Motherhood in the 21st Century

Two recent conferences raised important questions about the way that medical discourse is framing concerns about the ‘optimal’ time and circumstances in which women should reproduce. By Jennie Bristow.

An inter-disciplinary conference held at University College London on 18 September 2009 brought together scientists, clinicians, ethicists, anthropologists and several notable names in the field of fertility treatment to address the topic of ‘Motherhood in the 21st Century’. (1) Speakers addressed questions such as: What is the relationship between maternal age and biological fertility? What are the clinical and ethical issues in treating women approaching, or beyond, the age of menopause? At what age should a woman be considered ‘too old’ to be given fertility treatment to enable her to have a child? 

For those working in the field of reproductive choice, these recent debates surrounding the use, and potential abuse, of fertility treatment raise a host of familiar issues. Moral judgements about the use of technologies such as IVF that interfere with a woman’s ‘natural’ fertility, often-politicised discussions about the kind of women who should and should not be encouraged to have children, and the relationship between clinical developments and legal regulations all have their parallels in discussions around contraception and abortion.

However, while the idea that women should not be forced to bear unwanted children is well accepted in the UK, the question of whether women should have a ‘right’ to access fertility treatment is a newer, and more contentious, area of debate. Speakers at the ‘Motherhood in the 21st Century’ conference sought to untangle the risks and opportunities provided by recent developments in fertility treatment, and to address the clinical and ethical dimensions that arise from the trend towards later motherhood, which has arisen in part from women’s decisions not to have children earlier in life.

Opening the proceedings, Lord Robert Winston argued that it was ‘regrettable’ to see the Royal College of Obstetricians and Gynaecologists (RCOG) wringing its hands over the trend for women to have babies later in life. (2) He argued that it should not be the role of the medical profession to worry about when women have their children. The focus in debates about ‘older mothers’ on women over the age of 55 is ‘inappropriate’, as these represent an extremely small number of the women giving birth.

Where there is a problem, Lord Winston explained, is in relation to women in their forties and their early fifties; and here, many of the problems were to do with the way the NHS and the private sector is ‘exploiting women in different ways’. He gave as examples of this exploitation the ‘scandal’ of expensive IVF cycles, and the issue of egg sharing, whereby women seeking fertility treatment are given a reduction in price in exchange for sharing the eggs they produce under treatment with another patient. This situation has become exacerbated with the legal changes surrounding donor anonymity, which has given rise to a potential scenario in which a woman unsuccessfully undergoes treatment using her own eggs, but is contacted 18 years hence by a child born to another woman using the first woman’s eggs.

Professor Sammy Lee, Chief Scientist of the Wellington Hospital IVF programme and convenor of the ‘Motherhood in the 21st Century’ conference, spoke briefly about why he had organised the event. The public views the idea of a 70-year-old woman carrying and delivering a baby as shocking, he explained – ‘but they do not know why. Faced with such widespread prejudice, this topic needs to be aired in public and the real issues determined and then debated’. Biological age should not be the only considerations taken into account when looking at mothers who have children later in life, suggested Lee: ‘indeed, the special love and drive such mothers have makes the endurance of motherhood a pleasure rather than a burden’.

In an interesting scientific presentation, Professor John Carroll, Associate Dean of UCL Division of Biosciences, described why women aged 35-45 experience a ‘precipitous decline in fertility’. Humans generate a limited and finite number of eggs, and eggs from older mothers are ‘prone to serious chromosomal errors that result in the generation of embryos that have limited developmental potential’. Further research into how eggs are made, stored and released may, suggested Carroll, provide new opportunities to treating sub-fertility in the future.

Peter Brinsden, MB FROG, Consultant Medical Director at the Bourn Hall, addressed the issues involved in treating older mothers. Noting that ‘the ready availability and wide choice of reliable contraception has been a major revolution in the lives of women in the last 40 years’, Brinsden argued that this has led to an increasing tendency for women to delay starting their families, with the result that ‘many women are now attending fertility clinics in their forties, and even fifties, having found that they cannot easily become pregnant, and [expecting] that IVF and related advanced fertility treatments will resolve their problem’.

Because of the relative lack of success of IVF to older women, Brinsden pressed the point that ‘women of all ages’ should be ‘fully informed of the consequences of delaying motherhood’. An audience member challenged his assumption that women were consciously deciding to delay motherhood because they had invested false hopes in the effectiveness of fertility treatment, and the idea that women should be pressed to worry about the optimal age at which they might have a child was tackled in further presentations.

Professor Dr N. Pandiyan, Chief Consultant in Andrology and Reproductive Medicine at Chettinad University, India, argued that ‘sex and reproduction are fundamental rights of every individual’, and that ‘where society cannot give the necessary help due to financial / resource / religious constraints, it should at least stay away from individuals achieving their desired goals by rightful means’. The decision about when to have a child, stressed Pandiyan, is a personal one ‘to be made by the couple in consultation with the doctor and the fertility centre, and not by any of us.’

Professor Anna Smajdor of the University of East Anglia, drew out the problematic of the ‘implicit ethical assumption’ that ‘women should reproduce at the optimal time’ – which in terms of medical risk is seen as between the ages of 20 and 35. If the discourse around reproduction is dominated by a preoccupation with medical risk, argued Smajdor, the consequence is to argue that women should not reproduce at all, as pregnancy and childbirth are risky for women at any age. If reproduction is recategorised as a necessary risk, but the narrow focus on medical risk is retained, this can lead to an ‘implicit pronatalism’ that views women’s responsibilities primarily in relation to the health of their potential pregnancies.

The problem of a new form of pronatalism, framed by a narrow preoccupation with medical risk, was addressed at a different conference organised by the academic Parenting Culture Studies network, in Birmingham on 16-17 September. (3) One session examined the phenomenon of ‘extending pregnancy backwards’ – a process by which the behaviours and anxieties associated with pregnancy are promoted to all women, on the grounds that they may become pregnant someday.

Rebecca Kukla, author of Mass Hysteria: Medicine, Culture and Mothers’ Bodies, described the growing trend towards ‘preconception care’. This policy idea promotes the notion that the way to ensure the birth of healthy babies is to ensure that all women of childbearing years are treated by doctors less as individual women than as potential mothers. This makes them subject to increasing lifestyle modification advice and lends itself to a situation where women may be given medical treatment determined on the basis of what might have the least adverse outcome for a potential fetus, rather than what will work best for the woman herself, right now. As Kukla put it, ‘Women’s healthcare is increasingly co-opted by reproductive management – whether or not a child is involved.’

The practical consequences of treating all women as mothers-in-waiting for the healthcare they are given are disturbing. But the broader cultural effect of such ‘preconception planning’ might also give us pause. One great achievement of the movement for reproductive choice has been to move away from assumptions that women matter, first, as mothers or potential mothers. A shift towards viewing, and treating, women in terms of their ability to become the optimal pregnant person could be seen as a step backwards for assumptions about women’s autonomy, both in terms of their treatment by health services and the wider validation of women’s lives. 

Jennie Bristow is editor of Abortion Review.

(1) ‘Motherhood in the 21st Century’ conference
(2) Concerns over older mother trend. BBC News Online, 12 June 2009
(3) Parenting Culture Studies