I submitted my PhD thesis to the University of Oxford in 2011. At the time, I planned to turn it into a book. But life had other plans for me - campaigning for equal civil partnerships, a career switch from academia to policy, and two beautiful babies. I wish I'd uploaded a PDF years ago, but it seems there's no time like the (uncertain) present.
No doubt some of the later chapters are out of date, and the policy debates have shifted. And I'm sure I'd have framed and phrased things differently if I'd written it now or turned it into a book. But that hasn't happened yet, perfection is the enemy of the good, and there's some useful material in here -- about covert discrimination in child allowances to encourage Jewish fertility, and on the flip side, the lack of data to back up the claim that Palestinian citizens of Israel were the only population group given free contraceptives.
My goal in sharing this now is to prevent any future researchers similarly intrigued by these questions of reproductive politics in Israel having to start from scratch. Hope it helps someone, somewhere, sometime.
Here it is.
Showing posts with label Fertility policy. Show all posts
Showing posts with label Fertility policy. Show all posts
Wednesday, 18 March 2020
Monday, 13 January 2020
Surrogacy – wish fulfilment or exploitation? Read my blog for Sprogcast
Whether surrogacy is wish fulfilment for those facing infertility or unethical exploitation of women's wombs is not an abstract question -- the Law Commission is in the process of a review of existing surrogacy laws in the UK, the aim of which is to reform them for the first time since 1985.
So, if you'd like to know more about some of the serious issues in this debate, please read my blog for Sprogcast via this link or copied below. As always, please let me know what you think.
Surrogacy – wish fulfilment or exploitation? A guest blog by Dr Rebecca Steinfeld, Senior Policy Officer for Health, Maternity Action
Surrogacy is a polarising issue. For some, it embodies true altruism – a woman realising the dreams of others by birthing their baby, with all the medical risks, and physical and emotional toll, that can come with pregnancy, birth and, ultimately, handing over a baby. Sprogcast’s interview with David Gregory-Kumar is a touching example of how surrogacy can help gay couples to become parents, as is the heart-warming story recently aired on BBC 2’s series The Baby Has Landed of Paul and Craig Saunders, whose work friend Mel carries their twins.
But that is not the whole the story. For others, surrogacy is inherently exploitative and unethical. They say it makes children commodities, and disadvantaged women “breeders.” Some even compare surrogacy to prostitution, and argue “womb rental” be the term used.
This debate is not abstract.
The Law Commission is in the process of a review of existing surrogacy laws in the UK entitled "Building Families Through Surrogacy: A New Law." Their proposals include a new pre-conception agreement and related pathway, as well as changes to the types and level of payments for surrogate mothers. The goal is to bring forward a Surrogacy Bill in 2021 that will constitute the first legal reform to surrogacy law in the UK since the Surrogacy Arrangements Act 1985.
We at Maternity Action, along with a number of feminist organisations, submitted responses expressing our concerns about law reform in this area. Our concerns focus on the process of the consultation, barriers to accessing it (the consultation document was 502 pages long and had 118 questions!), and the extent to which surrogate mothers' rights and experiences are being taken into account.
But beyond the specifics of the consultation, there are several other serious issues at stake in this debate. These include potential power imbalances between surrogate mothers and intended parents, the risks of pregnancy and birth taken on by the surrogate mother, and human rights concerns that may crop up during a surrogate mother’s antenatal, intrapartum and/or postnatal care. It is crucial to acknowledge and reflect on these difficult areas in any discussion of surrogacy.
Surrogates may be vulnerable to exploitation as there is often socioeconomic inequality between surrogate mothers and intended parents. Intended parents tend to be older, wealthier, better educated and employed in higher status jobs than surrogate mothers. Though there does not appear to be any research exclusively considering the demographic characteristics of surrogates in the UK, evidence from other studies indicates that the majority of women who act as surrogate mothers are substantially less well-off, less powerful and less endowed with status than the majority of intended parents.
Though there may be some exceptions to this pattern in what are known as “traditional” or “altruistic” surrogacy arrangements – such as a sister carrying a baby for her brother/sister – these arrangements account for the minority of surrogacy arrangements. Plus, there may be other power imbalances in these familial arrangements, and economic inequalities may still exist.
There are inherent risks involved in pregnancy and birth for the surrogate. Emeritus Professor Susan Bewley, a retired consultant obstetrician with direct, first-hand experience of many UK surrogates contends that there are documented medical and psychosocial risks to surrogacy. All pregnancies carry physical and mental health risks to pregnant women, ranging from trivial to very severe (sepsis, pre-eclampsia, haemorrhage and maternal death for the woman; abnormality, prematurity, stillbirth, brain damage, infant death for the baby). For untested first-time mothers, or primigravidae, these risks are entirely unknown, and the Law Commission rightly asked whether primigravidae should be allowed to be surrogates.
Risks for the surrogate may be higher if she, or another woman, are involved as egg donor, which involves undergoing ovarian stimulation, egg extractions and a small risk of the serious complication of ovarian hyperstimulation syndrome. The surrogate may have many appointments, drug treatments, invasive procedures and timed embryo transfer. More importantly, she is at a significantly increased risk of developing pre-eclampsia. If it is a twin pregnancy, she is at increased risk of every complication barring postmaturity. Pre-eclampsia and multiple pregnancy, which remain high in the UK IVF sector, both increase the risk of prematurity, with possible lifelong health consequences for the child.
On a perinatal mental health level, although many surrogates are keen to hand over the baby, there are a lot of dramatic hormonal events in the first days and weeks after birth, and some find that handover triggers or exacerbates perinatal mental ill-health conditions, like postnatal depression or postpartum psychosis.
Finally, surrogates may experience coercion from intended parents during their antenatal care or birth. In their consultation response, the Woman’s Place UK said “it is not difficult to imagine a scenario where the mother may find it difficult to make choices which prioritise her own health and wellbeing if the intended parents are in the room with her, even if they do not actively put pressure on her to prioritise the welfare of the foetus. Or in a scenario where a scan reveals a foetal anomaly, the pregnant woman may feel unduly pressured to conform to the intended parents’ wishes regarding continuing or terminating the pregnancy if they are present in the room when the scan takes place.” As these scenarios suggest, the surrogate mother’s rights to dignity and bodily autonomy may be subtly undermined by the known wishes or momentary reactions of the intended parents.
Given the current policy climate and controversy around surrogacy, it’s crucial that public discussion of this issue includes the fullest range of perspectives. As well as hearing moving stories from intended parents about how surrogacy enabled them to overcome biological or social infertility to realise their dreams of becoming parents, we also need to hear from a range of surrogate mothers. That includes those whose experiences have not been so rosy, and who instead encountered challenging power imbalances between themselves and the intended parents, or who felt that their human rights were subtly or overtly undermined during their pregnancy or birth, or who suffered unexpected physical or emotional repercussions. There are two sides to this story, and both must be told.
So, if you'd like to know more about some of the serious issues in this debate, please read my blog for Sprogcast via this link or copied below. As always, please let me know what you think.
Surrogacy – wish fulfilment or exploitation? A guest blog by Dr Rebecca Steinfeld, Senior Policy Officer for Health, Maternity Action
Surrogacy is a polarising issue. For some, it embodies true altruism – a woman realising the dreams of others by birthing their baby, with all the medical risks, and physical and emotional toll, that can come with pregnancy, birth and, ultimately, handing over a baby. Sprogcast’s interview with David Gregory-Kumar is a touching example of how surrogacy can help gay couples to become parents, as is the heart-warming story recently aired on BBC 2’s series The Baby Has Landed of Paul and Craig Saunders, whose work friend Mel carries their twins.
But that is not the whole the story. For others, surrogacy is inherently exploitative and unethical. They say it makes children commodities, and disadvantaged women “breeders.” Some even compare surrogacy to prostitution, and argue “womb rental” be the term used.
This debate is not abstract.
The Law Commission is in the process of a review of existing surrogacy laws in the UK entitled "Building Families Through Surrogacy: A New Law." Their proposals include a new pre-conception agreement and related pathway, as well as changes to the types and level of payments for surrogate mothers. The goal is to bring forward a Surrogacy Bill in 2021 that will constitute the first legal reform to surrogacy law in the UK since the Surrogacy Arrangements Act 1985.
We at Maternity Action, along with a number of feminist organisations, submitted responses expressing our concerns about law reform in this area. Our concerns focus on the process of the consultation, barriers to accessing it (the consultation document was 502 pages long and had 118 questions!), and the extent to which surrogate mothers' rights and experiences are being taken into account.
But beyond the specifics of the consultation, there are several other serious issues at stake in this debate. These include potential power imbalances between surrogate mothers and intended parents, the risks of pregnancy and birth taken on by the surrogate mother, and human rights concerns that may crop up during a surrogate mother’s antenatal, intrapartum and/or postnatal care. It is crucial to acknowledge and reflect on these difficult areas in any discussion of surrogacy.
Surrogates may be vulnerable to exploitation as there is often socioeconomic inequality between surrogate mothers and intended parents. Intended parents tend to be older, wealthier, better educated and employed in higher status jobs than surrogate mothers. Though there does not appear to be any research exclusively considering the demographic characteristics of surrogates in the UK, evidence from other studies indicates that the majority of women who act as surrogate mothers are substantially less well-off, less powerful and less endowed with status than the majority of intended parents.
Though there may be some exceptions to this pattern in what are known as “traditional” or “altruistic” surrogacy arrangements – such as a sister carrying a baby for her brother/sister – these arrangements account for the minority of surrogacy arrangements. Plus, there may be other power imbalances in these familial arrangements, and economic inequalities may still exist.
There are inherent risks involved in pregnancy and birth for the surrogate. Emeritus Professor Susan Bewley, a retired consultant obstetrician with direct, first-hand experience of many UK surrogates contends that there are documented medical and psychosocial risks to surrogacy. All pregnancies carry physical and mental health risks to pregnant women, ranging from trivial to very severe (sepsis, pre-eclampsia, haemorrhage and maternal death for the woman; abnormality, prematurity, stillbirth, brain damage, infant death for the baby). For untested first-time mothers, or primigravidae, these risks are entirely unknown, and the Law Commission rightly asked whether primigravidae should be allowed to be surrogates.
Risks for the surrogate may be higher if she, or another woman, are involved as egg donor, which involves undergoing ovarian stimulation, egg extractions and a small risk of the serious complication of ovarian hyperstimulation syndrome. The surrogate may have many appointments, drug treatments, invasive procedures and timed embryo transfer. More importantly, she is at a significantly increased risk of developing pre-eclampsia. If it is a twin pregnancy, she is at increased risk of every complication barring postmaturity. Pre-eclampsia and multiple pregnancy, which remain high in the UK IVF sector, both increase the risk of prematurity, with possible lifelong health consequences for the child.
On a perinatal mental health level, although many surrogates are keen to hand over the baby, there are a lot of dramatic hormonal events in the first days and weeks after birth, and some find that handover triggers or exacerbates perinatal mental ill-health conditions, like postnatal depression or postpartum psychosis.
Finally, surrogates may experience coercion from intended parents during their antenatal care or birth. In their consultation response, the Woman’s Place UK said “it is not difficult to imagine a scenario where the mother may find it difficult to make choices which prioritise her own health and wellbeing if the intended parents are in the room with her, even if they do not actively put pressure on her to prioritise the welfare of the foetus. Or in a scenario where a scan reveals a foetal anomaly, the pregnant woman may feel unduly pressured to conform to the intended parents’ wishes regarding continuing or terminating the pregnancy if they are present in the room when the scan takes place.” As these scenarios suggest, the surrogate mother’s rights to dignity and bodily autonomy may be subtly undermined by the known wishes or momentary reactions of the intended parents.
Given the current policy climate and controversy around surrogacy, it’s crucial that public discussion of this issue includes the fullest range of perspectives. As well as hearing moving stories from intended parents about how surrogacy enabled them to overcome biological or social infertility to realise their dreams of becoming parents, we also need to hear from a range of surrogate mothers. That includes those whose experiences have not been so rosy, and who instead encountered challenging power imbalances between themselves and the intended parents, or who felt that their human rights were subtly or overtly undermined during their pregnancy or birth, or who suffered unexpected physical or emotional repercussions. There are two sides to this story, and both must be told.
Thursday, 9 March 2017
Some reflections on last night's 'Reproductive Justice in Europe' panel discussion at UCL for #IWD2017
Last night, I contributed to a panel discussion at UCL about 'Reproductive Justice in Europe' for International Women’s Day. Thank you to co-conveners Cara Spelman and Dr. Rory Archer for organising such a great line-up of speakers, and for facilitating a very stimulating discussion. Below I summarise my remarks and reflect on some of the questions posed by attendees.
During my opening remarks, I explained why ‘reproductive justice’ constitutes such an important intellectual breakthrough. I also identified what I consider some of the most egregious and pressing reproductive injustices in Europe today. This is where I believe we should focus our collective efforts.
A very brief summary of 'Reproductive Justice:'
I for one am convinced that RJ is currently the best way forward for academics and activists working on reproductive issues.
During my opening remarks, I explained why ‘reproductive justice’ constitutes such an important intellectual breakthrough. I also identified what I consider some of the most egregious and pressing reproductive injustices in Europe today. This is where I believe we should focus our collective efforts.
A very brief summary of 'Reproductive Justice:'
As I explained, reproductive justice was coined by feminist women of colour in
1994, who recognised the limitations of focusing on theoretical 'choices' and 'rights.' Instead these academics and activists drew attention to the ways in which the complex interplay of
race, class, sexual orientation, disability and age (among other factors) can - and do - influence people’s reproductive
experiences, as well as their ability to access reproductive healthcare services. In so doing, RJ broadened the scope of inquiry, expanding reproductive rights to include not only the right not to bear children, but also the right to bear children, and to raise them with dignity. It also moved beyond rights themselves in order to consider people's actual experiences, and specifically the barriers to their accessing services. RJ therefore covers an enormous breadth of important and fascinating topics - everything from contraception, reproductive
technologies, surrogacy and pregnancy to birth, infant feeding, parenting, and childcare. It expands the range of settings examined in order to shine a light on those who may be most adversely effected by reproductive injustice: Prisons, refugee camps, detention centres and diseased environments - to name a few. Most importantly, RJ engages with affected communities, eschewing an abstract top-down approach. Researchers committed to the RJ approach work with affected communities,
activists and providers (including midwives
and doulas), among others. They engage in fully participatory research, from design to execution to
publication to evaluation. The research opened up by the RJ framework is complex and controversial. It asks difficult questions, like:
- Is contraception birth
control or population control?
- Are non-invasive prenatal tests (NIPTs) at odds with
disability rights?
- What are the social
challenges to childbearing?
- What social and health
challenges confront pregnant transgender men?
- How is teenage motherhood
represented?
What are the most pressing reproductive injustices in Europe today?
Clearly this is not an easy question to answer. When I posed it on Facebook though, one response stood out: Refugee women’s lack
of access to reproductive healthcare services.
Migration and statelessness are barriers to accessing
reproductive healthcare. Refugee women are vulnerable to gender-based violence, but it is difficult for them, in transit, to access emergency contraception, antibiotics to treat STIs, post-exposure
prophylaxis to prevent HIV, and psychosocial support. It is estimated that 1 in 10 refugee women in
Europe is pregnant. A recent joint field assessment from the UN refugee
agency (UNHCR), its Population Fund (UNFPA) and the Women’s Refugee Commission
(WRC) regarding the risks for refugee and migrant women and girls in Greece and
Macedonia found that women often left hospitals less than 24 hours after giving birth, some having
had Caesarean sections. Pregnant and lactating women were reluctant
to access services or visit hospitals for fear of delaying their journey,
losing their baby or being separated from their family. A preliminary report on antenatal care,
birth and postnatal care of refugees in Greece, collated by the legal group Hellenic Action for Human Rights, shows that every single one of the women reported having
medical procedures carried out on them without consent or the chance to
question the decision.
Lack of access to abortion, especially second
trimester abortion also came up as a pressing reproductive injustice. As my co-panelists eloquently explained, some European countries forbid abortion entirely, either in law or in practice by erecting impassable barriers to access. Poland and Ireland stand out in this respect. But another issue is that only six countries in the whole of Europe offer abortion on
demand after 12 weeks: Brussels, Romania and Spain (14 weeks), Sweden (18
weeks), Holland (22 weeks), and the UK (excluding Northern Ireland) (24 weeks). This is a major problem for women seeking
second trimester terminations. In addition, even in those countries where abortion is relatively easily accessible, it nevertheless often remains criminalised. The UK is a case in point. Abortion is still criminalised in the UK as a result of the 1861 Offences Against Person Act. This is not only paternalistic and outdated, but it denies women reproductive autonomy. #wetrustwomen is campaigning for the decriminalisation of abortion prior to 24 weeks, and on 13th March 2017, MPs will vote on a bill to change the law to decriminalise abortion. In line with the call from #wetrustwomen, I asked attendees to ask their MP to vote to protect women who are currently at risk of criminal prosecution and to vote in favour of Diana Johnson MP’s Reproductive Health (Access to Terminations) Bill.
Birth injustice also stood out as a Europe-wide problem: Theoretically, women in Europe have the right to choose where, how and with whom they give birth. Yet certain legislative and other regulatory moves have called that abstract right into question. In Dubska v Czech Republic, the European Court of Human Rights found that the Czech government was not obliged to regulate midwives to enable
them to attend women at home births, despite the significant negative impact
this may have on the safety and wellbeing of childbearing women. Five of
the judges dissented, arguing that the Czech system effectively forces women to
give birth in hospital and could not be justified by any public
health argument. According to the UK-based Birthrights organisation: “For women in eastern Europe this will
create a significant bend in the road that activists, mothers and health
care professionals will need to navigate with clarity and purpose to minimise
the damage.” Meanwhile in the UK, independent midwives' indemnity coverage was withdrawn in January 2017 in a decision by the Nursing and Midwifery Council (NMC) that prevents many independent midwives from caring for women in labour. The decision has resulted in the regulator instructing pregnant women to make immediate alternative arrangements for their birth care. Birthrights is actively challenging this decision, given its negative impact on women's birthing choices. Finally, a worrying study released in January 2017, and conducted by the National Childbirth Trust and the National
Federation of Women's Institutes (NFWI), found that 50 per cent of new mothers had
experienced “red flag” events during labour. These include women in labour
being left without a midwife, waiting more than half an hour for pain relief,
or more than an hour to be washed or receive stitches after labour. Women described “humiliating and degrading”
experiences, being left to feel like they were on a “conveyor belt” and feeling
like “cattle.” These findings suggest there is a chronic midwife shortage, with estimates that 3,500 more are needed in England alone. As I explained to attendees last night, these findings reflect my own experience of giving birth in an NHS London hospital in 2015: During labour, I waited for two hours for pain relief
after I initially requested it (due to the only two anaesthetists being in emergency surgery). Recovering in the postnatal ward, I pressed the call bell once, to ask for help on my second night. I explained that I was in agony and hadn’t slept in 48 hours. The response from the head midwife: “Welcome to motherhood.”
***
During the Q&A, a number of interesting issues were raised: What kind of language is necessary and productive to use when challenging these injustices? Direct, blunt and radical language or less confrontational, perhaps watered-down terms? Does context matter when deciding what language and which arguments to use? Could better sex education reduce abortion?
This final question led to a particularly animated conversation. My co-panelists pointed out that sex education could entail an abstinence-based approach that has proven to be unsuccessful at preventing both sex and pregnancy. More broadly, the content of education and the provider of said education could skew how effective it could be at preventing pregnancy. I agree, but would add that there is also the issue of contraceptive failure: Since no method of contraception is 100% effective, unplanned pregnancy is inevitable. In addition, unforeseen pregnancy occurrences, such as the discovery of a foetal anomaly or the woman developing a medical condition as a result of pregnancy, often arise that necessitate terminations. All of this undermines the idea that 'education' could prevent pregnancy or eliminate the need for abortion. It's also worth noting vis the UK Secretary of State for Education's recent decision to make offering sex education in schools compulsory that (a) parents remain entitled to remove their children from these classes, so children do not have a right to receive sex education, and (b) faith schools (of which there are many) are allowed to teach the subject in accordance with their beliefs, meaning that certain pertinent or even essential information may be absent or misrepresented. Evidently, 'education' is not a silver bullet in relation to a range of reproductive injustices.
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