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12 March 2015

From abortion to childbirth: what we need is choice

Jennie Bristow reviews Rebecca Schiller’s new book, All That Matters: Women's rights in childbirth.

‘The woman who has an abortion or miscarriage is the very same one who births a baby and feeds him. Undermining one aspect of her reproductive freedom, whether it is where or how she gives birth or if she can safely have an abortion, inevitably has knock-on consequences for others. Across the board there’s a need to give women the evidence and trust them to make their own choices.’

As stereotypes go, the image of the home-birthing mother is very different to that of the woman who has an abortion. One is depicted as maternal, earth-motherly, contented, ‘natural’, and possibly rather wacky; the other is often presented as young, single, self-centred, and lacking in maternal instinct.

In recent years, some sensible commentators have tried to challenge these stereotypes, indicating that not all women who have home births are irresponsible hippies and that many women who have abortions are in their thirties, with an established partner, and have children already. But few have stated so clearly the point that lies at the heart of Rebecca Schiller’s compelling little book: that these are all ‘the same women’. If reproductive autonomy means anything, it means that women should have the choice to decide where, how, and whether she gives birth.

Schiller is chair of Birthrights, an energetic British charity that promotes human rights in childbirth. Campaigns around childbirth have historically been associated with supporting women’s right to give birth at home, or in other non-medicalised environments, and have attracted both support and opprobrium from the medical establishment. Rarely have such campaigns engaged with the wider issues related to women’s reproductive autonomy: the regulation of women’s behaviour during pregnancy; the legal constraints placed on women who need to end their pregnancy through abortion; and the healthcare needs of women who lack access to maternity services.

Schiller’s book engages with all of these issues, making some arguments that badly need to be heard.

One of Schiller’s central challenges to the current orthodoxy around pregnancy and birth, as expressed in the book’s title, is that when it comes to childbirth ‘a healthy baby is all that matters’.  Schiller deftly unpicks the way this assumption is marshalled to castigate pregnant women for failing to obey the myriad demands to which they are subjected.

In the twenty-first century, the idea that women should be treated as second-class citizens, as the means to growing babies rather than as individuals in their own right, would be an unacceptable thing even to suggest. Yet once a woman is pregnant, in practice this is often how she is treated.

Schiller cites Lynn Paltrow, of the US organisation National Advocates for Pregnant Women (NAPW): ‘It is women’s capacity for pregnancy that is used as the excuse for differential treatment’. Once the birth of a ‘healthy baby’ is considered to be the only thing that matters, women can be stripped of their rights and their dignity for the sake of the ‘unborn child’. This has been starkly exemplified in the USA by the use of ‘fetal protection laws’ against allegedly drug-abusing women. And it is a dangerous, and regressive, step.

To challenge this trend, Birthrights and BPAS made a joint intervention into a case held by the Court of Appeal in December 2014. In that case lawyers representing a child born with Fetal Alcohol Syndrome attempted to gain compensation from the government-funded Criminal Injuries Compensation Scheme as a victim of crime, because the child’s mother had drunk excessive amounts of alcohol while pregnant.

In seeking to establish that the damage caused to a fetus through heavy drinking was a criminal offence, the case called into question women’s legal status while pregnant, and women’s right to make their own decisions. Any ruling which found that drinking while pregnant constituted a ‘crime of violence’ could have paved the way to the criminalisation of pregnant women’s behaviour.

In the end, three judges at the Court of Appeal ruled against the claimant. Lord Justice Treacy said an ‘essential ingredient’ for a crime to be committed ‘is the infliction of grievous bodily harm on a person - grievous bodily harm on a fetus will not suffice’. This was an extremely important ruling, in affirming that women must be able to make their own decisions about their pregnancies.

Under the law, a fetus does not hold the same status as a woman. A pregnant woman is considered to have a certain amount of autonomy in making decisions about how she conducts her pregnancy: what she eats and drinks during pregnancy, how she behaves, and whether she takes drugs or medication. While certain substances or actions may harm the fetus, this should not be considered a reason for treating the welfare of the fetus as paramount: as to do so would inevitably mean treating the woman as being less important, less deserving of consideration, than the fetus in her womb.

However, while the law in the Fetal Alcohol Syndrome case affirmed the importance of allowing women to make decisions about their pregnancies, such assumptions are often culturally contested. The moral opprobrium that greets any woman drinking any alcohol during pregnancy has expanded hugely in recent years, bolstered by official advice that prescribes abstinence – despite the fact that evidence around the impact of moderate drinking levels on the developing fetus remains equivocal. Women are not thrown into jail for drinking a glass of wine, but this does not mean that their choice to do so is respected: they are seen as deviant, irresponsible, and careless of the interests of their baby.

The impact of social norms around ‘ideal’ pregnancy behaviour is even stronger for other drugs and behaviours, which are seen to position pregnant women as risky to their unborn child. For example, women struggling with mental illness are often caught in a double bind, where they fear taking medication in case it harms the fetus, and they fear not taking medication, in case they are presumed to be mentally unfit to keep their baby.

And when it comes to abortion, women’s reproductive autonomy remains hugely constrained. In Britain today, it is widely accepted that a woman should not have to continue her pregnancy if she doesn’t want to, and that it would be a bad thing for society to force women to become mothers just because they happen to be women who have happened to become pregnant. Yet under the law, a woman is not permitted to have an abortion ‘just because’ she thinks it is the right thing for her: two doctors have to agree that continuing the pregnancy will pose a risk to her physical or mental health.

The kind of paternalism bound up with the framing of the abortion law, or the rules laid down by official bodies on exactly how much a woman should drink (or not drink) during pregnancy, sit uneasily with our wider idea about women as free, autonomous, equal citizens who are perfectly capable of making choices about their lives. Yet because of the assumption that pregnancy overrides equality – that ‘a healthy baby is all that matters’ – pregnant women become treated as second class. This happens whether they have home births or hospital births, abortions or miscarriages, mental health conditions or the odd glass of wine. In this, we are all the same women.

By taking a stand against this pernicious orthodoxy, Rebecca Schiller’s book adds to the work of Dr Ellie Lee (Parenting Culture Studies), Guardian columnist Zoe Williams (The Madness of Modern Parenting), and other academics and commentators who have highlighted the dangers posed by a culture that pits the interests of pregnant women against those of their fetuses – and, by extension, their children.

‘I want to say that a healthy baby is not all that matters and that, resoundingly, it all matters,’ writes Schiller. ‘This is the story of women, of why they matter too, and the things that happen when they are pushed to the bottom of a hierarchy in birth.’

All That Matters: Women’s rights in childbirth, by Rebecca Schiller, is published by GuardianShorts (2015). Buy the book here.