As the global pandemic escalates, health services are rapidly changing, creating tension between reproductive rights and safeguarding against COVID-19 spread, revealing the question: what is essential and what is not?
As the world grapples with the growing threat of COVID-19, health systems are being put to the test, rushing to radically reconfigure themselves in time to absorb a large influx of sick people with complex care needs. In the midst of this reconfiguration, reproductive care and services, particularly for pregnancy, labour and birth, are experiencing rapid changes that have left parents more anxious than before and that lay bare questions of essentiality and optionality in regards to reproductive health. In the U.S. state of Ohio, there is a debate as to whether abortion care is an essential service, after the Attorney General issued a letter instructing Planned Parenthood and other abortion providers to delay procedures without risk to the “current or future health of the patient”. Similar actions are being undertaken in Texas. In the United Kingdom (U.K.), where termination of pregnancy requires signatures from two doctors after face-to-face consultations, temporary changes to abortion law, allowing remote consultations and letting women take medical abortion pills at home, were instated only to be swiftly withdrawn, leaving thousands of women in limbo as to whether they will be able to access services. Many advocates of telemedicine for abortion care, such as the British Pregnancy Advisory Service, argue that sending women to multiple face-to-face appointments is “non-essential,” and travel to them should also be considered non-essential, meaning it would be subject to restriction under the government’s recent lockdown measures.
The challenges are not limited to abortion services. Antenatal classes, though still regarded as necessary, are being curtailed and going digital. In England, where multiple birth place settings are available for women with straightforward pregnancies, reports trickle in that birth centres, which are solely midwifery-led, and home birth services are being suspended, as staff are reassigned to labour wards. Women will now have to choose between their partner and their doula in British maternity units. In the U.S., New York hospitals have barred “all visitors, including partners, for women admitted in labour”. The COVID-19 cases in the state currently account for half of those reported in the U.S., and as the numbers rise in other regions, more health systems are sure to implement this ban. Equally concerning is the Centers for Disease Control and Prevention’s (CDC) recommendation that hospitals should consider “temporarily separating (e.g., separate rooms)” women with confirmed or suspected COVID-19 from their newborns. Similar measures have been reported in France and Italy. This means thousands of women will not only be alone when they give birth, but they will also be denied skin-to-skin contact and breastfeeding initiation, both of which help infants thrive, if they have or are suspected to have novel coronavirus.
What is essential, and what is optional when it comes to reproductive health? The boundaries, as we have found out, are incredibly malleable, just as those of risk and safety. Doula care, birth centres and home birth, only on the cusp of being recognised as essential, are suddenly deemed optional and, therefore, subject to limitations. In a blink of an eye, birth partners, breastfeeding and even skin-to-skin contact have been relegated to non-essential in some areas of the world, which should make us question how clinicians, medical systems and health infrastructures perceive and produce essentiality. To provide a foil to these reports of shrinking reproductive health services, the World Health Organisation (WHO) recognizes women’s right to a safe and positive birth experience, regardless of confirmed COVID-19 infection. This includes:
- Being treated with respect and dignity;
- Having a companion of choice present during delivery;
- Clear communication by maternity staff;
- Appropriate pain relief strategies;
- Mobility in labour where possible, and birth position of choice.
The WHO guidance also supports skin-to-skin contact, safe breastfeeding, which means practicing respiratory etiquette, wearing a mask if available and hand washing before and after feeding, and room sharing with babies for women with COVID-19. All of these constitute a safe and positive birth, to which all women have a right. They are, by the WHO standards, essential, in that they immutable, remaining stable in the face of the shifting services and considered constants in all systems, regardless of resource level. Yet, this essentiality has not held with the emergence of COVID-19. Likewise, abortion care, though considered essential by the American College of Obstetricians and Gynecologists, American Board of Obstetrics & Gynecology, American Association of Gynecologic Laparoscopists, American Gynecological & Obstetrical Society, American Society for Reproductive Medicine, Society for Academic Specialists in General Obstetrics and Gynecology, Society of Family Planning and Society for Maternal-Fetal Medicine, will become even more embroiled in biopolitical contestations over essentiality, bodily autonomy and right-to-care. It is important not to forget that, at the centre of these spinning tensions, are women and their families, who are anxious and uncertain, perhaps vulnerable and exposed, now more than ever, to higher chances of medical interventions, such as forceps delivery and caesarean sections, and birth trauma. The consequences of service changes are intensely corporeal. Thus, amending the discrepancies between international guidelines, national policies, professional mandates and local reproductive health services takes on an urgency because the erosion of reproductive rights is an erosion of human rights.
As a medical anthropologist, my research focuses on health decision-making, particularly about maternity care, examining the convergence of policy, history and choice in the British health system. From my analysis of English maternal health policy history and ethnographic work in East London, a population-dense area of the city that includes pockets of ultra-wealth despite high rates of deprivation, I dissected how contemporary notions of ‘choice’ in maternity are often built on a market ideology, rather than on a platform of human rights. The recent developments in reproductive care have only reinforced this argument. If certain reproductive health choices, such as choice of companion, choice of place of birth and choice of infant feeding, were considered a right, as opposed to an action made by a health services consumer, they would not be reproduced as optional, something that women can just go without. If crisis alters the parameters by which we judge what is essential and what is not, how do reproductive health services pragmatically respond to the novel coronavirus, when making reproductive choices are in themselves considered a human right? So far, logistical decisions are made with the aim to slow the spread of COVID-19, but these actions uncover the contradictory nature of biomedically ‘managed’ reproduction. For instance, centralising all births, even for healthy women with straightforward pregnancies, to hospitals where chance of infection is potentially higher. Others, such as restricting breastfeeding and recommending separation at birth of an infected woman and her infant, reveal that obstetric concerns remain rooted with the health of the infant, rather than the health of the parent-infant, as initially demonstrated over 20 years ago by Emily Martin (1987), Robbie Davis-Floyd (1993), and Brigitte Jordan (1997).
COVID-19, as Helen Lewis pointed out in The Atlantic, is a disaster for feminism. It has the potential to not only exacerbate and prolong gender inequality, as woman disproportionally shoulder care roles, but also diminish bodily rights. “Things that aren’t priorities get cancelled. That can have an effect on maternal mortality, or access to contraception,” Clare Wenham, an assistant professor of global health policy at the London School of Economics, told Lewis. The cancellation has already started in reproductive health, with little or no way to argue against it. It seems that biopolitical contentions about reproduction have been forced to a head by the COVID-19 crisis, displaying how power dynamics, usually obfuscated by patient-centred care, choice and health ownership narratives enshrined in policy, are distributed. However, in unpacking the apparent tension between essentiality and optionality in reproductive health, we need to also scrutinise this tension in and of itself: is it, perhaps, illusory? The very rationale that there is a tension – and so the pandemic takes precedence over reproductive rights because it is a public health emergency requiring short term containment – rests on a set of assumptions about whether reproductive rights conflict with the greater good of public health and the deeply embedded beliefs that, for example: small services, such as birth centres, are inefficient and, therefore, a luxury to be cast aside; core maternity services are acute ones, and primary care services are peripheral; and hospitals are safe places for people who are not in an acute health crisis.
From a human rights perspective, reproductive rights are not incongruous with public health, as providing them is essential to establishing an effective, humane care system and, therefore, diminishing them in times of crisis are counterproductive to this system’s functioning. Yet, rights to choice in contraceptive and pregnancy care and to safe, positive childbirth experiences are evaporating in the name of public health, making tangible this illusory tension, and increasingly, it will become difficult to argue against reproductive care changes, as they are reproduced as ‘necessary’ actions for staggering infection. This is the rub for biopolitics in the time of COVID-19, which Panagiotis Sotiris articulated: “Is it possible to have collective practices that actually help the health of populations, including large-scale behaviour modifications, without a parallel expansion of forms of coercion and surveillance?” Sotiris suggests that social distancing and restricted movement measures fall more in line with a “democratic biopolitics”, in which individual and collective care are amalgamated without coercion. Suspending our individual movement and physical interactions, collectively, does benefit wider health and well-being, but at what point does this suspension infringe on rights to dignified, respectful and positive health care?
Navigating health, care and rights during COVID-19 is, therefore, (Campbell, 2006) slippery, with the potential to slide between quasi ‘states of exception’, which Giorgio Agamben has argued are being enacted through pandemic responses, and ‘democratic biopolitics’. “It remains a fact that anyone with eyes to see cannot deny the constant deployment of biopolitics,” wrote Roberto Esposito in his response to Agamben. What is crucial is how biopolitics is deployed. As Esposito elaborated in his discussion of immunity and community, an “affirmative biopolitics” is one of life, not over life, the opening to which “takes place when we recognize that harming one part of life or one life harms all lives” (Campbell, 2006, p. 16; Esposito, 2008). In this sense, prioritising social distancing measures, including supporting telemedicine for abortion care, remote work and generous maternity leave, among pregnant women can be seen asaffirmative biopolitics. Complicating access to abortion, isolating labouring woman from their birth partners and separating women with COVID-19 from their newborns should not. Supporting and strengthening the capacities of birth centres and home birth services are forms of affirmative biopolitics. Centralising birth care to hospitals and making healthy women go to these units with potentially higher chances of infection are not. This is why cohesively setting boundaries, such as establishing a distinction between essential and optional reproductive services, becomes necessary in the midst of a pandemic conditions, when some care, viewed as fundamental by those who receive it, is not viewed as a ‘priority’ by those who provide it. Medical anthropologists already interrogate taken-for-granted boundaries and investigate how they are made up and expanded, but it is in helping others to navigate and set them, where we could be useful during this extraordinary period of global health.
Campbell, T. (2006). Bios, Immunity, Life: The Thought of Roberto Esposito. Diacritics, 36(2), 2-22.
Davis-Floyd, R. (1993). The technocratic model of birth. In S. Hollis, L. Pershing, & M. Young (Eds.), Feminist Theory in the Study of Folklore (pp. 297-326). Champaign: University of Illinois.
Esposito, R. (2008). Bíos: Biopolitics and Philosophy. Minneapolis: University of Minnesota Press.
Jordan, B. (1997). Authoritative Knowledge and Its Construction. In R. Davis-Floyd, & C. Sargent (Eds.), Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives (pp. 56-79). Berkeley: University of California Press.
Martin, E. (1987). The Woman in the Body: A Cultural Analysis of Reproduction. Boston: Beacon.
Cassandra Yuill, PhD, is a medical anthropologist specialising in maternal health and health decision-making in the United Kingdom. Her research interests encompass a range of reproductive health topics, including interaction of policy and maternity services, midwifery-led care and e-Health. She is currently a Research Fellow in the Centre for Maternal and Child Health Research at City, University of London, working on a project about induction of labour.