconnected systems of power (Ross and Solinger, 2017). The framework was developed by Women of Colour working within the USA, including the group Women of African Descent for Reproductive Justice, and draws on long histories of activism from within racialised communities. It intentionally centres the experiences of marginalised communities, and how these communities’ reproduction has been uniquely governed (Ross and Solinger, 2017; Sistersong, n.d.). This includes acknowledging how the reproduction of racialised and Indigenous communities globally, and within North America, has been implicitly and explicitly discouraged through processes including coerced sterilisation, economic incentives and stereotypes that position racialised women as bad mothers (Ginsburg and Rapp, 1995; Roberts, 2009). These processes are also referred to as reproductive stratification, a process in which the reproduction of certain communities is discursively and materially discouraged, while that of others is encouraged (Ginsburg and Rapp, 1995). Using a biopolitical lens to understand how the reproduction of marginalised communities is governed is an important means of elucidating how reproductive stratification has continued even when no direct coercion appears to be at work (Morgan and Roberts, 2012).

By examining the full spectrum of means by which reproduction is governed, reproductive justice is concerned not only with the tactics by which reproduction is encouraged or discouraged but also with how these tactics are deployed in ways that align with dominant hierarchies of power (Ross and Solinger, 2017). Within Canada, the reproduction of Indigenous communities has been discouraged through practices such as coerced sterilisation (Stote, 2015) and the promotion of family planning as an intervention to address fetal alcohol spectrum disorders (Tait, 2008). Indigenous families have been denied the right to parent through the residential school system and through an over-representation of Indigenous children who are removed from families by the child welfare system (McKenzie et al., 2016). The reproductive justice framework demonstrates how these practices align with the colonial goals of Indigenous erasure (Tait, 2008; de Leeuw, 2016). The reproductive justice framework and the concept of reproductive stratification are also useful for examining how, during the mid-twentieth century, women in the Global South were targeted by population control interventions that prioritised the perceived need to reduce fertility rates over the reproductive health, preferences and rights of these women themselves (Silliman, 1999; Takeshita, 2012; Murphy, 2017). It allows for interrogating how reproduction in the Global South continues to be governed and constrained through less direct means, given the explicit disavowal of coercive population control policies during the 1994 Cairo Conference on Population and Development. Acknowledgement of these historical and ongoing processes of reproductive stratification informs the reproductive justice movement's articulation of reproductive rights as including not only the right not to have children but also the right to have children, and to parent those children in safe and healthy environments (Ross and Solinger, 2017). It also helps link the ways that reproductive stratification works to uphold dominant hierarchies of power, such as colonialism and white supremacy, across borders.

Reproductive justice is concerned with issues of maternal health, including access to healthcare, disparities in access and how these disparities shape reproductive outcomes, choices and experiences (ACRJ, 2005). Yet this framework also challenges the common conflation of reproductive rights with access to healthcare, including access to contraception and abortion, acknowledging that the medical sector has itself acted as a site of reproductive oppression, for example through forced sterilisation conducted by physicians (Stote, 2015; Ross and Solinger, 2017) The framework thus informs interrogation of how reproductive technologies, often assumed to inherently expand reproductive choices, have been and continue to be deployed in ways that restrict and control the reproduction of marginalised individuals and communities within Canada and globally (Roberts, 2009; Dyck, 2013; Ross and Solinger, 2017) This lens allows feminist scholars to look beyond the promotion of services such as contraception by the Muskoka Initiative and other maternal health interventions, to interrogate how even this promotion might contribute to reproductive governance within the Global South.

Risk and the medicalisation of pregnancy and childbirth in the Muskoka Initiative

When the Muskoka Initiative was announced in 2010, it was both welcomed and criticised. Notably, both the Global Muskoka Initiative and Canada's enactment of it heightened global awareness of MNCH as a global problem, while mobilising significant resources to improve the health and wellbeing of vulnerable women and children. While there is certainly evidence that the interventions funded through Canada's Muskoka Initiative helped improve MNCH, I argue that it provides an important case study for examining how highly medicalised approaches to MNCH not only limit the efficacy of maternal health interventions but also act as a site of reproductive governance and stratification.

Early on, the Muskoka Initiative was critiqued for failing to adequately address the social determinants of health (Black, 2013), and in particular for excluding any reference to gender inequality (Tiessen, 2015). My analysis supports these critiques, demonstrating that the Muskoka Initiative downplays social determinants of health by framing maternal health as a series of biomedical problems that can be resolved through interventions that increase access to medical care. ³ For instance, one website states in relation to childbirth that ‘few acts are as anticipated … or as dreaded’, positioning childbirth as a time of fear and danger, and as inherently risky (Government of Canada, 2015a; ellipsis in original). Another webpage states that ‘Every 2 min a woman dies of pregnancy related complications like: bleeding following childbirth; infections; or high blood pressure during pregnancy’ (Government of Canada, 2014a). This statement again constructs pregnancy and birth as inherently risky, while simultaneously situating this risk within the physiological sphere.

At the same time, the Muskoka Initiative emphasises how the inherent risks associated with childbirth can be managed through access to formalised medical care. This positioning is evident in the following statements, taken from two of the Government of Canada's MNCH webpages: ‘In Ethiopia, many women give birth in their homes, especially in rural areas. With some of the highest rates of maternal and child mortality in the world, these home births can put both the mother and the baby at risk’ (Government of Canada, 2015b); ‘Mothers need skilled health workers like midwives during childbirth. This alone could prevent 42 percent of newborn deaths. Yet, more than 40 million women give birth without a skilled health worker every year’ (Government of Canada, 2014b). These quotations demonstrate how, while maternal health is constructed as inherently risky, vulnerability to these risks is seen to reside in inadequate access to medical care. In turn, medical care is situated as neutralising these risks and ensuring safe childbirth.

The construction of medical care as ensuring safe childbirth is exemplified in the following account of one woman's experience giving birth in Tanzania: ‘This woman received quality prenatal care from a Canadian supported clinic in Tanzania. She got tablets to prevent anemia and was treated when she became ill. She delivered her baby safely’ (Government of Canada, 2014b). While childbearing is itself constructed as inherently risky, these statements construct the real source of danger in a failure to manage these risks through access to appropriate medical care. This failure is presented as occurring not only at the level of the individual but across ‘developing’ countries whose healthcare systems are constructed as incapable of managing risk at the level of the population. For instance, one website states that ‘lacking sufficient health systems and primary health care services, Nigeria lags behind in terms of maternal and child ill health’ (Government of Canada, 2015b). I argue that this construction of medical care as a means of managing medical risk underpins the Muskoka Initiative's emphasis on interventions that increase healthcare provision and access, and its lack of significant engagement with or consideration of the social determinants of health.

Improving maternal health by increasing access to healthcare

Given that risk to maternal health is situated in inadequate access to healthcare during pregnancy and childbirth, it is logical that the Muskoka Initiative situates the solution to maternal health in the improvement of healthcare systems, which is identified as one of the Muskoka Initiative's three priority action areas. This focus manifests in the relatively straightforward provision of inputs that are presented as making healthcare systems more effective. Programming funded through the Muskoka Initiative focused significantly on training healthcare workers, providing medical supplies and infrastructure and improving managerial capacity, including through data collection. For example, training provided to healthcare workers is presented as a key result of interventions, with statements such as: ‘Since 2010 the project has achieved impressive results, such as training 248 nurse-midwives to provide life-saving care to an estimated 100 000 pregnant women. Two hundred and eighty community health extensions workers have been trained and equipped to provide community-based newborn care’ (Government of Canada, 2015c). Here, as elsewhere, training is presented as directly increasing access to medical care, in turn improving maternal health outcomes. Provision of infrastructure and of medical supplies were similarly listed as key outcomes, including the building of maternal and child health centres (DFATD, 2016a) and the provision of neonatal care kits (DFATD, 2016b) and newborn resuscitation kits (DFATD, 2016c). As with the training provided to healthcare workers, the provision of supplies and infrastructure is situated as improving the provision of healthcare within ‘developing’ countries in ways that do not require an examination of the systemic issues that necessitate them. That is to say, the root causes of barriers or limits to education or training are not addressed, nor are the root causes of limited access to resources and infrastructure.

Muskoka Initiative programmes also sought to improve access to healthcare by improving the managerial capacity of healthcare providers and systems within the ‘developing world’. For example, projects claim to strengthen ‘the management and supervision practices in health care facilities’ (DFATD, 2016d) and to be ‘improving procedures and communication across all levels of community health facilities’ (DFATD, 2016e). These again represented technocratic interventions that improve healthcare systems through the sharing of expertise. Within two project descriptions, managerial improvements do include references to gender, citing an increased ‘ability to coordinate and collaborate with the Ministry of Health in the delivery of maternal, newborn and child health services in a gender-sensitive manner’ (DFATD, 2016f), and the ‘strengthened capacity of graduate midwives, midwifery students and health workers to deliver gender-responsive reproductive health and midwifery services’ (DFATD, 2016g). Despite a lack of further detail regarding what constitutes gender-sensitive or gender-responsive healthcare delivery, they are presented as technical improvements to healthcare delivery, rather than as engaging with systemic gender roles or gendered power relations. In this way, in the rare instances where gender is referenced within the Muskoka Initiative, it too is depoliticised and made technical.

By presenting a medicalised construction of maternal health, the Muskoka Initiative allowed for a focus on increasing access to healthcare services by building the capacity of national healthcare services. As I have outlined elsewhere Potvin (2020), these were combined with initiatives that sought to improve the ability of individuals to access healthcare, particularly through education and awareness-raising activities aimed at helping individuals understand the importance of seeking healthcare during pregnancy and childbirth. Such initiatives represent part of the broader technocratic approach to maternal health that I have outlined above, which focused on improving health by providing inputs such as training, supplies and managerial expertise. Within this approach, little attention is given to the social determinants of health, and at no point is it addressed how the social determinants of health might shape vulnerability to the medical risks associated with childbearing, or how they might contribute to continuing inequities in maternal health globally and within individual countries. For example, while economic poverty is implicitly situated as a barrier to healthcare by interventions that seek to improve access by removing or mitigating the healthcare costs, systemic and political drivers of poverty are left unexamined, as are the myriad other ways in which poverty might affect maternal and child health outcomes beyond reducing access to services. The exceptions are brief references to the importance of water and sanitation services and/or the need to improve household capacity to meet nutritional needs, issues that are in turn addressed through technocratic interventions such as educational programming, building infrastructure or distributing micronutrients. While these interventions, as with the strengthening of healthcare provision, may indeed have helped to improve the health of vulnerable populations, they reinforce a narrow understanding of health that fails to engage with the systemic roots of the social determinants of health and their role in producing health inequities.

Constructing family planning as life-saving medical care

Family planning was identified as a core component of the International Muskoka Initiative signed in 2010. Within Canada's Muskoka Initiative, family planning is referenced in six of the thirty-six government webpages, and eleven of the eighty-eight project descriptions analysed for this project. Within these texts, family planning is presented as part of the broader set of healthcare interventions that, if accessed, can save lives. Specifically, contraception was situated as a form of healthcare that can minimise the medical risk associated with pregnancy and childbirth by reducing the number of pregnancies themselves. In this way, family planning is presented in a way that is more palatable to those who oppose reproductive freedoms, being not only medicalised but also delinked from issues of reproductive rights and gender equality. This depoliticisation, rather than rendering contraception politically neutral, reinforced reproductive stratification by promoting averted birth as a key path to development (Murphy, 2017). It is notable that, though family planning programming is never described in detail, in every instance it is presented as a means of preventing pregnancy, and never of terminating it. For example, one webpage refers to family planning as ‘averting 220 000 unintended pregnancies’ (Government of Canada, 2015c). Thus, even though none of the analysed texts explicitly define family planning, it is constructed throughout the texts as referring only to contraception, and never to abortion.

Family planning and contraception are situated as a form of healthcare, in part by being included in lists of medical services that are being provided through Muskoka Initiative-funded programmes. In one text, a healthcare centre supported through one project is described as having ‘offered immunization, family planning, antenatal and postnatal care’ (DFATD, 2016h). Another text described monitoring supplies of ‘essential medicines, vaccines, contraceptives, and other supplies (DFATD, 2016i). In addition, family planning is explicitly identified as a means of saving lives and reducing deaths with one website stating that ‘Family planning support funded by Canada has contributed to averting 220 000 unintended pregnancies and prevented an estimated 1350 women from dying during childbirth’ (Government of Canada, 2015c).

Similarly, one of the project descriptions states that ‘More than one million couples were provided with protection against unwanted pregnancies that contributed to averting over two hundred thousand pregnancies and over 1000 pregnant women from dying during childbirth’ (DFATD, 2016c). In both examples, averting pregnancy is explicitly equated with saving lives. Lives saved are expressed quantitatively, even though these numbers can only be estimated, presumably based on current maternal mortality rates. As such, these estimates do not appear to take into account how other forms of intervention may have affected the number of predicted maternal deaths. Yet these estimates of how many lives were saved through the provision of contraception help to further establish contraception use as an inherently positive outcome. Within this framing, project descriptions can list increased use of family planning as a key outcome, without additional explanation as to why such increases are significant or desirable. For example, one project description states that ‘the percentage of women between 15 to 49 years of age using family planning increased from 15.4 percent to 19.5 percent’ (DFATD, 2016j), while another states that ‘the total number of acceptors of new modern contraception methods has almost doubled from 122,817 users in 2011 to 231,627 in 2013’ (DFATD, 2016k).

Significantly, these examples show that it is increased use of contraception that is presented as a project outcome, rather than its increased accessibility. Situating increased contraception use as a desired outcome draws on and reinforces the assumption that not only should contraception be more accessible to women in the ‘developing world’ but more women should be using it (Murphy, 2017). Based on the overarching construction of pregnancy and childbirth as inherently risky, and particularly so for ‘developing world’ women with limited access to healthcare, the construction of family planning as life-saving appears logical, as does the construction of increased use as a desirable outcome of interventions. Yet this discursive construction depoliticised family planning by separating it from issues of reproductive rights and of reproductive and sexual autonomy, while also drawing on and reinforcing understandings of ‘developing-world’ reproduction as risky, dangerous and needing to be curbed.

The technocratisation of global maternal health

My analysis shows that the Muskoka Initiative took a medicalised and technocratic approach to maternal health, which focused on providing inputs in order to address biomedical problems, rather than on bringing about systemic change to improve the social and political determinants of health. This technocratic approach is scaffolded on the construction of maternal health as a problem of managing medical risk, rather than deconstructing the inequitable production of risk. This technocratic approach can be understood as part of a broader trend of depoliticising maternal health over the past four decades. Though the Muskoka Initiative was heralded as putting maternal health on the global agenda, maternal health had long been considered a critical component of global health and development, starting with the 1987 Safe Motherhood conference and the resulting Safe Motherhood Initiative (SMI). ⁴ (Starrs, 2006). At that time, advocates were already debating the extent to which global maternal health programming should engage with systemic issues such as poverty and gender inequality, versus focusing on healthcare delivery (MacDonald, 2019).

Storeng and Béhague argue that while the conference included advocates who were motivated by a desire to improve women's overall social positioning and material wellbeing, politicised elements of the initiative eventually gave way to a narrower focus on reducing maternal mortality through straightforward, technical solutions. Even in the early days of the SMI, Storeng and Béhague state that ‘The specific term “safe motherhood” was coined to draw attention to how unsafe motherhood could be, but also because it was deemed an uncontroversial term, disassociated from ongoing debate in fertility control and abortion yet encompassing a range of actions to improve women's health that would not antagonize socially conservative donors or governments’ (2014: 262). As such, maternal health interventions at this time took into consideration the extent to which politicised approaches would diminish efficacy by failing to consolidate international support. Despite acknowledging socioeconomic risk factors as ‘indirect’ causes of maternal mortality (Allen, 2002), in practice the SMI maintained a focus on increasing access to westernised medical services and overcoming what were characterised as ‘harmful cultural attitudes’ (Allen, 2002; MacDonald, 2013). Thus, though it preceded the Muskoka Initiative by almost twenty-five years, the SMI is largely aligned with the latter's depoliticised framework and technocratic approach to health. While this depoliticised framework may have helped consolidate support for maternal health, it is notable that the SMI's failure to achieve its goal of halving maternal deaths by the year 2000 has been attributed by its critics at least in part to a continued lack of political will, as well as a failure to engage in politicised issues such as gender equality (Allen, 2002; MacDonald, 2013).

In the decades that followed, international efforts to address maternal health continued to focus on the provision of healthcare, despite efforts by women's health advocates to promote more politicised approaches (Petchesky, 2003; Harcourt, 2009). This trend towards depoliticisation can be seen as culminating in the Millennium Development Goals (MDGs), unveiled in 2000, which aimed to halve extreme poverty by creating a series of measurable development targets, often viewed in isolation (Fukuda-Parr, 2017). Goal 5 of ‘Improving Maternal Health’ aimed to reduce the maternal mortality rate by three-quarters, and was measured through the maternal mortality ratio, as well as the proportion of births attended by skilled health personnel (UN, n.d.). These indicators suggest a medicalised and technocratic approach that reduces health to the accessibility of healthcare during the moment of birth. Furthermore, Goal 5 was critiqued for being named as ‘maternal’, rather than ‘reproductive’, health, despite the inclusion of reproductive health and access to family planning under its umbrella (Yamin, 2013). This labelling reflects how maternal health has continued to be depoliticised not only through medicalisation but also from being delinked from issues of reproductive rights, and as such from debates around access to abortion (Yamin, 2013; McPherson, 2016). As Harcourt notes, given the backlash against reproductive rights that emerged following the UN conferences in Cairo and Beijing, ‘It was easier to speak about maternal death in a technical medical way that could be measured, rather than enter into the messy and politically more radical sexual and reproductive rights agenda’ (2009: 61). In this context, it might be that population control was similarly a more palatable and hence strategic discourse through which to pursue goals associated with reproductive rights; specifically, increased access to family planning. By framing family planning as a technocratic issue of not only service delivery but also managing seemingly problematic population control, the latter could similarly be delinked from issues of human and reproductive rights (Hodgson and Watkins, 1997). As my analysis demonstrates, and as I argue in more detail below, this delinking allowed for population control to act as a site through which reproductive rights were pursued as well as as a site of reproductive governance and stratification.

In 2015, the MDGs were replaced by the more integrative Sustainable Development Goals (SDGs) (Le Blanc, 2015). Since then, several countries have also implemented feminist foreign assistance policies. While both developments point to the potential for more politicised approaches to global maternal health, how these will translate into practice is yet to be seen. Yet this history of depoliticisation demonstrates that the Muskoka Initiative’s medicalised and depoliticised approach to maternal health did not occur in isolation. The history of maternal health in development demonstrates the tensions between those who advocate for a politicised approach and the desire for depoliticised approaches that are understood as making maternal health more palatable (Harcourt, 2009). In this context, the Muskoka Initiative is an important example of how this depoliticised approach was translated into practice within national development policies and programming, particularly those implemented by more conservative governments.

Population control and the medicalisation of family planning

The Muskoka Initiative's inclusion of family planning constructs contraception as a means of managing and responding to the risks associated with pregnancy and childbirth in the ‘developing world’. This discourse aligns with a broader medicalisation of contraception that has taken place since the 1960s, associated with the advent of the Pill in the Global North (Tone, 2012), and of the intrauterine device (IUD) in the Global South (Takeshita, 2012). These reproductive technologies ushered in a new framing of not only pregnancy but also the avoidance of pregnancy as a medical issue requiring input from medical experts. Acknowledging that medicalisation is not in and of itself good or bad, but rather should be analysed for how it might be used to govern or oppress, I argue that the medicalisation of contraception in the Muskoka Initiative depoliticises, and hence makes more palatable, the provision of contraception through development interventions. This strategic move is significant given the conservative leanings of the government that enacted the Muskoka Initiative, and the fact that organisations who sought funding needed to ensure that their project goals aligned with the Muskoka Initiative's overarching objective of improving maternal, newborn and child health. I argue that this depoliticisation not only leads to a technocratisation of family planning as a development intervention but also combines with discourses of medical risk to govern reproduction in ways that reinforce historical patterns of reproductive stratification in which reproduction in the Global South is discouraged. As such, within the Muskoka Initiative, family planning is made technical through medicalisation and is positioned as a tool of reproductive governance through which the reproductive choices of women in the Global South can be directed towards a seemingly more desirable outcome. As stated, in North America, the medicalisation of contraception is associated with the development and release of the pharmaceutical contraception known collectively and colloquially as ‘the Pill’ during the 1960s, which necessitated both a prescription and ongoing medical surveillance to manage side-effects (Tone, 2012). In the Global South, the medicalisation of contraception was more closely aligned with the development and distribution of the IUD, which was specifically designed as a birth control method appropriate for populations in what was then called the ‘Third World’, and which required even greater medical surveillance and, often, control (Takeshita, 2012). As Takeshita (2012) outlines in her history of the IUD, this contraceptive method was understood as a means of controlling ‘Third World’ populations, in part because it placed control over women's reproduction in the hands of medical professionals who were needed to both insert and remove IUDs. Addressing enthusiasm for the IUD by the Population Council in the 1960s, Takeshita explains that the council ‘reasoned that, since men and women of the global South were incapable of regulating their own fertility, a technology that takes control over their bodies for them would best address the ostensible need to regulate population growth in the Global South’ (2012: 41). The consequences of this iteration of medicalisation can be seen in accounts of women who, upon having an IUD inserted, faced difficulty in having them removed, either because of a lack of access to medical care or because doctors simply refused to remove them (Hartmann, 1995). In this way, the medicalisation of contraception in the Global South is inextricably bound up in the goals of population control that characterised the ‘family planning’ efforts of the mid- and late 1900s.

Population control interventions during the 1960s and 1990s were motivated by racist beliefs that people living in the Third World were incapable of responsibly managing their own reproduction and that such management was imperative to avoid the perceived dangers of overpopulation (Connelly, 2008). Western demographers and economists believed that overpopulation acted as an inherent barrier to a country's modernisation and economic development, and put too great a strain on both national economies and natural environments (Murphy, 2017). Overpopulation was hence understood as a path to increased violence and suffering, whereas population control would allow for increased GDP per capita and by extension improved quality of life (Murphy, 2017). As Murphy has articulated, this framework endorsed the idea that for the lives of the population to flourish, the lives of some had to be averted. The popularity of population control amongst Western experts during this era was also bolstered by Cold War anxieties that overpopulation would increase Third World countries’ susceptibility to communism, further diminishing Western control over these populations in the period following decolonisation (Connelly, 2008; Takeshita, 2012). The perceived need to prevent population growth, combined with the construction of ‘Third World’ populations in Africa and Asia as incapable of acting as rational reproductive citizens, was used to justify population control methods that, though often called family planning programmes, sought primarily to limit fertility rather than to further reproductive rights and autonomy. Notably, these programmes often not only sought to meet existing demand for contraception but also actively worked to create demand by promoting smaller family sizes as a reproductive norm, and at times resorting to coercive measures if deemed necessary (Hartmann, 1995; Murphy, 2017). Such interventions can be understood as biopolitical interventions that used medical authority to discipline individuals’ reproduction in order to manage Third World population growth, ostensibly for their own good (Murphy, 2012).

In the mid-1990s, the sustained work of reproductive justice advocates helped to install recognition of reproductive rights and denouncement of coercive population control measures into mainstream development institutions. In 1994, the Programme of Action created at the UN Conference on Population in Cairo was the first global conference document to state that family planning initiatives should not use coercive measures (Eager, 2004). While the Cairo Programme of Action established reproductive rights and health as a new norm, it nevertheless continued to treat population control and reduced fertility as valid goals that would continue to advance the project of development, and sparked debates as to what exactly constitutes coercive versus non-coercive or voluntary family planning (Hodgson and Watkins, 1997). These debates remain relevant given that, while many countries in the Global North fret about declining birth rates, concern regarding overpopulation in the Global South persists, particularly in relation to environmental degradation and climate change (Hartmann and Barajas-Román, 2009; Foster, 2011).

Family planning as reproductive governance

As the above analysis demonstrates, the history of family planning is one of biopolitical governance, wherein direct disciplinary power acted alongside processes of normalisation. Population control intervention often sought to govern reproduction by educating the reproductive desires of ‘Third World’ populations and to create a market for the contraception these programmes were providing (Murphy, 2017). Following the global development community's rejection of coercive measures in the mid-1990s, family planning programmes have continued to circulate reproductive norms, relying on biopolitical self-governance to continue the project of managing population. For example, Newland's (2001) research on Indonesian-based family programming found that these programmes actively promote smaller family sizes by associating them with modernity and with economic prosperity for both the household and the nation. These programmes draw on the authority of ‘expert’ knowledge to encourage reduced fertility as a reproductive norm to which women are expected to comply. Similarly, De Zordo's (2012) study of a family planning clinic in Brazil shows that healthcare practitioners participated in the promotion of a small family size as both a rational practice and a civic duty. In both of these examples, restricted fertility is promoted as a rational, reproductive norm to which rational subjects are expected to comply. They exemplify how neoliberal governance operates through normalising discourse, drawing on socioeconomic expertise that continues to promote a contested association between restricted fertility and economic development.

Although the Muskoka Initiative does not explicitly draw on discourses of population control, its use of medicalised discourse reinforces the construction of limited fertility as a rational norm and promotes a reduction in ‘developing world’ births. Within the Muskoka Initiative, contraception is presented as a risk-minimising tool, whose use is encouraged for those who are identified as at risk of maternal death by virtue of living in ‘developing’ countries where healthcare services are weak or inaccessible. Women in the developing world are thus encouraged to act rationally and minimise maternal risk, making reproductive decisions based not on their own desires but in response to their perceived medical vulnerability. The construction of contraception as a tool for medicalised risk management, and the presentation of increased contraception use as a necessarily positive outcome of maternal health programming, thus exemplifies how risk discourse operates as a form of reproductive governance. This is not to say that contraception does not have the potential to allow individuals to manage their reproduction, including their reproductive health. However, without addressing how and why certain populations come to be at greater risk during pregnancy and childbirth, the promotion of contraception as a form of individualised risk management re-entrenches patterns of reproductive stratification in which reduced fertility among racialised populations in the majority world is devalued and discouraged.

The promotion of contraception as primarily, if not exclusively, a strategy for managing reproductive risk rather than as a component of reproductive rights also further depoliticises global maternal health. The Muskoka Initiative supported the provision of contraception as a means of allowing individuals to manage risk, without addressing the systemic factors that produce and exacerbate maternal risk among marginalised communities. Notably, this approach is at odds with a reproductive justice framework that values every individual's right to have the children they desire in safety and dignity, and takes seriously the ways in which reproduction, including reproductive health, is constrained by political, economic and social conditions (Ross and Solinger, 2017). While a reproductive ‘choice’ perspective emphasises the right for individuals in the majority world to access contraception in order to exercise their reproductive preferences, including risk minimisation, a reproductive justice framework problematises the production of economic and social conditions in which an individual would feel compelled to prevent or limit reproduction due to their inequitable vulnerability to maternal risk (for example, see: Tait, 2008). Without considering how the social determinants of health put certain populations at higher risk of maternal death, a medicalised, risk-based approach to contraception is likely to perpetuate reproductive stratification that devalues the reproduction of economically marginalised women of colour in the Global South.

Again, in problematising the medicalisation of contraception within the Muskoka Initiative, my goal is not to dispute the importance of ensuring contraception is accessible within the Global South, where contraception is desired and the reproductive control it provides is valued. Both Tone (2012) and Takeshita (2012) explicitly acknowledge that the medicalisation of contraception is a process that, while contested by some, has also been desired and sought by many women who embrace the ability to prevent pregnancy. However, my analysis demonstrates that medicalised discourse can also be deployed in ways that individualise and depoliticise global maternal health, and that reinforce reproductive norms in ways that devalue and discourage reproduction among already marginalised communities. The medicalisation of family planning not only contributes to a technocratic approach to maternal health, in which maternal death is addressed through a straightforward provision of contraception; it also sidesteps the relationship between family planning and gender equality, racial inequality and economic justice while acting as a site of governance in which established power relations remain intact, and patterns of reproductive stratification are reinforced.