Navigating Miscarriage: Social, Medical and Conceptual Perspectives 9781789206647

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Navigating Miscarriage

Fertility, Reproduction and Sexuality General Editors: Soraya Tremayne, Founding Director, Fertility and Reproduction

Studies Group and Research Associate, Institute of Social and Cultural Anthropology, University of Oxford. Marcia C. Inhorn, William K. Lanman, Jr. Professor of Anthropology and International Affairs, Yale University. Philip Kreager, Director, Fertility and Reproduction Studies Group, and Research Associate, Institute of Social and Cultural Anthropology and Institute of Human Sciences, University of Oxford. Understanding the complex and multifaceted issue of human reproduction has been, and remains, of great interest both to academics and practitioners. This series includes studies by specialists in the field of social, cultural, medical and biological anthropology, medical demography, psychology and development studies. Current debates and issues of global relevance on the changing dynamics of fertility, human reproduction and sexuality are addressed. Recent volumes:   Volume 45

Volume 40

Navigating Miscarriage: Social, Medical and Conceptual Perspectives Edited by Susie Kilshaw and Katie Borg

Being a Sperm Donor: Masculinity, Sexuality, and Biosociality in Denmark Sebastian Mohr

Volume 44

Global Fluids: The Cultural Politics of Reproductive Waste and Value Charlotte Kroløkke

Privileges of Birth: Constellations of Care, Myth and Race in South Africa Jennifer J.M. Rogerson

Volume 43 Access to Assisted Reproductive Technologies: The Case of France and Belgium Edited by Jennifer Merchant

Volume 42 Making Bodies Kosher: The Politics of Reproduction among Haredi Jews in England Ben Kasstan

Volume 41 Elite Malay Polygamy: Wives, Wealth and Woes in Malaysia Miriam Koktvedgaard Zeitzen

Volume 39

Volume 38 Reconceiving Muslim Men: Love and Marriage, Family and Care in Precarious Times Edited by Marcia C. Inhorn and Nefissa Naguib

Volume 37 The Anthropology of the Fetus: Biology, Culture, and Society Edited by Sallie Han, Tracy K. Betsinger, and Amy B. Scott

Volume 36 Fertility, Conjuncture, Difference: Anthropological Approaches to the Heterogeneity of Modern Fertility Declines Edited by Philip Kreager and Astrid Bochow

For a full volume listing, please see the series page on our website: http://www.berghahnbooks.com/series/fertility-reproduction-and-sexuality

NAVIGATING MISCARRIAGE Social, Medical and Conceptual Perspectives

Edited by Susie Kilshaw and Katie Borg

berghahn NEW YORK • OXFORD www.berghahnbooks.com

First published in 2020 by Berghahn Books www.berghahnbooks.com © 2020 Susie Kilshaw and Katie Borg All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system now known or to be invented, without written permission of the publisher. Library of Congress Cataloging-in-Publication Data Names: Kilshaw, Susie, editor. | Borg, Katie, editor.  Title: Navigating miscarriage : social, medical and conceptual    perspectives / edited by Susie Kilshaw and Katie Borg.  Description: New York : Berghahn Books, 2020. | Series: Fertility,    reproduction and sexuality ; volume 45 | Includes bibliographical    references and index.  Identifiers: LCCN 2019051621 (print) | LCCN 2019051622 (ebook) | ISBN    9781789206630 (hardback) | ISBN 9781789206647 (ebook)  Subjects: LCSH: Miscarriage. | Miscarriage--Social aspects. |    Miscarriage--Psychological aspects. Classification: LCC RG648 .N38 2020  (print) | LCC RG648  (ebook) |    DDC 618.3/9--dc23  LC record available at https://lccn.loc.gov/2019051621 LC ebook record available at https://lccn.loc.gov/2019051622 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 978-1-78920-663-0 hardback ISBN 978-1-78920-664-7 ebook

Contents

Acknowledgements vii Introduction. Ambiguities and Navigations Susie Kilshaw Chapter 1. Does Twenty-First-Century Technology Change the Experience of Early Pregnancy and Miscarriage? Pedro Melo and Ingrid Granne

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Chapter 2. The Meanings of Miscarriage in Twentieth-Century Britain 59 Rosemary Elliot Chapter 3. Alleviating the Ambiguities around Miscarriage: Discursive Tactics in Cameroon and Romania Erica van der Sijpt

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Chapter 4. Some Babies Cannot Be Stopped from Falling: Miscarriage in Pakistani Punjab Kaveri Qureshi

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Chapter 5. God’s Design, Thwarted Plans: Women’s Experience of Miscarriage in Qatar and England Susie Kilshaw

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Chapter 6. ‘It Felt Like the Longest Time of My Life’: Using Foetal Dopplers at Home to Manage Anxiety about Miscarriage Aimee Middlemiss Chapter 7. Miscarriage and Its Resulting Losses during Commercial Surrogacy in India Sayani Mitra

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Chapter 8. Unwitnessed Ceremonies: Funeral Services for Pre-24-Week Pregnancy Losses in England Karolina Kuberska

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Conclusions Susie Kilshaw

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Index

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Acknowledgements

W

e would like to thank everyone who has played a vital role in the ideas and making of this book, including the series editors: Marcia Inhorn, Philip Kreager and Soraya Tremayne for giving us the opportunity to produce this book. In particular, thanks to Philip for inviting us to act as editors and his support and guidance throughout the process. Thanks to the Fertility and Reproduction Study Group (FRSG), the Institute of Social and Cultural Anthropology (ICSA) and Oxford University, who organized and hosted the seminar series, which was its impetus. The series provided much discussion and we are grateful to all the speakers, including those who were unable to contribute to the book. Suzannah Williams garners thanks for her passion and drive to lay the foundations for the seminar series that proceeded this volume – thank you for pushing to break the silence around miscarriage. Our contributors produced wonderful chapters, helped enormously by meeting deadlines and were patient with unexpected delays. We have enjoyed working with this group of inspirational scholars. We are appreciative of the publishing team at Berghahn, particularly Tom Bonnington, Marion Berghahn and Caroline Kuhtz. We are grateful to the anonymous reviewers for their time and for one in particular who gave especially detailed and thoughtful comments, which helped to improve the book. The book could not have been produced without the support of our colleagues, including Clare Connolly, Katie’s wonderful nursing colleague and friend who covered for her so she could attend the original seminars. Susie is grateful for the constant support of her colleagues at UCL Anthropology and to the funding bodies, which have supported her work: The Qatar National Research Fund, Qatar Foundation and the Wellcome Trust.

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Acknowledgements

A great deal of thanks is owed to our families, including Nick Cooper, Katie’s long-suffering and patient partner who became her husband during the production of the book. Susie’s family, particularly her husband, Ed, and daughters, Scarlett and Annabel, were generous with their support. Most of all we would like to thank all those impacted by pregnancy loss who inspired us to produce a book that we hope will shed further light on the subject of miscarriage and loss.

Introduction Ambiguities and Navigations Susie Kilshaw

A

striking feature of accounts of and literature on miscarriage is the trope of silence. The slogan of Baby Loss Awareness Week, which began in the UK sixteen years ago, is ‘Break the silence’. Associated with the American Pregnancy and Infant Loss Remembrance Day Campaign, which began in 2002, the week concludes each year on 15 October, International Pregnancy and Infant Loss Remembrance Day. Approaches to miscarriage have changed dramatically and the silence has steadily eroded in much of Euro-America, as evidenced not only by the introduction of such awareness days and other public forums to articulate feelings of loss, but also by recent campaigns to provide certificates of life for miscarried foetuses under 24 weeks’ gestation; a growing market for miscarriage memorials; and shifts in medical practice, including changes to disposal practices. In the past, pregnancy tissue would be discarded as clinical waste and routinely incinerated in the UK, but following increased levels of public scrutiny, including a 2014 Dispatches programme, the UK Human Tissues Authority (HTA) developed guidance on the disposal of the remains of pregnancy (March 2015). This guidance, which influences national policy, outlines that women should be informed of and have access to a range of disposal options (burial, cremation, incineration1), the woman’s wishes should be carried out and that remains should be ‘sensitively’ disposed of. In Texas, USA, a 2017 senate bill requiring hospitals and clinics to bury pregnancy remains (miscarried, stillbirth and aborted as well as those from ectopic pregnancies)

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regardless of the woman’s wishes was passed and it appears that other states may follow suit. While the responsibility rests with the clinic, not the women, the bill will impact the availability of abortion (and early pregnancy) care providers, as they may not be in a position to provide the required disposal services. This law would in effect prevent clinics from providing abortions if a disposal/burial pathway was not established, while placing additional financial burdens on them. The bill was blocked and taken to trial in July 2018, and it remains opposed for the time being, although in September 2019 Texas attorneys asked the courts to revive it. Such shifts in the treatment of these materials have been informed by broader societal changes regarding pregnancy loss in these contexts and in turn this loops back to impact on how women experience a pregnancy ending: the way these entities are considered subsequently informs the nature of interactions with them. Miscarriage has increasingly been framed as a significant loss of a baby or child that is typically met with distress, grief, post-traumatic stress and depression (Farren et al. 2016). Such a shift has come about in large part due to support groups and charities: in the UK, the Miscarriage Association and campaigns such as Mumsnet’s ‘Miscarriage Care Campaign’ have been influential in shifting public and medical thinking. The medical profession has responded to the call to manage miscarriages with greater sensitivity, including changing the approach to care, and the medical terminology used. Until recently, the surgical removal of pregnancy remains in the case of incomplete or missed miscarriage was referred to as ‘Evacuation of Retained Products of Conception’ (ERPC); this has now been renamed the more neutral ‘Surgical Management of Miscarriage’ (SMM). Changes in clinical approach have been informed by broader societal transformation in how society approaches pregnancy loss, whilst also reinforcing understandings of miscarriage as the death of a baby. Framing miscarriage as significant loss may result in frictions in contexts when it is not perceived in this way or is framed more normatively or pragmatically. Furthermore, what impact might this have on the framing of other kinds of pregnancy endings? This book reveals variation and highlights the fluidity of miscarriage definitions, categories, meanings and approaches. Despite its prevalence, there is very little scholarly social science literature on miscarriage. This book responds to this gap, positioning itself among the impressive body of work on anthropology of reproduction and, particularly, on reproductive disruptions (see Inhorn 2007c). Anthropology provides a means to explore miscarriage as

Introduction3

simultaneously biological, social and cultural and thus provides rich insights. The chapters consider how such an event interacts with kin, marital, gender, religious and political structures and reveal how these vary significantly between cultures. Social and political forces shape miscarriage, adding further evidence to the way in which ‘reproduction is always embedded within larger social, cultural, economic, and political relations and forces’ (Inhorn 2007a: 10; see also Lock 1993; Rapp 2000; Scheper-Hughes 1992). The first significant anthropological consideration of pregnancy loss, Cecil’s (1996) collected volume, responded to the scholarly silence, which Cecil suggests may be because of notions of miscarriage as failure and that it is typically accompanied by mess, blood, pain and embarrassment and, thus, not easy to speak about. Layne’s work on miscarriage, most notably Motherhood Lost: A Feminist Account of Pregnancy Loss in America, published in 2003, marked the advent of miscarriage as a subject of anthropologists’ attention. Revealing how middle-class American women grapple with the two affective political forces of foetal rights and a cultural code of silence, Layne notes an absence of a ‘cultural script’ to articulate the grief of pregnancy loss (see also Cecil 1996). Yet the efforts of Linda Layne, other scholars and pregnancy loss support groups have meant public disclosures of miscarriage are now more common in northern Euro-America (Kilshaw 2017b; Layne 2003). Layne’s landmark work reflects the broader scholarly focus, which has primarily rested on white, middle-class Euro-American women; meaning that reproductive loss in a large group of women has been ignored, including those from other ethnic backgrounds and non-hetero-normative people. Building on literature such as Wojnar and Swanson (2006), Peel (2010) and Luce (2010), Craven and Peel (2014, 2017) argue that LGBTQ people have an amplified experience of loss due to the challenges in achieving conception and adoption. Indeed, the emotional and financial investment made in quests for motherhood and the heterosexism of health professionals in many cases heightens the distress of miscarriage (Wojnar and Swanson 2006) whilst homophobia intensifies feelings of isolation (Luce 2010). Responding to a significant gap in the scholarship on miscarriage, Craven and Peel’s work on non-traditional families is a welcome addition, as is that of scholars such as Berend (2010, 2016), who looks at loss in the context of surrogacy. With the literature primarily exploring Euro-American heterosexual women’s experiences (e.g. Layne 1992, 2003; Letherby 1993) and only a few scholars examining the issue from the viewpoint

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of women and men outside of these contexts (e.g. Cecil 1996; Rice 2000), a significant absence has been an understanding of how women in other parts of the world experience miscarriage. This book is part of a small but growing body of work that explores miscarriage beyond Euro-America (see also Kilshaw 2017a, 2020; Van der Sijpt 2017, 2018). Unanticipated and often undesired, miscarriage is a reminder that reproduction is disorderly, its misfortune outside our control (Boddy 1989). Scholars have outlined the sense of chaos that arises when reproductive expectations and aspirations are not met (e.g. Inhorn 2003). Reproductive loss has been conceptualized as a major disruption, which potentially causes a crisis in gendered identity, relationships and life plans (Becker 1999). As a theoretical concept, miscarriage provides opportunities to make sense of the discourses and dynamics that evolve in times of uncertainty, ambiguity and reorientation. The uncertainty of miscarriage causation provides possibilities for the negotiations of interpretations. Such flexibility of explanations can make a woman vulnerable to accusations of inducing pregnancy loss, but can also provide opportunities to tailor interpretations to suit circumstances (Jeffery and Jeffery 1996; Jenkins and Inhorn 2003; Van der Sijpt 2010). It is during such moments that explicit ‘reproductive navigation’ (Van der Sijpt 2018) takes place, providing opportunities to explore social life. Miscarriage engages a woman’s relationship with her body, her self, the foetus, as well as past and future children; it features possibility and loss as well as ongoing negotiations of the self. The book explores how miscarriage is framed and understood rather differently in diverse contexts: Cameroon, Romania, Qatar, India, Pakistan and the UK, revealing how social context and cultural norms dramatically impact on miscarriage. And yet miscarriage always involves liminality and uncertainty, engaging core questions of social life. We use miscarriage as a lens through which to explore some of the most central issues within anthropology, including the thresholds of humanity, categories of personhood and the boundaries of life and death. Pregnancy endings provide opportunities to interrogate anthropological assumptions and significant issues of theory and practice in anthropology about personhood and the foetal subject; boundaries around bodies, categories and definitions; and how society understands and frames gender, women and, particularly, motherhood.

Introduction5

Demography and Miscarriage The demographic contexts within which miscarriage arises also impact reactions: lowering fertility means having a child becomes an exceptional occurrence in the life course and may lead to greater feelings of loss, whereas high fertility rates may mitigate mourning and grieving as will contexts with higher rates of infant mortality. Low fertility rates may increase emotional, financial and other investments in pregnancy, emphasising miscarriage as loss and entailing acts of mourning, which will be similarly felt in contexts of demographic anxieties. Miscarriage is a potential personal and social problem: it may lead to psychological distress, such as parental depression, which in turn may impact family members and lead to marital dissolution. In some contexts, women who miscarry have a higher risk of postpartum depression even after having a child (Blackmore et al. 2011). There may be additional social costs associated with miscarriage such as loss of work or chronic health problems associated with depression. Of course, miscarriage may increase space between children and may reduce the number a woman is able to or chooses to have, although the demographic approach to miscarriage suggests that this is minimal. Miscarriages are frequent critical events and we might expect quantitative approaches to give them major attention, yet miscarriage has relatively little significance for fertility trends. The historical demography of communities around the world, together with contemporary anthropological research on them, showed a vast range of fertility levels while overthrowing the widespread assumption that women in the past always had many children. Even in the absence of contraception, the completed family size of women was shown to vary by 200 per cent. The old demographic view, following Malthus, according to which delayed marriage was the main factor leading to such variation – and that most people simply did not try to control their fertility – was clearly inadequate to account for such differences. This led demographers to consider more comprehensively the way social and biological aspects of reproduction interact. In addition to the timing and incidence of marriage, and the possible role of abstinence, the main factors in the absence of widespread contraception have turned out to be the role of lactation in inhibiting ovulation, and the impacts of pathological factors (i.e. gonorrhoea and AIDS). Long before the rise of contraceptive technology there were serious and sustained controls on fertility.

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However, it is the timing of births rather than quantity that is being controlled. Studying the dynamics of women’s reproductive life courses more carefully, with particular consideration to the length of intervals between births, demographers looked at a variety of factors, including induced abortion, ‘waiting time to conception’, as well as miscarriage. One purpose of the framework (called the ‘model of proximate determinants’ [Bongaarts and Potter 1983]) was to specify what influence miscarriage has on changing numbers of children relative to the other factors, revealing two important trends in miscarriage: maternal age and length of the gestation period.2 In constructing their model of how length of birth intervals is impacted by these factors, demographers realized that miscarriage refers particularly to the ‘waiting time to conception’. On balance, in societies where sustained breastfeeding is practised, most of the interval between births is taken up by lactation, together with the nine months while a woman is typically pregnant. Indeed, the model showed that, on average, intervals including concerted lactation (often supplemented by abstinence to ensure spacing) might regularly reach three years or longer in the absence of contraception. In the context of this finding, we can readily understand why demographers came to regard the influence of miscarriage – which most often occurs in the early stages of gestation – as not a major factor shaping the number of births. The model shows that the number of months that miscarriage contributes to birth intervals is much smaller than other factors. While demographers have clarified much by their careful attention to how miscarriage can be measured, the secondary status the subject has played in fertility trend research has done little to encourage attention to the genuine problem that miscarriage creates for many women – a problem that is amplified for those who have repeat miscarriages, a variable not factored into demographers’ models.

Boundaries, Definitions and Metaphors Person Categories Discussions of miscarriage inevitably lead to questions about the meaning ascribed to the embryo/foetus. Han (2018) points out the centrality of the dilemma of what to call ‘it’ in the first place: our choice of term (foetus, baby, child) is to refer not only to it in its material existence but also to the social relations that surround it;

Introduction7

to define a foetus is also to describe what is a pregnancy and what is a pregnant woman. In biomedical terms, ‘foetus’ only comes into effect after the eighth week of gestation (Maienschein 2002). However, the term is often used for earlier gestational ages. Nomenclature neither maps neatly onto clinical gestational stages nor correlates with clinical, physical, legal, religious and cultural distinctions. A foetus is made into being by the different practices around it. Medical, religious, legal, social and personal definitions inform the production of the thing (i.e. baby, tissue, no-thing) and yet such categories may not be coherent, are often ambiguous and open to negotiation. Early pregnancy is often framed as tentative, precarious and uncertain, with ambiguity about what is contained within. Writing about conception and pregnancy in eighteenth-century Germany, Duden (1993: 14) shows that conception was ‘an ambiguous stage in a woman’s somatic experience’. A delayed period was ‘maybe a sign that she was “with child”, maybe not’, as it could be due to a blockage or retention of menses (ibid.: 16). It was only when a woman felt ‘“quickening” that she would perceive herself as being “really pregnant”’ (ibid.: 17). Person categories may be rigid or flexible. In their ethnography of pregnancy loss in rural North India, Jeffery and Jeffery (1996: 24) note that if a pregnancy ends before three months gestation, the contents are commonly referred to as ‘merely a blob of flesh … that broke up into blood clots and caused bleeding’, with such bleeding framed as a menstrual period. Nearly three months will have elapsed before women speak of pregnancy, referring to a bacha (baby) with a spirit; before this point an early foetus is not recognized as such. A distinction is made between early and later loss in Cameroon, with the latter representing the loss of a child. Despite this conceptual distinction, however, the line between them is fluid: foetal development is determined by the strength of one’s blood, which varies, meaning a woman will not know when her foetus is formed, viable or at term. A lack of a clear boundary between the end of a pregnancy and the loss of a child leaves space for women to propose what is lost (see Van der Sijpt’s chapter in this volume). A miscarriage may represent the death of a baby (Layne 2000), a child (see the chapters by Van der Sijpt and Kuberska in this volume), the creation of a cosmological being (Kilshaw 2017a; Van der Sijpt 2018), but for others in other contexts a miscarriage may be understood as the expulsion of blood, water, dirt, tissue, a ‘piece of meat’, an assortment of cells, or ‘matter out of place’ (Jeffery and Jeffery 1996; Kilshaw 2017a; Littlewood 1999; Murphy and Philpin 2010). The development of

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spirit or soul may be part of the continuum of development, in most cases conception, pregnancy, birth and early life, a series of stages of strengthening personhood and humanity. Miscarriage has been absent from feminist scholarship because of the political nature of the questions involved in the foetal subject: something worth grieving accedes it to personhood (Layne 1997: 305). The concern has been that to focus on the foetus surrenders to the pro-life movement its major premise and forecloses the feminist insistence of reproductive freedom for women (Michaels and Morgan 1999: 1). Indeed, the meanings ascribed to foetuses and the history of efforts to grant social identities to them is a problematic topic in current feminist thought (see Michaels and Morgan 1999). Research is scant precisely because of the surrounding ambiguity: living but not yet alive, an embryo falls between the categories of ‘human’ and ‘non-human’. We have difficulty in articulating exactly what these beings or materials are, making scholarly analysis difficult. As Rapp (2018: xiv) eloquently notes: [The] foetus, a foetus, and the differential life chances of foetuses everywhere constitute a perfect storm of what the feminist theorist Donna Haraway would call material-semiotic objects. Liminal in the most profound sense, foetuses serve as lightning rods for any ontology you’d care to imagine, providing our meaning-making species with a continually self-reproducing nature-culture, a biosocial or material-vitalistic entity to which every generation must necessarily address itself.

Uniquely symbolic and yet innately flexible, the foetus “matters in so many dimensions of our experiences and expectations because it is both materially and metaphorically a product of the past, a marker of the present and an embodiment of the future” (Han, Betsinger and Scott 2018: 1). Scholarly reluctance to engage with the foetus is compounded with unsuccessful pregnancies: the miscarried foetus is a source of the profoundest ambiguity and yet the meanings ascribed to it are not value-free and have significant implications for a variety of practices, such as abortion; embryo creation, storage and disposal; the use of such material for research purposes; and fertility treatments. While scarce, anthropologists’ work on embryos and foetuses, particularly in relation to new technologies such as Assisted Reproductive Technologies (ARTs), has been influential in thinking about issues around person categories, personhood and potential. Work such as Cromer’s (2018) on embryos ‘left over’ following in

Introduction9

vitro fertilization (IVF) reveals they are not inherently valuable; it is the considerable efforts at framing, defining and classifying that transform them into waste, preborn persons or frozen assets. Berend’s (2010, 2016) research on surrogacy in the USA has shown that surrogates often mirror the rhetoric of anti-abortion activists despite their own stance on abortion, in terms of their conviction that life begins at conception. For many surrogate mothers, chemical pregnancies are considered miscarriages despite the lack of presence of an embryo or foetus because of the focus on the imagined and potential child; indeed, the distinction between egg, embryo, foetus and baby is often erased. Such understandings of personhood developing at conception with little distinction in relation to gestational age emerge in the USA, which may have as much to do with technology as it does with religious perspectives. American understandings of the foetus as ‘bare facts of biological life’ are the result of specific historical and social processes with the same moral, political or medical importance and meaning not necessarily ascribed to these entities in other contexts (Han 2018). Miscarriage provides an opportunity to explore the foetal subject: categories, such as legal, medical and religious classifications, grapple with definitions of life before birth, the boundaries of humanity and what value is attributed to an embryo, foetus or pregnancy residues. A plethora of relational values inform what these materials are, how they are regarded, and meanings ascribed to them. The landscape around miscarriage shifts: in many contexts, legislation continues to change, categories around foetuses, their value and notions of personhood are in flux. The meanings attached to life before birth vary considerably from culture to culture (Conklin and Morgan 1996; Morgan 1989), with the boundaries in relation to the thresholds of humanity and personhood informing how miscarriage is framed and appropriate responses. Knowledge of the foetus may become contested terrain with conflicting claims structuring debates about reproduction (Newman 2018: 201). Definitional Boundaries and Language A recent article in the UK’s Guardian newspaper argued that ‘language matters’ when it comes to miscarriage (Lindemann 2018). Influencing practices as well as shaping experience, definitions and concepts of pregnancy ends are multiple, often drawn around considerations of what is lost as well as intentionality; boundaries around miscarriage are contingent and open to renegotiation and vary depending on cultural and historical context. Murphy (2019:

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35) points out that scholarly literature tends to conflate various forms of pregnancy loss into one category, with miscarriage often considered alongside neonatal death and stillbirth, making for an imprecise literature. This book focuses specifically on miscarriage and considers the impact of definition categories. Miscarriage may be described in terms of falling: in Arabic, miscarriage is referred to as Isqat or Tasqeet, both originating from saqat (to miscarry), which means to ‘drop something from up to down’. Conveying a drop or a fall is similarly found in Urdu (‘a baby falls’) (Shaw 2014; Qureshi’s chapter in this volume), Hmong (Rice 2000), and in early gestational pregnancy in Cameroon (abum ia song, ‘the pregnancy has fallen’). The Oxford English Dictionary (OED) defines miscarriage in general terms: ‘a failure, blunder or mistake’; ‘a mishap or disaster’; ‘an instance of misconduct or misbehaviour’; before coming to ‘the spontaneous expulsion of a foetus from the womb before it is viable’. The usage thus partakes inevitably of the wider implications of wilful human agency and mere accident, of culpability and chance, and of failure. Definitions and understandings typically suggest an event of bleeding and (swift) emission of tissue. However, this rarely tallies with women’s experience of an extended process, unfolding over days if not weeks, with women commonly expressing alarm when their experience does not correspond with common perceptions. Boundaries separate miscarriage from other pregnancy endings. This may be in relation to intentionality, attributes of the pregnancy (i.e. gestational age) and/or what is lost. The interrelationship between categories around foetal death is a key feature of the first chapters of this book and emerges in subsequent chapters too, with particular attention given to the way in which abortion (induced pregnancy ending) influences how miscarriage (spontaneous pregnancy ending) is framed. Miscarriage, stillbirth, abortion and infant death are distinguished in biomedical discourse, with different implications for management (Shaw 2014) and perception of the event. However, distinctions are not always concise. Miscarriages are distinguished from medically induced abortion in local Urdu and Panjabi idiom, where in the former the pregnancy ‘becomes’ wasted or ‘a baby falls’, whereas the latter are events that involve human agency (Shaw 2014). The circumstances and cause of a pregnancy ending often remain unknown, which may lead to vulnerability to accusations of wilfully ending the pregnancy, but also provides flexibility in how the event is presented. Ambiguity may extend to language around categories, lending itself to uncertainty around intentionality. The moral associations of labels may generate

Introduction11

navigations as miscarrying women try to disprove their culpability (see Van der Sijpt’s chapter in this volume; see also Erviti, Castro and Collado 2004; Van der Sijpt 2017). Women and carers may choose particular language or descriptions of events as they navigate uncertainty, as Suh (2014) describes among health care providers in the Senegalese medico-legal domain where abortion is illegal. Categories of pregnancing endings take shape in clinical practice with health providers obscuring induced abortion in medical documents in a number of ways, including using terminology that does not differentiate between spontaneous and induced abortion (Suh 2014). Medico-legal-religious constraints define these categories and inform women’s experiences; reproduction occurs within these constraints but there are opportunities for subversions, as women and their carers navigate ambiguities and resist particular framings. In some contexts, there is little linguistic distinction between induced and spontaneous endings, such as in Qatar where Ijhad (abortion) is used interchangeably with Isqat or Tasqeet (miscarriage). With abortions rare due to legal, social and religious prohibitions, there is little requirement to linguistically distinguish from miscarriage. Elliot (Chapter 2, this volume) describes how the historic conflation of abortion and miscarriage in the UK has shaped how miscarriage has been approached in medical and public contexts, with the two entwined in terms of language, medical practice and ethical discussion around viability and personhood. The conflation can be seen in legal definitions where the law in the UK (and former colonial jurisdictions) makes it a crime for a woman to ‘procure her own miscarriage’ (https://www.legislation. gov.uk/ukpga/Vict/24-25/100/section/58, last accessed 14 June 2019). ‘Spontaneous abortion’ has traditionally been the term used for miscarriage in UK medical settings. In 1997 a Royal College of Obstetricians and Gynaecologists study group recommended that the word ‘abortion’ be avoided in cases of spontaneous early pregnancy loss, noting that ‘abortion’ was associated in the public mind with planned termination of pregnancy (RCOG 33rd Study Group 1997). Legal and commonplace in the UK, with one in three women undergoing an induced abortion, the study group recognized that cultural associations deemed the term inappropriate for the loss of a wanted pregnancy. It adopted this in its guidelines in 2006, noting the ‘historical terminology … distressing’ (RCOG 2006: 1). ‘Miscarriage’ or ‘pregnancy loss’ have now become the favoured terms in both public and medical settings, and linguistically separated from abortion, with the latter implying intentionality. Thus, by referring

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to their loss as a ‘miscarriage’, women in the UK convey clearly that the loss was unintended; women typically refer to abortions as ‘terminations’, denoting their active component. Boundaries drawn around miscarriage may be defined by the object produced, its weight and ability to survive outside its mother’s body, but definitions are multiple and fluid. Primarily a legal distinction to do with the death of a human being, classifications of stillbirth versus miscarriage revolve around viability in global policy initiatives, but viability shifts in relation to medical knowledge, technology as well as locale. There is no clear limit of development, age or weight at which a human foetus automatically becomes viable, and thus categories defining when the end of a pregnancy constitutes the end of a life are variable. The World Health Organisation (WHO) recommends that any baby born without signs of life at greater than or equal to 28 weeks’ gestation be classified as a stillbirth (WHO 2016), which means that those under 28 weeks’ gestation are considered a miscarriage. This definition is used in a variety of settings, including in the UK until 1992 and in present-day Romania. In other contexts, a combination of less than 16, 20, 22, 24 or 28 weeks gestational age or 350g, 400g, 500g or 1000g birth weight are used as the boundary: there is ‘probably no health outcome with a greater number of conflicting, authoritative, legally mandated definitions’ (Nguyen and Wilcox 2005: 1019). There are eight different definitions of stillbirth by combinations of gestational age and weight in the United States, and at least as many in Europe (Nguyen and Wilcox 2005). Advances in medical technology have increased survival rates of previously unviable foetuses, bringing forward the threshold between miscarriage and stillbirth. The British Parliament supported a change to the stillbirth definition from ‘after 28 weeks’ to ‘after 24 completed weeks’ in 1992, following consensus from the medical profession about the age of viability. The Stillbirth (Definition) Act 1992 meant that a foetus born dead at or after 24 completed weeks of pregnancy is recognized in law as an individual: the baby’s death must be registered in person by one or both parents at a register office, and a stillbirth certificate issued. However, definitions are not always straightforward: late gestation pregnancies terminated due to congenital abnormalities are registered as stillbirths in the UK. While the boundary between miscarriage and stillbirth has shifted to an earlier gestational threshold in the UK, others have called for further changes that would incorporate and legally recognize earlier pregnancy losses. In 2014, Conservative MP Tim Loughton3

Introduction13

introduced a bill that would have enabled parents to register a pre24 weeks’ gestation death by basing the definition of stillbirth on the experience of giving birth. The bill did not proceed, but there have been a number of petitions calling for the law to be changed, with a recent campaign led by Labour MP Sharon Hodgson calling for optional birth certificates or registration for miscarried pre-24 weeks’ gestation babies. Such categories and the legal mechanisms around them impact social perceptions of the importance of the loss by defining whether or not it is considered the death of a human being. The 2016 Lancet series ‘Ending Preventable Deaths by 2030’ (de Bernis et al. 2016) situates pregnancy loss on the global health agenda, specifically by outlining the stillbirth rate as a marker of quality of care in pregnancy and childbirth which should be integrated within initiatives for women’s and children’s health and women’s rights and empowerment (de Bernis et al. 2016: 707). This raises questions about interventions for what we might call ‘avoidable loss’ and the right to reproduce, but also about protecting the rights of the unborn and rights to protection – similar to the abortion debate. Discourses of reproductive governance (Morgan and Roberts 2012: 241) are increasingly framed through contestations over ‘rights’, including the ‘right to life’ of the unborn, the latter found in emerging policies, laws and tactics of surveillance. The entanglement of women’s reproductive rights and foetal rights is evident when a woman is recast as a potential threat to her foetus; with whomever is classed as the foetus’s protector in command of her body. Marshae Jones’ provocation of an altercation in which she was shot while pregnant in Alabama, US, was interpreted as wilful endangerment of her foetus and led to her being indicted for manslaughter. Being shot, consuming drugs or blue cheese, or losing a pregnancy may be interpreted as a failure by a woman to protect her body, or, more succinctly, the environment of the foetus. Alabama, Georgia, Ohio and Missouri have all recently passed restrictive bills on abortion which may lead to suspicions that a woman is responsible when her pregnancy ends spontaneously and make women vulnerable to investigation in the case of a miscarriage, leading to a situation where she would have to prove she lost her baby through miscarriage. The interrelationship between categories of miscarriage and abortion and how they relate to legal and religious understandings informs women’s experiences. A 1998 blanket ban on abortion in El Salvador (including cases of rape, incest, when a woman’s life was at risk, or the foetus was fatally

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impaired) led to the prosecution of women who were assumed to be guilty of abortion when their babies were miscarried or stillborn. Reproduction is disciplined, with certain forms of motherhood valued while others are discouraged, perhaps characterized as social problems, with such framings informing policy and impacting experiences of loss. Recently, Ellie Lee (2017) has reflected on how sex-selective abortion became institutionalized as a social problem in Britain and problematized as associated with perceived problems of religion and ethnicity, presented as a form of violence against women. By placing pregnancy loss on the global health agenda, the 2016 Lancet series pointed to the heavy psychosocial burden and economic cost of stillbirth on families and nations. Similarly, miscarriage is a significant negative life event for many, affecting physical and emotional welfare, and may lead to psychological distress for a woman and others around her. In the UK, miscarriage accounts for fifty thousand hospital admissions annually (https:// www.northdevonhealth.nhs.uk/wp-content/uploads/2016/04/ Guidelines-for-Management-of-Miscarriage-V1.0-30Mar16.pdf, last accessed 14 June 2019), and there are additional social costs associated with miscarriage such as loss of work and further impacts on health. Miscarriage is thus a potential personal and social problem. Body Boundaries Body boundaries are problematized in miscarriage: pregnant bodies are often thought to be vulnerable, at risk, permeable; body boundaries need to be monitored and protected during pregnancy and miscarriage results when boundaries are traversed by diffuse dangers, as Qureshi (this volume) describes. Social networks and borders around groups are engaged in such events and may represent lines of tension or networks of care. A pregnancy is typically embedded in social relationships: the sperm donor may have claims on the foetus and/or the body of the woman in which it grows, but wider kin groups may also be invested (Qureshi, this volume). Mitra (this volume) extends this discussion further by illustrating that miscarriage in the context of surrogacy impacts relationships beyond kin groups to include intended parents and those involved in the business of surrogacy. In the case of traditional surrogacy the woman is genetically related to the foetus; or as described in Mitra’s chapter, gestational surrogacy involves a foetus that is not genetically connected to the gestating woman, further problematizing lines between kin and non-kin. In such cases, Berend (2010)

Introduction15

found the primary bond was between the intended parents and the woman rather than the foetus and the woman. The foetus has its own genome, but that genome is the collaborative output of two other individuals, including their input from past generations (Rutherford 2018). Revealing complexities of temporality and materiality, Rutherford (2018) discusses the foetus as a biological entity with labile boundaries, its signature reaching into the past and extending beyond gestation into the future, requiring a more inclusive and expansive approach. A foetus and pregnancy materials are both separate and part of the woman as well as having genetic ties to the father. ARTs and other developments in reproductive medicine such as in utero foetal surgery, artificial womb creation, and research into fetomaternal microchimerism challenge assumptions about body boundaries and pregnancy. Research showing that cells from the foetus have been found to pass through the placenta to establish cell lineages with the woman that may persist and multiply in the mother for several decades forces us to question notions about bodily boundaries between foetus and woman. Miscarriage provides an opportunity to more fully explore cultural assumptions about pregnancy and the relationship between bodies of foetuses, of women and those beyond.

Technology Advances in biomedical technology have had a significant role in shaping the way pregnancy and miscarriage are understood and experienced, as foregrounded in this volume by Melo and Granne (Chapter 1) and further developed by Elliot (Chapter 2), Qureshi (Chapter 4) and Mitra (Chapter 7). Developments in biomedicine, such as sensitive and inexpensive pregnancy tests, have reduced ambiguity around early pregnancy by making it detectable with a high degree of certainty just over a week following conception, meaning that women who experienced early miscarriage as late menstruation are now more likely to experience it as the loss of a pregnancy. Early detection informs imaginings of the foetus and developing personhood, which is further strengthened by ultrasound technology that enables us not only to discern its presence, but to ‘see’ it (Mitchell 2001; Rapp 2000). Seeing, like any other human activity, is as much conditioned by culture and society as by biology: seeing itself produces the object that is being seen (Han 2013: 80). The meaning of foetal images has been explored by anthropologists

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Taylor (2008) and Mitchell (2001), revealing how the interpretations of sonograms are commonly structured to lend weight to foetal personhood, with an interlinking between such technology, the social construction of foetality and the politics of reproduction more broadly (Mitchell 2001). Technologies influence expectations of and meaning invested in life before birth, as have developments that have increased the possibility of survival for earlier gestation foetuses. Ultrasound scans are commonly used to date, detect and monitor pregnancy and may be framed as a means to develop foetal–parental relationships. They may also be the means to diagnose miscarriage: discovery may precede embodied knowledge in the event of a missed miscarriage (when the foetus stops developing without any outward signs of bleeding or passing tissue). Howes-Mischel (2018) reminds us that materiality as a body is not only seen but heard, as explored by Middlemiss (Chapter 6, this volume). Foetal Dopplers and other medical technologies are used to make social claims about foetal presence: they reiterate expectations about forms of ‘proof’ offered by technological mediation that displace women’s sensed and bodily relationship with their foetuses as authoritative (Han, Betsinger and Scott 2018; Howes-Mischel 2018). Scholars have discussed such technology and its impact on the recession of the authority of women’s somatic knowledge. Middlemiss shows how women embrace and take ownership of this in light of previous experiences of their own somatic ignorance of foetal death, contributing to feminist debates over whether reproductive “technologies allow women to exert agency and control over their own reproduction, or whether they represent new forms of control over pregnancy (Ginsburg and Rapp 1991; Murphy 2012; Neyer and Bernardi 2011; Rothman 2014)” (Middlemiss, this volume). Ultrasound technology has been influential in producing images of foetuses, with anti-abortion propaganda central in presenting such images to the public (Layne 2000; Michaels and Morgan 1999), but the images have escaped these confines and become unremarkable features of the public landscape. They are found in medical journals and on television, used to advertise products (Taylor 1992), shared online via Facebook and Instagram and inhabit the imaginations of pregnant woman and those who wish to be pregnant (see Layne 2000, 2003; Rothman 1986). A foetus may be introduced to family, friends and the wider public on social media accounts, having an online presence before it has an outer utero one; they may be used as artefacts in order to support the

Introduction17

legitimacy of grief in the face of miscarriage (Layne 1992). Such images have become sites of intense politicization, particularly in the UK and US: foetuses are the raw material onto which hopes, fears and political and religious views are projected. Despite their ubiquitousness foetuses remain ambiguous entities that take on value and meaning dependent upon the context in which they reside.

Rituals and after Death Interrogating what happens following a pregnancy ending and how the resulting tissue, material, body or being are handled reveals what society makes of them. The ritualization of pregnancy loss and ensuing cultural responses provide further opportunities for interrogating societal notions of personhood. In some contexts, foetuses are granted full burial rites suggesting their status as persons, yet in other contexts pregnancy loss, whether through miscarriage or elective abortion, is not necessarily recognized as the loss of a human child or life. Scholars have written about foetal death and surrounding rituals and memorializations, including their increasing popularity (Gammeltoft 2003, 2010; Hardacre 1997; Harrison 1999; Kilshaw 2017b; Kuberska, Chapter 8, this volume; Layne 2003; Peelen 2007; Van der Sijpt 2017, 2018) in a number of contexts, including Romania, Qatar, Japan, Taiwan, the USA and the UK. The aim of rituals may be to appease the spirit of the foetus or to attend to feelings of guilt (Gammeltoft 2003; Hardacre 1997; Moskowitz 2001; Van der Sijpt 2018), most commonly in the case of aborted rather than miscarried foetuses. Scholars have shown how we can approach pregnancy remains as cultural artefacts from which we can glean how foetuses were imagined and cared for in the past. Practices including preservation and disposal help us to infer what a society made of these materials and overthrow assumptions that interest in and care for the foetus is primarily an interest of modern humans as a result of reduced risks of pregnancy and foetal death (Han, Betsinger and Scott 2018). Respect given to perinates in Neolithic graves in Egypt suggests they were considered part of the social group (Kabacinski, Czekaj-Zastawny and Irish 2018), and a lack of significant differences in the treatment of foetuses compared to older children in the mortuary context of seventeenth-century Poland suggests a similar identity ascription (Scott and Betsinger 2018). In contemporary Romania, all remains are sent to the laboratory and then incinerated,

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reflecting that official personhood is granted by religious status as either baptised or unbaptised, rather than by gestational age or the reason for its demise. However, that some women who miscarry perform their own practices to commemorate babies reflects that they acknowledge them as having person status and, thus, do not share the official position (Van der Sijpt, Chapter 3 in this volume, and 2018). In Qatar, all remains are buried with specific practice depending on gestational age and ensoulment (Kilshaw 2017a) and, thus, burial practices are informed by religious and cultural notions of personhood. The changes in recent years in British disposal practices, including ‘sensitive disposal’ and hospital-arranged shared cremation services that Kuberska details in this volume (Chapter 8), reflect shifting cultural approaches to pregnancy loss, the value afforded to foetal remains, and notions of personhood. Classifications are context dependent: remains of pregnancy are handled and managed in ways that are informed by duration and location in the body of their mother. The way these entities are considered subsequently influences how they are interacted with, and yet practices around their disposal may subsequently inform how we value them, impacting our experience of their loss.

Motherhood Miscarriage provides opportunities to investigate cultural understandings of motherhood: how we approach miscarriage tells us about what a pregnant woman or mother is to be. Scholars have explored children as a site of ‘identity-work’ (Faircloth 2013) and motherhood as highly moralized (Faircloth 2013; Gammeltoft 2007; Taylor 2008), and valorized, documenting the resulting disorder when expectations of motherhood cannot be achieved (e.g. Inhorn 2003). Practices that commemorate lost babies enact ongoing care and demonstrate ‘good’ parenting (Van der Sijpt, Chapter 3 in this volume), asserting the woman’s identity as a mother, even if she does not have a child to parent. Acts of memorialization may help to resolve the crisis of life plans, gendered identity and relationships that reproductive loss creates (Becker 1999). Developments in and the global spread of reproductive technologies, including widely available birth control and ARTs, have informed how we imagine foetuses, babies, children, parents and families and how we think of reproduction, informing a broader rhetoric of choice. This has led to a prevailing view, particularly

Introduction19

among middle-class, educated, predominantly white women, that pregnancy timing can and should be chosen (Elliot, this volume). Those seeking fertility treatments engage with and commit to parenting long before becoming parents, with new forms of ARTs such as egg freezing demanding they be forward thinking, reflexive reproducers in advance (Faircloth and Gurtin 2017). Self-improvement and self-monitoring have become central to fertility and pregnancy in contemporary Euro-America, part of a broader trend of what Faircloth and Gurtin (2017) have termed ‘anxious reproduction’. These technologies create new choices, but also more burdens, accountabilities and anxieties (Faircloth and Gurtin 2017). The implication is that by following expert guidelines and engaging in this discourse, you are keeping your foetus safe; hence it is unsurprising that women in such contexts experience shock and feelings of culpability in the face of reproductive loss, perceiving miscarriage as a failure of successful monitoring or appropriate planning (see the chapters by Kilshaw and Middlemiss in this volume). Such experiences highlight the innate contradiction in the discourse of control and responsibility in pregnancy/conception versus miscarriage. Feelings of personal guilt and failure may accompany miscarriage, particularly in neoliberal and medically technologically sophisticated settings and where a sense of responsibility, accountability and agency dominate reproductive experiences (McCabe 2016; Rapp 2000; Thompson 2005). The emphasis on individuality, choice and agency contributes to an assumption that women may be responsible for their miscarriage (Layne 1997); it can be seen as an ‘instance of failed production’ or ‘moral failing’ (Layne 2003: 148). Miscarriage as failure may be particularly acute in pregnancies conceived through ARTs and in the case of surrogacy experienced as a lack of success in giving a baby to its intended parents, as well as the failure of the surrogacy ‘journey’ and loss of membership to the community (Berend 2010). A sense of loss may include an important financial or status forfeiture, as described by Mitra in this volume (Chapter 7). ARTs further influence the production and framing of this experience because of the hope of success that they breed, the role of early constant monitoring adding weight to notions of responsibility, accountability, pregnancy as success, and foetal personhood (Berend 2010, 2016; Mitra, this volume). Yet miscarriage may not always be framed as failure; it may be a positive demonstration of fertility (Kilshaw, this volume; Varley 2008) or a sign of the body acting as it should by preventing the ongoing development of an unviable foetus. Framing miscarriage as the

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body functioning normally is found in biomedical interpretations (Layne 1997: 291; Melo and Granne, this volume), where miscarriage is a natural process of quality control.

Summary of Chapters The impetus for this book was a seminar series of the Fertility and Reproduction Study Group (FRSG), Institute of Social and Cultural Anthropology, Oxford University that brought together material on diverse historical and cultural contexts to explore societal approaches to miscarriage. At the outset a key aim was to take up the challenge of questioning the language and categorization of ‘miscarriage’ and its implications. Melo and Granne’s opening chapter presents the (primarily UK National Health Service (NHS)) biomedical framing of miscarriage, providing an excellent overview of miscarriage definitions and categorization, treatment protocols, as well as risk factors and causes. Melo and Granne establish the fluidity of definitions and approaches to miscarriage; the chapters that follow continue to grapple with shifting and negotiable category boundaries. Revealing just how inefficient humans are at conception, with miscarriage one aspect of this, they challenge assumptions about notions of control over reproduction. The authors question whether or not miscarriage should be viewed as failure; according to biomedical understandings, miscarriage is instead framed as the body responding in a healthy way to an unviable pregnancy. Elliot’s comprehensive and fascinating exploration of the history of miscarriage in twentieth-century Britain provides evidence for the medical view of miscarriage as beneficial. Advances in biomedicine altered the way pregnancy and loss were understood, including the discovery by the 1960s that there are forty-six human chromosomes. The recognition that chromosomal abnormalities are a significant cause of miscarriage means it begins to be framed as a natural, healthy and positive process. This established the foundation for therapeutic screening and abortion in the 1970s as a means to reduce birth defects. As Elliot argues, there was a significant shift from a desire to avoid ‘foetal wastage’ and ‘salvaging’ the foetus to seeing miscarriage as a beneficial process of rejecting unsavoury foetuses or ‘products’ and a process of quality control. Attempts at defining types of pregnancy endings and their unclear boundaries emerge throughout the book, with Elliot’s discussion of the relationship between abortion and miscarriage particularly

Introduction21

striking. Classifications are not always clear, and the shadow of abortion continues to be cast over miscarriage. In the second half of the twentieth century, while the types of pregnancy loss were increasingly seen as distinct medical and social phenomena, they remained entwined in terms of language, medical practice and ethical discussion around viability and personhood. The boundaries around miscarriage and, particularly, the delineation around intentionality are further explored by Van der Sijpt’s (Chapter 3) deft comparison of miscarriage in two settings: Romania and Cameroon. Van der Sijpt shows how the broad social forces including historical memories profoundly shape experience: cultural and historical resonances, particularly the history of suspicion surrounding pregnancy loss in the aftermath of Communist Romania’s strict abortion prohibitions, continue to inform women’s experience of miscarriage. While the settings differ in many ways, women’s navigations reveal similar dynamics, she argues. The emphasis on having children in these two settings contributes to an environment in which pregnancy loss becomes silenced and shrouded in suspicions. In Cameroon, it is the shifting nature of sexual relationships and the knowledge that women may not wish to keep all their pregnancies that is particularly relevant. Like many of the chapters, the boundaries around categories are explored, yet what is particularly novel is how Van der Sijpt shows how women are able to navigate in a way that best suits their situation: miscarriage produces ambiguity and uncertainty, but the opportune flexibilities contained within reveal miscarriage to be a potential for reorientation. Moral discourses entailing agency and blame are often evoked in the face of miscarriage and attempts at explanation made. The cause of miscarriages is rarely determined (Melo and Granne, Chapter 1), which can frustrate attempts at understanding. Elliot’s (Chapter 2) historical account reflects on how medical knowledge around the cause of miscarriage influenced how it is framed more broadly. The aetiological repertoire is typically broad: the ethnographic chapters suggest a range of possible causes, including God’s will, witchcraft, evil eye, food consumed or not consumed, stress, emotional upset, carrying heavy objects, exhaustion, age or anatomical problems of the woman, and genetic problems with the embryo. Each society will have notions of how best to protect a pregnancy and reduce risk of miscarriage: women in early twentieth-century Britain were advised to ‘avoid riding, dancing, golfing, tennis, cycling, falls, blows, excessive coitus, lifting, pushing, walking too far, standing too long, and, in fact, everything that causes great and often sudden excess

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in the intra-abdominal pressure’ (Horrocks 1901: 946); as Elliot (Chapter 2) surmises, such avoidance advice is likely social stricture and a comment on respectable femininity. The burden of prevention and possibly guilt is placed on women, as it is throughout a variety of social contexts. Considered causes may be contradictory and changeable: possible causes provide a flexible idiom that can be differently employed in different social situations (Van der Sijpt and Notermans 2010) and may be used to divert attention away from or direct attention to culpability. The lack of a consensus about cause increases uncertainty and ambiguity. Miscarriage causation is considered in most chapters, but it is Qureshi’s contribution that explores this in depth. In Pakistani Punjab, miscarriages demand accountability: while they are deemed God’s will, Qureshi reveals how space for human action is opened, where culpability is passed from women’s natal families to their marital families, who directly influence their workload, diet and care during pregnancy. The relationships between women’s natal and marital families represent common fault-lines, but ‘there is more to miscarriage than the anthropological story about accusations following lines of social tension’, she argues. Providing a dramatic illustration of the shifting nature of miscarriage and person categories, Qureshi argues that the distinction reported by Jeffery and Jeffery (1996) between bacha girna (the falling of a baby) and a maas-ka-pinda (blob of flesh) has eroded, mainly due to the availability of medical technologies. Qureshi describes collapsing boundaries around classifications of pregnancy endings and their understandings, but she also speaks of other blurred boundaries – those of the pregnant body. Informed by Pinto’s (2008) account of visualization, Qureshi describes the ‘intensely personalizing gaze of the sister-in-law’, which penetrates the pregnant body and causes anxiety. In her discussion of athra, a particular form of spirit contagion, Qureshi provides entirely novel and nuanced material on this precise ethnomedical diagnosis, which is activated in cases of recurrent miscarriage. The dominant explanation for reproductive misfortune and a preoccupation among the women she met, Qureshi reports an almost complete gap in the scholarly literature. In her account of athra, Qureshi comments upon anxieties around body boundaries and the need to be vigilant in protecting and maintaining them against diffuse threats. Despite the increasing medicalization of pregnancy and access to inexpensive diagnostic tools, which shift notions of uncertainty, pregnancy

Introduction23

continues to be seen as precarious and concealment a means to protect fragile early pregnancies. In her discussions of risk and threat, Qureshi notes similarities between women who suffer from recurrent miscarriage or ongoing reproductive misfortunes and infertile women. Kilshaw (Chapter 5) also explores the relationship between miscarriage and infertility in her discussion of how choices and notions of control impact a woman’s experience of miscarriage in two settings: Qatar and England. Like Van der Sijpt (Chapter 3), Kilshaw illustrates that uncertainty arises from miscarriage, but argues that wider social factors, particularly notions of control over reproduction, exacerbate feelings of anxiety. She demonstrates how perceptions of avoiding pregnancy loss and being a ‘good’ ‘pre-conception’ parent are situated within a broader cultivation of neoliberal citizens in England, compared with the experience in Qatar where miscarriage is more about reproductive proof than loss. Middlemiss (Chapter 6) provides another example of the impact of anxious reproduction: uncertainty features heavily in pregnant women’s home Doppler use in Cornwall, England; here it is the management of uncertainty in the aftermath of miscarriage. Miscarriage may be diagnosed by a health professional during antenatal visits by use of medical technologies such as ultrasound. Diagnoses are often unexpected by women, as the foetus may stop developing without the woman experiencing bleeding or pain (yet). A lack of awareness of the death of the foetus may lead to women feeling that they failed as mothers by not effectively monitoring or being aware of the status of the pregnancy. In some cases, it is the missed element of the experience of a missed miscarriage that is significant. Women may then embrace further technology and surveillance, such as the use of foetal Dopplers or non-indicated ultrasounds, to manage risk. Using a Doppler at home is a means to manage not risk, as Middlemiss’s interlocutors were aware a miscarriage could not be prevented, but control over knowledge. Throughout the book, the impact of advances in and increasing access to biomedical and reproductive technology on women’s experience of miscarriage is discussed, including Mitra’s (Chapter 7) exploration of surrogacy in India, where the financial and contractual aspect of the surrogate pregnancy further shapes miscarriage experience. Miscarriage is a social event that, in this case, breaks ties between people and due to its contractual nature bears financial consequences and hardship. Contributing to the literature on the labour and market economy surrounding commercial

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surrogacy in India (see Pande 2014; Rudrappa 2015; Sama 2012), Mitra provides a welcome and novel addition by exploring those instances when the process is disrupted. Miscarriage presents a particularly problematic challenge to the narrative of success (Berend 2016; Mitra and Schicktanz 2016) that dominates commercial surrogacy in India. Mitra provides additional insights, particularly to the cultural meanings assigned to reproduction and miscarriage in India elucidating surrogates’ experience of miscarriages. In a context where miscarriages are culturally silenced and shamed, surrogate miscarriages are doubly so in order to deflect from the inability of the technology to overcome fertility problems. Mitra argues that miscarriage is proactively silenced by the surrogacy industry, leaving women unprepared when one occurs. Technology plays a key role in this performance by contributing to confidence that the process will be successful and establishing the reality of pregnancies through visual technology of ultrasound and regular reports. What is striking in Mitra’s account, and differs dramatically from the accounts described by Berend (2010, 2016), is the gravity of the financial loss as well as the emotional and identity loss. Not only do surrogates lose the financial rewards for this particular pregnancy, but they also lose the opportunity to act as a surrogate again, eliminating possible future financial gain as well as inclusion in a community of surrogates. Indeed, a miscarriage could place a woman in a financially precarious position due to costs of treatment for the miscarriage, instead of securing her family’s future. Thus, miscarriage results in complex loss that goes beyond the loss of a foetus and has ongoing implications for the woman and her future aspirations. In this way, Mitra’s discussion reveals the tentativeness not only of pregnancy, but also of a woman’s identity (as a surrogate, as a mother) and how a woman may be dependent on a foetus for a particular role or identity. Exploring the way pregnancy remains following a miscarriage are managed in England, Kuberska (Chapter 8) illustrates the moral ambiguity around that which is produced by a miscarriage with practices pointing to the liminal nature of these beings. In her discussion of the disposal of pre-24-week pregnancy remains, Kuberska contributes to the discussion about the contingent and potentially fractious nature of boundaries around miscarriage. In particular, she reveals contradictions in legal categories, institutional practices and national guidance, and also suggests that these may differ still from lived experience. While English law requires the registration of stillbirths but not miscarriages, guidance around

Introduction25

disposal frames miscarriage as a death of a baby. Through a focus on the funeral arrangements that accompany hospital-arranged shared cremations and how these are shaped by notions of ‘respect’ and ‘sensitivity’, Kuberska reveals a certain view of foetal personhood contained in these practices. Rather than relying on what the woman thinks of the material, unwitnessed ceremonies for pre-24-week foetuses presuppose a miscarriage as a death deserving of a funeral. Such a discussion is particularly welcome given the way practices around the handling and disposal of remains are imbued with meaning and loop back, informing what we think of these materials. With one in four pregnancies ending in miscarriage, it is unsurprising that a number of the authors have personal experience of miscarriage. Indeed, the subject of pregnancy loss has often been initiated by such scholars: Layne (2003), Letherby (1993), Davidson (2008) and Murphy (2012, 2019). During the production of this book, this issue of personal, political and professional entanglements emerged, shedding light on the complex negotiations when it comes to miscarriage. A number of contributors grappled with whether or not to include their own experience and how to disentangle it from scholarly investigations. Women may feel the need to conceal pregnancy and motherhood from professional realms, and so speaking about one’s experience in this way feels transgressive, which may also account for the absence of scholarly work on the subject and the more general silence around the topic. This book is intended to further impede such silences by populating the landscape of miscarriage with a diversity of voices and perspectives. The book explores shifting and negotiable category boundaries around miscarriage and the foetus, exploring medico-legal-religious constraints that inform women’s experiences as well as provide opportunities for subversions. By exploring miscarriage in a number of different contexts, we aim to reveal multiple possibilities of approaches to and framings of this common women’s health experience.

Acknowledgements Thank you to Philip Kreager for his support throughout the writing of the book, his comments on earlier versions and, particularly, for his invaluable contribution to the demographic section of the introduction. This publication was made possible by NPRP grant

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[5–221–3-064] from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the author. This work was also supported by the Wellcome Trust [212731/Z/18/Z]. Susie Kilshaw is a Wellcome Trust Principal Research Fellow in the Department of Anthropology, University College London. Her research interests are in reproduction and risk, compromised fertility and pregnancy endings. She has worked in Qatar and in the UK. Her current Wellcome Trust-funded research focuses on the practices around pregnancy endings in England. She has written two monographs, Pregnancy and Miscarriage in Qatar: Women, Reproduction and the State. (I.B. Tauris, 2020) and Impotent Warriors: Gulf War Syndrome, Vulnerability and Masculinity (Berghahn Books, 2009).

Notes   1. This is the case excepting Scotland where incineration is not allowed.  2. As Bongaarts and Potter (1983: 40) remark, these patterns have to be viewed as hypotheses, as the number of representative sample studies on which they are based is small. Their work has, however, been widely accepted as the trends are consistent with aetiology.  3. Loughton has been an activist on reproductive health issues, leading an All-Party Parliamentary Group on conception to childhood. See https:// publications.parliament.uk/pa/cm/cmallparty/190102/conception-toage-two---first-1001-days.htm, last accessed 14 September 2019.

References Becker G. 1999. Disrupted Lives: How People Create Meaning in a Chaotic World. Berkeley: University of California Press. Berend, Z. 2010. ‘Surrogate Losses: Understandings of Pregnancy Loss and Assisted Reproduction among Surrogate Mothers’, Medical Anthropology Quarterly 24(2): 240–62.  . 2016. The Online World of Surrogacy. New York: Berghahn Books. Blackmore, E.R., D. Cote-Arsenault, W. Tang, V. Glover, J. Evans, J. Golding and T.G. O’Connor. 2011. ‘Previous Perinatal Depression and Anxiety’, British Journal of Psychiatry 198(5): 373–78. Boddy, J. 1989. Wombs and Alien Spirits: Women, Men, and the Zar Cult in Northern Sudan. Madison: University of Wisconsin Press.

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Bongaarts, J., and R.G. Potter. 1983. Fertility, Biology, and Behaviour. New York: Academic Press. Cecil, R. 1996. The Anthropology of Pregnancy Loss: Comparative Studies in Miscarriage, Stillbirth and Neonatal Death. Oxford: Berg. Chapman, R.R. 2003. ‘Endangering Safe Motherhood in Mozambique: Prenatal Care as a Pregnancy Risk’, Social Science & Medicine 57(2): 355–74. Conklin, B., and L. Morgan. 1996. ‘Babies, Bodies, and the Production of Personhood in North America and a Native Amazonian Society’, Ethos 24(4): 657–94. Craven, C., and E. Peel. 2014. ‘Stories of Grief and Hope: Queer Experiences of Reproductive Loss’. In M.F. Gibson (ed.), Queering Maternity and Motherhood: Narrative and Theoretical Perspectives on Queer Conception, Birth and Parenting. Bradford, ON: Demeter Press, pp. 97–110.  . 2017. ‘Queering Reproductive Loss: Exploring Grief and Memorialization’. In A. Deveau and E. Lind (eds), Interrogating Pregnancy Loss: Feminist Writings on Abortion, Miscarriage, and Stillbirth. Ontario: Demeter Press. Cromer, R. 2018. ‘Waiting: The Redemption of Frozen Embryos through Embryo Adoption and Stem Cell Research in the United States’. In S. Han, T. Betsinger and A. Scott (eds), The Anthropology of the Fetus: Biology, Culture and Society. Oxford: Berghahn Books. de Bernis, L., M.V. Kinney, W. Stones et al. 2016. ‘Stillbirths: Ending Preventable Deaths by 2030’. The Lancet Ending Preventable Stillbirths Series study group with The Lancet Ending Preventable Stillbirths Series Advisory Group. Retrieved 4 November 2019 from https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)00954-X/fulltext. Davidson, D. 2008. ‘A Technology of Care: Caregiver Response to Perinatal Loss’. Women’s Studies International Forum 31: 278–284. Duden, B. 1993. Disembodying Women: Perspectives on Pregnancy and the Unborn. Trans. Lee Hoinacki. Cambridge, MA: Harvard University Press Erviti, J., R. Castro and A. Collado. 2004. ‘Strategies Used by Low-Income Mexican Women to Deal with Miscarriage and Spontaneous Abortion’, Qualitative Health Research 14(8): 1058–76. Faircloth, C. 2013. Militant Lactivism? Attachment Parenting and Intensive Motherhood in the UK and France. Oxford: Berghahn Books. Faircloth, C., and Z.B. Gurtin. 2017. ‘Fertile Connections: Thinking across Assisted Reproductive Technologies and Parenting Culture Studies’, Sociology 51(3): 1–18. doi:10.1177/0038038517696219. Farren, J., M. Jalmbrant, L. Ameye et al. 2016. ‘Post-Traumatic Stress, Anxiety and Depression Following Miscarriage or Ectopic Pregnancy: A Prospectus Cohort Study’, BMJ Open 2016(6). Gammeltoft, T. 2003. ‘The Ritualization of Abortion in Contemporary Vietnam’, The Australian Journal of Anthropology 14(2): 129–44.  . 2007. ‘Sonography and Sociality: Obstetrical Ultrasound Imaging in Urban Vietnam’, Medical Anthropology Quarterly 21(2): 133–153.

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 . 2010. ‘Between Remembering and Forgetting. Maintaining Moral Motherhood after Late-Term Abortion’. In A. Whittaker (ed.), Abortion in Asia: Local Dilemmas, Global Politics. Oxford: Berghahn, pp. 56–77. Ginsburg, F., and R. Rapp. 1991. ‘The Politics of Reproduction’. Annual Review of Anthropology 20: 311–43. Han, S. 2013. Pregnancy in Practice: Expectation and Experience in the Contemporary US. New York: Berghahn Books.  . 2018. ‘Pregnant with Ideas: Concepts of the Foetus in Twenty-First Century United States’. In S. Han, T. Betsinger and A. Scott (eds), The Anthropology of the Fetus: Biology, Culture, and Society. Oxford: Berghahn Books. Han, S., T. Betsinger and A. Scott. 2018. ‘Introduction: Conceiving the Anthropology of the Foetus’. In S. Han, T. Betsinger and A. Scott (eds), The Anthropology of the Foetus: Biology, Culture, and Society. Oxford: Berghahn Books. Hardacre, H. 1997. Marketing the Menacing Fetus in Japan. Berkeley: University of California Press. Harrison, E.G. 1999. ‘“I Can Only Move My Feet towards Mizuko Kuyo”: Memorial Services for Dead Children in Japan’. In D. Keown (ed.), Buddhism and Abortion. Honolulu: University of Hawaii Press, pp. 93–120. Horrocks, P. 1901. ‘A Discussion on the Causation, Prevention and Treatment of Miscarriage’, British Medical Journal 5 October 1901: 943–47. Howes-Mischel, R. 2018. ‘The “Sound of Life” or How We Should Hear a Fetal “Voice”’. In S. Han, T. Betsinger and A. Scott (eds), The Anthropology of the Fetus: Biology, Culture, and Society. Oxford: Berghahn Books. Inhorn, M. 2003. Local Babies, Global Science: Gender, Religion and In Vitro Fertilization in Egypt. New York: Routledge. Inhorn, M.C. 2007a. ‘Introduction: Definining Women’s Health: A Dozen Messages from More Than 150 Ethnographies’. In M. Inhorn (ed.), Reproductive Disruptions: Gender, Technology and Biopolitics in the New Millennium. New York: Berghahn Books, pp. 1–42.  . 2007b. ‘Reproductive Disruptions and Assisted Reproductive Technologies in the Muslim World’. In M. Inhorn (ed.), Reproductive Disruptions: Gender, Technology and Biopolitics in the New Millennium. Oxford: Berghahn Books, pp. 183–99.  . (ed.). 2007c. Reproductive Disruptions: Gender, Technology and Biopolitics in the New Millennium. New York: Berghahn Books. Jeffery, P., and R. Jeffery. 1996. ‘Delayed Periods and Falling Babies: The Ethnophysiology and Politics of Pregnancy Loss in Rural North India’. In R. Cecil (ed.), The Anthropology of Pregnancy Loss: Comparative Studies in Miscarriage, Stillbirth and Neonatal Death. Oxford: Berg Publishers, pp. 17–38. Jenkins, G.L., and M.C. Inhorn. 2003. ‘Reproduction Gone Awry: Medical Anthropological Perspectives’, Social Science and Medicine 56(9): 1831–36. Kabacinski, J., A. Czekaj-Zastawny and J. Irish. 2018. ‘The Neolithic Infant Cemetery at Gebel Ramlah in Egypt’s Western Desert’. In S. Han, T.

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Betsinger and A. Scott (eds), The Anthropology of the Fetus: Biology, Culture and Society. Oxford: Berghahn Books. Kilshaw, S. 2017a. ‘Birds, Meat, and Babies: The Multiple Realities of Foetuses in Qatar’, Anthropology and Medicine 24(2): 189–204. http://dx.doi. org/10.1080/13648470.2017.1324617.  . 2017b. ‘How Culture Shapes Perceptions of Miscarriage’. Sapiens. Retrieved 4 January 2018 from https://www.sapiens.org/body/ miscarriage-united-kingdom-qatar/.  . 2020. Pregnancy and Miscarriage in Qatar: Women, Reproduction and the State. London: I.B. Tauris. Layne, L.L. 1992. ‘Of Foetuses and Angels: Fragmentation and Integration in Narratives of Pregnancy Loss’. In D.J. Hess and L.L. Layne (eds), Knowledge and Society: The Anthropology of Science and Technology. Greenwich, CT: JAI Press, pp. 29–58.  . 1997. ‘Breaking the Silence: An Agenda for a Feminist Discourse of Pregnancy Loss’. Invited submission to a special issue of Feminist Studies 23(2): 289–315.  . 2000. ‘“He was a Real Baby with Baby Things”: A Material Culture Analysis of Personhood, Parenthood and Pregnancy Loss’, Journal of Material Culture 5(3): 321–45.  . 2003. Motherhood Lost: A Feminist Account of Pregnancy Loss in America. New York: Routledge. Lee, E. 2017. ‘Constructing Abortion as a Social Problem: “Sex Selection” and the British Abortion Debate’, Feminism and Psychology [Online] 27:1533. http://dx.doi.org/10.1177/0959353516678010. Letherby, G. 1993. ‘The Meanings of Miscarriage’, Women’s Studies International Forum 16(2): 165–80. Lindemann, K. 2018. ‘Please, Doctor, Don’t Call My Lost Baby a “Product of Conception”’, The Guardian, 11 October. Littlewood, J. 1999. ‘From the Invisibility of Miscarriage to an Attribution of Life’, Anthropology & Medicine 6(2): 217–30. Lock, M. 1993. Encounters with Aging: Mythologies of Menopause in Japan and North America. Berkeley: University of California Press. Luce, J. 2010. Beyond Expectation: Lesbian/Bi/Queer Women and Assisted Reproduction. Toronto: University of Toronto Press. Maienschein, J. 2002. ‘Part ii – What’s in a Name: Embryos, Clones, and Stem Cells’, American Journal of Bioethics 2(1): 12–19. doi:10.1162/152651602317267781. McCabe, K. 2016. ‘Mothercraft: Birth Work and the Making of Neoliberal Mothers’, Social Science & Medicine 162: 177–84. Michaels, M.W., and L.M. Morgan. 1999. ‘Introduction: The Fetal Imperative’. In M.W. Michaels and L.M. Morgan (eds), Fetal Subjects, Feminist Positions. Philadelphia: University of Pennsylvania Press, pp. 1–10. Mitchell, L.M. 2001. Baby’s First Picture: Ultrasound and the Politics of Fetal Subjects. Toronto: University of Toronto Press.

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Mitra, S., and S. Schicktanz. 2016. ‘Failed Surrogate Conceptions: Social and Ethical Aspects of Preconception Disruptions during Commercial Surrogacy in India’, Philosophy, Ethics, and Humanities in Medicine 11(1): 9. Morgan, L. 1989. ‘When Does Life Begin? A Cross-Cultural Perspective’. In W. Haviland and R. Gordon (eds), Talking about People. Mountain View, CA: Mayfield, pp. 24–34.  . 2009. Icons of Life: A Cultural History of Human Embryos. Berkeley: University of California Press. Morgan, L., and E. Roberts. 2012. ‘Reproductive Governance in Latin America’, Anthropology and Medicine 19(2): 241–54. Moskowitz, M.L. 2001. The Haunting Fetus: Abortion, Sexuality, and the Spirit World in Taiwan. Honolulu: University of Hawaii Press. Murphy, F., and S. Philpin. 2010. ‘Early Miscarriage as “Matter Out of Place”: An Ethnographic Study of Nursing Practice in a Hospital Gynaecological Unit’, International Journal of Nursing Studies 47(5): 534–41. Murphy, M. 2012. Seizing the Means of Reproduction: Entanglements of Feminism, Health, and Technoscience. Durham, NC: Duke University Press. Murphy, S. 2019. ‘“I’d Failed to Produce a Baby and I’d Failed to Notice When the Baby Was in Distress”: The Social Construction of Bereaved Motherhood’, Women’s Studies International Forum 74: 35–41. Newman, J. 2018. ‘Deploying the Foetus: Constructing Pregnancy and Abortion in Morocco’. In S. Han, T. Betsinger and A. Scott (eds), The Anthropology of the Fetus: Biology, Culture and Society. Oxford: Berghahn Books. Neyer, G., and L. Bernardi. 2011. ‘Feminist Perspectives on Motherhood and Reproduction’, Historical Social Research 36(2): 162–76. Nguyen, R.H.B., and A.J. Wilcox. 2005. ‘Terms in Reproductive and Perinatal Epidemiology: I. Reproductive Terms’, Journal of Epidemiology and Community Health 59: 916–19. Pande, A. 2014. Wombs in Labor: Transnational Commercial Surrogacy in India. New York: Columbia University Press. Peel, E. 2010. ‘Pregnancy Loss in Lesbian and Bisexual Women: An Online Survey of Experiences’, Human Reproduction 25(3): 721–27. Peelen, J. 2007. ‘Reversing the Past: Monuments for Stillborn Children’, Mortality 14(2): 173–86. Pinto, S. 2008. Where There is No Midwife: Birth and Loss in Rural India. Oxford: Berghahn Books. Rapp, R. 2000. Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America. New York: Routledge.  . 2017. ‘Foreword: How/Shall We Consider the Fetus’. In S. Han, T. Betsinger and A. Scott (eds), The Anthropology of the Fetus: Biology, Culture and Society. Oxford: Berghahn Books. Rice, P.L. 2000. ‘When the Baby Falls! The Cultural Construction of Miscarriage among Hmong Women in Australia’, Women & Health 30(1): 85–103.

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Rothman, B. 1986. The Tentative Pregnancy: Prenatal Diagnosis and the Future of Motherhood. London: Pandora. Rothman, B.K. 2014. ‘Pregnancy, Birth and Risk: An Introduction’, Health, Risk & Society 16(1): 1–6. doi:10.1080/13698575.2013.876191. Royal College of Obstetricians and Gynaecologists (RCOG) 33rd Study Group. 1997. ‘Recommendations from the 33rd Study Group’. In J.C. Grudzinskas and P.S. O’Brien (eds), Problems in Early Pregnancy: Advances in Diagnosis and Management. London: RCOG Press, pp. 327–31. Royal College of Obstetricians and Gynaecologists (RCOG). 2006. ‘The Management of Early Pregnancy Loss’. Retrieved 4 November 2019 from http://www.jsog.org/GuideLines/The_management_of_early_ pregnancy_loss.pdf. Rudrappa, S. 2015. Discounted Life: The Price of Global Surrogacy in India. New York: NYU Press. Rutherford, J. 2018. ‘The Borderless Fetus: Temporal Complexity of the Lived Foetal Experience’. In S. Han, T. Betsinger and A. Scott (eds), The Anthropology of the Fetus: Biology, Culture and Society. Oxford: Berghahn Books. Sama. 2012. ‘Birthing a Market: A Study on Commercial Surrogacy’. Retrieved 30 July 2014 from http://www.samawomenshealth.org/publication/ birthing-market-%E2%80%98commercial-surrogacy-india. Scheper-Hughes, N. 1992. Death without Weeping: The Violence of Everyday Life in Brazil. 2nd ed. Berkeley: University of California Press. Scott, A., and T. Betsinger. 2018. ‘Excavating Identity: Burial Context and Fetal Identity in Postmedieval Poland’. In S. Han, T. Betsinger and A. Scott (eds), The Anthropology of the Fetus: Biology, Culture and Society. Oxford: Berghahn Books. Shaw, A. 2014. ‘Rituals of Infant Death: Defining Life and Islamic Personhood’, Bioethics 28(2): 84–95. Suh, S. 2014. ‘Rewriting Abortion: Deploying Medical Records in Jurisdictional Negotiation over a Forbidden Practice in Senegal’, Social Science and Medicine 108: 20–33. Taylor, J. 1992. ‘The Public Foetus and the Family Car: From Abortion Politics to a Volvo Advertisement’, Public Culture 4(2): 67–80.  . 2008. The Public Life of the Fetal Sonogram: Technology, Consumption, and the Politics of Reproduction. New Brunswick, NJ: Rutgers University Press. Thompson, C. 2001. ‘Strategic Naturalizing: Kinship in an Infertility Clinic’. In S. Franklin and S. McKinnon (eds), Relative Values: Reconfiguring Kinship Studies. Durham, NC: Duke University Press, pp. 175–202.  . 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge, MA: MIT Press. Van der Sijpt, E. 2010. ‘“Filling with Force”: Reproductive Loss Reconsidered’, Viennese Ethnomedicine Newsletter 12(2–3): 21–27.

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———.2017. ‘The Pain and Pride of “Angel Mothers”: Disappointments and Desires around Reproductive Loss in Romania’, Medical Anthropology 37(2): 174–87. ———.2018. Wasted Wombs: Navigating Reproductive Interruptions in Cameroon. Nashville, TN: Vanderbilt University Press. Van der Sijpt, E., and C. Notermans. 2010. ‘Perils to Pregnancies: On Social Sorrows and Strategies Surrounding Pregnancy Loss in Cameroon’, Medical Anthropology Quarterly 24(3): 381–98. Varley, E. 2008. ‘Belaboured Lives: An Ethnography of Muslim Women’s Pregnancy and Childbirth Practices in Pakistan’s Embattled, Multi-Sectarian Northern Areas’, Unpublished Ph.D. thesis. Univerity of Toronto. World Health Organization (WHO). 2016. ‘Stillbirths’. Retrieved 4 October 2019 from https://www.who.int/maternal_child_adolescent/ epidemiology/stillbirth/en/. Wojnar, D.M., and K.M. Swanson. 2006. ‘Why Shouldn’t Lesbian Miscarriage Receive Special Consideration: A Viewpoint’, Journal of GLTB Family Studies 2(1): 11–12.

Chapter 1

Does Twenty-First-Century Technology Change the Experience of Early Pregnancy and Miscarriage? Pedro Melo and Ingrid Granne

Introduction Miscarriage occurs in approximately 20 per cent of pregnancies and may cause significant distress to many women and their families (Bardos et al. 2015; Nynas et al. 2015). Of the 250,000 miscarriages diagnosed annually in the United Kingdom (UK), 85 per cent happen in the first trimester of pregnancy and approximately 50,000 require hospital admission (National Institute for Health and Care Excellence [NICE] 2012a). Historically, the care of women with miscarriage has largely involved surgical evacuation under general anaesthetic because of concerns regarding the risk of bleeding and infection due to retained pregnancy tissue (Sagili and Divers 2007). In the UK, however, there has been a recent shift towards using expectant management as the first-line treatment choice, where women wait for a miscarriage to be completed naturally without medical or surgical intervention. This has led to significant cost reductions for the National Health Service (NHS) and an improvement in patient satisfaction rates (NICE 2012b). Women in the UK can access early pregnancy care through their general practitioners and, in some areas, by directly contacting

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dedicated hospital units. Following recent biomedical developments and service changes, hospital admissions due to miscarriage have reduced significantly over the past decade, and so have serious complications such as sepsis and maternal death (NICE 2012a; Sagili and Divers 2007). Moreover, a patient-centred approach empowers women to make informed choices on management options, thus profoundly impacting patients’ views about the way they are treated (Bardos et al. 2015). However, the provision of secondary care in the form of emergency gynaecology services is uneven across the country, with regional allocation of resources impacting significantly on availability – and quality – of specialized care (NICE 2012b). This chapter provides a biomedical account of miscarriage in the UK and particularly in the NHS. It emphasizes terminology changes in recent decades, common causes of miscarriage, diagnostic and treatment pathways, as well as new developments in the field of early pregnancy which have significantly shaped women’s views on miscarriage.

Miscarriage: A Biomedical Perspective Gestational age of the foetus is measured using the first day of a pregnant woman’s last menstrual period, meaning that a pregnancy of six weeks’ gestation in fact describes an embryo conceived four weeks previously (Jukic et al. 2013). A normal pregnancy lasts between 37 and 42 completed weeks of gestation, and the term ‘early pregnancy’ encompasses its first trimester – that is, up to 12 completed weeks. This is a period of rapid embryonic cell division and differentiation during which organ formation is established. At 10 weeks, the fully differentiated conceptus is no longer called an embryo and clinicians use the term ‘foetus’ instead (Chalmers 1992; Nguyen and Wilcox 2005). Obstetricians have long struggled to develop a unifying nomenclature for pregnancy loss (Chalmers 1992; Silver et al. 2011). This is, to some extent, the result of research input from a wide range of disciplines such as reproductive biology, sociology and anthropology, which in turn has led to inconsistent terminology (Nguyen and Wilcox 2005; Elliot, this volume). The World Health Organization (WHO) defines miscarriage as the demise of a foetus before 22 weeks or weighing less than 500 grams (g). This is somewhat incongruous, given that only at 23 weeks does the average foetal weight reach 500 g (Silver et al. 2011). In the UK, a cut-off of 24 weeks is

Does Technology Change the Experience of Early Pregnancy and Miscarriage?35

used instead, and at that point the foetus weighs on average 600 g. This is considered the gestational age of viability – before 24 weeks, the foetus is deemed unable to subsist outside the maternal uterus, even though approximately 20 per cent of babies born at 23 weeks of gestation will survive (Seaton et al. 2013). Any pregnancy loss prior to 24 weeks is therefore considered a miscarriage in the UK – early if it occurs before 12 weeks, and late when it happens after the first trimester. Abortion law in England has also used 24 weeks as a cut off for viability, after which time terminations can only be carried out for very specific medical reasons (Berer 2017). In utero death, also known as stillbirth, refers to infants born from 24 weeks onwards without signs of life. Finally, the term ‘neonatal death’ is used when an infant is born alive after 24 weeks but dies within 28 completed days of life (Silver et al. 2011). Birth is labelled ‘preterm’ when it occurs once viability has been reached, that is, between 24 and 37 weeks (Nguyen and Wilcox 2005). An infant born at or around the limit of viability is much more at risk of developing neonatal complications (e.g. infection, respiratory distress and neonatal death) and lifelong disability (e.g. cerebral palsy) than one born after 37 weeks (Seaton et al. 2013). After 37 weeks, a pregnancy is considered to be full term. If a baby is not born spontaneously at 41 to 42 weeks, women are offered induction of labour to prevent in utero death associated with post-maturity (Jucik et al. 2013). Throughout the years, biomedical advances have led to changes in the terminology applied to early pregnancy (with terms like ‘biochemical pregnancy’ used when women have a positive pregnancy test but a gestational sac is not visualized with ultrasound, for example) and early pregnancy loss (Chalmers 1992). The term ‘abortion’ first started to be used in the English language in the mid sixteenth century, with roots in the Latin word aboriri (to miscarry) (Kuller and Katz 1994). While the words ‘miscarriage’ and ‘abortion’ have been applied interchangeably for centuries by the medical community, women who spontaneously miscarry often prefer the former unless they have voluntarily opted for a termination of pregnancy (Moscrop 2013). In 1985, Beard, Mowbray and Pinker wrote to the Lancet calling for a clear distinction between a spontaneous and an induced pregnancy loss (Beard, Mowbray and Pinker 1985). This echoed concerns by their own patients at Saint Mary’s Hospital in London, who felt offended by the fact that doctors used the word ‘abortion’ when referring to miscarriage. A stark decline in academic publication titles using ‘abortion’ to refer

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to early foetal demise ensued in the United Kingdom (Chalmers 1992), even though internationally it is still a widely used term for miscarriage (Elliot, this volume; Moscrop 2013).

Classification There are many different classifications for early miscarriage, depending on the clinical presentation and extent of tissue loss – threatened, inevitable, missed, incomplete and complete. The differences between these clinical definitions are often nuanced, and they result in large measure from the widespread use of ultrasound to diagnose miscarriage. In a normal pregnancy, the foetal heartbeat can be detected as early as five weeks of gestation using transvaginal ultrasound. In addition, guidance from the National Institute for Clinical Excellence (NICE) establishes that cardiac activity should be expected on ultrasound imaging whenever the embryo measures more than 7 mm (NICE 2012a). At that size, if a sonographer does not visualize a heartbeat on the ultrasound screen, a diagnosis of miscarriage is made. If the woman is not bleeding vaginally, this is referred to as a ‘missed miscarriage’. Missed miscarriages are often detected when women present for their ‘dating’ scan, which is routinely scheduled for when they are 12 weeks pregnant. Commonly, if the pregnancy is considered uneventful and not requiring any medical intervention, this will be the first scan, and such a diagnosis can result in significant upset in women who are asymptomatic and did not anticipate a problem with their pregnancy (Nikcevic, Tunkel and Nicolaides 1998). ‘Threatened miscarriage’ refers to vaginal bleeding (with or without abdominal pain) when an ultrasound scan has confirmed that a foetal heartbeat is present and no obvious cause can be identified for the bleeding. Furthermore, a miscarriage is deemed inevitable when, upon performing a vaginal examination, a clinician identifies an open cervix, with or without pregnancy tissue protruding through the cervical canal. The term ‘incomplete miscarriage’ refers to the passage of some pregnancy tissue through an open cervix, but not all of it – if there is retained tissue inside the uterus, the woman will carry on bleeding and may require medical or surgical intervention. Finally, a miscarriage is considered complete when an ultrasound scan reveals no pregnancy tissue remnants in the uterine lining following vaginal bleeding and loss of tissue (Kolte et al. 2014).

Does Technology Change the Experience of Early Pregnancy and Miscarriage?37

Pathogenesis Miscarriage is by far the most common complication of pregnancy, with approximately one in five known pregnancies miscarrying (NICE 2012a). One in four women will experience a miscarriage in their lifetime, with most miscarriages (more than 80 per cent) occurring within the first trimester of pregnancy (Benagiano, Farris and Grudzinskas 2010). Fifty per cent of these contain a gestational sac but no embryonic tissue and have been referred to as a ‘blighted ovum’, though it has recently been suggested that ‘anembryonic miscarriage’ is a more appropriate term (Kolte et al. 2014). The remaining half – called ‘embryonic miscarriages’ – are associated with abnormal development of the embryo and adjacent structures such as the placenta. Chromosomal abnormalities are involved in approximately half of all miscarriages, although they become less prevalent as gestational age advances; at term, only 5 per cent of stillbirths are due to abnormal chromosomes (Kroon et al. 2011). The most common factor underlying chromosomal anomalies leading to miscarriage is the effect of maternal age (Dunson, Colombo and Baird 2002; Kroon et al. 2011). Indeed, increasing female age is by far the largest independent risk factor for early pregnancy loss. This is thought to derive from a phenomenon called ‘meiotic nondisjunction’ during egg development, whereby the egg receives an abnormal number of chromosomes and goes on to form a non-viable embryo once fertilized (Benagiano, Farris and Grudzinskas 2010). Numerous studies have shown that the risk of miscarriage is significantly higher in women aged thirty-five years or more. After the age of forty, the miscarriage rate rises exponentially: around 30 per cent of pregnancies will miscarry in women aged forty and 60 per cent at age forty-four (De La Rochebrochard and Thonneau 2002; Dunson, Colombo and Baird 2002; Lean et al. 2017). The impact of paternal age on the incidence of miscarriage has only more recently been analysed. Study participants are often recruited following attendance at fertility clinics, however, where other confounding features (e.g. smoking status, alcohol intake, female factor infertility) make it difficult to identify an independent effect of male age on a couple’s fertility (Johnson et al. 2015). Research by De La Rochebrochard and Thonneau (2002) revealed that in couples where the male was aged forty years and older, maternal age began to have a negative effect on miscarriage earlier, from the age of thirty years. More recently, a large systematic review showed

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that male age is associated with an increase in DNA fragmentation and a decrease in semen volume, total sperm count and normal sperm percentage (Johnson et al. 2015). Unsurprisingly, research investigating DNA quality in sperm has in turn revealed that DNA damage contributes significantly to miscarriage rates (Robinson et al. 2012). Despite the evidence indicating that paternal age has an impact upon the reproductive aspirations of a couple, fertility clinics often ignore it as a contributing factor, particularly because studies have failed to accurately quantify its effect on subfertility (Coughlan et al. 2015). Obesity, quantified as a body mass index (BMI) above 30 kg/m2, has become an international epidemic over the past thirty years, with significant consequences for miscarriage and fertility rates (Best, Avenell and Bhattacharya 2017). The prevalence of obesity has nearly tripled since 1975, and more than 600 million adults are obese today (World Health Organization 2017). A raised BMI has been linked to delayed conception in women (Gesink Law, Maclehose and Longnecker 2007), particularly in those who have never conceived before (Wise, Plamer and Rosenberg 2013). In 2008, results from a large Dutch study suggested that in women with regular periods, the probability of conception declined linearly by 4 per cent for every BMI point above 29 kg/m2 (Van der Steeg et al. 2008). Female obesity has been shown to produce a negative impact on reproductive potential through multiple hormone-mediated mechanisms that affect ovulation, oocyte quality, embryo quality and the endometrium’s receptiveness to the implanting embryo (Best, Avenell and Bhattacharya 2017; Broughton and Moley 2017; Talmor and Dunphy 2015). Obese women are therefore at a significantly higher risk of early miscarriage when compared to the general population (Boots and Stephenson 2011; Lashen, Fear and Sturdee 2004). The impact of paternal obesity on miscarriage has been less studied, although research has linked it to increased testicular temperature affecting sperm development, increased oestrogen levels and reduced sperm concentration and motility (Best, Avenell and Bhattacharya 2017; Hammiche et al. 2012; Ramlau-Hansen et al. 2007; Sallmen et al. 2006). Lifestyle choices play a significant role in miscarriage. For example, legal drugs such as alcohol and tobacco, which many women use widely outside of pregnancy, are well known for their teratogenic effect – that is, they contribute to genetic mutations which may result in abnormal foetal growth or delayed mental development (Goodlett, Horn and Zhou 2005). It remains unclear,

Does Technology Change the Experience of Early Pregnancy and Miscarriage?39

however, whether only heavy use is associated with an increased risk of miscarriage, with a low-level alcohol intake appearing to be relatively innocuous in early pregnancy (Henderson, Gray and Brocklehurst 2007; Skogerbo et al. 2012). Lee, Sutton and Hartley (2016) analysed the role of the media in portraying sensationalized views of alcohol in pregnancy, and concluded that while researchers themselves often report their results in ways that tend to be overly cautionary, the media then tends to introduce and perpetuate factual inaccuracies by highlighting some of those findings and omitting others. Excessive caffeine consumption is significantly associated with a rise in miscarriage risk, and studies suggest that there may be a benefit in reducing caffeine intake to less than 200 mg per day – about two cups of regular coffee (Chen et al. 2016). Occupational exposure to environmental toxins in a workplace setting has also been reported as potentially contributing to miscarriage – substances like arsenic, lead, formaldehyde and benzene have all been the object of scientific studies (Kumar 2011; Lamadrid-Figueroa et al. 2007; Quansah et al. 2015). Moreover, chemotherapy drugs and X-ray tests have been linked to an increased risk of miscarriage in nurses and technicians who handle them regularly (Lawson et al. 2012). Finally, medical intervention is occasionally responsible for pregnancy loss, particularly in the context of diagnostic procedures that aim at detecting chromosomal abnormalities such as Down Syndrome. This often involves using fine needles to obtain placental tissue or samples of amniotic fluid through the maternal abdomen, and is associated with a 1 to 2 per cent risk of gestational sac rupture and miscarriage (Ogilvie and Akolekar 2014). Despite new knowledge on the possible reasons contributing to early pregnancy loss, in most instances the specific cause of a woman’s miscarriage remains unknown. This is largely the perspective clinicians take when counselling women being treated for miscarriage in the NHS. Women are given advice on how to maximize their health status for pregnancy (e.g. by taking nutritional supplements or seeking specialist input on any known medical conditions that might affect their pregnancies). However, in the absence of categorical evidence identifying a clear reason for a single miscarriage, doctors are generally reluctant to discuss specific risk factors that may have led to foetal demise in hopes of minimizing feelings of guilt in their patients and reiterating the high likelihood of future successful pregnancies (Nynas et al. 2015).

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Treatment In the UK, miscarriage has been classically treated by surgical evacuation of pregnancy tissue under general anaesthetic, due to concerns about the potential risks of infection and haemorrhage associated with retained pregnancy tissue (Sagili and Divers 2007). Until the late twentieth century, pregnant women with abdominal pain or vaginal bleeding in early pregnancy were admitted to hospital, in order to undergo ultrasound scans and blood tests to confirm pregnancy viability. Prior to the 1980s when ultrasound became more widely available, decisions as to whether a woman was undergoing a miscarriage or ectopic pregnancy were made on clinical signs and symptoms alone (Kuller and Katz 1994). Furthermore, the decision as to whether to proceed with surgical management was made weighing the risks to the mother of not performing an operation with the possible chances of an ongoing pregnancy if conservative management was pursued. When a presumed diagnosis of miscarriage or ectopic pregnancy was made, women would be added to emergency surgical lists. Such lists were at times haphazard, often resulting in unpredictable delays, which aggravated the distress of patients and their families (Sagili and Divers 2007). In the early 1990s, Bigrigg and Read were the first to report the impact of an innovative approach based on the development of early pregnancy units (EPUs), where multidisciplinary teams of clinicians and nurses provided women with rapid and supportive care (Bigrigg and Read 1991). Access to blood results and ultrasonography was available in EPUs and women were booked into appointment slots in a dedicated clinic where they were appropriately counselled and hence better able to make informed decisions about available management options. The concept quickly gained popularity as it allowed women to access early pregnancy care in an organized manner, with clear improvements in service provision, patient satisfaction rates and cost-effectiveness. Moreover, complications such as sepsis and death associated with surgical procedures became less common (NICE 2012a). Depending on the clinical circumstances surrounding a miscarriage, women may now choose from a number of different treatment options (Kim et al. 2017). If a woman presents to hospital with vaginal bleeding in pregnancy and a diagnosis of miscarriage is made, she might opt to await events and let the process of miscarriage conclude spontaneously, which occurs in approximately 60 per cent of miscarriages. This process is referred to as ‘expectant’

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or ‘conservative’ management. Alternatively, drugs that promote uterine contractions may be administered in the form of tablets or vaginal pessaries, in what is commonly referred to as ‘medical’ management of miscarriage, with a success rate of approximately 80 per cent. Misoprostol is usually the drug of choice for medical management of miscarriage. Following the diagnosis of miscarriage and counselling about treatment options, if a woman opts for medical treatment, a specialist nurse or the patient herself will administer vaginal or oral misoprostol. The woman is then able to return home provided she is in the company of a responsible adult for twenty-four hours. A follow-up telephone consultation usually ensues within the next few days to ensure the woman has passed all of the pregnancy tissue and the bleeding has subsided. If her symptoms are consistent with incomplete miscarriage, the woman will be invited back to the EPU for a repeat ultrasound scan and planning of further management if required. If, however, her bleeding and pain have improved, she will be asked to repeat a urine pregnancy test three weeks later and contact the EPU if the result is positive, as this may indicate retained or invasive placental tissue requiring further specialist input. The third management procedure available to women with miscarriage on the NHS is termed ‘surgical’ management of miscarriage (SMM), which involves dilatation of the cervix and suction of the pregnancy tissue under local or general anaesthesia. Women may choose this option in the first instance, but SMM is also conducted in situations where conservative and/ or medical management fails (Sagili and Divers 2007; Smith et al. 2006). Several studies have been carried out to compare the outcomes of different treatment options. Meta-analysis data show that on average, women undergoing expectant management are more likely to require an unplanned intervention (e.g. emergency surgery due to first-line treatment failure, surgical completion on maternal request, or treatment to deal with a complication such as infection or bleeding) (Kim et al. 2017). Others have looked at differences in pain severity and duration, although poor methodological quality and high variability resulted in a lack of definitive answers as to which approach is less painful (Wong et al. 2003). Finally, qualitative data on emotional and psychological outcomes and women’s satisfaction with management have revealed that many women fear unnecessary intervention, and that there is a general desire for predictability of events and more information from clinicians (Smith et al. 2006).

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While studies comparing different treatment approaches are often of poor quality, a recent systematic review showed that there is no robust medical argument for either of the three options (expectant, medical or surgical) and that the main deciding factor should be the woman’s preference (Kim et al. 2017). Moreover, cost analyses have shown that expectant management is significantly less expensive and less taxing on NHS resources (NICE 2012b). Consequently, in the past twenty years there has been a shift towards alternative non-surgical treatment methods which are associated with an equally low (and, in some cases, lower) risk of complications when compared to surgery. However, when a woman presents with severe bleeding or a miscarriage complicated by significant infection, clinicians often advise surgical management as the safest and most effective treatment option (NICE 2012a). Offering timely and appropriate information to women with miscarriage has a crucial impact on their experience as patients. There is clearly no universal treatment option that suits every individual, but data show that women often have a strong desire to be able to make an informed choice based on full knowledge of the possible outcomes associated with each method (Bardos et al. 2015). In addition, the prospect of clinical treatment as opposed to an expectant approach is often viewed negatively in hindsight, when women wonder whether medical or surgical interventions could have been avoided (Smith et al. 2006). To feel cared for, rather than being an ‘object’ of care – by both clinicians and their families – is also a key factor in determining women’s experiences in the context of miscarriage (Bardos et al. 2015; Smith et al. 2006).

Is Miscarriage a Failure? The immune system’s ability to identify and eliminate foreign organisms, while not causing any damage to tissues recognized by immune cells as ‘self’, constitutes the basis of defence against external insults such as bacterial infection or mismatched organ transplants (Munoz-Suano, Hamilton and Betz 2011; Pearson 2002). In 1953, Medawar was the first to recognize the immunological paradox of pregnancy: even though half the foetal genes are paternal in origin, rendering it a genetically foreign organism, the maternal immune system tolerates the foetus in successful pregnancy while still being able to avoid infection (Medawar 1953; see also Alecsandru and Garcia-Velasco 2015; Burnet 1959). The

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regulatory mechanisms that allow the successful implantation of a foetus in the uterus are not fully understood. Still, increasing evidence supports a modern paradigm of maternal-foetal tolerance, which postulates that (1) multiple mechanisms provide protection, and (2) both the foetus and the mother contribute to development and maintenance of the pregnant uterus as an immune-privileged site (Hunt et al. 2005; Karsten and Kruse 2008; Pearson 2002; Seavey and Mosmann 2008). However, the odds of reproductive success are overwhelmingly against the embryo. It is estimated that in humans 70 per cent of embryos will not lead to a healthy live birth: 30 per cent of embryos fail to implant, 30 per cent will miscarry before six weeks of pregnancy and 10 per cent will miscarry at the stage of clinical pregnancy (and before 12 weeks) (Teklenburg et al. 2010). The female body is thought to actively select against embryos that are less likely to develop successfully by imposing natural hurdles that make implantation and ongoing pregnancy more difficult. Evidence suggests that the developmentally competent embryo elicits very little response from cells of the endometrium (that is, the uterine lining) while abnormal embryos provoke an inflammatory response from maternal cells (Chen et al. 2017). Consequently, miscarriage is often viewed by the medical community as a natural process of quality control through which the body recognizes a genetically or developmentally abnormal pregnancy and prevents successful implantation (Benagiano, Farris and Grudzinskas 2010). Given that most human pregnancies are limited to one embryo – and very rarely exceed three – these early barriers are thought to function as a natural selection mechanism through which abnormal progeny are eliminated, thus allowing for further attempts at successful procreation (Chen et al. 2017; Hunt et al. 2005; Karsten and Kruse 2008). From the moment an oocyte is fertilized and becomes a zygote (that is, the primordial cell that through division will form the human embryo), multiple barriers will hinder the chances of achieving a successful pregnancy. Research has revealed that even in an ideal set of circumstances, the probability of becoming pregnant and achieving a live term birth per menstrual cycle with regular sexual activity is around 20 per cent (Benagiano, Farris and Grudzinskas 2010). A series of unlikely events is required for reproductive success after fertilization. Firstly, the fertilized egg needs to travel from the outer portion of the fallopian tube (where the sperm meets the egg) and reach the endometrium. As it travels through the tube, the embryo will undergo rapid cell division – this alone is prone

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to numerous errors which could trigger cell death and embryonic demise. Upon reaching the endometrium, the embryo will then attach to it through a mechanism called implantation, which occurs on average five to seven days after ovulation. Implantation relies on the development of new blood vessels (‘angiogenesis’) in a process regulated by local immune cells that render the endometrium tolerant to the formation of a maternal-embryo interface. It is through these developing blood vessels that the embryo will receive sustenance in the form of oxygen and nutrients. Abnormal angiogenesis may therefore halt embryonic attachment and result in reproductive demise (Chen et al. 2017). In fact, implantation anomalies are involved in a myriad of pregnancy complications even when the worst scenario of miscarriage is avoided – these include hypertensive disorders such as maternal pre-eclampsia (a systemic condition marked by high blood pressure and abnormal amounts of protein in a pregnant woman’s urine) and impaired growth in the foetus due to a lack of adequate nourishment in utero (Sargent, Borzychowski and Redman 2007). While the medical community views miscarriage as a normal – and arguably desirable – process that is intrinsically related to natural selection (Coulam 2016), societal interpretations of miscarriage differ dramatically. In recent decades, the age at which women fall pregnant for the first time in mid- to high-income countries has shifted upwards, and the average age for first-time mothers to conceive in England and Wales is currently above thirty years as compared to twenty-six in the 1970s (Lean et al. 2017; Office for National Statistics [ONS] 2016, 2017). Interestingly, in 2015, women aged forty and over had a higher fertility rate than those below twenty years for the second time since 1947 (ONS 2017). This illustrates the overall increase in maternal age as a consequence of women having more control over their reproductive choices, but it is also proof of the technical advances made in the field of assisted reproduction over the past couple of decades. At the age of forty, a woman who has not been able to conceive despite trying naturally will still have a live birth rate of approximately 50 per cent if she opts to undergo in vitro fertilization (IVF) using a donor egg (Yeh et al. 2014). As mentioned above, older age comes with an inevitable decline in fertility. It is therefore understandable that, among a plethora of environmental stressors and delayed fulfilment of fertility aspirations, higher stakes are involved when couples do decide to actively try to fall pregnant. Women commonly engage in pre-conception

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planning which may entail medical check-ups, lifestyle changes (like smoking or alcohol cessation) and nutritional supplementation with folic acid, which is known to decrease the risk of neurological abnormalities in the foetus (Lindqvist et al. 2017; Pitkin 2007). Technological developments that aid in tracking one’s menstrual cycle have now become widespread, with online tools and apps trying to predict a woman’s optimal fertile period. Women have access to personal kits that measure urinary levels of luteinizing hormone at the time of ovulation, which is used to predict the optimal time to have sexual intercourse and increase the chances of becoming pregnant. Research has yet to validate the value of such tests and their impact on conception rates, but regardless, they are now commonplace among those trying to conceive (Su et al. 2017). When such high personal effort is put into conceiving, it is unsurprising that miscarrying a wanted pregnancy should bring feelings of disappointment, sadness and – at times – guilt (Bardos et al. 2015; Wong et al. 2003). Indeed, many women fear their miscarriage might have been a result of something they did wrong – and they worry that their partners and family too would see them as culprits of an event that they may not perceive as unavoidable (Adolfsson et al. 2004). This has been particularly relevant in recent decades, when information on what one ‘should and should not’ do to have an optimal pregnancy has been so readily available online – and, overwhelmingly so, based on claims that are not scientifically validated (Bick 2010; Lee, Sutton and Hartley 2016; Luce et al. 2016; Song et al. 2012). Content sources vary widely from reality television to sensationalistic tabloid headlines, where pregnancy and birth are often depicted as traumatic experiences (Morris and McInerney 2010). Many women are unable to critically engage with the narratives portrayed, thus taking what they see or read as factual as opposed to anecdotal, which may reinforce fears of not having an ‘uneventful’ pregnancy (Luce et al. 2016). In addition, most women do not discuss the information they obtain online or through other media with their health care providers, which could further perpetuate misinformed notions about pregnancy and childbirth (Sayakhot and Carolan-Olah 2016). The feelings of guilt and despair that follow a miscarriage carry a significant risk of psychological illness for both women and men (Hunter, Tussis and MacBeth 2017). Indeed, studies show that early miscarriages are associated with high rates of depression and anxiety among couples (Huffman, Schwarts and Swanson 2015). The vast majority (up to 80 per cent) will carry uncomplicated future

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pregnancies which result in the birth of babies who are alive and well, but it is often the case that women with a previous miscarriage worry about the chance of miscarrying in a future pregnancy. In fact, recent data show that depression and anxiety associated with a previous miscarriage tend to persist even after women give birth to a subsequent healthy child (Blackmore et al. 2011). In turn, this is thought to have an impact on rates of postpartum depression, as well as long-term implications on maternal-infant attachment, cognitive development and childhood behaviour (Murray et al. 2006).

Medical Technology and Impact on Pregnancy Experience Using women’s urine as a means to diagnose pregnancy goes as far back as ancient Egypt, where the sprouting of wheat and barley seeds watered with urine from a woman suspected to be pregnant was seen as a positive test (Haarburger and Pillay 2011). However, it was only once symptoms began – morning sickness, uterine growth and eventually foetal movements – that pregnancy was confirmed. The advent of endocrinology in the late nineteenth century introduced the notion of pregnancy-associated hormones, but it wasn’t until the 1920s that human chorionic gonadotropin (hCG) became known as the specific hormone of pregnancy (Gnoth and Johnson 2014). Subsequent laboratory tests were developed using rabbits, frogs and rats with a view to detect urinary chorionic hormone. These were rudimentary at first, producing slow and unreliable results. In the 1970s, scientists were able to identify that only the beta-subunit of the hCG molecule is biologically active, which in turn led to the development of more sensitive antibody-based assays and home pregnancy tests in 1978 (Haarburger and Pillay 2011). Today, the use of home pregnancy tests (HPTs) has spread widely across the world, with some being nearly as sensitive as laboratory-based blood measurement of hCG. The sensitivity of these tests has been improved in recent years, which has resulted in earlier and earlier testing being possible. Indeed, some manufacturers claim high accuracy for tests performed as early as two to three weeks of pregnancy – well before the first missed period, when hCG levels are as low as 10 international units (IU) (Gnoth and Johnson 2014). The shift from identifying a pregnancy based on symptoms to using serum and urinary markers introduced the notion of biochemical

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pregnancy, characterized by a positive pregnancy test before a gestational sac can be identified on ultrasound examination (Nguyen and Wilcox 2005). The vast majority of early miscarriages occur in the pre-clinical stage, where symptoms are still not present and historically women did not suspect or know that they were pregnant (Benagiano, Farris and Grudzinskas 2010). At around five to six weeks of pregnancy, clinicians expect to be able to visualize a gestational sac using ultrasonography. Once a gestational sac is seen with ultrasound scanning, the term ‘clinical pregnancy’ applies. Ultrasound imaging was first used to diagnose pregnancy in the 1950s, and it has since evolved substantially (Whitworth, Bricker and Mullan 2015). Its use relies on the principle that sound waves whose frequency is above the audible range of human hearing will bounce when directed at body structures, hence revealing their morphology. When kept at low power and for short periods of time, ultrasound waves are deemed safe to the human foetus (Torloni et al. 2009). Ultrasonography is widely used for obstetric scanning across the world and has been enthusiastically received by pregnant women as it provides them with visual confirmation of pregnancy. Moreover, it may contribute to establishing a first connection between parents and foetus while reassuring women that their baby is well (Garcia et al. 2002; Littlewood 1999; Roberts et al. 2015; Whitworth, Bricker and Mullan 2015). Modern ultrasound imaging has made it possible to diagnose embryonic miscarriages, even before the visualization of foetal heart activity, but also anembryonic pregnancies which can be identified prior to the symptoms of miscarriage (pelvic cramps and bleeding). Alongside biochemical testing, ultrasonography has revolutionized the way clinicians approach early pregnancy and miscarriage. However, ultrasound can also be a source of considerable distress and anxiety. When women present with abdominal pain or bleeding prior to six weeks of gestation, for example, it is often impossible to identify an embryo or a beating heart and a repeat scan is usually required a week later. Not only does this fail to provide women with reassurance, it may further exacerbate feelings of anxiety (Garcia et al. 2002; Roberts et al. 2015). In women who present with vaginal bleeding or abdominal pain in the context of a positive urinary pregnancy test, clinicians will in the first instance quantify the blood level of hCG. If ultrasonography fails to demonstrate a gestational sac, this may indicate that the woman has either completely miscarried or that a pregnancy exists outside the uterus (termed ‘ectopic pregnancy’) and is thus

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non-viable. In such circumstances, clinicians usually rely on clinical symptoms and trends of blood hCG levels to monitor patients – a significant drop in hCG is deemed consistent with miscarriage, whereas plateauing hCG levels raise the suspicion of an ectopic pregnancy (NICE 2012a). Concomitantly to biochemical testing and ultrasonography, contemporary perspectives on pregnancy in the UK have been markedly shaped by assisted reproductive technology (ART) – that is, the employment of techniques that aim to achieve pregnancy without the need for sexual intercourse. ART is used to treat subfertility, which in the UK refers to the inability to conceive despite having regular unprotected intercourse for at least one year (NICE 2013). Approximately one in six couples experience subfertility. Although the majority will end up conceiving spontaneously within one to two years, 7 per cent of couples do not conceive within two years of trying and may be offered some form of ART (Kamel 2013). A number of reasons are thought to lead to subfertility – female factors such as ovulation disorders and tubal blockage are implicated in up to 45 per cent of cases, and 30 per cent result from male factors (e.g. hormonal abnormalities or lack of sperm) (Brugo-Olmedo, Chillik and Kopelman 2001; NICE 2013). In up to a third of couples no obvious cause is found for their infertility (NICE 2013). Depending on the reasons behind a couple’s subfertility, different ART approaches may be used – including intrauterine insemination, in vitro fertilization, intracytoplasmic sperm injection, donor insemination and egg donation. In the late 1960s, Edwards, Bavister and Steptoe initiated efforts to develop a technique whereby eggs were extracted from ovaries and mixed with sperm in a laboratory setting (Edwards, Bavister and Steptoe 1969). Once an egg was fertilized in vitro, it was then transferred back into the woman’s uterus in hopes of achieving implantation and subsequent pregnancy. This technique, called in vitro fertilization (IVF), first resulted in a live human birth in the United Kingdom in 1978 (Edwards and Steptoe 1978). Since then, further advances have made it possible to directly inject one sperm cell into one egg, in what has been termed ‘intracytoplasmic sperm injection’ (ICSI). ART has been the subject of much controversy and discussion since its very inception, due to ethical, religious and legal factors (Harper et al. 2013; Kovacs 2003). Public debate has been generated on a number of issues, including the artificial ‘creation’ of life, gamete donation, surrogacy, same-sex couples and single women,

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posthumous use of frozen sperm or embryos, use of surplus embryos in research, or even the cost constraints associated with providing ART in the context of a publicly funded national health system (Harper et al. 2013; Human Fertilization and Embryology Authority [HFEA] 2010). The need to develop appropriate legislative frameworks in such a rapidly evolving field led to the creation of the HFEA in 1990. The HFEA has since been strictly regulating ART as well as providing patients with evidence-based information in the UK, in conjunction with the Royal College of Obstetricians and Gynaecologists (RCOG) and NICE (HFEA 2010). Many other advances have been made recently in the field of ART, including the ability to test the DNA of IVF-conceived embryos for genetic abnormalities prior to embryo transfer, in what is termed ‘pre-implantation genetic diagnosis’ (PGD) (Geraedts and De Wert 2009). This has been used to select embryos free of inherited diseases such as haemophilia, for example – and, controversially, for social sex selection. While many countries prohibit sex selection in IVF for non-medical reasons, in some this remains a nebulous field where no legislation or guidance exists (Kovacs 2003). ART is not always successful. Despite significant technical developments, the chance of having a live birth following an IVF cycle is at best 30–40 per cent, although considerable improvements have been seen in the past decade (Wade, MacLachlan and Kovacs 2015). The main predictor of success remains maternal age – indeed, success rates decline to less than 20 per cent in women who are thirty-eight years of age or above and less than 5 per cent above forty-four (Lean et al. 2017; Yeh et al. 2014). Moreover, these figures can vary significantly between IVF clinics, which may derive from the use of different local protocols. Importantly, IVF centres may not always be transparent in how they report success rates – indeed, some will quote inflated pregnancy rates which do not necessarily mean a higher chance of having a live baby, as some of those will only be biochemical pregnancies which do not progress and eventually miscarry. However, the HFEA demands that clinics submit all their data and publish live birth rates per embryo transferred (HFEA 2010). In the UK, funding for IVF is limited to a small number of cycles and depends on strict criteria (e.g. maternal age, existence of previous offspring) – in stark contrast with Israel, for instance, where unlimited cycles of IVF are offered to all Israeli women with up to two children in a given relationship, until the age of forty-five, even if the woman already has living children (Simonstein et al. 2014). It

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is thus unsurprising that in the UK most IVF cycles are carried out privately, with costs that may be as high as £7000 per cycle (Pandey et al. 2014). Indeed, the field of ART is part-science, part-business – and a lucrative one. In the UK, more than fifty thousand cycles of IVF are performed every year (McLernon et al. 2016). The financial investment associated with ART adds to the psychological and emotional burden experienced by women undergoing fertility treatment, which in turn may put a significant strain on relationships. This is further exacerbated when IVF is unsuccessful and couples require multiple cycles. Complications associated with stimulation drugs in the context of IVF (e.g. ovarian hyperstimulation, poor ovarian response, intra-abdominal organ injury during egg collection) also remain an issue. Moreover, as explained above, falling pregnant through ART does not necessarily mean carrying it to term or taking a live baby home, as approximately 20–30 per cent will miscarry, although the age-related risk of miscarriage after IVF is the same as for spontaneous pregnancy (NICE 2013). In 1 to 3 per cent of couples, infertility presents in the form of recurrent miscarriages – that is, three or more consecutive pregnancy losses before 20 weeks of gestation, regardless of whether conception occurred through natural means or ART (Quenby et al. 2002). Despite modern advances and detailed investigations (which include testing parental DNA and, when possible, the genetic makeup of the miscarried foetus), clinicians are unable to identify a cause for recurrent miscarriage in the majority of cases (RCOG 2011). Autoimmunity is thought to play a significant role in the aetiology of recurrent miscarriage, and a number of adjuvant therapies (including aspirin, anti-coagulants and immunosuppressive steroids) have been employed in an attempt to improve pregnancy outcomes, although not always successfully and often without adequate scientific evidence (Jeve and Davies 2014).

Conclusion Technological advances have played a crucial role in the way people perceive pregnancy. For centuries, only the cardinal symptoms of morning sickness and uterine growth would reveal a woman’s pregnant state. In the early twentieth century, biochemistry contributed significantly to identifying pregnancy-specific hormones and developing immune-based assays that made the diagnosis of pregnancy easy and affordable to women at an early stage and in

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privacy. The introduction of ultrasound into obstetric care, in the 1950s, has made it possible for women to visualize their babies in utero, somewhat conferring a more concrete dimension to the developing foetus several weeks before it becomes viable. While ultrasound has had a powerful impact upon pregnancy care worldwide, it has also significantly shaped the way women and those around them experience pregnancy loss. Miscarriage is no longer a self-declared event through which one’s body expels an abnormal foetus – it now involves visualizing the absence of a baby’s heartbeat on a computer screen often prior to abdominal pain or bleeding. Over the past decades, the care of women with early pregnancy loss in the UK has sustained significant improvements, with the introduction of dedicated clinics that aim to provide efficient and compassionate care while minimizing hospital admissions and life-threatening complications. Moreover, a rise in the age when women decide to become mothers has had a profoundly negative impact on conception and miscarriage rates, making way for assisted reproduction. Becoming pregnant is now seen by many as an emotional and financial endeavour which, when unfulfilled, may generate feelings of frustration and shame. In a world filled with mediatic advice that is not always evidence-based, misconceptions on miscarriage and fertility are often perpetuated, thus prompting couples to spend more time, energy and financial resources on achieving their fertility aspirations, sometimes to the benefit of private enterprises. In the ever-evolving field of early pregnancy, awareness of miscarriage and its powerful consequences on women’s health has been rising. Women are now empowered to make informed choices about their pregnancies, and clinicians are expected to address the reality of miscarriage in a sensitive and holistic manner that takes into account the woman’s knowledge, preferences and wider social context. Pedro Melo has been a specialty trainee in Obstetrics and Gynaecology in the Oxford Deanery since 2015. He regularly contributes to peer-reviewed publications in the field of Reproductive Medicine and Obstetrics, and teaches Medical and Clinical Embryology students. His special interests include subfertility, early pregnancy and ultrasound scanning. He is currently undertaking a PhD in assisted reproduction and IVF at the University of Birmingham under the supervision of Professor Arri Coomarasamy.

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Ingrid Granne is a Senior Clinical Fellow in Reproductive Medicine at the University of Oxford. She gained her medical degree in 1998 from the University of London. In 2004 she undertook a Master’s degree in medical law and ethics at the University of London and gained her doctorate in 2011 from the University of Oxford investigating immunological changes in women who experience recurrent miscarriage. Her research continues to focus on the immunology of pregnancy in which she has published widely. She trained in Obstetrics and Gynaecology in the North West, Australia and Oxford, becoming a consultant in 2014. Her clinical interests are in assisted reproduction and IVF, and in the care of women experiencing miscarriage. In 2018 her team in Oxford opened the UK’s first community-based Early Pregnancy Assessment Unit.

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Kolte, A.M., L.A. Bernardi, O.B. Christiansen, S. Quenby, R.G. Farquharson and M. Goddijn. 2014. ‘Terminology for Pregnancy Loss Prior to Viability: A Consensus Statement from the ESHRE Early Pregnancy Special Interest Group’, Human Reproduction 30(3): 495–98. Kovacs, G. 2003. ‘Should Couples Be Allowed to Select the Sex of Their Offspring?’ Journal of Obstetrics and Gynaecology of Canada 35(12): 1105–7. Kroon, B., K. Harrison, N. Martin, B. Wong and A. Yazdani. 2011. ‘Miscarriage Karyotype and Its Relationship with Maternal Body Mass Index, Age, and Mode of Conception’, Fertility and Sterility 95(5): 1827–29. Kuller, J.A., and V.L. Katz. 1994. ‘Miscarriage: A Historical Perspective’. Birth 21: 4. Kumar, S. 2011. ‘Occupational, Environmental and Lifestyle Factors Associated with Spontaneous Abortion’, Reproductive Sciences 18(10): 915–30. Lamadrid-Figueroa, H., M. Téllez-Rojo, M. Hernández-Avila, B. Trejo-Valdivia, M. Solano-González, A. Mercado-García et al. 2007. ‘Association between the Plasma/Whole Blood Lead Ratio and History of Spontaneous Abortion: A Nested Cross-Sectional Study’, BMC Pregnancy and Childbirth 7: 22–29. Lashen, H., K. Fear and D.W. Sturdee. 2004. ‘Obesity Is Associated with Increased Risk of First Trimester and Recurrent Miscarriage: Matched Case-Control Study’, Human Reproduction 19(7): 1644–46. Lawson, C.C., C.M. Rocheleau, E.A. Whelan, E.N.L. Hilbert, B. Grajewski, D. Spiegelman and J.W. Rich-Edwards. 2012. ‘Occupational Exposures among Nurses and Risk of Spontaneous Abortion’, American Journal of Obstetrics and Gynecology 206: 327. e1–8. Lean, S.C., H. Derricott, R.L. Jones and A.E.P. Heazell. 2017. ‘Advanced Maternal Age and Adverse Pregnancy Outcomes: A Systematic Review and Meta-Analysis’, PLoS ONE 12(10): e0186287. Lee, E., R.M. Sutton and B.L. Hartley. 2016. ‘From Scientific Article to Press Release to Media Coverage: Advocating Alcohol Abstinence and Democratising Risk in a Story about Alcohol and Pregnancy’, Health, Risk & Society 18(5–6): 247–69. Lindqvist, M., M. Lindkvist, E. Eurenius, M. Persson and I. Mogren. 2017. ‘Change of Lifestyle Habits: Motivation and Ability Reported by Pregnant Women in Northern Sweden’, Sexual & Reproductive HealthCare 13: 83–90. Littlewood, J. 1999. ‘From the Invisibility of Miscarriage to an Attribution of Life’, Anthropology & Medicine 6(2): 217–30. Luce, A., M. Cash, V. Hundley, H. Cheyne, E. van Teijlingen and C. Angell. 2016. ‘“Is It Realistic?” The Portrayal of Pregnancy and Childbirth in the Media’, BMC Pregnancy and Childbirth 16: 40. McLernon, D.J., A. Maheshwari, A.J. Lee and S. Bhattacharya. 2016. ‘Cumulative Live Birth Rates after One or More Complete Cycles of IVF: A Population-Based Study of Linked Cycle Data from 178 898 Women’, Human Reproduction 31(3): 572–81.

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Chapter 2

The Meanings of Miscarriage in Twentieth-Century Britain Rosemary Elliot

W

riting in 1924, the obstetrician J.P. Hedley wrote in the British Medical Journal that ‘a threatened or actual abortion in the early months is often looked upon by the public as trivial and in consequence frequently goes untreated’ (Hedley 1924). He was using the word ‘abortion’ to denote spontaneous pregnancy loss in this instance, but contemporary writings also used the word ‘abortion’ to mean induced pregnancy loss. While Hedley’s comment clearly ignores the financial and practical costs of medical assistance for women prior to the advent of the National Health Service in 1948, it also points to the linguistic, social and political overlap between different types of pregnancy loss historically. This contrasts to understandings today which see abortion and miscarriage as more distinct phenomena. This chapter draws on medical writings and women’s written experiences to consider the history of miscarriage in twentieth-century Britain. Three linked arguments are made. The first argument is that the conflation of abortion and miscarriage historically shaped how pregnancy loss was perceived and managed by doctors as well as society more broadly in Britain through the twentieth century. This was evident in different ways as the century progressed. During the first half of the twentieth century at least, much medical and scholarly discussion focused on disaggregating

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induced and spontaneous pregnancy loss at a population level, while discussion of prevention and treatment often conflated the two. This was because, prior to changes in abortion law and developments in reproductive technologies, medical professionals often did not know what caused pregnancy loss if a woman presented for treatment (and, as Hedley suggests, many women did not seek medical attention). At the same time, politicians and social reformers were focused on ensuring healthy and continuing pregnancies, given high levels of neonatal and infant mortality, and concerns about so-called national efficiency in an increasingly competitive and conflicted international context (Koven and Michel 1993). This meant, as I will show, that pregnant women’s bodies and lives came under increased scrutiny, with a heightened focus on their ‘unborn children’; hence, the reasons for pregnancy loss assumed medical and political importance. This emphasis on the ‘unborn child’ predated later twentieth-century debates about the attribution of foetal personhood (Littlewood 1999), but nonetheless made pregnancy (including pregnancy loss) a political and social matter in a way it had not been previously. In the second half of the twentieth century, with developments in the legal framework around abortion and advances in understanding foetal development, the two processes of pregnancy loss were increasingly seen as distinct medical and social phenomena on one hand, but remained entwined in terms of language, medical practice and ethical discussion around viability and personhood on the other. The second, linked argument is that the emphasis on induced termination of pregnancy (hereafter referred to as abortion) obscures the experiences and meanings of spontaneous pregnancy loss (hereafter referred to as miscarriage), both at the time and in the historiography. Disentangling the history of miscarriage in twentieth-century Britain from that of abortion opens space to understand the ways in which medical understandings of miscarriage developed and to consider the implications and meaning of miscarriage for women themselves. This is important because miscarriage is, and has always been, a common part of women’s reproductive experience (Regan 2001: 8). However, until the advent of widely available birth control, the emphasis for many women was on controlling fertility, rather than seeking it, often for economic reasons. With the advent of more widely available birth control, more liberal abortion laws and advanced reproductive technologies in the developed world, a rhetoric of choice emerged within the context of late twentieth-century neoliberalism (Robertson 1994). This

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arguably led to a prevailing view, particularly among middle-class, educated, predominantly white women, that pregnancy timing can and should be chosen. In reality, fertility cannot be chosen, and there is still little way of stopping a natural miscarriage. As Ross showed in 2016, women were often aware of the ‘tentative’ nature of early pregnancy, employing a range of emotional strategies, dietary practices and regimens to retain emotional equilibrium and foster optimum bodily conditions as their pregnancy developed. Passing the end of the first trimester was often seen as a milestone (Ross 2016). Thus, the emotional labour of pregnancy is internalized, and unspoken, while bodily and lifestyle practices may be publicly scrutinized. In the early twenty-first century, while internet forums and social media provide a platform for discussing pregnancy experiences anonymously or among ‘friends’, it remains relatively uncommon to speak openly about miscarriage. This chapter shows that women, and their reproductive capacities and histories, have long occupied a liminal space between public and political discourses and personal experience. This is linked, in part, to awareness of the political precarity of women’s reproductive autonomy globally and historically. As Parsons (2010) has argued, safeguarding the right to abortion has led to a lack of consensus about the moral status of the foetus or embryo, and a lack of clarity about what is lost in abortion and miscarriage. Nonetheless, the ‘nebulous’ nature of what is lost (Allen and Marks 1993: 15) is historically contingent: prior to the passage of the Abortion Act in 1967, and advances in chromosomal research and foetal screening, both medical professionals and women themselves referred routinely to the ‘unborn baby’ or ‘unborn child’ as a coherent entity. In other words, the nature of what was lost was clear. This leads me to my third argument, that developments in understanding the nature and causes of miscarriage, as well as the legalization of abortion, fragmented the coherence of the foetus as a medical, cultural and political entity, with implications for how women themselves framed their losses. Thus, writings about miscarriage by and for women from the early 1980s onwards centred on articulating their experiences and giving miscarriage meaning. This was done through miscarriage support organizations, selfhelp literature and, to a very limited extent, in the medical press. Nonetheless, the ways in which women articulated their experiences were, and remain, overshadowed by debates on abortion; the need to gain, and later uphold, female reproductive autonomy; and medical and social pressure to obtain the optimum outcome of a

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continuing pregnancy. Hence, liminality, even when the focus was on pregnancy loss, extended to the state of miscarrying itself. Overall, this chapter demonstrates that miscarriage features historically at an intersection between medical advances (into foetal health and reproductive knowledge), political and population concerns, relative cultural silence and lived experience. As I will show, the primacy accorded to each of these aspects changes over time, but it is also contingent on the writer or speaker.

Researching the History of Miscarriage When I initially researched and wrote about the history of miscarriage, I approached it within the Enlightenment model of knowledge creation, examining developing medical knowledge through empirically driven, documentary archival scholarship, attempting to maintain objective distance. As Smith argued in 2000, the notion of ‘historical truth’ was envisaged in the West as established through rational patterns of scientific enquiry, excluding both emotions and subjectivity, in a context constructed in practice and discursively as male (Smith 2000: 1–3), or, as Jan Plamper put it, ‘A lack of passion is what is expected of historians’ (Plamper 2015: 290). I made a comprehensive survey of literature in the British Medical Journal, the Lancet and the Glasgow Medical Journal, as well as pamphlets and clinical literature, from 1900 onwards, relating to miscarriage, abortion and other related keywords. Some of this work has been published elsewhere, particularly in relation to the close links in medical understandings of spontaneous and induced pregnancy loss in the first half of the twentieth century in Britain (Elliot 2014). On revisiting this material for the purposes of this chapter, it became clear that there was and is a disjuncture between the experiences and understandings of medical professionals and those of women who miscarried, which I had not represented. This chapter therefore expands in conceptualization from exploring medical understandings to also exploring the experiences of the women affected, within the context of changing medical knowledge but also varying emotional terrain. The additional sources consulted here include written testimonies, for example in Maternity: Letters from Working Women, letters collected and edited by the Women’s Co-operative Guild (WCG), an auxiliary organization of the co-operative movement in Britain, in 1915, as well as more recent testimonies collected for popular accounts of miscarriage and

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sociological studies in the 1980s and early 1990s. Both groups of experiences come from points in time when women’s voices about reproduction and the lived inequalities based on female biology were being heard, through maternal feminist movements in the first instance, and the impetus of second wave feminism in the second. Feminist authors have highlighted the notion of subjectivity (the way in which the self is created and represented in relation to narratives about others and cultural and political discourses) and its relation to gendered and embodied experiences (Kruks 1992). This chapter explores the ways in which women writing were alert to wider cultural and social discourses around reproduction, and situated themselves within these changing contexts, while describing biological and emotional processes. The first writings focused on the need for adequate maternity care, while the second also touched on recognition of loss and need for emotional support. The miscarriage books of the 1980s and 1990s were in the main authored or co-authored by women who had experienced miscarriages and sought to give voice and guidance to other women in their position or were professionally involved in supporting women experiencing pregnancy loss (not mutually exclusive categories). The final methodological point is my own subjective position. Writing in 2012, on emerging debates in the history of emotions, Gammerl raised the potential benefit to historical practice of scholars being transparent about their own emotional style and its impact on their research path and process, where this has been decisive. This point, he argues, ‘holds true for historians’ political opinions and positions in terms of class and gender distinctions as well as their emotional styles’ (Gammerl 2012: 171). The benefit of such transparency is to the reader’s ability to reach their own conclusions about the work being presented. This call for emotional transparency becomes problematic and pressing when the research subject crosses intimately into personal and bodily experience; it is, or should be, always a matter of discretion how much of oneself to reveal, particularly in a professional context. As a trained medical historian, my path into understanding miscarriage was to understand how current medical knowledge had been reached, and to appreciate that miscarriage research was still very much a developing science. But it was also to understand the cultural silence around pregnancy loss, and possibly therefore my own experiences. My first encounter with miscarriage was being told, in 2002, somewhat abruptly over the phone after a set of blood tests, that I

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was miscarrying my first pregnancy. Left to absorb this news with no medical or professional support or further information, I only reported to the hospital when I was in such pain, without bleeding, that my friends and family expressed concern. I was then given a laparoscopy for a suspected ectopic pregnancy, which uncovered that the pregnancy was continuing and in the correct place. The explanation was that the blood test results were wrongly recorded. There were no social or cultural scripts in which to understand this experience; indeed, my relief that my pregnancy was in fact continuing overrode any sense of annoyance at the ten-day uncertainty around that fact. It seemed ungrateful to complain, when the outcome was a continuing pregnancy and a healthy baby. Several years later, my second pregnancy ended in miscarriage: I started bleeding, I passed a very tiny foetus, it was clear what had happened, I did not seek medical advice. I continued my daily life without really communicating my feelings about it. I had a daughter already, and to that extent I was blessed, if distressed; my sister had had a stillbirth at 37 weeks and no subsequent child. My loss, such as it was, was not trivial, but it was relative. Thus, while my experiences of miscarriage, assumed and actual, were not personally ‘trivial’, they were set against and understood within a range of reproductive possibilities across space and time; reproductive possibilities, such as maternal and infant mortality, neonatal death and abortion, which have arguably been more visible through medical and historical writings over the twentieth century (Lewis 1980; Loudon 1992). As I experienced two more miscarriages over the course of 2008 and 2009 and became more involved with medical pathways through miscarriage, I began to search out more literature, as I am professionally trained to do, looking for explanations and ways of locating my experience within social and cultural discourses. I was struck by the cultural silence that surrounded what was happening to me, which clearly contrasted with the number of women who disclosed in conversation that they too had miscarried at some stage, once or more.

Miscarriage or Abortion? The cultural silences surrounding early pregnancy loss can be only partially explained by the lack of prominence it has received in the history of reproduction and in contemporary discussions of women’s experiences. One of the first issues as a historian is the lack

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of agreement around terminology used, which leads to confusion over what is being discussed when. The word ‘abortion’ was used interchangeably with ‘miscarriage’ to describe various kinds of pregnancy loss for most of the twentieth century. Medical writers sought to clarify their categories to avoid confusion. For example, Dr Robert Jardine, president of the Glasgow Obstetrical and Gynaecological Society (GOGS), discussed the meaning of the word ‘abortion’ in 1902, concluding that: the true definition of an abortion I take it to be the expulsion of the uterine contents up to the end of the third month …. From the end of the third month onwards until the foetus is viable, the term miscarriage is the correct one. (Jardine 1902: 45)

It was not until 1997 that a Royal College of Obstetricians and Gynaecologists (RCOG) study group recommended that medical staff use the word ‘miscarriage’ for spontaneous early pregnancy loss and avoid the word ‘abortion’ (Royal College of Obstetricians and Gynaecologists 33rd Study Group 1997). Furthermore, doctors themselves were not sure of the miscarriage rate in the context of illegal abortion and the secrecy surrounding the practice prior to the 1967 Abortion Act. Medical professionals frequently made connections between early pregnancy loss and criminality, that is, illegal abortion (Elliot 2014). The letters from women writing to the WCG also refer to taking abortifacient substances to bring on the end of a pregnancy (Women’s Co-operative Guild [WCG] 1915: 15). But ascertaining prevalence or numbers of women who sought or procured abortion was impossible: the women concerned and, where relevant, the doctors who saw them kept silent, the latter ‘for fear of making a breach of professional secrecy’ (Hall and Ransom 1906: 428). A correspondent in the Lancet in 1915 advised colleagues to ‘wisely refrain from putting questions to his patient or receiving information from her which will throw upon him the difficult burden of “professional secrecy”’ (Willcox 1915: 97). The 1937 Ministry of Health report on maternal mortality highlighted the levels of maternal mortality due to abortion – and here too included procured abortion alongside natural miscarriage (Ministry of Health 1937: 207). Where pregnancy loss resulted in maternal mortality, the Registrar General of England and Wales recorded both abortion and miscarriage under the heading ‘Abortion’ (ibid.: Appendix One, 302), with the focus on whether sepsis and/or haemorrhage had occurred or not. In short,

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doctors and the state were able to observe the effects, rather than the causes, of pregnancy loss, and even then, only partially.

The Political and Medical Relevance of Pregnancy Loss in Early Twentieth-Century Britain Attempts to quantify the risk of miscarriage took place within a wider political context about preventing foetal ‘waste’, and medical desire to understand (and in the feminist view, control) reproduction. As this section will show, such intentions made reproduction a public and medical good, in a way that transcended individual experiences. From the Boer War and heightened in the First World War, concerns about fertility decline and infant mortality were shared by the medical profession, political elites and social reformers, with the result that an unprecedented level of medical attention, policy and public health engagement focused on women of reproductive age. This anxiety led to discourses and interventions highlighting the importance of motherhood in improving the quality and quantity of the nation and ‘race’ (Robb 1997). As Anna Davin has argued, motherhood was elevated to women’s prime duty (Davin 1978). Indeed, for many maternalist feminists, women’s claims to suffrage were founded on the need to advocate for women’s rights as mothers, not as autonomous citizens (Pugh 1992). Social reformers, such as Dr J.W. Sykes and the poet Anna Wickham, both associated with the St Pancras School for Mothers, founded in 1907, and obstetricians, such as J.W. Ballantyne in Edinburgh, an early twentieth-century pioneer in antenatal health, advocated for the development, provision and extension of antenatal care. This was prompted by concerns about the socio-economic and environmental contexts of pregnancy and birth (Al-Gailani 2013). The political and medical focus on reproduction and motherhood extended concerns about infant welfare from conception through to birth, with implications for what constituted life. In 1916, Amand Routh, consulting obstetrician to Charing Cross Hospital and consulting physician to The Samaritan Hospital for Women, asserted that ‘the death rate of infants during their mothers’ pregnancies was as great as, or probably greater than, the death rate amongst their survivors in the first year of life’ (emphasis added). This calculation was based on the notification of 3 per cent of births as stillbirths and estimates that abortions and miscarriages were four times as numerous as stillbirths. Routh did not distinguish between

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miscarriage and abortion, partly because he was not able to quantify these separately, and partly because his wider point was about the loss of population. He continued: The fact is that the life of the infant and of the unborn babe … was of small account with a high birth rate and a prolonged peace. Now, with a small birth rate, and when mothers are mourning the loss of ‘only sons’ and have an added and expressed sorrow that they might have had others, the life of the child is of utmost importance, and steps to ensure maternal and infant welfare are being initiated at conception instead of being delayed till childbirth, to the great advantage of both the mother and the child. (Routh 1916: 1056)

The reference to ‘only sons’ reflects and is informed by wider fears about the birth rate in the context of the high levels of male mortality of the First World War. But it also suggests that, if women did not fulfil their political duty to reproduce, there could be no existence, and therefore no demonstration of masculine citizenship. The fewer children a woman had, whether through choice or the natural loss of pregnancy, the more pregnancy was valued to society, and the more justification for its external scrutiny. Medical intervention was justified by the construction of the foetus as a (male) citizen in the making. Almost a decade later, obstetrician Thomas Watts Eden, at Charing Cross Hospital, London, was clear that antenatal care should not only focus on the mother, but the ‘child in utero’. Speaking at St Mary’s Hospital in Manchester, and reprinted in the Lancet, Eden called on colleagues to be concerned with ‘the well-being of the child before birth’ in the context of falling infant mortality after birth, ‘to ensure that the intrauterine child is given the best chance of completing its development, and entering upon its separate existence under the most favourable possible conditions’ (Eden 1926: 35). The language of the ‘child in utero’ collapses the boundaries between foetal and legal existence, without consideration of questions of viability, while the reference to ‘separate existence’ acknowledges reliance upon the mother for progression between the two states. In other words, intervention and support for the pregnant woman was primarily directed at the well-being of the foetus. ‘Unborn’ in this case was presented as a developmental stage and used to distinguish from ‘born’. This had legal ramifications: until a foetus was born, it had no formal existence. Even then, the bounds of its legal existence depended on the stage of gestation it reached and whether it breathed, a point discussed later in this chapter.

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In order to prevent miscarriage, women were advised in the early twentieth century to ‘avoid riding, dancing, golfing, tennis, cycling, falls, blows, excessive coitus, lifting, pushing, walking too far, standing too long, and, in fact, everything that causes great and often sudden excess in the intra-abdominal pressure’ (Horrocks 1901: 946). Some of these activities would have pushed the boundaries of respectable femininity at the time and can be read as social strictures as much as medical advice. Such advice also placed the burden of prevention and possibly guilt on women: one does not walk into the path of a blow or fall intentionally. However, by the First World War, discussion about antenatal and infant welfare focused on the relationship between (married) women working and reproductive issues, as the number of married women in employment increased. Here too, there were concerns about heavy unsuitable work, an action which potentially contributed to pregnancy loss; but also that women may seek abortion for fear of losing their employment (Adamson and Palmer Jones 1918: 310). Evidence by Mrs Heppell Marr, Section Director of the Aircraft Production Department in the Ministry of Munitions, to the War Cabinet Committee on Women in Industry, suggested it was ‘probable that lifting and pushing too heavy weights resulted in miscarriages’, while Dr Rhoda Adamson, Honorary Medical Officer of the Maternity Hospital in Leeds and Clinical Lecturer in Obstetrics at Leeds University, also noted that women who had experienced miscarriages previously also suffered health effects from such work (House of Commons Parliamentary Papers 1919b: 208, 203). The report of the War Cabinet Committee acknowledged the need for proper nutrition, antenatal care and medical supervision in labour for all women but stopped short of providing any substantive recommendations to achieve this. Women in the workplace, particularly married women, were seen as a necessary expedient of war conditions, not a positive or permanent fixture. Indeed, the report reiterated married women’s role as mothers for the ‘well-being of the race as a whole’, a role that was not compatible with labour force participation (House of Commons Parliamentary Papers 1919a: 70). Thus, in the circumstances of war and in the years thereafter, concerns about the ‘unborn babe’ were expressed by doctors and law-makers from the earliest stages of its existence in a way that was both related to the perceived well-being of the family, but more fundamentally to the good of the state – both in the creation of male citizens and the ability to balance this, for the lower classes, with providing the means for the state to preserve itself (working in

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the munitions factory). While arguments about foetal personhood are not made directly here, it is not difficult to see pregnancy becoming a public, rather than a private concern.

Women’s Experiences in the First World War For women themselves, the primacy of motherhood provided a political tool to advocate for social reform. For the editors of the letters contained in Maternity: Letters from Working Women (hereafter Maternity), it was clear that pregnancy occurred in a set of socio-economic circumstances that were detrimental to positive foetal outcomes, and thus there was a social class gradient to the matter. Women within the working class, even those with a steady household income, had ‘nothing over for the additional outlay upon maternity’ (WCG 1915: 5), and many of the women writing to the Women’s Co-operative Guild also wrote of the precarious and unstable nature of money coming into the house. The introduction to Maternity states: … a working-class woman is … too poor to obtain medical advice during the months of pregnancy, she ‘learns by ignorance and experience’, comforting herself with the belief that however ill she be it is only ‘natural’. Meanwhile she has to scrape and save to put by money for the inevitable expenses that lie before her … she stints herself in order to save … If the mother is not working long hours in a factory, she is working even longer hours in her own home. (WCG 1915: 5)

Many of the letters accord with this view. Writing of her second pregnancy, one woman says: I had a miscarriage about three months. Don’t know how to account for it, excepting there is so little rest in the married working woman’s life. From early morning until late at night, she is on her feet. (WCG 1915: 85)

Similarly, a woman with multiple losses wrote: I looked after my husband and children well, but I often went short of food myself, although my husband did not know it … I was always scheming and planning to make ends meet, which was not good for me or the unborn baby. (WCG 1915: 159)

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In other words, what the women themselves said here does not indicate that miscarriage was treated as ‘of no consequence’ but seen as a result of the conditions of their lives. Working-class women who had existing family responsibilities and little additional income eschewed medical attention for financial and practical reasons, rather than neglect of the foetus. The clarity with which women describe and categorize their reproductive experiences contrasts with the opaqueness of medical views on the prevalence and causes of loss. For example, the second woman quoted above writes: I had children very fast, seven one after the other, not more than a year and nine months between them, and in one case only one year and two months. Then I lost a sweet little girl, aged four years and eight months. She was ill a fortnight and I nursed her night and day. I was so done up with attending her and the grief, that I had a dreadful miscarriage which nearly cost me my life. I had to work very hard to do everything for my little family, and after that I never had any more children to live. I either miscarried or they were still born. I have had two miscarriages in a year, one in January and one in August. (WCG 1915: 158)

The woman quoted here had seven living children, three stillbirths and four miscarriages. This letter was not unusual. The WCG received letters from 386 women, 348 of whom had experienced 1396 live births, 83 stillbirths and 218 miscarriages between them, without considering neonatal mortality and/or later childhood deaths and without direct accounting for induced pregnancy loss. The editors of the collection noted that ‘it is probable that not all the writers have included miscarriage, but even as it is, the number of miscarriages is 15.4 per cent of the live births, whilst the number of stillbirths is 5.9 per cent’ (WCG 1915: 10). Then as now, recognition and disclosure of early pregnancy lay, with few exceptions, with the woman experiencing it and often remained a private matter. Although there were calls for the notification of pregnancy during the First World War, this view was controversial, not least because of the privacy implications for women and their husbands (Ballantyne 1916; Donald 1916: 34– 35). Recognition of pregnancy relied on physical symptoms and absence of menses, hence any figures will have excluded very early miscarriages before a period had been missed or explained as a late period. As the women writing here highlighted the financial barriers to seeking medical assistance for miscarriage, and there was a

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climate of suspicion among many medical men that losses might be (illegally) procured or induced, it is not surprising that ascertaining the prevalence of miscarriage proved difficult.

Medical Responses to Miscarriage While much medical writing focused on ‘saving’ the ‘unborn child’ through antenatal care and medical scrutiny, researchers stressed the importance of research and the need for pathological testing of the lost foetus (Donald 1916). Improved environmental, nutritional and health measures were aimed at optimum pregnancy outcomes for a live birth, while research on miscarried foetuses sought to understand the reasons for their demise. The overall effect of both tracks of research was to fragment the ‘unborn child’ into a series of endocrinological processes and developmental stages, which worked against seeing it as a coherent entity. By the interwar period, there was an increasing awareness of nutritional and hormonal factors beneficial to successful pregnancy outcomes (Eden 1931). The need for intervention and support applied generally to all pregnant women with inadequate nutrition and circumstances, but in the case of miscarriage, additionally to those who suffered repeat miscarriages. Such women presented voluntarily to doctors for help with maintaining pregnancy and were often discussed in case studies in the medical journals (Beckwith 1929: 1098–99). By the 1940s, vitamin E in particular was seen to have a positive effect in terms of making full-term births possible among these women, while adequate nutrition, vitamins and calcium were seen to be more generally beneficial (Bacharach 1940; Cross 1946). In addition, understandings of the hormonal relationships in pregnancy through the 1930s and into the 1940s provided another avenue for medical research into miscarriage and assistance for women experiencing multiple losses (Elliot 2014). Naturally occurring progesterones, androgens and oestrogens were isolated and their role in reproduction demonstrated, while the relationship between ovulation and menstruation was also clarified (Johnstone 1933; Robson 1936). Advances in hormonal understandings of reproduction led to experiments in the use of hormones (oestrogen and progesterone) to try to prevent miscarriage from the mid 1930s onwards (Dodds 1936: 269–70; Brown 1948: 852). Therapeutic efforts were facilitated by the creation of pharmaceutical

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synthetic hormones, most notoriously the synthetic oestrogen Diethylstilbestrol (DES), which were marketed to women as ‘modern miracles’ (Fox Connell 1942). DES was popular through the postwar decades as a prophylaxis to miscarriage, although more recent scholarship has cast doubt on its efficacy and the original research underpinning its use (Al Jishi and Sergi 2017). However, the ‘miracle’ pill exposed women, their daughters and granddaughters, and to a lesser extent sons and grandsons, to an increased risk of reproductive cancers, abnormalities and infertility (Langston 2010). The spectre of DES cast a long shadow over the development of synthetic hormonal therapies to address recurrent miscarriage. An article in 1965 stated that any drug needed to be ‘shown beyond all reasonable doubt’ to be harmless to the foetus, and that supportive psychotherapy delivered good results, in a safer manner, to women going through pregnancy after recurrent miscarriages (MacDonald 1965). It is notable that the multi-centre PROMISE (progesterone in recurrent miscarriage) trial led by Dr Rajendra Rai at St Mary’s in London between 2010 and 2013 addressed the same questions that clinicians in the 1950s sought to answer (Bishop 1952; ISRCTN Registry 2010). By the early 1980s at least, it was recognized that potential risk factors for miscarriage included environmental factors, exposure to toxins, such as radiation, lead or even pharmaceutical products intended to help pregnancy, the presence of infections, including sexually transmitted infections, and the woman’s own reproductive history. Thus, one could suggest that it was safer to conduct research on deceased foetal remains, rather than pregnant women themselves, by ‘saving’ the foetus for medical research. While researchers in the early twentieth century meant ensuring foetal survival or pathological testing of foetal remains when they talked of ‘saving the foetus’, this extended by the 1950s into experiments to culture cells from the limbs and amniotic fluid from miscarried foetal remains. The purpose was to understand human genetic make-up and chromosomal abnormalities. Writing in 1961, Penrose, Galton Professor of Eugenics, and Delhanty, a research student also at the Galton Laboratory of Eugenics, University College London, noted that: Although the first accurate observations on normal human chromosomes (Tjio and Levan 1956) were made with cell cultures taken from foetal tissues, the opportunities for investigating the chromosomes in cases of natural abortion have not so far been greatly exploited. (Penrose and Delhanty 1961: 1261)

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International exchange of data by scientists helped standardize understandings of human karyotyping, and by 1960 it was established that there were forty-six human chromosomes and sex chromosomes were designated X and Y. This understanding of normal human karyotypes paved the way for recognition of abnormal patterns (Miller et al. 1962). This is relevant to the history of miscarriage in two linked ways. The first is the recognition that chromosomal abnormalities were a significant cause of early miscarriage; the second is that medical professionals began to see the miscarriage of such foetuses as a natural and ultimately beneficial process, with social implications. By 1963, researchers began to tentatively suggest that ‘chromosomal abnormalities are a significant cause of early embryonic wastage’ (Carr 1963: 605) and by 1965 that ‘the chromosome complements of foetuses from spontaneous abortion reported so far reflect the trisomies and the sex monosomies of the living’ (Kelly, Almy, Jakovic and Buckner 1965) (trisomy and monosomy being chromosomal abnormalities). The idea of ‘embryonic wastage’ echoes earlier medical discourses around foetal wastage, but without the overtone of medical responsibility to address this. Rather, the miscarriage of chromosomally abnormal foetuses was seen as a natural (and positive) phenomenon. Writing in 1972, embryologist C.R. Austin, who held the specially created Charles Darwin Chair in Animal Embryology at the University of Cambridge, stated that: Accumulating evidence suggests that prenatal elimination is in the main an important and valuable provision of Nature. The fact is becoming increasingly clear that a large proportion of resorbed or aborted embryos and foetuses are abnormal, and that their summary disposal is in the best interests of the race. (Austin and Short 1972: 152)

Such language had clear echoes of early twentieth-century discourses about national efficiency and eugenic discourse, and, while the phrase ‘best interests of the race’ gives pause in light of historical precedents for such concepts, the content is unsurprising given the antecedents of genetics in eugenics. By the mid 1970s, therapeutic screening and abortion at an early stage of pregnancy was advocated as a means of reducing the likelihood of severe birth defects. Roberts and Lowe wrote in 1975: The notion of controlling the problem of severe malformation at birth by early recognition and abortion is so good and so simple that

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one wonders why Nature did not think of it first. We believe she did. There is now good evidence that product rejection by way of implantation failure and spontaneous abortion is her principal method of quality control. (Roberts and Lowe 1975)

This was a substantial shift in rhetoric from avoiding ‘foetal wastage’ and ‘salvaging’ the foetus to rejecting ‘products’ and controlling the quality of the population. Referring to termination of pregnancy for medical reasons, Roberts and Lowe suggested such terminations were a societal good, beyond the rights of the individual (‘in the long term society may come to regard abortion as a natural function responsible for control, not only of quantity, but of quality’), and made a link with abortion rights campaigns: ‘If Nature resorts to abortion to maintain genetic stability by discarding as many as three in every four conceptions, it will be difficult for anti-abortionists to oppose abortion on moral and ethical grounds’ (Roberts and Lowe 1975). While other correspondents rejected this connection (for example, Scott (1975) referred to it as a step of ‘staggering illogicity’), advances in understanding spontaneous foetal loss were intimately tied up with debates around the ethics and practice of planned termination of pregnancy. In addition, I would suggest there was a clear departure from the notion of the ‘unborn child’ as a coherent entity, as discourses reflected medical advances in understanding of chromosomes and likely deformations. Scientists culturing amputated aborted foetal limbs and cell growths were by necessity dissociating from the idea that this was a potential person, rather than a collection of malformed cells. This departure was in many ways necessary to progress the idea that abortion and termination of pregnancy for medical reasons were both ethically acceptable and represented medical progress.

Articulating Miscarriage Experiences The framing of the 1967 Abortion Act, and its 1990 amendment, meant that abortion became a medicalized process, an outcome intended by those doctors who supported the legalization of abortion for medical and public health reasons, and a formalization of conventional practice in Scotland (Davis and Davidson 2006). This meant that much of the confusion around women presenting with symptoms of pregnancy loss was removed. Nonetheless, as Fran Amery has demonstrated, this process of medicalization involves

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‘complex struggles and negotiations concerning the identities of doctors, women and foetuses’ (Amery 2014). As women have asserted their rights to effective and safe contraception and abortion, the categorization of the foetus as a ‘baby’ or ‘child’ has again become politically charged. Indeed, the fragmentation of the foetus to component karyotypes, cells and limbs in genetic research aligns with the disavowal of the foetus as ‘a baby’ in abortion discourse, and indeed in British law. The fragmentation of the foetus contrasts starkly with public images that increasingly proliferated from the 1970s onwards of the living, growing optimum foetus (and subsequent healthy baby) which became iconic with the widespread use and cultural appropriation of ultrasound scanning (Nicolson and Fleming 2013). By the end of the twentieth century, women in Britain had access to home pregnancy tests, and to medical services free at the point of delivery, including increasingly early ultrasound scanning and blood tests, to assist with the recognition of early pregnancy. While pregnancy was increasingly considered a private matter of choice, its progress was still seen as a public good, evident by the proliferation of foetal imagery and antenatal guidance featuring images of the developing foetus. These guidelines and pressures were, and are, reinforced by the social and medical stigmatization of female behaviour contrary to these guidelines which could potentially harm the (optimum) foetus (Oaks 2001). Similarly, where the development of the foetus is not perceived to be optimal, access to abortion easily tips over into pressure to terminate (Löwy 2014: 293). Within this context, the dead or dismembered foetus remains largely hidden, featuring only as a visual tool of pro-life campaigns, while the miscarried foetus remains almost absent from public and cultural discourses. Indeed, it is often the absence of a foetus that confirms miscarriage. On Christmas Eve in 2008, at eight weeks pregnant, I started bleeding heavily and thought I passed the foetus. I was scanned at the local hospital and told my uterus was empty, there was no pregnancy there. While this merely confirmed what I had already guessed, the brutality of the language remains with me. There was no discussion, no follow up, just a walk back into the dark night. There was nothing to see, no cultural script to refer to, and a not uncommon experience. In among the medical case studies and research articles of the medical journals, I found a book review by an anonymous reviewer in the Lancet from 1988. The reviewer wrote:

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Most women who miscarry never see the foetus. The few who do, despite the distress and shock, seem almost glad to describe their babies …. Seeing the child has given human shape to a bereavement which is rarely discussed publicly, since it combines the taboo of death with the even greater taboo of female blood. (Anon. 1988)

The review was of Margaret Leroy’s book Miscarriage, which discussed miscarriage and brought together personal testimonies from women who had contacted The Miscarriage Association, a patient advocacy and self-help organization founded in 1982 (Leroy 1988). Leroy’s book forms part of a small, but significant, number of books published in the 1980s and 1990s that provided space for women to articulate and recognize their experiences of miscarriage. Such publications appeared in the wake of second wave feminism and the imperative to empower women, but also the need to situate miscarriage in light of new technologies. In Leroy’s book, ultrasound and foetal imagery are explained in the introductory pages. She writes: the picture is blurred, but a trained ultrasonographer will be able to tell whether there is a foetus, whether it is the right size, and whether it is alive as the heartbeat can be seen after about eight weeks of pregnancy. (17)

Leroy makes no assumption that the foetus will be alive: the book, after all, is on miscarriage, and ultrasound is positioned as the means of discerning life or death. One woman, Tina, is quoted explaining that there was no heartbeat detected at a check-up of her pregnancy: I forced myself to look at the screen. Where there had been lively movement of arms and legs, there was none – no movement at all, his body was deathly still. Frantically, I searched for a little sign, something to say that all was not lost … I had two more scans that day to make quite sure medically, these times I could not look, I needed no confirmation, the picture was vividly etched on my mind, a stillness never to be forgotten. (17–18)

In place of an attribution of life, the women who experienced a miscarriage describe its absence, in a way that goes beyond the absence of life on an ultrasound scan. The absence is of a baby, of motherhood, of emotional equilibrium, which had previously been there. Emma speaks of her grief at the empty nursery (87), Pamela speaks of ‘emptiness’, an emptiness that is both emotional and physical (88). Sandra says, ‘I knew I had lost the baby because I felt

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so empty’ (88). There is a clear recognition that the grief is not for something tangible – ‘to draw the form of a miscarried baby … “is to sketch the shape of the rain”’ (89) – but this intangible entity is consistently equated with a person. Lorna is quoted thus: It does not matter at what stage a baby vanished from your body and your life, it’s hard to come to terms with the silence which surrounds a baby who is not full-term. (89)

As well as the silence around miscarriage, the quotes speak to the very blurred boundaries around what was being experienced – the loss of a foetus or the loss of a baby? My third miscarriage was a missed miscarriage in April 2009, that is, the foetus died in utero but was not passed out by my body. This time I had an early viability scan at seven weeks, the technology so advanced that I was no longer looking at a blurred black and white image with a white flashing dot. There was a visible foetus with a clearly beating heart. I went back for another scan after the first trimester. The scan showed a foetus with arm and leg buds, but no heartbeat, a still little black and white, large-headed Gummy Bear inside me. In the waiting room, I could hear the unmistakable sound of foetal heartbeats from pregnancies more successful than mine. I went back a week later, and was looked after in a side room, where the sound of the successful pregnancy heartbeats still permeated the walls intermittently. I passed the foetus cramping on the floor in the bathroom, and it was sent for testing to see what, if any, cause of its demise could be found. They found nothing, I got nothing back, I was told there was too little to meet any medical guidelines for release. For weeks afterwards, I had nightmares in which I was searching the hospital looking for the lost foetus. But what was I looking for? This question cannot clearly be answered. If I think about the 37-week stillborn daughter of my sister laid out in a Moses basket, compared to my expelled foetus on the bathroom floor, there are legal and medical lines drawn around what/who has been lost, as well as personal sensitivities and ethical issues. Until 1990, stillbirth was recognized after 28 weeks, which was seen as the age at which the foetus became viable. Advances in neonatal care and increased chances of survival for premature infants from 24 weeks by the 1980s led patient advocacy groups (Stillbirth and Neonatal Death Society and the Miscarriage Association), and professional medical groups (midwives, nurses, general practitioners and obstetricians), to seek an earlier age of viability. The stage of viability was relevant to practical matters such as

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whether the birth should be registered, access to burial and cremation services, whether the bereaved mother was able to exercise her rights to maternity leave, as well as the ways in which others perceived the pregnancy loss. By the late twentieth century, guidance on stillbirth explicitly recognized the loss bereaved parents experienced, hospitals became more sensitive in providing details of burials, albeit often in mass graves, and access to religious and pastoral care for women and their partners experiencing a stillbirth improved (Duchemin-Pelletier 2017). These developments meant that the gap in provision for women experiencing miscarriage, particularly late miscarriage, became more pronounced from the 1980s. Guidance from the Royal College of Obstetricians and Gynaecologists in 1984 noted that parents experiencing late miscarriage ‘may show as much grief’ as those experiencing bereavement at a later stage of development and may wish for a burial (RCOG 1984), but patients themselves did not feel this was recognized (Oakley, McPherson and Roberts 1984: 106). There were also difficulties around the disposal of foetal remains prior to 28 weeks as these were not officially human remains, a point which caused some women seeking formal burial or cremation significant distress (Royal College of Midwives to Mr Atlay, March 1985). In 1983, Lovell noted that burial was not suggested to bereaved parents as an option if the baby was under 28 weeks’ gestation and quoted a graphic, and unpleasant, description of what happened instead to the deceased foetuses (Lovell 1983: 756). For some of the women Lovell interviewed, not knowing what happened to the bodies of their miscarried and stillborn babies was a source of distress (758). Lovell also found that health care workers considered that the earlier the pregnancy failed, the ‘lesser’ the loss, a view not necessarily shared by bereaved parents (756). Lovell’s research highlights the patchy, haphazard and inadequate care of women experiencing pregnancy loss, and the prevailing medical view that ‘unless it [was] a “proper” baby, it [did] not count’ (759). Around the same time, Henderson, who had had five miscarriages, said that the terms ‘foetus’ and ‘baby’ were interchangeable for doctors, ‘depending on whether the baby [was] dead or alive’. She explained: Listen to the next conversation during a normal scan. ‘There’s the baby’s head. See his leg there.’ Should that baby die in utero though, they hide behind ‘foetus’ or ‘embryo’ or ‘16-week pregnancy’. (Oakley, McPherson and Roberts 1984)

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Similarly, in 1993, sociologist Letherby noted that ‘doctors talked about the “foetus”, whereas to [interview respondents] it was their baby’ (Letherby 1993: 168). Maria Saunders explained her feelings thus: ‘I was devastated. It had taken me five years to get pregnant. The doctors treated it as an everyday event and just tough luck’ (Oakley, McPherson and Roberts 1984: 141). Indeed, as I have shown above, for some medical professionals, miscarriage was not only routine, but a natural process that could help advance understandings of genetic abnormalities and diseases. Change in the care of women experiencing pregnancy loss was gradual, and arguably is still incomplete. From the 1980s onwards, there was a shift towards articulating the experience of miscarriage from an emotional as well as a physical point of view. In 1988, a woman called Althea Hayton wrote to the Lancet. She described herself as ‘a housewife’ with ‘no medical qualifications’, a point that makes the publication of her letter notable. Drawing on anecdotal evidence from her social circle, Althea Hayton highlighted the experiences of depression that her female acquaintances and friends experienced following a miscarriage, particularly at the unmet due date (Hayton 1988). A year later, an editorial in the same journal noted the mismatch between clinical practice, which saw miscarriage as ‘routine’, and the feelings of women who experienced spontaneous pregnancy loss as ‘major trauma’, particularly if there had been preceding fertility issues (Anon. 1989). The language used to describe women’s experiences is illustrative of changing attitudes – ‘distress and shock’, ‘depression’, ‘trauma’. Such language was a step-change from medical opinion in the earlier decades of the century, which berated women for viewing miscarriage as a natural occurrence and failing to seek medical advice, and from the words of women themselves, who saw it as part and parcel of what women had to put up with for lack of any alternative. However, substantive guidance on the care of women experiencing miscarriage and on providing sensitive disposal of foetal tissue only really emerged some twenty years later, and practice remains inconsistent (McGuinness and Kuberska 2017).

Conclusion This chapter has considered miscarriage as a normal part of women’s reproductive experience, which has been overshadowed by debates around abortion. I wrote the chapter after a hiatus in my research

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on miscarriage, and returning to it I find that it raises more questions than my research to date is able to answer. Nonetheless, it is possible to offer some preliminary conclusions. For the first half of the twentieth century in Britain, the legal position of a foetus as not (yet) born had no bearing on its right to (future) life, as evidenced by the legal prohibition of abortion and the discursive power of the ‘unborn child’ in justifying maternalist, political and medical claims over reproduction. At a very basic level, the medical profession, and indeed law-makers, did not, and could not, know the rate of miscarriage compared to abortion. Both abortion and miscarriage were framed as the responsibility (and fault) of the woman concerned, either through procuring or inducing pregnancy loss or behaviours not perceived to be compatible with healthy pregnancy. The women from the working classes who wrote about their losses in 1915 explained that financial pressures meant they often did not seek medical assistance, for what was considered either a natural part of reproductive life or a consequence of material circumstances they could not change, only cope with. The writings of women suffering pregnancy losses were collected and published at a point when there was an upsurge of concern about population health, and a desire to improve the conditions of mothers and children. Here, the extending of childhood backwards to the period ‘in utero’ in the notion of the ‘unborn child’ allowed foetal health to be considered and included in this rubric. This was evident both in moves to increase antenatal care, and in medical claims to the foetus for research purposes. This led to a focus on environment, nutrition and the role of vitamins, particularly vitamin E, in preventing spontaneous pregnancy loss, in the first instance; in addition, the desire for optimum pregnancy outcomes drove research on hormonal interventions, with quite disastrous results, in the case of DES. While the tragedy of DES is well documented, it is less clear when and how research on nutrition and hormones developed relating to the foetus, and the implications of this for beginning to erode the central and coherent conceptualization of the foetus as a child or baby ‘in utero’. Medical claims to the foetus also included retaining the products of conception for research into understanding and identifying the chromosomal make-up of human beings, and the implications where abnormalities occurred. This involved a conceptual shift from seeing the foetus as an ‘unborn child’ to seeing it as a collection of cells and unformed limbs which could be amputated, cultured and analysed. It is worth considering when and how this shift occurred,

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and the link with abortion politics, which by necessity calls into question the view that the foetus is or can be analogous with a person. Identifying the role of chromosomal abnormalities paradoxically led to screening and the option of medical termination, an intervention which does not save the foetus involved and depends on the cultural, political and medical belief that pregnancy should have an optimum outcome, lacking any avoidable abnormality or incompatibility with life. This is a complex medical and ethical issue beyond the scope of this chapter; suffice to say such interventions were and are not value neutral. The issues were further complicated as the notion of the foetus as an ‘unborn baby’, with a set of moral and ethical rights, was increasingly used to support positions that would end women’s medical and legal ability to terminate a pregnancy. The concrete, coherent idea of the ‘unborn child’ was reinforced by increasingly sophisticated ultrasound technology, which provided a visual identity for the ‘unborn child’, which was also picked up and used in pro-life positions in abortion debates. Where do these developments leave women who experience natural pregnancy loss? As I have shown, such losses are hard to place culturally. Expectant mothers are provided with nutrition and lifestyle guidelines from pre-conception through to breastfeeding, which emphasize maternal responsibility. These guidelines are reinforced by the social and medical stigmatization of behaviour contrary to these guidelines which could potentially harm the foetus. While becoming pregnant or continuing pregnancy is surrounded by a rhetoric of choice, many factors are beyond the individual’s control: chromosomal abnormalities, as well as environmental factors, toxins or even pharmaceutical products intended to help pregnancy, to give some examples discussed in this chapter. Women who experience miscarriage are thus left with a cultural knot of competing values in which to locate their own experiences, which is compounded by the silence that surrounds it. This can be located within the context of awareness of the precarity of women’s reproductive choices (within their relationships, nationally and at a global level); but also, I would suggest, awareness of the many worse outcomes of maternal mortality, stillbirth, infant or child death which form reproductive experience. All of this makes it hard to articulate what has been lost in miscarriage in a politically and personally sensitive manner. Publications that attempted to articulate the loss experienced in miscarriage emerged in the 1980s and 1990s, in the wake of second wave feminism and activism to raise awareness of the issues affecting women as a result of their

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biological and reproductive role in society. While second wave feminism challenged the primacy of motherhood and sex-based social roles, it also provided a platform for health activism and the recognition of female needs in the traditionally private sphere. The books published in this period provided a space for women to speak of their experiences of early and mid-pregnancy foetal loss, in a way that was protected from other political imperatives. The books and publications focus only on what it is like to miscarry and what that means for women. There is brief mention of the feelings of husbands and partners, but they often received even less support or acknowledgement of their loss. Despite this brief burst of literature, there remains a level of silence around the fact that miscarriage, stillbirth and perinatal mortality still affect a substantial proportion of pregnancies. In 1993 Letherby explained that ‘several of my [research interview] respondents said they didn’t realize that miscarriage was so common until it happened to them’ (Letherby 1993: 170). A lifestyle article in the Observer in 2010 headlined with the statement: ‘Up to 20% of pregnancies end in miscarriage – and yet most women never reveal they have had one’ (Carpenter 2010). As I wrote at the outset, I too did not realize that miscarriage was so common until it happened to me. As this article has shown, miscarriage occupies a space between not-pregnant and pregnant; not being a mother and being a mother. There is thus no socially or culturally recognized space or place for the miscarried foetus, or for the woman who has miscarried. This chapter has made a start on considering why, historically speaking, that may be. Dr Rosemary Elliot is a senior lecturer in Economic and Social History at the University of Glasgow. Her current area of research is the history of the family from the mid nineteenth century to the present day focusing on Scotland but with reference to developments internationally. This includes and develops a large project on the History of Working-Class Marriage in Scotland, 1855–1976, funded by the Arts and Humanities Research Council 2012–2017. Dr Elliot’s work centres on expectations and experiences of marriage, understandings of parenting and childhood, marital breakdown and child welfare. Dr Elliot has also done work on the history of miscarriage in Britain, which explores medical understandings and personal experiences of pregnancy loss and informs the chapter in this book. Dr Elliot has previously worked on smoking and public health in Britain and Germany, funded by the Wellcome Trust.

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This also covered developing medical awareness of the health implications of smoking in pregnancy.

References Adamson, R., and H. Palmer Jones. 1918. ‘The Work of a Department for Employing Expectant Mothers in a Munition Factory’, British Medical Journal 21 September 1918: 309–10. Al-Gailani, S. 2013. ‘Pregnancy, Pathology and Public Morals: Making Antenatal Care in Early Twentieth Century Edinburgh’. In J. Greenlees and L. Bryder (eds), Western Maternity and Medicine, 1880–1990. London: Pickering & Chatto, pp. 31–36. Al Jishi, T., and C. Sergi. 2017. ‘Current Perspective of Diethylstilbestrol (DES) Exposure in Mothers and Offspring’, Reproductive Toxicology 71: 71–77. Allen, M., and S. Marks. 1993. Miscarriage: Women Sharing Stories from the Heart. New York: John Wiley & Sons, Inc. Amery, F. 2014. ‘Social Questions, Medical Answers: Contesting British Abortion Law’, Social Politics: Studies in Gender, State and Society 21(2): 26–49. Anon. 1988. ‘Miscarriage’, The Lancet, 16 January. Anon. 1989. ‘Primary Care for Spontaneous Abortion’, The Lancet, 9 December, 1409. Austin, C.R., and R.V. Short (eds). 1972. Reproduction in Mammals. Vol. 2. Cambridge: Cambridge University Press. Bacharach, A. 1940. ‘Vitamin E and Habitual Abortion’, British Medical Journal 1 June 1940: 890. Ballantyne, J. 1916. ‘Notification of Pregnancy’, British Medical Journal 22 April 1916: 594–95. Beckwith Whitehouse, ‘Abortion: Its Frequency and Importance’, British Medical Journal 14 December 1929: 1095–1099. The author here is assumed to be Harold Beckwith Whitehouse (1882–1943), although the first name is not given. Bishop, P. 1952. ‘Habitual Abortion: Further Observations on the Prophylactic Value of Progesterone Pellet Implantation’, British Medical Journal 2 February 1952: 244–46. Brown, C.R. ‘The Biological Aspect in Treatment of the Infertile Marriage’, British Medical Journal, 13 November 1948: 851–3. Carpenter, L. 2010. ‘Miscarriage: A Mother’s Last Taboo’, The Observer, 22 August. Retrieved 5 September 2018 from https://www.theguardian. com/lifeandstyle/2010/aug/22/pregnancy-miscarriage-lesley-regan. Carr, D. 1963. ‘Chromosome Studies in Abortuses and Stillborn Infants’, The Lancet, 21 September, 602–7.

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Cross, R. 1946. ‘Repeated Abortions, Miscarriages and Stillbirths’, The Lancet, 23 November, 754. Davin, A. 1978. ‘Imperialism and Motherhood’, History Workshop Journal 5: 9–65. Davis, G., and R. Davidson. 2006. ‘“A Fifth Freedom” or “Hideous, Atheistic Expediency”? The Medical Profession and Abortion Law Reform in Scotland, c. 1960–1975’, Medical History 50(1): 29–48. Donald, A. 1916. ‘The Care of the Pregnant Woman’, British Medical Journal, 8 July 1916: 33–35. Duchemin-Pelletier, M. 2017. ‘Stillbirth: Medicalization and Social Change, 1901–1992’, Unpublished Ph.D. thesis. University of Glasgow. Eden, T. 1926. ‘Antenatal Care as It Affects the Child in Utero’, Postgraduate Medical Journal 2(15): 35–39.  . 1931. ‘The Infant Mortality of Birth’, The Lancet, 5 December, 1223–27. Elliot, R. 2014. ‘Miscarriage, Abortion or Criminal Feticide? Understanding Pregnancy Loss in Early Twentieth Century Britain’, Studies in History and Philosophy of Biomedicine and Biomedical Science 47: 248–56. Fisher, J. 2008. ‘Termination of Pregnancy for Fetal Abnormality: The Perspective of a Patient Support Organization’, Reproductive Health Matters 16(31): Supplement: Second Trimester Abortion. Fox Connell, L. 1942. ‘Science Dries a Woman’s Tears: New Drugs and Treatments Which Work Miracles on Women’, Vogue 100(9): 46–47. Gammerl, B. 2012. ‘Emotional Style: Concepts and Challenges’, Rethinking History: The Journal of Theory and Practice 16(2): 161–75. Hall, A., and W. Ransom. 1906. ‘Plumbism from the Ingestion of Lead as an Abortifacient’, British Medical Journal 24 February 1906: 426–29. Hayton, A. 1988. ‘Miscarriage and Delayed Depression’, The Lancet, 9 April, 834. Hedley, J. 1924. ‘Abortion and Threatened Abortion’, The Lancet, Extra Numbers, 34. Horrocks, P. 1901. ‘A Discussion on the Causation, Prevention and Treatment of Miscarriage’, British Medical Journal 5 October 1901: 943–47. House of Commons Parliamentary Papers, 1919a. Women in Industry: Report of the War Cabinet on Women in Industry. Cmd. 135. London: HMSO. House of Commons Parliamentary Papers. 1919b. Report of the Committee on Women in Industry: Appendices, Summaries of Evidence etc. London: HMSO. ISRCTN Registry. 2010. ‘Progesterone in Recurrent Miscarriages (PROMISE) Study’. Retrieved 26 October 2019 from http://www.isrctn.com/ ISRCTN92644181. Jardine, R. 1902. ‘Proceedings of the Glasgow Obstretrical and Gynaecological Society: Discussion on the Treatment of Miscarriage’, Glasgow Medical Journal 58: 44–54. Johnstone, R. 1933. ‘Gynaecological Aspects of Endocrinology’, British Medical Journal 23 September 1933: 557.

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Kelly, S., R. Almy, L. Jakovic and L. Bucker. 1965. ‘Autosomal Monosomy in Spontaneous Abortion’, The Lancet, 16 January, 166. Koven, S., and S. Michel. 1993. Mothers of a New World: Maternalist Politics and the Origins of Welfare States. New York: Routledge. Kruks, S. 1992. ‘Gender and Subjectivity: Simone de Beauvoir and Contemporary Feminism’, Signs: Journal of Women in Culture and Society 18(1): 89–110. Langston, N. 2010. Toxic Bodies: Hormone Disrupters and the Legacy of DES. New Haven, CT: Yale University Press. Leroy, M. 1988. Miscarriage. London: MacDonald Optima, Ltd. Letherby, G. 1993. ‘The Meanings of Miscarriage’, Women’s Studies International Forum 16 (2): 165–180. Lewis, J. 1980. The Politics of Motherhood: Child and Maternal Welfare in England, 1900–1939. London: Croom Helm. Littlewood, J. 1999. ‘From the Invisibility of Miscarriage to an Attribution of Life’, Anthropology & Medicine 6(2): 217–30. Loudon, I. 1992. Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800–1950. Oxford: Oxford University Press. Lovell, A. 1983. ‘Some Questions of Identity: Late Miscarriage, Stillbirth and Perinatal Loss’, Social Science & Medicine 17(11): 755–761. Löwy, I. 2014. ‘Prenatal Diagnosis: The Irresistible Rise of the “Visible Fetus”’, Studies in History and Philosophy of Biology and Biomedical Sciences 47: 290–99. MacDonald, R. 1965. ‘Norethynodrel and Mestranol (Enavid) in the Prevention of Recurrent Abortion’, The Lancet, 21 August, 362–65. McGuinness, S., and K. Kuberska. 2017. ‘Report to the Human Tissue Authority on Disposal of Pregnancy Remains (Less than 24 Weeks’ Gestational Stage)’. Retrieved 28 September 2018 from https://deathbeforebirthproject.org/research/htareport2017/. Miller, O., et al. 1962. ‘Normal Variations in the Human Karyotype’, Transactions of the New York Academy of Sciences 4(4) series II: 373–82. Ministry of Health. 1937. Report on an Investigation into Maternal Mortality. Cmd. 5422. London: Her Majesty’s Stationery Office. Nicolson, M., and J. Fleming. 2013. Imaging and Imagining the Fetus: The Development of Obstetric Ultrasound. Baltimore, MD: Johns Hopkins University. Oakley, A., A. McPherson and H. Roberts. 1990. Miscarriage. 2nd ed. London: Penguin Books. Oaks, L. 2001. Smoking and Pregnancy: The Politics of Fetal Protection. New Brunswick, NJ: Rutgers University Press. Parsons, K. 2010. ‘Feminist Reflections on Miscarriage in Light of Abortion’, International Journal of Feminist Approaches to Bioethics 3(1): 1–22. Penrose, L., and J. Delhanty. 1961. ‘Triploid Cell Cultures from a Macerated Foetus’, The Lancet, 10 June, 1261–62. Plamper, J. 2015. History of Emotions: An Introduction. Trans. K. Tribe. Oxford: Oxford University Press.

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Pugh, M. 1992. Women and the Women’s Movement 1914–1959. Basingstoke: Macmillan. Regan, L. 2001. Miscarriage: What Every Woman Needs to Know. 2nd ed. London: Orion Books, Ltd. Robb, G. 1997. ‘Race Motherhood: Moral Eugenics vs Progressive Eugenics, 1880–1920’, in C. Nelson and A. Sumner Holmes (eds), Maternal Instincts: Visions of Motherhood and Sexuality in Britain, 1875–1925. Basingstoke: Macmillan Press, pp. 58–74. Roberts, C., and C. Lowe. 1975. ‘Where Have All the Conceptions Gone?’ The Lancet, 1 March, 498–99. Robertson, J. 1994. Children of Choice: Freedom and the New Reproductive Technologies. Princeton, NJ: Princeton University Press. Robson, J. 1936. ‘Hormones and Pregnancy’, British Medical Journal 23 May 1936: 1033–38. Ross, E. 2016. ‘Locating the Foetal Subject: Uncertain Entities and Foetal Viability in Accounts of First-Time Pregnancy’, Women’s Studies International Forum 58: 58–67. Routh, A. ‘The Need for Medical Supervision in the Care of the Pregnant Woman’, British Medical Journal 29 July 1916: 158–159. Rowthorn, W. 1906. ‘Lead as an Abortifacient’, British Medical Journal 10 February 1906: 355. Royal College of Midwives to Mr Atlay, March 1985. RCOG Archives, M 17/5. Royal College of Obstetricians and Gynaecologists. 1980. ‘Confidential Enquiry into Perinatal Mortality: Working Party Report 1980’. RCOG Archives C16/1.  . 1984. Guidance on Management of Perinatal Deaths, 17 September. RCOG Archives 17/5. Royal College of Obstetricians and Gynaecologists 33rd Study Group. 1997. ‘Recommendations from the 33rd Study Group’. In J.C. Grudzinskas and P.S. O’Brien (eds), Problems in Early Pregnancy: Advances in Diagnosis and Management. London: RCOG Press, pp. 327–31. Scott, J.S. 1975. ‘Where Have All the Conceptions Gone?’ The Lancet, 15 March. Smith, B. 2000. The Gender of History: Men, Women and Historical Practice. Cambridge, MA: Harvard University Press. The Women’s Co-operative Guild. 1915. Maternity: Letters from Working Women Collected by the Women’s Co-operative Guild. London: G. Bell and Sons, Ltd. Willcox, W. 1915. ‘Criminal Abortion and Professional Secrecy’, The Lancet, 9 January, 97.

Chapter 3

Alleviating the Ambiguities around Miscarriage Discursive Tactics in Cameroon and Romania Erica van der Sijpt

Introduction Early pregnancy losses are often ambiguous events, for various reasons. First, happening at a stage when a pregnancy may not yet be officially confirmed, physically felt, socially disclosed or visibly present, the unexpected event of a miscarriage often raises ontological questions about what has been lost. The answers people give to such fundamental questions vary enormously, depending not only on the gestational moment at which the loss occurred, but also on wider cultural notions of physiology, embryology, personhood, life and death. While for some a miscarriage represents the death of a developing baby (Layne 2000), for others it may be no more than the expulsion of blood, water, dirt, a collection of cells, or any other ‘matter out of place’ (Littlewood 1999; Murphy and Philpin 2010). People may use both interpretations simultaneously, or foreground one or the other depending on the circumstances (Jeffery and Jeffery 2010; Jenkins and Inhorn 2003; Van der Sijpt 2010). As a result, the event of pregnancy loss is often an ambiguous one – both for the women experiencing loss and for those around them.

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Second, miscarriages may raise aetiological questions about the cause of the loss. Medically, the exact causal mechanism underlying pregnancy loss is often far from clear-cut; culturally, aetiological interpretations can be very diverse. Often covering a whole range of naturalistic and personalistic understandings of causation (Foster 1976), aetiological interpretations of pregnancy loss may be complex, changeable and contradictory (Cecil 1996; Pool 1994; Rice 2000; Sobo 1996; Van der Sijpt and Notermans 2010; Wembah-Rashid 1996). Ideas about external threats may further be complemented with feelings of personal guilt and failure – especially in neoliberal and technologically advanced (health care) settings in which pregnancy experiences have become imbued with a sense of responsibility and accountability (Kilshaw, this volume; Lupton 2012; McCabe 2016; Rapp 2000; Thompson 2005). The lack of a univocal consensus about the provenance of pregnancy loss increases uncertainty and ambiguity when reproduction goes awry. Third, when disclosed to others, early pregnancy losses may raise questions about the intentionality behind the mishap. Especially in settings where abortions are secretly induced and publicly presented as miscarriages because they are legally or morally condemned, the exact distinction between spontaneous and induced loss often becomes blurred for outsiders (Suh 2014, 2018). The news of an unexpected pregnancy loss is then likely to raise suspicions about the potential involvement of the previously pregnant woman. Such dynamics may be exacerbated by local terms for pregnancy loss that refer to both spontaneous and induced abortions, or at least leave the distinction between the two ambiguous. The agentic (and often moral) associations of such ambiguous labels may generate complex discursive navigations from miscarrying women trying to disprove their culpability (Erviti, Castro and Collado 2004; Van der Sijpt 2018). It has been argued that, due to these various ambiguities, miscarriages are difficult to cope with emotionally (Brier 1999; Frost and Condon 1996; Lee and Slade 1996; Letherby 1993). While I do not wish to deny the challenges around miscarriage, in this chapter I aim to show that this ambiguity, for all the uncertainty it may imply, also creates opportunities. Drawing on a growing understanding of reproduction as a domain ‘in which people reconceptualize and reorganize the world in which they live’ (Van Hollen 2003: 5), I argue that instances of reproductive disruption can be explicit moments of reorientation. It is exactly when previously held reproductive imaginations are unexpectedly distorted

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and one’s reproductive future is left hanging in the balance that explicit ‘reproductive navigation’ (Van der Sijpt 2018) takes place.1 Miscarriages, then, are moments par excellence for understanding the discourses and dynamics that may evolve in times of uncertainty, ambiguity and potential reorientation. In this chapter, I will focus especially on women’s navigation at a discursive level. Drawing on insights from my fieldwork in Cameroon and Romania, I will explore some elements of the discursive environment that profoundly shape experiences of pregnancy loss in both countries, and I will illustrate how miscarrying women try to alleviate the resulting ambiguity. While the country settings and particular case studies differ in many ways, women’s tactical navigation reveals similar dynamics. Indeed, it is exactly by comparing two contexts that are radically different in many ways that cross-cultural patterns and similarities can be more easily discerned.2 The illustrations from two different corners of the world thus contribute to a more general understanding of women’s tactical responses to the ambiguities that may arise when reproduction goes awry.

Study Details The ethnographic research that lies at the basis of this chapter stretches over more than a decade. In Cameroon, I spent fifteen months (between 2004 and 2009) conducting my MA and Ph.D. studies; in Romania, I spent a similar amount of time (between 2012 and 2015) in the framework of my post-doctoral research project. In both countries, I was interested in the social dynamics that evolve around involuntary pregnancy loss and other moments of heightened reproductive uncertainty. Despite the countless geographical and cultural differences between the two settings, I found that the topic of pregnancy loss was similarly silenced or approached with apprehension; it turned out to be an ‘open secret’ (Ledeneva 2011) about which neither my Gbigbil informants in the eastern Cameroonian rainforest nor my Romanian interlocutors in the Carpathian Mountains and Bucharest would talk very openly. The consequence was that I had to spend a lot of time ‘hanging around’ in both fields, while chatting informally (in Cameroonian French and in Romanian) and approaching the topic only indirectly – a strategy that has also been called ‘rear-mirror methodology’ (Ledeneva 2011; Wamsiedel 2017) – before I could comfortably resort to more classical anthropological methods such as in-depth

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interviews, focus group discussions, (intimate) observations, and various specific rapid appraisal techniques.3 Eventually, I ended up interacting with numerous people – men and women, elderly people and youngsters – who had experienced some sort of reproductive loss or uncertainty. My closest connections, however, were forged with about twenty-five women in Cameroon and fifteen women in Romania, who had all lost at least one pregnancy in their lives. These women allowed me to be part of some very intimate reproductive moments, such as (problematic) deliveries, abortions and baby funerals in Cameroon, or the emotionally charged commemoration of lost foetuses in Romania. Such first-hand experiences proved to be indispensable for a deeper understanding of a largely undiscussed and socially unacknowledged private matter. To the extent that it was socially acceptable and possible, I recorded my interviews and focus group discussions, and transcribed them verbatim afterwards. These transcripts and all my notes (of informal conversations and observations) were coded systematically in Atlas.ti. Due to the sensitive nature of the information described in this chapter, all names that appear in the text are pseudonyms.

The Childbearing Imperative Cameroon From the moment I started asking questions about reproduction in eastern Cameroon, my Gbigbil interlocutors consistently told me that they loved children (‘nous on aime les enfants’) and that they considered their descendants to be their greatest wealth (‘l’enfant, ç’est la richesse’). Such expressions were backed by the regional fertility rates at the time: on average, women in the East Province would bear 5.4 children during their lives (Demographic and Health Survey [DHS] 2011). Ideally, people told me, those children would be born within a conjugal arrangement, concluded through a series of bride-price exchanges between both partners’ families as a woman sets out to live in the compound of a man. Every child born in such a setting is considered to belong to the father and his family; even if a woman decided to leave her husband, her children should stay with their patrilineal kin. In such a framework, then, children are a source of wealth and pride for their fathers because they expand the patriliny, and they offer social status and security to their mothers who, by producing offspring, contribute to this

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expansion. This equilibrium is presented as the situation to which everybody aspires. In practice, however, things are much less harmonious. As has been noted for other patrilineal societies as well (Bonnet 1988; de Thé 1970; Geschiere 1982), the position of a (newly) married woman has always been pervaded by ambivalence: for the family of the man, she is an outsider on whom they depend for the continuation of their lineage; for her own family, she eventually becomes an outsider as well, since she will leave her paternal home to go and bear (precious) children for another family. Never really ‘belonging’ somewhere, married women are in an ambivalent position, facing hostility and solidarity from both families. Traditionally, bride-price exchanges that compensated for the ‘loss of childbearing potential’ experienced by the woman’s family would attenuate such frictions and enable the creation of an enduring alliance between the two lineages. Yet, in present-day Cameroon, and especially in the impoverished eastern region, this bride-price often remains unpaid or only partially paid. Consequently, many marriages are essentially mere informal arrangements constituted by the communal living, eating and sleeping of a man and a woman. These informal unions easily dissolve as soon as one of the partners loses interest or finds a better ‘catch’. Within this unstable marriage setting, bearing children has become an important strategy for women to convince their partners of their worth and of the necessity to initiate negotiations between families – but it is never a guarantee, as men (and their families) may just be unable or unwilling to collect all the required goods and money, despite their desire for children. When deprived for too long of the gifts they expect as wife-givers, women’s kin might, in return, claim the children of their daughters and make them ‘belong’ to their matriliny instead. Thus, both familial and conjugal relationships are characterized by flexibility, potential conflict and competition, and clear discrepancies between norms and practices. Pregnancies are surrounded by multiple interests, values and strategies as a result. In this pronatalist but discordant environment, the loss of a pregnancy is in principle lamented, but in practice variously interpreted, depending on the circumstances. Those who wish to consolidate their marital relationship through successful childbearing generally respond differently to a reproductive mishap than those who have a disappointing relationship, or other ambitions – educational, financial, familial or relational – altogether. The desirability of a

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pregnancy is contingent on the context, and so are the meanings of its loss. Sometimes a loss may be downplayed, while at other times it is dramatized. Sometimes it is wise to hide it, while at other times one may prefer to disclose or denounce it. The complex navigation of such moments shows that reproductive issues are less straightforward than generally presented (Van der Sijpt 2018). The ambiguity of Gbigbil women’s reproductive desires is not unknown to outsiders. Any unexpected loss of a pregnancy, when known by others, is therefore often carefully scrutinized. Especially those with a vested interest in the successful outcome of a pregnancy and/or with a potentially conflictual relationship with the pregnant woman – in particular partners and in-laws – may suspect the loss to have been consciously induced. Although prohibited by national law, condemned by all Christian denominations in the area and frowned upon in the local pronatalist environment, induced abortions are known to be frequently used tools for reproductive management. Among the numerous reasons for abortion that women may have, the above-described clash between patriarchal ideals and real-life conjugal fragilities was frequently mentioned to me in my interactions with Gbigbil women.4 Their abortive attempts often remain hidden, as the first few months of pregnancy are not only physically invisible, but also traditionally surrounded by silence and secrecy. Given this secrecy around pregnancy and loss, women also have some leeway to influence the public interpretations given to their reproductive mishaps. Whether or not consciously induced, generally it is in women’s interest to present any pregnancy loss that has become known to outsiders as a spontaneous event. It is not desirable to be seen as somebody who does not adhere to the patriarchal, pronatalist ideals – for it may reduce the interest and financial involvement of current or future partners, or cause trouble with in-laws and kin. The childbearing imperative, even if at times secretly undermined, is therefore often publicly upheld in order to reduce social suspicions and maintain individual status. Romania Until relatively recently, Romania’s childbearing climate was heavily politicized. Between 1966 and 1989, dictator Nicolae Ceaus¸escu, who aimed to build a strong, populous communist nation, subjected the Romanian population to extreme pronatalist interventions. Most infamous was Decree no. 770, issued in 1966, which outlawed abortions on request, with only very limited exceptions.5 Moreover,

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the communist regime prohibited the import and production of contraceptive methods (to increase the rate of conception) and subjected women of reproductive age to regular gynaecological examinations (to detect and register any possible pregnancies). All these interventions were complemented by an aggressively pronatalist propaganda. These efforts notwithstanding, the birth rate increased only in the year after the implementation of the abortion ban; in the subsequent years, women increasingly found illegal means to prevent or interrupt the pregnancies they did not want.6 These abortions were often unsafe and caused a dramatic increase in maternal mortality rates, as well as morbidity and infertility levels.7 Apart from the destructive consequences for women’s bodies, Ceaus¸escu’s politics of reproduction also severely affected social life and intimate relationships in communist Romania. As the state’s secret police apparatus had infiltrated all domains of social life in order to hunt for any subversive ideas and practices, even the most intimate interactions – between family members, partners and lovers – were pervaded by fear and distrust (Anton 2009; David and B˘aban 1996). Over the nearly three decades since the 1989 revolution, the Romanian reproductive landscape has changed drastically. Induced abortions were legalized up to 14 weeks of pregnancy; contraceptives were made available in the entire country. While Romania’s abortion rates initially peaked and still rank highest in Europe, contraceptive use gradually increased over time. Today, Romania has reached one of the lowest fertility levels in the world; on average, women bear only 1.3 children in their lives (Institutul Nat,ional de Statistic˘a [INS] 2014). In response, new pronatalist discourses have entered the public arena. While policy makers and demographers stress the urgency of redressing the ‘demographic catastrophe’ in the light of an ageing population, out-migration and ethnic mixing, the Orthodox Church uses its increasingly powerful voice to morally condemn the contraceptive and abortive practices that it claims lie at its basis. The childbearing imperative, although not strictly imposed like it was during communism, is still central to many public discussions. Such messages generally resonate well with the Romanian population, for which parenthood – next to the ownership of a house and the conclusion of a marriage – is considered one of the main achievements in life. Even if, in practice, post-communist neoliberal reforms have brought about pervasive financial insecurities, crumbling social welfare services and increasing emigration, which

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all seriously encumber processes of family formation, having children still represents a crucial part of the ‘expected order of things’ (rânduiala˘ ). People may postpone childbearing – until the age of twenty-seven on average – or interrupt pregnancies that appear at the wrong time, but rarely do they consciously choose not to have children at all in their lives. Unless unwanted from the outset, the pregnancies that are conceived often come with considerable investments (for those who can afford it), and the (single) children that are born are surrounded with multiple hopes. The possibility of spontaneously losing a desired pregnancy is largely unacknowledged and often unanticipated. When it happens, people often face not only profound feelings of disappointment, but also a widespread social silence. Due to the historical focus on the wilful termination of pregnancies in Romania, the situation of those who lose their pregnancies against their will has long been ignored. Those who happened to experience a miscarriage or stillbirth during communism were regarded with suspicion, had to undergo interrogations and faced the possibility of a criminal sentence (Kligman 1998). Nowadays, as abortions gain renewed public attention and have become imbued with negative moral connotations, miscarriages are still uncomfortably associated with the intentional interruption of a pregnancy – implicitly imbued with culpability and explicitly surrounded by silence. The childbearing imperative, then, closes people’s eyes to some of the most intimate experiences that Romanians face when their reproduction goes awry. Both in Cameroon and in Romania, official public discourses are pronatalist in nature. Though very different in nature, the political rhetoric, religious prescriptions and local ideals of family formation in both countries all stress the importance of having children. As such, they contribute to an environment in which the event of pregnancy loss is likely to become silenced, or even surrounded by suspicions. The resulting ambiguity is reflected, as well as enhanced, by the words that are locally used to denominate pregnancy loss. These will be discussed in the next section.

Terminologies of Pregnancy Termination Cameroon In Cameroon, local classifications of reproductive mishaps are quite at odds with Western interpretations of pregnancy development and loss. When Gbigbil people talk about pregnancy loss, they

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distinguish between what they call the loss of a pregnancy (abum) that does not yet contain a clear human being, and the loss of a child (mon) presenting human forms. During the first months of a pregnancy, the uterus is considered to be rather ‘void’, containing at most some ‘water water’ or ‘blood’ that will slowly transform into some lizard-like creature. When a pregnancy is lost during this early stage – something that would be labelled a ‘miscarriage’ in Western terminology – people usually say that ‘the pregnancy has fallen’ (abum ia song), ‘the pregnancy has come out’ (abum ia so) or ‘the pregnancy has left’ (abum ia vawa). Once something more firm and human-like has been created, the pregnancy itself is also said to be ‘hard’; it can no longer ‘fall’. Denotations of pregnancy loss change accordingly: the expulsion of the foetus is phrased in terms of the delivery of a dead child. Common expressions relate that ‘the child has passed’ (mon ia nul), ‘the child is dead in the belly’ (mon ia wa abum), ‘she has given birth to a child who is dead’ (abiali mon ia wa), or simply ‘the child has died’ (mon awali). Despite this conceptual distinction between early and late pregnancy losses, the exact dividing line between them is fluid. When exactly ‘abum’ turns into ‘mon’ during foetal development is not determined by a clear, linear, time-based gestational process but by the strength of one’s blood; given that this strength varies over a lifetime, one can never know exactly when a foetus is formed, viable or at term. As a result, there is no clear temporary boundary between the loss of a ‘pregnancy’ and the loss of a ‘child’ either. Such fluid conceptions leave some room for women to strategically nominate what is actually lost – mere ‘water water’ or a ‘baby’. The same interruption may be defined as a ‘falling pregnancy’ in one situation and as a ‘child death’ in another – depending on whether women choose to downplay (‘it was just blood’) or dramatize (‘a child was killed’) their pregnancy losses within the given circumstances and contestations. More than a fixed temporal framework, Gbigbil person-dependent and flexible embryology allows for person-dependent and flexible interpretations of pregnancy loss (Van der Sijpt 2010, 2013a). Distinctions between types of interruption may become even more fuzzy under the veil of similarity invoked by the general notion of ‘wasted womb’ (abum ia digela). Whether talking about ‘falling pregnancies’ or ‘child deaths’, Gbigbil people often stretch their arms and show their empty hands, to convey the sense of emptiness that remains after any of these pregnancy losses. ‘You are not left with anything, are you?’ was the rhetorical question

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they posed while shrugging their shoulders. Irrespective of the specific moment and cause of loss, the possibility of having a living baby has been ‘wasted’. By talking about ‘wasted wombs’, people stressed the fact that the meanings and effects of early and late pregnancy loss may not be as different as the separate classifications suggest. Instead, there are common consequences: all pregnancy losses make potential lives leave, and they all leave a woman’s life with less potential. General notions such as ‘wasted wombs’, but also those of ‘falling’ or ‘leaving’ pregnancies, are non-revealing as to what, or who, actually ‘wasted’ the womb or made the pregnancy ‘fall’ or ‘leave’. They describe the effect of loss, not the cause. In a setting in which it is known that women, as outsiders to their husband’s lineage, may or may not want to bear children at particular points in their lives, any invocation of a ‘wasted womb’ or a ‘fallen pregnancy’ therefore raises suspicions about the intentionality behind the loss. The gossip that almost invariably ensues when cases of early pregnancy loss come to light will often include speculations about the abortion having been consciously induced. In some circumstances, women may be indifferent about, or even fuel or confirm these suspicions; in most cases, however, they will try to alleviate the ambiguities that arise as a result. Downplaying the loss as involving (only) ‘water water’ or, alternatively, stressing the fact that what is lost was a (developing and desired) ‘child’ can be effective ways of diverting attention from the potentiality of intentionality. Romania In Romania, I found a similar ambiguity of terms. In everyday parlance, most people simply talk about ‘pregnancy loss’ (pierdere de sarcin˘a), irrespective of the gestational stage at which the loss happened. Alternatively, people use the medical terms ‘abortion’ (avort), or, less frequently, ‘stillbirth’ (f a˘ t n˘ascut mort). The colloquial use of those terms is, however, much less rigid than official definitions propose: in medical jargon, the term ‘avort’ specifically denotes ‘the expulsion of a product of conception without any signs of life [called avorton] before the gestational age of twenty-eight weeks’; when expulsion happens after 28 weeks, the lifeless ‘product of conception’ should be declared a ‘f˘at n˘ascut mort’ (decree 359/2012). In everyday language, the notion of ‘avort’ has become so widespread, however, that it is also invoked for describing cases that would medically be defined as ‘stillbirths’. Practically, the notion of ‘avort’ is almost as generic a term as ‘pierdere de sarcin˘a’.

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Like the Cameroonian notions described above, the Romanian terms ‘avort’ and ‘pierdere de sarcin˘a’ leave the question of intentionality unaddressed. The most prominent Romanian dictionary defines ‘avort’ as ‘the accidental or induced interruption of a pregnancy before a foetus reaches viability’ (Academia Român˘a 2016, emphasis added). The term thus connotes both chance and culpability. Although one could add adjectives to specify whether an abortion happened spontaneously (avort spontan) or was consciously induced (avort provocat), the word is usually mentioned in its uncompounded, and thus polysemous, form. Due to its particular usage in both past and present public discourse, however, agentic interpretations often prevail. ‘Avort’ is the word that is consistently used in the public discourse about the subversive reproductive practices during the communist regime, in critical analyses of the current ‘demographic catastrophe’ and in negative religious propaganda about immoral, wilful pregnancy terminations. Not surprisingly, those who unexpectedly miscarry are reluctant to use the term at all when describing their experiences. One informant, whose foetus died in utero and had to be removed through a curettage, illustrated the incomprehension and moral apprehension she received from those around her: Many associate this pregnancy loss with an [induced] abortion. When the thing with my child had happened and I called to say that ‘look, it’s gone’ and I said that the doctor had scheduled me for a surgery … abortion – because it’s called an abortion in medical terms, whether you accept it or not – [people said] not to do it, because it is an [induced] abortion. [But I said:] ‘No, the child is dead in me; there’s a risk of septicaemia. There’s a risk that I will die and I have another child at home. So it is not an abortion’. … I did not say wilfully: ‘I don’t want this child, take it out of me’. That is why I am telling you: people … mmmm … many are understanding, but few understand. … So I try to avoid these words. I always say ‘surgery’, because I find it hard to say ‘abortion’, I find it hard to say ‘curettage’. Because it was neither an abortion, nor a curettage. For me it was a medically necessary surgery.

Associations with intentional behaviour are also easily made when Orthodox texts and clergy mention the religious term ‘a lep˘ada’, which means both ‘to give birth to a dead foetus before term’ and ‘to abort’ (Academia Român˘a 2016). Although the verb officially designates both involuntary and voluntary loss, its alternative meanings reveal its rather agentic connotations: ‘a lep˘ada’

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also means ‘to drop or to throw a useless or worthless object’, ‘to leave behind (forever and willingly)’, ‘to push aside’ or ‘to shed’. The term figures prominently in the prayers that are sung to grant women access to the Church from which they were temporarily expelled after their pregnancy loss – irrespective of its cause. It may also be mentioned by priests who advise the confessing bereaved parents on how to redress the reproductive misfortune. Even if not intended as such, these wordings (and the rituals in which they are expressed) evoke a sense of sinfulness and blame; Romanian women who seek consolation from a priest after unexpectedly losing their pregnancies often feel shocked to encounter them so often. Both in Cameroon and in Romania, I found that the generic local denotations of pregnancy loss allow for multiple uses and ambiguous interpretations, since they are non-revealing about the cause or intentionality behind the loss. As a result, in both countries, one particular case of a miscarriage may be surrounded by a variety of ambiguous and conflicting interpretations. Given the predominantly pronatalist environment in both settings, the general disapproval of induced abortions and the resulting reluctance to talk openly about reproductive mishaps, the use of such generic terms in the case of miscarriage may give rise to misinterpretations, suspicions or even accusations of induced abortion. Miscarrying women may respond to such suspicions by strategically choosing labels for their miscarriages that best suit their own interests – from avoiding the word ‘avort’ in Romania, to talking purposively about the loss of ‘just a pregnancy containing only water’ or of ‘a desired and developing child’ in Cameroon. Discursive strategies and other tactical practices extend beyond the mere denomination of the loss. In what follows, I will present some instances of ‘reproductive navigation’ that I observed in each country. Although very different in nature, each of the examples will showcase how women inventively use dominant discourses in an attempt to pursue their own goals within their respective restrictive contexts.

Reproductive Navigations Cameroon In the above, I showed that, at least for Cameroonian outsiders, the unclear intentionality behind most ‘wasted wombs’ blurs a strict divide between spontaneous and induced loss. Spontaneous

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pregnancy losses are often suspected to be provoked as induced abortions are often presented as miscarriages. As a result, those who really miscarry (and who would like to keep their marital status intact) have a particular interest in presenting themselves as well-intended, innocent or even powerless. In the stories they tell after experiencing an unexpected pregnancy loss, ‘suffering’ (la souffrance) and ‘fate’ (le destin) are key themes indeed. This is clearly perceptible in the aetiological explanations they propose in the immediate aftermath of loss. The local aetiological repertoire is vast; women might invoke the will of God, physical burdens, diseases, curses or witchcraft as factors that can negatively affect a pregnancy. These different naturalistic and personalistic aetiological categories imply various degrees of culpability and possibilities of accusation; they therefore constitute a flexible idiom that can be differently employed in different social situations (Van der Sijpt and Notermans 2010). What they all have in common, however, is that they appoint external causes of loss and divert attention from their own intentions and potential culpability. Whether focusing on something negligible (‘work’ or ‘a small disease’), an abstract agent (‘God’ or ‘the witches’) or specific people with whom social relations have been distorted (‘my mother who cursed me’ or ‘my jealous co-wife’), women portray themselves as passive sufferers of those external influences in the process. By asserting themselves as passive sufferers, and therefore ‘morally good’ women without any bad intentions, women contest any negative image that may result from a miscarriage and the associated suspicions. Relatedly, complaints about the concomitant physical suffering are ubiquitous. Such complaints can inform, and raise (financial) support for, the treatment itineraries that many women prefer to seek after pregnancy loss. Since miscarriages are considered to provoke heavy blood loss, both indigenous and biomedical treatments (such as blood-producing concoctions, vitamin substances, cleaning purges or anti-inflammatory biomedical injections) are deemed indispensable to replenish the blood reservoir and to prevent further reproductive suffering. While valid strategies in themselves, stressing the physical suffering that one is exposed to, and showing the willingness to go to lengths to make the body reproductively ‘fit’ again, are often also effective ways of proving one’s goodwill and innocence towards those who may suspect the abortion to have been wilfully provoked. Yet, in some cases, it is exactly the repeated complaints about heavy blood loss, abdominal pain or other forms of suffering after

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pregnancy loss that may raise the suspicions of outsiders. When one of my informants lost her pregnancy of four months, for instance, an enormous commotion ensued after she had demanded 5000 CFA francs (around 7.5 euros) from her husband for the alleviation of her purported suffering. While she claimed to me to have spent this money on cheap medicines from ambulant sellers and ‘some good food since you should eat well after a miscarriage’, others blamed her for having used her husband’s contribution for her own purposes. Her request to me to finance her post-abortum curettage was met by their warnings that she was probably deploying an idiom of pain and suffering to ‘eat’ my money and to cover the fact that she herself had induced this pregnancy loss. In the face of potentially persistent suspicions, women often imbue their complaints of suffering with religious meanings as well. Comparing their ordeals to those undergone by Jesus, many of my informants talked about their suffering in terms of a cross they had to carry. During a focus group discussion on reproductive agency and suffering, one informant noted: People often say that you carry the cross that God has given to you. And you should carry it to the bitter end. You should always endure your suffering. Suffering is a school of wisdom; it is part of life. You should abandon discouragement. You should be strong and perseverant in order to succeed, in order to dominate this suffering.

Others compared themselves with female biblical personages whose suffering features prominently both in the Holy Scriptures and in the weekly sermons in the various Christian churches in the region. After a miscarriage, many Gbigbil women invoke the fate of the Virgin Mary, who had to sacrifice her son, or the situation of Elizabeth, who remained childless for a long time (until she gave birth to John the Baptist at an advanced age) – challenges that both were strong enough in enduring. Not only do such religious notions of suffering make the unexpected miscarriage more meaningful and acceptable, but they also endow women with feelings of female solidarity and even superiority. It is exactly the capacity to suffer that marks them as good women and wives.8 The idea that only strong women are able to carry a personal burden or ‘cross’ during life is further complemented with a notion of divine judgement upon death. On Judgement Day, God will reward those who showed persistence in their suffering. Victims during life will turn into victors after death. Religious rhetoric thus adds a moral element to idioms of distress: suffering is an

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expression not only of shared female strength but also of individual ‘moral superiority’ that will be rewarded in the future. It provides a powerful counternarrative to the implicit or explicit abortion accusations that women may encounter after miscarriage. Finally, pervading most post-loss stories of suffering is also the idea of resignation to fate, predestination and the ultimate divine determination. By claiming to put their pregnancy outcomes and futures in the ‘hands of God’, women again publicly deny any personal involvement in their reproductive matters. Yet such claims are persistently contradicted by their own post-loss practices – their tactical aetiological appointments and accusations, their active quests for money and treatment, and their highly situational interpretation of the ‘word of God’. Paradoxically, then, passive notions of fate are actively deployed whenever they can give appropriate meaning and direction to the critical conjunctures that may evolve around an unexpected miscarriage. Notions of suffering and fate thus contribute to a general portrayal of powerlessness but veil as much as they publicly reveal. They are often more instrumental to women’s navigation of reproductive ambiguities than they seem to be obstructive. While women portray themselves as powerless, such portrayals are actually empowering, and even a manifestation of women’s power itself. Gbigbil women are very aware that tactically clinging to passive discourses enables them to realize different goals. It is what they call their ‘politique’, and they are proud of it. Successful exertion of these discursive ‘politics’ requires skills of anticipation of, and adaptation to, social circumstances. Towards the end of a focus group discussion on reproductive agency and suffering, one woman concluded: We shouldn’t have constrained visions, but look a bit ahead. A woman should walk like a cat. Because before posing her feet, a cat knows whether it’s good or not good to walk where she walks. If there’s a mouse, she knows how to walk. If there’s no mouse, she knows how to walk. A woman should do the same. She should know where to walk, what to do, with whom to walk, and what to say, in order to attract people who will form her physically and spiritually. Some women spend a hundred years somewhere without being able to change. But there are others who know how to adapt their lives and language right upon their arrival somewhere. It’s these women who will succeed.

For Gbigbil women, whose lives are characterized by constant geographical, marital and social mobility, adaptation and

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anticipation might long have been a key to their ‘success’. Such skills allow them to successfully move from their own families into those of their various partners over life. But, as it turns out, such abilities of adaptation also allow them to tactically navigate the uncertainty and ambiguity that may arise when their reproduction goes awry. Romania Earlier in this chapter, I showed that the official Orthodox dogma contributes to an environment that is both pronatalist in nature, and conducive to suspicion and blame towards those who unexpectedly lose a pregnancy in Romania. For many bereaved parents, this was a reason to either distance themselves from the Church or change their religiosity altogether. I noticed, however, that both adherents and non-adherents did resort to an important Orthodox post-mortem ritual that allowed them to commemorate their lost foetuses – even if, officially, the ritual was not supposed to be performed by parents of unbaptized babies. In the Orthodox tradition, the death of a person is followed by a recurring ritual called poman˘a (pl. pomeni), consisting of the preparation and distribution of food in commemoration of the deceased. The food is usually pierced by burning candles and blessed by a priest during a memorial service, and may be accompanied by objects, such as candles, incense, cutlery, towels, clothes or furniture. Upon distributing any of these items to family members, friends or community members, the givers specifically mention that it is done ‘for the soul of X [name of the deceased]’, after which the receivers utter a ritualized acknowledgement of reception (bogdaproste). This ritual happens three days, nine days, forty days, six months and one year after death, after which it is repeated yearly for another six years. In addition, at any point in time, it is possible to commemorate a beloved person by giving alms (a da de poman˘a) to the poor and socially disadvantaged. There are no strict rules for what to give or to whom to give; one may ‘feed’ the elderly people in a retirement home, ‘dress’ the children of a poor family, ‘entertain’ (with toys) some sick children in a hospital, ‘treat’ (with symbolic food items) one’s colleagues, or just give away one’s own sandwich to a beggar on the street. Again, the gesture is accompanied by information about the ‘soul’ being commemorated, and reciprocated through the appropriate acknowledgement of reception. Irrespective of their particular manifestation, such acts of giving serve two purposes. First, although enacted in this earthly life, they

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are supposed to directly increase the comfort of the commemorated person in the afterworld: he or she would ‘eat’ the food that is served or given away, use the candlelight accompanying the served food to navigate the dark terrains of the afterlife, and stay warm with the clothes that are distributed. Second, these charitable deeds would enhance the process of post-mortem redemption. Unable to obtain God’s mercy by doing good themselves – as they can no longer pray, confess or fast as living people can – the dead depend on others to ask God for forgiveness for them. As pomeni are explicitly performed in the name of the dead, they contribute to the absolution of the sins the latter committed during life. Caring for the dead in these ways deeply soothes those who engage in the ritual. People spoke about an intense feeling of satisfaction, calm and peace after having shared their food or items with others. More than an obligation imposed by the Church, many believed the act of giving to be a ‘gesture from the soul’ (gest de suflet), emanating from an inner desire to do good – for the dead, for the needy in society. As a result, such acts of giving are frequent and widespread in Romanian society, and even taken up by those who may be ambivalent about the Orthodox dogma, do not see themselves as observant Christians, or belong to a different religious denomination altogether. Unsurprisingly, many Romanian women who lost a pregnancy expressed a desire to organize pomeni in order to commemorate their foetuses and give themselves some inner peace. They all thought that what was lost had contained a ‘soul’ (suflet), from the moment of conception. Many believed that this soul had turned into a little ‘angel’ once it arrived in Heaven, and could stay connected to the earthly realm through appearances in dreams, the transmission of ‘signs’ and other manifestations of post-mortem relationships (Van der Sijpt 2017).9 The desire to care for, and commemorate, such a soul through pomeni felt completely natural to bereaved parents. According to Orthodox dogma, however, such practices should not exist after pregnancy loss. Pomeni can be organized only for baptized members of the Orthodox community, who received an official Orthodox name that can be invoked in the context of the post-mortem alms. Miscarried – and thus unbaptized – babies are ‘nameless’ within the church and excluded from such personalized rituals. Priests may even explicitly deny the existence of a foetal soul needing any care or commemoration, as the recollections of a mother who miscarried her twins show:

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I asked [the priest]: ‘what can I do for these two souls?’. I don’t know, [I meant to ask] how to organize pomeni, or prayers, or … something. And he told me: ‘For whom?’. [I answered:] ‘For the souls that…’. And he told me: ‘Well, what can you do? You confess and that’s it!’ And I said: ‘But…’. ‘Yes, but they don’t exist anymore; that’s it’.

Many ‘mothers of angels’ expressed indignation about this dogmatic stance. They felt that, by ignoring their needs after pregnancy loss, the Orthodox Church painfully disregarded the existence of both their foetuses and themselves as caring and loving mothers. My most critical informants therefore rejected the practice of poman˘a altogether, considering it ‘a human invention’ that has nothing to do with the dead, but rather reinforces the power of the Orthodox Church. Many others who disagreed with the Orthodox dogma did not abandon the idea and practice of poman˘a, however. On the contrary, they often found their own, informal ways of talking about, and giving, pomeni. They rephrased the practice as a purely sentimental affair that could be performed independently from any priest or religious institution. The response that one of my informants gave (on an online forum for ‘parents of angels’) to a bereaved mother’s complaint about an unreceptive priest is illustrative: The soul of your gentle little angel is pure. Being an angel, she does not need any coliv˘a [prescribed food item for pomeni] and alms. In fact, we give alms for our own inner calm, for our own reconciliation, knowing that we can do something to commemorate our angels. Maybe in some other church you will find a priest who will want to [help you]. But maybe it is better to find another way to give alms to commemorate your little angel. Don’t be disappointed anymore. Listen to your soul and you will feel what you need to do to commemorate her, for her soul and for your own, for inner calm.

Both in my direct interactions with women who had miscarried, and in personal stories shared online, I found numerous indications of semi-ritualized sharing practices that were performed, more or less explicitly, for the sake of lost foetuses. In order to commemorate their ‘angels’ informally, women appear to undertake diverse non-institutionalized, charitable actions, which often target small children. They prefer to give food, sweets, new clothes or toys to sick little patients, poor large families, or just random children walking with their parents on the street. The idea is that other children benefit from all the things the miscarried foetus would

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have received had it been born alive, and that this good deed would somehow also benefit their little angel in heaven. Although the givers clearly consider this an act of poman˘a, they are aware of its illicit character as well as of the uncomfortable silence that generally surrounds pregnancy loss in Romania. Many anticipate that, if they mention their miscarried baby explicitly, receivers will either uncomfortably silence it or condemn the act of giving altogether. As a result, those commemorating a dead foetus often alter the utterances used in the act of giving. Contrary to common practice, they do not always reveal the ‘soul’ for whom the gift-giving takes place: some simply say they perform the poman˘a for their ‘little angel’ (which could as well be a dead baptized child); others feel the need to invoke a generic name – the stereotypical ‘Maria’ for girls and ‘Ioan’ for boys – that indicates the sex of the lost foetus (thus, again, not revealing its unbaptized status). Many do not mention anything at all. They just count on the receivers accepting their ‘gesture from the soul’ without an explicit explanation. Sonia, for instance, told me that she had not done any ‘proper’ pomeni for the foetus she lost after she fell while pregnant; she had, however, thought of the soul of her baby whenever she had offered a piece of clothing to a poor person, or food to invitees. Asked whether she had explicitly referred to her baby in those instances, she answered: I mention it only at the moment when we put the candles and incense at home. Then I call [the baby], at home, without a priest, without a church. … At a poman˘a in the church you cannot mention their names because the church does not accept that. … Instead of that, we can also share things with some incense, with a candle. We can also share at home without arriving at the church. The people [who are invited] do not know what it is about. They simply say a certain word (bogdaproste), take the package and eat it. People do not necessarily ask you for whom it is.

By adjusting both its general interpretation and its particular discursive manifestation, Romanian women have reconfigured and re-appropriated the ritual of poman˘a – which is officially inaccessible to them after a miscarriage – as a meaningful act of commemoration and consolation. In informal ways, they succeed in confirming and caring for the miscarried babies about whom few Romanians dare to talk. Ambiguous feelings about what was lost are reduced in the process. The sense of calm, connection and moral virtue that these bereaved mothers derive from informally expressing their parental

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dedication stands in contrast to the distant suspicions they often experience from those around them. Ambiguous feelings about their own guilt and intentionality behind the loss may thus be appeased as well. The Orthodox priests that I spoke to were generally aware of these informal practices. Some condemned them fiercely; they called the act of invoking somebody who cannot be invoked a ‘ridiculous’ one that reveals people’s lack of real faith. Others showed more leniency; they acknowledged that such practices can provide comfort to bereaved parents and show, at the very least, people’s intrinsic desire to do good and be generous. None of the priests, however, would label such practices as ‘pomeni’ or mention them in their interactions with bereaved parents. They clearly distanced themselves from what Romanian ‘mothers of angels’ found to be a soothing strategy in a context of ambiguity and misrecognition. Both in Cameroon and in Romania, where those who lose their pregnancies generally face suspicion and silence, women have found inventive ways of attaining their desired goals – be it medical treatment, the consolidation of marital relationships or the appeasement of social tensions in Cameroon, or the commemoration of lost babies and expression of parental dedication in Romania. In both cases, their manoeuvres involve discursive tactics, in the sense given to the word by Michel de Certeau (1984). These tactics allow women, who might not have the power to define and impose dominant frames of reference, to inventively use and reinterpret these very frames in order to pursue their own goals – without upsetting the dominant order. Such tactics require constant adaptation and improvisation; people ‘must constantly manipulate events in order to turn them into “opportunities”’ (ibid.: xix). Indeed, Gbigbil women’s flexible use of dominant discourses about suffering, fate and religious dogma, and Romanian women’s appropriation and adaptation of an inaccessible religious ritual involve constant creative manipulation; dominant discourses are deployed in such a way that they enable women to acceptably pursue their own, socially unacknowledged or unknown projects within the given contexts.

Conclusion In this chapter, my aim was to shed light on the navigation of the ambiguities brought about by early pregnancy loss, by drawing on similarities I observed in East Cameroon and Central Romania. In

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their own ways, both settings constitute a profoundly pronatalist environment, in which unexpected miscarriages are ambiguously silenced and surrounded by suspicions. Local terms of pregnancy loss, which are used to denote miscarriages and induced abortions, exemplify and exacerbate this ambiguity in both contexts. As a result, both Gbigbil and Romanian women feel the need to disprove their culpability – either implicitly or explicitly – after an experienced miscarriage becomes public. Instrumental to women’s navigation of such ambiguities are their interpretations of what was lost, why that was lost, and how such a loss should be labelled. Different interpretations allow women to downplay or dramatize a loss, and to reinforce or attenuate abortion suspicions. They are used flexibly, and constantly adapted to the social situations and stakes at play. Discursive tactics also reach beyond the mere denomination of loss. The two examples described in this chapter show how women in both settings appropriate dominant, mainly religious, discourses in such a way that they can hope to achieve their personal after-loss goals without raising eyebrows. Although local manifestations of reproductive ambiguities and navigations are highly particular and context-dependent, these cross-cultural findings suggest that, more generally, the reproductive uncertainties that arise around early pregnancy loss may well create opportunities. Exactly because they are such indeterminate conjunctures (Johnson-Hanks 2006; Van der Sijpt 2013b), miscarriages are likely to become explicit moments of reorientation. The public invisibility of the event, the general lack of univocal consensus about its ontological and aetiological status, as well as the usual presence of different discursive frameworks offer women some leeway in this process of reorientation. Without denying the silence, suspicions and other numerous constraints that may arise when pregnancies get disrupted, I argue that we should not overlook women’s tactical moves and navigational manoeuvres, as they interestingly reflect, and are the result of, the ambiguous event that a miscarriage is. Erica van der Sijpt is a medical anthropologist affiliated to the University of Amsterdam. For over a decade, she has studied the social dynamics and decision-making processes around reproductive loss. She completed a Ph.D. project on pregnancy interruptions in Cameroon, and a post-doctoral study on reproductive uncertainties in Romania. The resulting articles have been published in journals such as Medical Anthropology, Social Science & Medicine, Medical

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Anthropology Quarterly, Sociology of Health & Illness, Culture, Health and Sexuality and Ethos. Her monograph, entitled Wasted Wombs: Navigating Reproductive Interruptions in Cameroon, was published in 2018. Erica also teaches various anthropological and methodological courses in academic and medical institutions in the Netherlands and abroad.

Notes  1. Drawing on my earlier conceptual work, I define ‘reproductive navigation’ as ‘the pragmatic directing of one’s reproductive life through uncertain and constantly changing circumstances’ (Van der Sijpt 2018: 11).  2. Such a strategy comes closest to the ‘most-different’ case selection method (Gerring 2006). Although such a case selection approach usually serves clearly delimited causal analysis purposes – and my aim in this chapter is not to make such a causal argument – its underlying rationale is essentially the same as the one driving my own choice of settings: selecting two cases (Cameroon and Romania) that are radically different with regard to a number of substantively relevant aspects (such as national reproductive histories, cultural perceptions of pregnancy and pregnancy loss, social norms and configurations, legal and discursive environments, etc.) and investigating how it can be that, despite these differences, processes of reproductive navigation are strikingly similar.  3. In total, I conducted over 250 interviews and twelve focus group discussions in Cameroon, and seventy-eight interviews in Romania. In Cameroon, I complemented these methods with two household surveys and several rapid appraisal techniques such as body mapping, free listing, pile sorting, severity ranking, village mapping and diary distributions. In both countries, I also did extensive archival research and collected relevant national and local health statistics.  4. Other commonly encountered justifications for abortion included women’s young age, fear of parents, the desire to complete education or fulfil other aspirations, instability of premarital sexual relationships, non-recognition of paternity by the partner, difficult economic situations, health concerns and birth spacing.  5. The law prohibited abortions except if a pregnancy endangered a woman’s life, was the result of rape, involved a hereditary disease, or was carried by a woman of forty-five years or older, or who had already delivered and reared at least four children (Kligman 1998).  6. It is estimated that, by the time they reached the age of forty, women had experienced an average of five illegal abortions (B˘aban 2000).

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 7. In 1989, the last year of the communist regime in Romania, the maternal mortality rate had increased to 170 deaths per 100,000 live births – the highest ever recorded in European history – out of which 87 per cent were estimated to have been caused by illegal abortions. Yet, as statistics were manipulated and falsified under the regime, these figures should be read with caution; real death rates were arguably even higher (B˘aban 2000; Creang˘a et al. 2007).  8. Tellingly, a focus group discussion on agency and suffering was filled with women’s constant referrals to themselves as the ones who suffered most – which, apart from creating the atmosphere of mutual understanding that I had hoped for, led to a sort of contest between women impressing each other by their display of personal misery. The acknowledgement of suffering as a marker of good womanhood formed not only a source of solidarity, but also a source of competition and distinction between women.  9. Some informants linked the use of the notion of ‘angel’ for deceased embryos and foetuses to the influence of a Romanian NGO that supports those experiencing pregnancy loss and calls them ‘parents of angels’. It is very possible, however, that such denominations already existed in the Romanian context before 2008, when the NGO was founded (Van der Sijpt 2017).

References Academia Român˘a. 2016. Dict,ionarul Explicativ al Limbii Române. Bucharest: Univers Enciclopedic. Anton, L. 2009. ‘On Memory Work in Post-Communist Europe: A Case Study on Romania’s Ways of Remembering Its Pronatalist Past’, Anthropological Journal of European Cultures 18(2): 106–22. B˘aban, A. 2000. ‘Women’s Sexuality and Reproductive Behavior in PostCeaus¸escu Romania: A Psychological Approach’. In S. Gal and G. Kligman (eds), Reproducing Gender: Politics, Publics, and Everyday Life after Socialism. Princeton, NJ: Princeton University Press, pp. 225–52. Bonnet, D. 1988. Corps biologique, corps social: Procréation et maladies de l’enfant en pays Mossi, Burkina Faso. Paris: ORSTOM. Brier, N. 1999. ‘Understanding and Managing the Emotional Reactions to a Miscarriage’, Obstetrics and Gynecology 93(1): 151–55. Cecil, R. 1996. The Anthropology of Pregnancy Loss: Comparative Studies in Miscarriage, Stillbirth and Neonatal Death. Oxford: Berg. Creang˘a, A.A., R. Acharya, S. Ahmed and A.O. Tsui. 2007. ‘Contraceptive Discontinuation and Failure and Subsequent Abortion in Romania: 1994–99’, Studies in Family Planning 38(1): 23–34. David, H.P., and A. B˘aban. 1996. ‘Women’s Health and Reproductive Rights: Romanian Experience’, Patient Education and Counseling 28: 235–45.

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De Certeau, M. 1984. The Practice of Everyday Life. Berkeley: University of California Press. De Thé, M.P. 1970. Des sociétés secrètes aux associations modernes. La femme dans la dynamique de la société Beti, 1887–1966. Paris: École Pratique des Hautes Études. Demographic and Health Survey [DHS] 2011. Demographic and Health Survey Cameroon. Calverton: ICF International. Erviti, J., R. Castro and A. Collado. 2004. ‘Strategies Used by Low-Income Mexican Women to Deal with Miscarriage and Spontaneous Abortion’, Qualitative Health Research 14(8): 1058–76. Foster, G.M. 1976. ‘Disease Etiologies in Non-Western Medical Systems’, American Anthropologist 78(4): 773–82. Frost, M., and J.T. Condon. 1996. ‘The Psychological Sequelae of Miscarriage: A Critical Review of the Literature’, Australian and New Zealand Journal of Psychiatry 30(1): 54–62. Gerring, J. 2006. Case Study Research: Principles and Practices. New York: Cambridge University Press. Geschiere, P. 1982. Village Communities and the State: Changing Relations among the Maka of South-Eastern Cameroon since the Colonial Conquest. London: Kegan Paul International. Institutul Nat, ional de Statistic˘a (INS). 2014. ‘INSSE Baze de date statistice: Institutul Nat, ional de Statistic˘a’. Retrieved 19 March 2017 from http:// statistici.insse.ro. Jeffery, P., and R. Jeffery. 2010. ‘Only When the Boat Has Started Sinking: A Maternal Death in Rural North India’, Social Science & Medicine 71(10): 1711–18. Jenkins, G.L., and M.C. Inhorn. 2003. ‘Reproduction Gone Awry: Medical Anthropological Perspectives’, Social Science and Medicine 56(9): 1831–36. Johnson-Hanks, J. 2006. Uncertain Honor: Modern Motherhood in an African Crisis. Chicago: University of Chicago Press. Kligman, G. 1998. The Politics of Duplicity: Controlling Reproduction in Ceaus¸escu’s Romania. Berkeley: University of California Press. Layne, L.L. 2000. ‘“He Was a Real Baby with Baby Things”: A Material Culture Analysis of Personhood, Parenthood and Pregnancy Loss’, Journal of Material Culture 5(3): 321–45. Ledeneva, A. 2011. ‘Open Secrets and Knowing Smiles’, East European Politics and Societies 25(4): 720–36. Lee, C., and P. Slade. 1996. ‘Miscarriage as a Traumatic Event: A Review of the Literature and New Implications for Intervention’, Journal of Psychosomatic Research 40(3): 235–44. Letherby, G. 1993. ‘The Meanings of Miscarriage’, Women’s Studies International Forum 16(2): 165–80. Littlewood, J. 1999. ‘From the Invisibility of Miscarriage to an Attribution of Life’, Anthropology & Medicine 6(2): 217–30. Lupton, D. 2012. ‘“Precious Cargo”: Foetal Subjects, Risk and Reproductive Citizenship’, Critical Public Health 22(3): 329–40.

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McCabe, K. 2016. ‘Mothercraft: Birth Work and the Making of Neoliberal Mothers’, Social Science & Medicine 162: 177–84. Murphy, F., and S. Philpin. 2010. ‘Early Miscarriage as “Matter Out of Place”: An Ethnographic Study of Nursing Practice in a Hospital Gynaecological Unit’, International Journal of Nursing Studies 47(5): 534–41. Pool, R. 1994. ‘On the Creation and Dissolution of Ethnomedical Systems in the Medical Ethnography of Africa’, Africa 64: 1–20. Rapp, R. 2000. Testing Women, Testing the Fetus: The Social Impact of Amniocentesis in America. New York: Routledge. Rice, P.L. 2000. ‘When the Baby Falls! The Cultural Construction of Miscarriage among Hmong Women in Australia’, Women & Health 30(1): 85–103. Sobo, E.J. 1996. ‘Cultural Explanations for Pregnancy Loss in Rural Jamaica’. In R. Cecil (ed.), The Anthropology of Pregnancy Loss: Comparative Studies in Miscarriage, Stillbirth, and Neonatal Death. Oxford: Berg Publishers, pp. 39–58. Suh, S. 2014. ‘Rewriting Abortion: Deploying Medical Records in Jurisdictional Negotiation over a Forbidden Practice in Senegal’, Social Science & Medicine 108: 20–33.  . 2018. ‘Accounting for Abortion: Accomplishing Transnational Reproductive Governance through Post-Abortion Care in Senegal’, Global Public Health. An International Journal for Research, Policy and Practice 13(6): 662–79. Thompson, C. 2005. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge, MA: MIT Press. Van der Sijpt, E. 2010. ‘“Filling with Force”: Reproductive Loss Reconsidered’, Viennese Ethnomedicine Newsletter 12(2–3): 21–27.  . 2013a. ‘Focusing on Force and Forms: Reproductive Loss Reconsidered’. In S. Earle, C. Komaromy and L. Layne (eds), Understanding Reproductive Loss: International Perspectives on Life, Death, and Fertility. Surrey: Ashgate, pp. 105–16.  . 2013b. ‘Complexities and Contingencies Conceptualized: Towards a Model of Reproductive Navigation’, Sociology of Health & Illness 36(2): 278–90.  . 2017. ‘The Pain and Pride of “Angel Mothers”: Disappointments and Desires around Reproductive Loss in Romania’, Medical Anthropology 37(2): 174–87.  . 2018. Wasted Wombs: Navigating Reproductive Interruptions in Cameroon. Nashville, TN: Vanderbilt University Press. Van der Sijpt, E., and C. Notermans. 2010. ‘Perils to Pregnancies: On Social Sorrows and Strategies Surrounding Pregnancy Loss in Cameroon’, Medical Anthropology Quarterly 24(3): 381–98. Van Hollen, C.C. 2003. Birth on the Threshold: Childbirth and Modernity in South India. Berkeley: University of California Press. Wamsiedel, M. 2017. ‘Approaching Informality: Rear-Mirror Methodology and Ethnographic Inquiry’. In A. Polese, C.C. Williams, I.A. Horodnic

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and P. Bejakovic (eds), The Informal Economy in Global Perspective: Varieties of Governance. London: Palgrave Macmillan, pp. 97–115. Wembah-Rashid, J.A.R. 1996. ‘Explaining Pregnancy Loss in Matrilineal Southeast Tanzania’. In R. Cecil (ed.), The Anthropology of Pregnancy Loss: Comparative Studies in Miscarriage, Stillbirth and Neonatal Death. Oxford: Berg.

Chapter 4

Some Babies Cannot Be Stopped from Falling Miscarriage in Pakistani Punjab Kaveri Qureshi

Introduction I met Shamim on one of her visits back to her natal family. Married to a distant relative, she lived at her husband’s family home in rural Okara district, to the south of Lahore. Shamim suffered repeated miscarriages in the first trimester and was seeking biomedical care from a private clinic, as well as healing from a peer (a spiritual healer) in Lahore – a pattern that was common among women in this predicament across my study. As the fieldwork continued, misfortune befell Shamim once more, and in circumstances that demanded explanation. While Shamim was again pregnant and on bed rest in the vulnerable early months, her mother-in-law left her in Okara so as to accompany another daughter-in-law to Lahore for a childbirth; Shamim’s sister-in-law, in keeping with the practice of cousin marriage which is common across Pakistan, was also the mother-in-law’s niece. In her mother-in-law’s absence, Shamim had to resume all of the domestic work in the marital home, and once again she miscarried. Shamim’s mother told me about it some months later, at the house of her neighbour Bibi Anwar.

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Shamim’s mother: Now it’s God’s will. So many of Shamim’s babies have been wasted (kinne bache zaiya ho gen) and these days she’s not even getting pregnant. She got an ilaaj (treatment) done from Lahore and the doctor said she will only be able to carry a baby if she has nine months of complete bed rest, and that too with tanken (stitches). Bibi Anwar: The poor thing’s babies fall very early (bechari ke bache bahut jaldi gir jate hain, i.e. they don’t stand a chance). Shamim’s mother: No, the last one was fully formed, it must have been four–five months. I saw the photo with my own eyes, it was a boy, about as big as this [points to the palm of her hand]. I saw it on a tray, it was a boy. This time, it was not God’s will.

As a married woman with no children despite four years of marriage, Shamim’s miscarriages were a tragedy, the memory of the lost foetus there in the conversation like a corpse, demanding accountability. When Shamim’s mother said so pointedly, ‘this time, it was not God’s will’, she was pointing her finger directly at Shamim’s mother-in-law, who had left Shamim in Okara during her time of need in order to partake in the happiness of her other daughterin-law’s delivery. Surprisingly for me, this narrative of culpability seemed completely public, as visiting Bibi Anwar’s house too that day was Shamim’s mother-in-law’s sister – the mother of the other daughter-in-law who had successfully delivered a baby boy – who fell silent at the accusation that her daughter had been favoured. The allegation hung in the air unanswered, an awkward, uncomfortable fact hovering between Shamim’s natal and marital families. As Kilshaw observes in the introduction to this volume, the English cultural construction of miscarriage is embedded in discourses of both culpability and chance, its meanings ranging from misconduct or misbehaviour to mishap or disaster. So too, it seems, in Pakistani Punjab. In this chapter I will outline how culpability for miscarriages is passed very often from women’s natal families to their marital families, who directly influence their workload, diet and care during pregnancy. In this setting, where marriages are usually patri-virilocal, the relationships between women’s natal and marital families represent common fault-lines of conflict. Yet I will suggest too that there is more to miscarriage than the anthropological story about accusations following lines of social tension. I take my direction of thought from Shamim’s mother’s debate about whether her daughter’s miscarriages are God’s will or, perhaps, not. This time, she concludes, ‘this time, it was not God’s will’. There were simple precautions that Shamim and those around her in her

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marital home could have and should have taken to protect the vulnerable early pregnancy. But with a sigh of resignation, she returns to ‘now it’s God’s will’, the formulation not merely customary, but as Shirene Hamdy (2009) argues, expressing an active stance of acceptance over the lack of control people feel they have in the face of such trials of misfortune. It is this capriciousness of pregnancy and fertility that is highlighted by stories about miscarriage. Pakistan, a country more often discussed in demographic circles in terms of its excess fertility and stalling fertility decline (Sathar 2013), and where state developmentalist agendas and civil society organizations have appropriated women’s bodies for the purposes of fertility limitation (Ataullahjan, Mumtaz and Vallianatos 2019a, 2019b; Varley 2012), is also a population afflicted by widespread pregnancy loss. In the five years previous to the last Demographic and Health Survey, 13 per cent of pregnancies in Pakistan ended in miscarriage, while 2 per cent ended in stillbirth (National Institute of Population Studies [NIPS] and the DHS Program 2019: 181). The interpretation of these statistics is difficult,1 but 13 per cent appears high compared with other countries in the region.2 Pakistan’s stillbirth rate, ranking worst in a list of 186 countries, has attracted recent calls for action from The Lancet (Frøen et al. 2016). Yet little attention has been given to the country’s high rates of miscarriage. In the sociological and anthropological literature, Varley’s (2008) ethnography is a significant exception. In her work on Gilgit in the Northern areas, she addresses women’s understandings of miscarriage alongside a host of other aspects of reproductive misfortune. She explores women’s beliefs that ‘due to “worries” or “nervousness”… they may have inadvertently precipitated “uterine weakness” and foetal loss’; ‘pregnancy loss is also said to be caused by overwork, jumping, carrying heavy loads, not enough rest or “rough” sex’ (ibid.: 312). She describes Gilgiti women viewing two to three miscarriages over the course of one’s reproductive life as normal, but more than five as ‘“too much”, signaling cosmological imbalance or “black magic”’ (ibid.: 313). Ethnographies from nearby North India reflect similar ethnophysiologies and cosmologies of pregnancy loss, but also draw attention to the opacity of the category of miscarriage. In Jeffery and Jeffery’s (1996) study, local models distinguished between ‘“delayed periods” and the “falling baby”, and only the latter is considered to have been a pregnancy’ (25). The context of which they write, rural Bijnor district in the 1980s, was one in which

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pregnancy was not highly medicalized. A woman suffering abdominal pains or vaginal bleeding was unlikely to be taken for medical care or enjoy much reprieve from her domestic work. The techniques available to arrest a miscarriage were simple domestic precautions, such as refraining from sexual intercourse, resting and taking home remedies. Even after such efforts, however, ‘some babies cannot be stopped from falling’ (ibid.). Pinto’s (2008) more recent North Indian ethnography agrees with the tentativeness of women’s recognition of pregnancy, but pushes us to think further about whether this tentativeness is because women don’t know or aren’t sure whether they are pregnant, or because of the stakes in acknowledging pregnancy in a context where some babies cannot be stopped from falling. As in the historical literature on Europe, there is an argument here about the significance, for attributions of miscarriage, of the visualization of the products of conception. Here it is not the medical gaze that is of import, however, so much as ‘other modes of seeing, other power/knowledge/sight equations’ (ibid.: 144). This chapter takes forward some of these arguments. In what follows, I address the cultural construction of miscarriage in Pakistani Punjab in terms of fallen, wasted or fused babies, and the implications of the products of conception being called a baby, before turning to women’s explanations of miscarriage, and finally to a local ethnomedical diagnosis which expresses the diffuseness of threats to successful reproduction. In the concluding discussion, I return to Shamim’s mother’s questions about whether anything can be done, in this context, to stop some babies from falling. Compared with Jeffery and Jeffery’s ‘delayed periods’ and ‘fallen babies’, my material suggests an earlier recognition of pregnancy, associated with an increasingly medicalized diagnosis. But I highlight the continued tentativeness of pregnancy, and the significance of the visual, specifically the importance of acts of concealment, where menstrual cycles are watched and dangers may be even more diffuse and ever-present.

Research Setting The context to this chapter is a study of motherhood in Pakistani Punjab in which I have been engaged since 2015. In this project I have adopted an intergenerational approach incorporating interviews with fifty-six new mothers in Lahore and its rural environs,

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interviews with their mothers and/or mothers-in-law and longer-term informal interactions, following a small set of families over time and making observations in domestic settings, the inter-domestic realm and health facilities. With a view to making explicit the structures of oppression that produce intersectional inequalities in maternity and motherhood in Pakistan, I met the women I worked with through three routes. First was a reproductive health NGO working in two adjacent villages. Second were two key informants in an urban working-class community: Bibi Anwar, whom I introduced in the opening vignette, who was a domestic servant at the university campus where I lived, and my Urdu teacher Asifa Parveen. Finally, I also recruited women through networks I developed through my own everyday life in the city, living on the campus and taking my eldest daughter to school. The research participants therefore reflected three distinct social locations of womanhood in Pakistani Punjab, allowing me to examine differences by class, rural-urban residence and migration status, as well as by caste and religious community. The interviews with the new mothers addressed histories of reproductive life, from conception, pregnancy, birth and the postpartum through to infant care. Out of the fifty-six new mothers, seventeen talked at length about miscarriage. I also draw on conversations with mothers and mothers-in-law who reflected on miscarriages from the perspective of looking back on long and complex reproductive careers, rather than the beginning or the middle of them.

Falling, Wasted, ‘Fused’ Babies In Urdu and Punjabi, women refer to the early months of pregnancy as the kuche maheene or raw months (and see Platts Dictionary of Urdu, Classical Hindi and English for the kuche din or raw days, defined as the first four–five months of pregnancy).3 Kucha, raw, is a polyvalent term. It shares the semantic field of the English term raw, including the connotation of tender – like a raw wound – as well as uncooked or not yet ready. It also has a more specific meaning of soft or earthen, as with kuche ghar (mud houses) vs pukke ghar (brick houses), or kuche sarak (dirt roads) vs pakke sarak (concrete roads), but it is the sense of tender that is implied here. The idea is that an early pregnancy is easily injured, not certain to go to full term.

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As in nearby North India, bacha girna, the falling of the baby, is the prevailing construction of miscarriage in Pakistani Punjab. Returning to Shamim, with whom this chapter began, when I questioned Bibi Anwar about the tanken (stitches) that Shamim’s mother had referred to, she explained that the treatment that had been advised for Shamim’s miscarriages would be to sew up the mouth to the bachedani (womb) after she next conceived, because Shamim’s problem was that her womb was weak. I can’t say whether this was the explanation of the treatment that Shamim’s medical practitioner would have offered; ethnographies of Pakistan argue that the care provided by medical doctors is frequently integrative of ethnomedical aetiologies, diagnostic categories and therapeutic recourse (e.g. Varley 2008: 196; see Nguyen and Lock 2018 on biomedicine as culturally embedded practice). Nonetheless, Bibi Anwar’s explanation of the treatment suggests the very literalness with which the idiom of the baby falling is taken. To survive, Shamim’s babies would have to be held in by stitches. There are other idioms too: bacha zaiya hona, the wasting of the baby, was used almost as commonly as bacha girna to refer to miscarriage. Alternatively, the English word ‘abortion’ could be used in the middle of an Urdu or Punjabi sentence, as in us ko abortion hua (she had a miscarriage). There is something interesting in both these terms, as there are parallels between the language used for miscarriage in Urdu and Punjabi and the English term miscarriage, with its semantic field of misconduct and mishap (Kilshaw, introduction to this volume). The terms used for miscarriage, bacha girna and bacha zaiya hona, are very similar to those used for the deliberate loss of a pregnancy, being compound verbs distinguished only by their intransitive or transitive form. The intransitive verb girna (to fall) easily turns into the transitive girana (to make fall, or in this case bacha girana, to abort a pregnancy). The zaiya (wasted) can also be made transitive, as in bache ko zaiya karna or karana (to have the baby wasted), meaning an abortion. In Urdu and Punjabi there is then the same closeness between miscarriage and abortion as we have in the etymology of the English term ‘abortion’, which until the late nineteenth century referred to ‘the expulsion of the foetus before it is viable’. The earlier noun for miscarriage was ‘abort’, and only in the nineteenth century does it appear for ‘deliberate premature fatal expulsion of the foetus’ (Online Etymological Dictionary, consulted June 2019). In the case of Urdu and Punjabi, the similarity between terms for miscarriage and abortion recalls the question of whether a person fell or was pushed. There is a suggestion of

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implicit violence here, as we see with the last synonym for abortion that I encountered during my fieldwork: the almost casual importation of the English word ‘fuse’, in this exchange between two sisters-in-law in one of the two villages: Sakina (talking about her sister-in-law Sumera): She had seven children, two of them were ‘fused’ (beech mein do bache fuse ho gaye hain). They left this world before entering it [both laugh].

‘Fused’, a synonym for being killed, is an importation of the English word via film dialogues, where heroes ‘fuse’ the bad guys or tragic heroines get ‘fused’. It is probably relevant that Sakina and Sumera, who were so offhand in their language, were two women burdened – because of their husbands’ objections to birth control – by successive undesired pregnancies. As intriguing as the language used for miscarriage is the language used for the product of the miscarriage, the bacha (baby). What’s interesting is that this term is used even in very early miscarriages that occur during the kuche maheene. This suggests a change from Jeffery and Jeffery’s (1996) study, where there were two different terms for a potential miscarriage, bacha girna (the baby falling) and din charhna (the days being in arrears, a delayed period), with the line between them drawn circa three months post last menses. Before three months, women will say ‘there was no pregnancy, merely a blob of flesh (maas-ka-pinda, maas-ka-gola, gola-ka-pinda) that broke up into blood clots and caused bleeding’. At that stage, there are no limbs or organs, and there is no baby (bacha) and bleeding is taken to be just another period. It is only after nearly three months have elapsed that women talk of pregnancy and refer to the baby as bacha and considered that it has ‘adhered’, ‘rooted’ or ‘flourished’ (jumna, also germination in plants). This is when the life or spirit (jan) enter the baby, its body parts begin developing and its sex is settled. From then on, bleeding is a ‘baby falling’ or the ‘belly falling’ (bacha girna, pet girna). (Jeffery and Jeffery 1996: 24)

Their ethnography echoes the historical work on Europe, where conception and pregnancy in the eighteenth century were similarly ‘an ambiguous stage in a woman’s somatic experience’ (Duden 1999: 14), a delayed period maybe a sign that she was ‘with child’, maybe not; perhaps the cessation of her ‘monthly’ was due to some blockage, some ‘retention of the menses’ (ibid.: 16). There is a wider argument here concerning the ways in which technologies

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of testing and ultrasound have imbued pregnancies with value at an earlier and earlier stage (see Melo and Granne, this volume, and Kilshaw’s introduction to and chapter in this volume). If pregnancy is diagnosed, or understood to happen at the point of implantation, then women may experience a pregnancy loss from then onwards. By contrast, the distinction between the maas-ka-pinda (blob of flesh) and the bacha (baby) in the Jefferys’ study captures the uncertainty of early pregnancy in a context where the diagnosis of pregnancy was not medicalized, and where technologies of testing and visualizing pregnancy were absent. It is then interesting that women in my study referred to an early miscarriage too as a bacha (baby), as it implies that a provisional personhood may be being granted to the foetus at an earlier stage than in the Jefferys’ research in the 1980s. This provisional personhood is being attributed at an earlier stage than the 120 days from conception, at which point, according to many interpretations of the Quran and Hadith, the ruh (spirit) is breathed by an angel into a foetus – although this point is contested, as are similar bioethical Christian pronouncements about the ‘ensoulment’ of the foetus and the inception of personhood as gradual and developmental (Neaves 2017; Watts 2019). On the basis of my study it seems plausible that, as Alison Shaw (2014) also describes of British Pakistani pregnancy losses, religious and customary processes are being negotiated in the context of recent changes in medical norms associated with pregnancy loss surrounding the diffusion of technologies of pregnancy testing. The women I spoke to attributed pregnancy and the presence of a bacha (child) at an early stage. Except in cases of new pregnancy during the period of amenorrhoea following a previous birth, the delay of a period and din charhna (the days being in arrears) were almost immediately interrogated as possible pregnancy. The dates of menstrual cycles were carefully noted, not only by a woman herself but also by her mother-in-law, mother, and other female family members, partly because of the concern for a newlywed woman to become pregnant, and partly because of the slight respite from domestic duties that accompanies menstruation, and partly because of open communication about menstruation among women. A few days’ delay resulted in attributions of possible pregnancy. I could see this very clearly with Bibi Anwar. Whenever I visited, she would update me on the menstrual cycles of her married daughters and brothers’ newlywed wives, and excitement about possible pregnancies while we caught up. For example:

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Sania [her brother’s wife] is saying she’s probably going to be giving us some good news in a few days’ time. But let’s wait and see, last month her ‘date’ was due on the 17th and by the 18th she was very happy, but then on the 24th it came.

Linked to the early apprehension of pregnancy is the ease with which it could be confirmed. This could be through the use of urine testing, which was cheap at Rs30 for a pack of two test strips (20p), and through ultrasound, which could be accessed on demand from private clinics at a relatively modest Rs300 (£2.15). But it could also be through the conventional wisdom of older family women, as shown by the example of Bibi Anwar’s newlywed daughter Kiran: Bibi Anwar: Kiran’s ‘date’ is a week late so she might be pregnant. The following week: Bibi Anwar: I’ve got some good news, Kiran is pregnant, she got the ultrasound done on the weekend, the doctor says everything’s going fine. Kiran: I did a ‘strip’ last week and it came out ‘negative’, but I was convinced that something must be up, so then on the weekend I went to see the ultrasound lady and she told me ‘congratulations, you’re pregnant’. I told her ‘I did a strip, but it came out negative’. She said ‘you probably did it at the wrong time of day. You need to do it first thing in the morning’. So on the way home I bought another strip and then the next morning I did the strip again and this time it showed two lines. Of course, my saas (mother-in-law) had already guessed that I’m pregnant. She could tell from my walk. Kaveri: What do you mean, from your walk? Kiran: She says when a woman is pregnant, her hips swing more.

It seems plausible then that the ambiguity about pregnancy that is captured by the ethnographic distinction between the maas-kapinda (blob of flesh) and the bacha (baby) has been chipped away by technologies of pregnancy testing. Not only are early pregnancies imbued with value, but also a provisional personhood may be granted to the foetus at an earlier and earlier stage. Here, however, the wider social recognition of pregnancy remained often tentative despite its recognition by a woman and others in her immediate family. Women did not talk explicitly about their pregnancies in the home or in the inter-domestic arena, referring to it if at all through plastic and euphemistic language such as tabeeat kharab hona (to

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be in a bad state of health). If they did not conceal the signs of a growing pregnancy through loose clothing and the careful arrangement of a dupatta, they were likely to be reprimanded for it. As we go further into women’s explanations for miscarriage, we see why concealment is deemed so necessary.

Explanations, Culpability and Chance Immediate explanations of miscarriage focused on excess heat, according to local ethnophysiologies of humourism; heavy domestic workloads; and kamzoori (an embodied state of weakness, with inseparable physical, mental and emotional dimensions). It is conventional knowledge that these conditions jeopardize early pregnancy and that women should take care to avoid situations, particularly heavy lifting or physical chores that produce abdominal strain, such as crouching, which may dislodge the baby and cause it to fall. As Jeffery and Jeffery (1996) also describe, pregnant women were supposed to take care to consume a correct balance of foods, eating well so that the mother’s khoon bharta hai (blood increases) and the baby grows appropriately, but also doing perhez (avoidances) to reduce the intake of foods with a strong heating effect – tea, eggs and meat, which were common elements of the diet in the wealthier families in my study, as well as certain vegetables, pulses and spices – until the final months, since these might produce such a large volume of blood that there could be risk of early delivery. Given the level of self-care that is expected, a miscarriage may then be read as a sign of carelessness. An exchange between the sisters-in-law Sumera and Sakina elaborates this point. Sumera: The first miscarriage, I was two months pregnant. Woh zaya ho gaya (it got wasted). I don’t know what happened. Sakina [Sumera’s sister-in-law]: Baji (elder sister) [directed at Meena, the birth attendant who introduced us to the family], she eats a lot of fish. She can eat five kilos at a time. Meena: Five kilos? Impossible. Sakina: It’s true, baji! Sumera: This time too [referring to her more recent pregnancy] I ate fish and I got sick. My brother bought Rs1500 worth of fish and gave this much to our parents and the rest to me. I ate it all. Then I started

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bleeding from below. My husband took me to a clinic and they said ‘we’ll have to deliver the baby now, this baby is in danger’. Well, three months passed. I completed my nine months of pregnancy and had the delivery. Meena: Couldn’t you tell that you were eating too much fish? Sumera: I just kept eating, it was there in front of me. I also had bottal (fizzy drink).

In this extract Sakina attributes Sumera’s two miscarriages to her lack of self-restraint and failure to take heed of the conventional wisdom about avoiding heating foods, like fish, until the very last months of pregnancy. And it seems that Sakina’s verdict was accepted, or at least it wasn’t challenged, by Meena, the trained birth attendant, who immediately admonished her for her carelessness (see Varley 2008 again on medical personnel’s synthesis of biomedical and ethnomedical models). This knowledge is conventional and supposedly time-old. It was nonetheless protested by many of the older women with whom I spoke, who insisted that there was less fuss about these kinds of proscriptions in their day, and also that their pregnancies went more smoothly as a result. Asifa’s aunt described the generational change she perceived: Before, we only came to know about pregnancy much later. There didn’t use to be these machines to test for pregnancy. We didn’t come to know about it until the second or third month. We didn’t used to take anything for taaqat (strength). But our pregnancies used to go better! Jis cheez ke baare mein ham ziyada sochte, woh uttni nazukh hoti hai (the more we think about something, the more delicate it becomes). These days girls are being careful about eating hot and cold things, they’re eating things for strength, they have become very ‘conscious’ about their pregnancy, they take rest. But kam chorne se bhi ho jate hain (miscarriages happen because of reducing one’s work).

Bibi Anwar described how few changes she had made to her domestic routine during her own pregnancies, and expressed the same sentiment that this only helped the process: These days girls take I don’t know what what, and how many many medicines! There’s a big difference between then and now. In those days we didn’t have problems with pregnancy. We got married at 16–17 and then immediately we got pregnant. I used to rush around during all my pregnancies. But these days they tell you ‘walk so

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carefully and so slowly that even the ground should not realize you are there’.

When it came to her own daughter Kiran’s pregnancy, however, Bibi Anwar made sure to assist Kiran in making as much fuss about it as possible, in ways that put pressure on Kiran’s mother-in-law to improve conditions in her marital home. As she told me in the summer of 2016: I had to have a word with Kiran’s saas (mother-in-law) on the weekend. Kiran has been suffering from low ‘bp’ and she fainted. Her saas told me to come and collect her because the room is too hot, she didn’t want the baby to get affected… // …There is some problem with the pedestal fan in Kiran’s room. The capacitor is broken and needs to be fixed by a mistri (workman)… // …[So] I had to speak to her saas about getting the fan fixed. ‘Do we have to pay the mistri for you?’

As well as illustrating slippages between older women’s grumbling about the fuss young women make about their pregnancies these days and their support for their own daughters in doing so, Bibi Anwar’s intervention in the matter of Kiran’s broken pedestal fan is interesting because it brings us to the important issue of how the success of a pregnancy is not only about a woman’s careful conduct or carelessness, but also a reflection of her treatment in her marital home, and therefore a buck to be passed between two sets of affines. As Jeffery and Jeffery (1996: 29) argue, these ethnophysiologies ‘must be comprehended in broader social and political terms, of which the situation of child-bearing women in their husband’s home is central’. The underlying reproductive politics here is the stake that a woman’s in-laws have over her fertility. A woman’s in-laws have responsibility over her workload and nutrition in the vulnerable early months of pregnancy, and they were therefore implicated in the blame if a baby fell. A clear example is Shaila, a woman in her early twenties who was related to Asifa, who had married in a village to the east of Lahore and was back at her natal home in Lahore, visiting her family, when we spoke to her. Shaila had had two early miscarriages before successfully giving birth to a son. She attributed the first miscarriage to several days spent in intense harvesting work in the heat. She had never worked the fields before her marriage, she explained, as her father was a grocer in the city, but she was married into a family with an agricultural livelihood.

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My saas told me ‘if my daughters go out to the fields to cut wheat then you should go too. We all do this work and you’re the same as us, so you should do it too. You’re not a foreigner, are you’ (i.e. you’re not from a different planet, you should do the same as us). I didn’t want to go out into the fields because I had never done that kind of work before. And I was worried for the baby. I even told my mother that my saas was asking me to do this kind of work, and my mother was angry. But I decided for myself, ‘if they’re demanding it of me then I must do it’. So I went out to the fields with a sickle, to cut wheat, my saas took me the first day and the second day the baby fell. My mother was furious, she said ‘when you’re pregnant you mustn’t sit like that, paon ke bal pe’ (crouching down, the position in which women cut wheat). My saas said ‘this has never happened with us, we’ve done this work all our lives, she’s too nazukh (delicate) this one, aaj kal larkian bahut lardli hoti hain, nakhre karti hain kamon se aur is liye yeh un ke saat hota hai’ (girls these days are pampered and fuss and that’s why these mishaps happen to them). And my nanden (husband’s sisters) said it was my fault for having done that work, ‘if she can’t do it then she shouldn’t have done it’. The second time I was pregnant, the baby fell at home. Then my saas and my nanden said ‘there’s no illness in our family like this, maybe it’s because she stays inside all the time’. They started saying ‘it’s two years since her marriage, why isn’t there any baby yet, hamare ghar mein koi raunak hee nahi hai’ (there’s no laughter and joy in our house).

In this extract Shaila pinned the blame for the miscarriages squarely on her in-laws and also complained about their logic, with which she couldn’t win. If she didn’t go to the field, then she would have been blamed for her fancy ways. When she did go, her inlaws charged her with irresponsibility: ‘if she can’t do it then she shouldn’t have done it’. Then, when she tried to manage her next pregnancy more carefully, they blamed her again: ‘maybe it’s because she stays inside all the time’. Shaila saw both miscarriages as the product of her gruelling workload. Asifa: Why did it happen? Shaila: It happened because of my kamzoori (weakness). The first time it happened to me because of the heat and the second time was because I was so kamzoor, I used to do all the jobs in the house and because of that I was in a poor state of health.

Eventually Shaila’s saas took her to their peer (spiritual healer) for dam (healing by the recital of Quranic verse) and the peer gave her verses written in amulet form to be soaked in water and consumed.

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After this intervention, she successfully conceived and carried her now infant son. From this conclusion to Shaila’s story, it seems that while physical states of heat, abdominal strain and weakness were involved in explaining her miscarriages, there was also apprehension of some spiritual ill-effect over Shaila which was successfully resolved by consultation with the peer. Spiritual ill-effects were often invoked in cases of miscarriage, as I now elaborate.

Dangers More or Less Diffuse In Jeffery and Jeffery’s (1996) study, miscarriages that happened despite all efforts to arrest them – limiting the consumption of food with a heating effect, refraining from sexual intercourse, resting and taking home remedies – were attributed to spiritual malevolence. ‘It is concluded that the woman has been possessed by evil spirits … or attacked by the evil eye of someone envious of her pregnancy’ (25). Women will try to protect any subsequent pregnancy by wearing amulets. The expectant mother will also avoid the haunts of evil spirits, such as wooded areas, graveyards and cremation grounds. Recalling the capriciousness of pregnancy and fertility, the Jefferys note that ‘some women, however, consider that such attacks by spirits can just as easily occur at home’ (ibid.: 25). The aptness of this insight about spiritual attacks occurring just as easily at home is suggested by the pregnancy of Bibi Anwar’s brother’s wife Sania. Above, I mentioned Sania’s hopeful anticipation of pregnancy. This was after the loss of a pregnancy that she conceived in the first month after her marriage in late 2015. Bibi Anwar told me how excited her brother was and how, on finding out that Sania was pregnant, he had distributed sweetmeats to his family. She characterized him as a simple, straightforward man. But in the spring of 2016, when the pregnancy was still in the kuche maheene, Sania miscarried. Initially, Bibi Anwar attributed the miscarriage to Sania’s outlandish consumption of heating foodstuffs. Even at that time I warned her not to overdo it on the chicken, but she paid no heed. She was eating lots of ‘dry fruit’ (nuts, raisins, figs and dates, also very heating foods). I think her mother put her up to it, to try and get the baby to fall. As you know, Sania works as a maid in a rich family and she’s earning good money. She is still giving all her money to her parents because

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they bought her an expensive dowry, well beyond their means, so she is paying off the loans they took out for her wedding.

Bibi Anwar alleged that Sania had deliberately caused herself to miscarry so that her earning potential would not be disrupted, citing her irresponsible food consumption in evidence. Significant too is the implication that she was put up to this by her natal family. But a few weeks later, Bibi Anwar implicated something like a spiritual ill-effect, a siah (shadow, shade). Maria [Sania’s husband’s older brother’s wife] had an ‘abortion’ and went to the doctor, so after that Sania had an ‘abortion’ too and everybody said that us ka siah lag gaya (the siah of Maria has gone on Sania). Maria was using that washroom with all the blood and everything [of the miscarriage], it had all gone down the plumbing of that washroom and then Sania had also used that washroom. You can very easily get a siah from somebody by sharing the washroom or by wearing each other’s clothes.

Here Bibi Anwar laid out a kind of spiritual contagion passing between the sisters-in-law through blood and water, taking the siah that caused the loss of Maria’s first pregnancy, to Sania, and making her lose her own. In cases of recurrent miscarriage, there was a more precise ethnomedical diagnosis, athra. Athra, a particular form of spiritual contagion, is a dreaded illness characterized by repeated miscarriages, stillbirths or infant deaths. In my study, it was the dominant explanation for reproductive misfortune, even in cases where a woman had only knowingly suffered one miscarriage. Although it was a huge preoccupation among the women in my study, I have found only scant reference to it in the literature. In a piece on childhood diarrhoea in South Punjab, Nielsen et al. (2013) note athra in passing, in connection with the more widely discussed ethnomedical diagnosis of sokra (sokra literally translates as ‘drying up’, an illness anthropologists have cast as a local descriptor of acute malnutrition; see Mull 1991): Athra and sokra were feared illness categories related to envy and malice. When a child died because of diarrhoea, athra and sokra were often the explanation. Athra and sokra are transmitted by the passing of a shadow over a child or its mother, according to the respondents. The main difference between athra and sokra was the age of the victims. Athra was related to stillbirth, abortions, or infants dying within the first weeks after birth. It could be passed from generation to generation and was in fact a disease of the mother which

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caused her child to die. In contrast, sokra affected older children, and could also be passed by one child to another by a shadow. (Nielsen et al. 2013: 348)

My fieldwork does not contradict Nielsen et al.’s (2013) briefly reported findings, but it extends their observations. Athra is indeed connected to sokra, and also to lykorea (leukorrhea), a condition that has been written about across South Asia (Nichter 1981; Osella and Osella 2002; Varley 2008, forthcoming) wherein women complain of excess white vaginal discharge. Women explained that lykorea too can cause babies to fall and is another form of athra. Asifa’s aunt explained that athra was something that affects every woman, to differing degrees: You can tell it’s athra if the babies die in the stomach or soon after delivery. A sign of athra is that you get a pain in your stomach on the left side, or in some women it might happen on the right side. Or if blue marks come on the body of the mother, on the hips, thighs, legs. Or sometimes the blue marks might come on the body of the baby.

Older women listed various numbers of classes of athra, one hazarding that there could be as many as eighteen different types. The common key distinctions were drawn between asebi athra (athra caused by bad spirits), kala athra (‘black’ athra, or athra caused by the ill-intent of another woman), sokra athra (where the baby ‘dries up’ and becomes progressively thin and weak) and lykorea (excess vaginal discharge, a complaint that can affect unmarried women too). The source of all these types of athra were parchawan or siah (shadows or spirits). An affected woman could pass on a parchawan deliberately to other women, through water, to rid herself of its ill-effect. She would wash her entire body, including her hair, and then go to the house of a woman with better fortune and deliberately touch her, or allow drops of water from the wet hair to fall upon another woman or her children. This process could also be augmented by the use of a taweez (an amulet of Quranic verses) obtained from a peer. The woman with the parchawan would dissolve the taweez in a bucket of water in which she would then wash. A parchawan could also be transmitted through the sharing of clothing and other portable substances too. Fears about this wilful spiritual contagion could fall into the familiar pattern described in the above example of Bibi Anwar’s sister-in-law Sania, of suspicions of kala athra or sokra following lines of interpersonal tension such as, typically, between a woman and her husband’s sisters or

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husband’s brother’s wives. Asifa’s aunt related a story about her sister’s daughter: My sister’s daughter married very early, at the age of thirteen–fourteen, and she had a son immediately but her jethani (husband’s older brother’s wife) has no child. And so one day when the jethani came to her with wet hair from just having washed and picked up the child, my niece confronted her and said ‘what are you trying to do, you shouldn’t do that’. The jethani took offence and said ‘what are you trying to say, you’re doing shak (suspicion) on me, from now on I won’t come anywhere near you and your son’ but afterwards the boy did get severely ill, and my niece blamed the jethani.

This pattern fits longstanding descriptions of how lines of spiritual accusation follow lines of social tension, as with Evans-Pritchard’s (1976) classic depiction of Zande witchcraft. But these spiritual ill-effects could also be more diffuse. There was a degree of avoidance of women afflicted by repeated miscarriages, as there was of infertile women. Asifa herself told me: When I was a child there was a woman who lived at the back side of our house and she had lots of miscarriages and my mother used to tell me ‘don’t go to her house’. People used to say the same thing to my mother, because she took four or five years to get pregnant after she was married – especially my father’s sisters, ‘yeh bimari aise lagg jaye gi’ (this is how this illness gets passed on).

Asifa’s aunt told us that in earlier decades of her life, before it was common for people to have indoor washrooms and toileting in the field was more common, athra was transmitted by stepping in another woman’s urine, and that one could also get athra from walking through a herd of sheep. A woman peer in one of the villages said that one could get athra or lykorea if one’s dupatta dragged in the dust. The sharing of clothes could also represent a diffuse, untraceable source of athra, as Kubra, domestic servant in the other village, said of her daughter: Kubra: She has lykorea, it’s a kala athra. Asifa: How do you know? How did she get it? Kubra: Listen beta (child), the way I have to go to work in people’s houses, I have worked in hundreds of people’s houses and they give us their old clothes, and I give them on to my daughter, so perhaps it came like that.

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In her own case, Asifa’s aunt identified a suspected source of the athra. She has six surviving children but has been pregnant twelve times: two died in miscarriage, and four died of sokra. When the baby was on the way, I used to make kulfian (ice-cream) so I used to go to people’s houses to fetch milk. We had some neighbours three doors down; I went to get milk from them and in that house the bahu (daughter-in-law) of that house had had a baby who had gone zaiya (wasted). So then I took milk from them and when I was coming back to my house, then my stomach began to hurt and just like that, my baby got zaiya. Then the second time I had been pregnant for eight months and one woman came to our house, she had brought some medicine from the dai to abort her baby, she didn’t want to have the baby. This woman was not our relative, she was an older woman, we used to call her maasi (mother’s sister, an honorific), she lived in our neighbourhood. The dai had given her some medicine. When she was coming back after having taken that medicine, on the way, she miscarried her baby. So then she came to our house and she took ash from the chuhla (wood fire) and wiped her legs [gestured to her inner thighs] and then she went. And after that, I picked up that ash and threw it outside and then I made food on that chuhla. After that, the baby died in my stomach.

In Asifa’s aunt’s story, revealingly, the malevolent spiritual effect came from women who were outsiders to the family. The ethnomedical category of athra therefore expresses a more general danger to pregnancy than that which runs in the grooves of kinship. As we see with these stories, and with the generalized avoidance of women suffering repeated miscarriage, it expresses the dangers of unrelated women who because of jealousy or malevolence could wish one harm. But it also offers narratives about less easily specified dangers that are out there in the ether, the danger of clothing and body fluids contaminated by parchawan, or of a dupatta that trails in the dust, or of the pressing bodies and stray contamination of passing through a herd of sheep, expressing just cause for constant vigilance about the maintenance of personal boundaries (an important theme in relationships among women; Ring 2006: 167). This need for containment and concealment comes out in this interview with Sunaina, a middle-aged woman from the second village who had been pregnant fourteen times, lost seven in miscarriage and two after birth: The third time the baby fell, a woman came to our house and sat for some time and then she left. And after that the baby fell. Then

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my saas told me that when a baby is in the stomach, ‘har kisi ko nahi batate hain’ (you shouldn’t broadcast the news).

We thus come back to the theme of the tentative pregnancy, not because women are unsure whether they are pregnant or not – as we see in the earlier ethnographies from North India, and in historical accounts of pregnancy in Europe – but because of the sheer dangers in making a pregnancy public in a sociomoral environment that includes jealous gazes and spirits. Returning to the practices of concealing pregnancy that I mentioned above – evading spoken announcements, speaking of pregnancy if at all in euphemisms, and covering one’s mouth and face with a dupatta while doing so, and concealing their changing bodily form behind reams of cloth – Pinto (2008: 160) observes that there is more to these than modesty and shame: Concealment and delicate revelation of pregnancy can be less about modesty and privacy and more – or as much – about the dangers of too much visibility. Good and auspicious things are attractive to threatening gazes, to the power of nazar.

In the rural North Indian context of which Pinto writes, sight involves ‘palpable and transmuting essences’ (2008: 145). For the pregnant woman to be gazed upon is to be offered up to another’s potentially dangerous will, in a deep interplay, she suggests, between power and knowledge. The ethnomedical aetiology of athra, of miscarriages caused by spiritual contagion, and perhaps by the malevolent transmission of an ill-fated woman, gives cause for vigilance about the revelation of pregnancy, recalling this question of whether it is the clinical gaze that captures women so much as ‘other modes of seeing, other power/knowledge/sight equations’ (144). It is prudent not to speak of pregnancy, to hide a growing stomach beneath loose clothing, and let life go on as usual, ‘until some signs are impossible not “to see”’ (158).

Concluding Discussion In the context of my study, miscarriage is bacha girna, the falling of a baby, not just the loss of a maas-ka-pinda (blob of flesh). My material suggests certain differences with Jeffery and Jeffery’s (1996) study, as the distinction between the maas-ka-pinda lost in the first trimester and the bacha lost thereafter seems likely to have eroded

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as a result of widespread and relatively cheap urine and ultrasound testing. Women apprehend that they are pregnant from an early stage, confirmed by two lines appearing on a test strip, and from then on vaginal bleeding is the falling of a bacha rather than the arrival of a delayed period. There are wider lines of argument about the significance for miscarriage of the increasingly technologically sophisticated visualization of the products of conception. But I am highly persuaded by Pinto’s (2008) suggestion that we have here a different configuration of the visualization of pregnancy than that of the clinical gaze. Rather than biomedicine’s dehumanizing isolation of the patient’s body from her person, it is the intensely personalizing gaze of the sister-in-law that penetrates the hidden truth of the growing belly and makes women worry and wonder. The patterns recall longstanding anthropological debates about accusations of misfortune, returning to Evans-Pritchard’s (1976) discussions of Zande witchcraft as ‘the socially relevant cause’ of misfortune, ‘since it is the only one which allows intervention and determines social behaviour’ (25). In discussions of recurrent miscarriages, the tensions expressed sometimes fit into this mould, as we may surmise from the general avoidance of women suffering repeated miscarriages, as of infertile women. But athra also offers narratives about less easily specified dangers that are out there in inchoate form, the dangers of unrelated women, of clothing and bodily fluids contaminated by parchawan, of a dupatta that trails in the dust of a footpath, of the pressing bodies of a herd of sheep, expressing just cause for constant vigilance about the maintenance of personal boundaries. The narratives recall Pinto’s rural North Indian ethnography, where ‘because of a fear that babies will “fall” (be miscarried), many women, in only partly disclosing their pregnancies to others, may only tentatively embrace pregnancy themselves’ (2008: 158). The issue is not that women don’t know or aren’t sure that they are pregnant, but the stakes of articulating that they do know, in a context where a pregnant belly attracts envious gazes, are high. ‘Evasions can be not only appropriate, but legitimate and necessary’ (172). Returning to Shamim’s mother’s questions about whether the loss of the pregnancy was God’s will, or a perversion of God’s will, my ethnography here traces the contours of a repertoire of practical human actions that may be drawn upon to try and protect a vulnerable early pregnancy. First are the simple domestic techniques of carefulness about dietary intake and taking respite from heavy domestic work, such as Shamim was unable to negotiate.

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Even after such efforts, ‘some babies cannot be stopped from falling’ (Jeffery and Jeffery 1996: 25). The next level of actions are those to thwart spiritual dangers, wearing amulets and avoiding the haunts of evil spirits, but ‘some women … consider that such attacks by spirits can just as easily occur at home’ (ibid.). When spiritual attacks can just as easily occur at home, then, Pinto (2008) heightens our appreciation of how home can be unhomely – a place where one’s menstrual cycles may be watched by jealous affinal kin rather than a space of comfort, a place porous to spirits that may enter it clinging to the gaze and to substances of various kinds. Strategies of evasion, deception and self-deception are the sensible, responsible, culturally appropriate response: ‘har kisi ko nahi batate hain’, ‘you shouldn’t broadcast the news’. Concealment and containment are imperative.

Acknowledgements This research was supported by the John Fell Foundation at the University of Oxford (under a fieldwork grant named ‘Modern motherhood in Pakistan’), and the Lahore University of Management Sciences (under a starting-up grant named ‘The anthropological demography of health’). Ethical procedures were approved by the University of Oxford’s Central University Research Ethics Committee. I am very grateful to Susie Kilshaw and Katie Borg, as well as to Philip Kreager, David Gellner and Susie Graham-Jones for their constructive criticisms at a seminar I gave at the Fertility and Reproduction Studies Group series in April 2017, and to Patricia Jeffery for her invaluable inputs over email. The most thanks are of course due to the NGO, and to Bibi Anwar and Asifa Parveen, for making this research happen. Kaveri Qureshi is Lecturer in Global Health Equity at the Global Health Policy Unit, Department of Social Policy, University of Edinburgh. Her research interests are in intersectional inequalities in health and gender violence, and she works in South Asia (Pakistan and India) and in the UK. She has written two monographs, Marital Breakdown among British Asians (Palgrave, 2019) and Chronic Illness in a Pakistani Labour Diaspora (Carolina Academic Press, 2019) and coedited Parenthood between Generations (Berghahn Books, 2016) and a special issue of Women’s Studies International Forum on Infant Feeding: Medicalization, the State and Techniques of the Body (2017).

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Notes   1. The question reads: ‘Women sometimes have pregnancies that do not result in a live born child. That is, a pregnancy can end in a miscarriage, or the child can be born dead. Have you ever had a pregnancy that did not end in a live birth?’ (NIPS and the DHS Program 2019: 432).   2. In India’s most recent National Family Health Survey, 6 per cent of pregnancies in the five years previous to 2015–16 ended in miscarriage (International Institute for Population Sciences [IIPS] and Inner City Fund [ICF] 2017: 160).   3. Thanks to Patricia Jeffery for drawing my attention to this dictionary entry.

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National Institute of Population Studies (NIPS) and the DHS Program. 2019. Pakistan Demographic and Health Survey 2017–18. Islamabad, Pakistan and Rockville, MD: NIPS and Inner City Fund (ICF). Neaves, W. 2017. ‘The Status of the Human Embryo in Various Religions’, Development, 144(14): 2541–43. Nichter, M. 1981. ‘Idioms of Distress: Alternatives in the Expression of Psychosocial Distress. A Case Study from South India’, Culture, Medicine and Psychiatry 5: 379–408. Nielsen, M., et al. 2013. ‘Causes of Childhood Diarrhea as Perceived by Mothers in the Punjab, Pakistan’, Southeast Asian Journal of Tropical Medicine and Public Health 34(2): 343–51. Ngyuen, V.K., and M. Lock. 2018. An Anthropology of Biomedicine. John Wiley & Sons. Osella, C., and F. Osella. 2002. ‘Contextualising Sexuality: Young Men in Kerala, South India’. In L. Manderson and P. Liamputtong (eds), Coming of Age in South Asia and South-East Asia: Youth, Courtship and Sexuality. London: Curzon Press. Pinto, S. 2008. Where There Is No Midwife: Birth and Loss in Rural North India. Oxford: Berghahn Books. Ring, L. 2006. Zenana: Everyday Peace in a Karachi Apartment Building. Bloomington: Indiana University Press. Sathar, Z. 2013. ‘Family Planning: A Missing Priority in Pakistan’s Health Sector?’, The Lancet 381(9884): 2040–41. Shaw, A. 2014. ‘Rituals of Infant Death: Defining Life and Islamic Personhood’, Bioethics 28(2): 84–95. Varley, E. 2008. ‘Belaboured Lives: An Ethnography of Muslim Women’s Pregnancy & Childbirth Practices in Pakistan’s Embattled, Multi-Sectarian Northern Areas’, Unpublished Ph.D. thesis. Univerity of Toronto.  . 2012. ‘Islamic Logics, Reproductive Rationalities: Family Planning in Northern Pakistan’, Anthropology & Medicine 19(2): 189–206.  . forthcoming. ‘Weeping Wombs: Leucorrhea and the Chronicity of Distress in Gilgit-Baltistan’, Anthropology & Medicine in press. Watts, G. 2019. ‘Helen Mary Warnock’, The Lancet 393(10186): 2118.

Chapter 5

God’s Design, Thwarted Plans Women’s Experience of Miscarriage in Qatar and England Susie Kilshaw

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iscarriage is a potentially disruptive event, often unanticipated and undesired, yet the perception of disruption varies, both individually and collectively. This chapter explores the social landscape in which fertility is embedded in two settings, Qatar and England, to understand how miscarriage is framed while also considering how cultural formulations of miscarriage are in flux. An exploration of Euro-American discourse and how it may differ from other approaches is particularly important given the hegemony of what Strathern (1996: 38) defines as ‘the largely middle-class, North American/Northern European discourse of public and professional life’ through which a ‘dominant’ language of reproduction has emerged, particularly in global policy initiatives (Faircloth, Hoffman and Lane 2013). Typically framed in discourses of agency and choice, the expectation is that with freedom, access and empowerment, desired fertility outcomes will be fulfilled (Van der Sijpt 2013: 278). Contained within is the suggestion that women are individual agents, able to choose their reproductive path; however, this ignores the uncertainty of reproduction and limits to reproductive agency. This chapter makes sense of women’s experiences in two contexts, particularly commenting on differences, by exploring

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notions of reproductive control. I argue that increased expectations around reproductive agency produce anxiety about uncertain fertility futures and increase feelings of culpability. Qatar and England are interesting locations in which to look at the tensions between reproductive choice and miscarriage because of the variation in women’s experiences of reproduction and reproductive agency. Such a comparison furthers analytic understandings of women’s responses to reproductive disruption by teasing out the impact of notions of agency on experience. A comparative approach to reproduction exposes the opposing and fluid meanings of ‘control’, when fertility rates are viewed across a continuum.

Miscarriage in Two Settings: England and Qatar People develop individual and collective understandings and responses to illness and misfortune but do so within a cultural framework. Thus, I begin with a brief overview of the two ethnographic settings within which women experience reproductive loss. In 2012 I embarked on an investigation of miscarriage in two of the countries I have called home – England and Qatar. The research was sparked by my own experience: following a missed miscarriage at 13 weeks’ gestation, I was intrigued by the silence surrounding miscarriage in England and observed women’s responses of grief, sadness and isolation. Five years after my first miscarriage, I found myself in a clinic in Qatar following a third. The contrasting experiences of my miscarriages and curiosity about the experience in other contexts encouraged me to study this subject formally. Approaching reproduction as culturally contingent, the research explored how the framing, management and experience of miscarriage are impacted by social context, including medical practice, religion, the value and importance of motherhood, indigenous knowledge of pregnancy and the pregnant body, notions of cause and culpability, as well as notions of life before birth. This chapter draws on fieldwork conducted over fifteen months in Qatar and twelve months in England between 2012 and 2016. Based primarily on interviews with eighty (forty Qatari and forty British) women who had recently miscarried, I also draw from interviews with twenty pregnant Qatari women, Islamic scholars and traditional healers in Qatar as well as family members and medical professionals in both England and Qatar (for a full description of methods, see Kilshaw et al. 2017). The research was a collaboration between a team of

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four clinicians and two researcher coordinators in Doha, the latter of whom conducted most of the interviews in Qatar, and two UCL anthropologists.

Qatar Qatar is a small country on the north-eastern coast of the Arabian Peninsula. It has experienced rapid and dramatic social and economic changes since the mid twentieth century as the result of the discovery of natural gas and oil in 1940, a discovery that led to it becoming the richest country in the world. The state religion is Islam; the vast majority of Qataris are devout Sunni Muslims, as reflected in our cohort, who were all Sunni Muslim Qatari women. Sexual relationships are governed by law, with those outside marriage prohibited, while polygamy is allowed. Most marriages are arranged and as in most of the Arab world, consanguineous unions remain most popular: 54 per cent within the family; 34 per cent between first cousins (Bener and Hussain 2006), a statistic supported by our findings. The local Qatari population has grown at a marginal rate while the country’s population has swelled dramatically in the past decades, reaching 2.6 million, of which close to 90 per cent is comprised of migrant workers (Ministry of Development Planning and Statistics [MDPS] 2016). Concerned about demographic imbalances, particularly their minority status, and eager to increase the capacity of the local population, the Qatari Population Policy 2009 focused on promoting fertility among Qataris (Gulf Research Centre 2014: 20) with a continuing emphasis on reproduction and fertility in subsequent development strategies, including the long-term ‘Qatar National Vision 2030’. Various direct and indirect pronatalist mechanisms include generous family allowances, high subsidies for housing, food and energy products and state-funded Assisted Reproductive Technologies (ARTs). The emphasis on reproduction is also a reflection of the Islamic belief that human reproduction and the need to preserve one’s social group are of the utmost importance (Tremayne and Inhorn 2012: 18). Contraception is available and made use of, though most women expressed ambivalence about its use, with some saying it was haram (prohibited) and others suggesting it was only permissible with their husband’s consent. The majority suggested that contraception should only be used after a woman had already given birth and for the use of birth spacing or in the case of illness (see Kridli, Ilori and Verriest 2013). Abortion

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is generally illegal in Qatar, although it is allowed in certain circumstances, but heavily restricted and uncommon. Qatari women experience multiple pregnancy events (Supreme Council of Health 2014) and thus are at risk of miscarriage and multiple losses, as reflected by the miscarriage rate, the three stillbirths, three neonatal deaths and one death of a one-year-old due to congenital abnormalities in our cohort. The rate of stillbirth is 5.8, which is higher than the 4.2 per 1000 births in England and Wales. The elevated rate could be due to higher rates of congenital abnormalities related to consanguineous marriages and low rates of medical terminations (Rahman et al. 2012). Qatari interlocutors were recruited through the main public hospital and are representative of the overall population. They were generally educated, with more than 50 per cent having achieved at least undergraduate education, and the majority (60 per cent) were employed, reflecting the emphasis on education and employment opportunities for women in state development strategies (Kilshaw 2020). The average age was thirty-three years old and all were married, reflecting the fact that pregnancy is only permissible in the context of marriage. Family characteristics and formation in Qatar have been changing in recent years, with women marrying and having children later than they did in previous generations and having fewer children overall. The average age of marrying has risen to 24.1 (MDPS 2016) and the total fertility rate (TFR) has declined from 5.7 in 1990 to 3.9 in 2009, but it remains high compared with other countries and is one of the highest in the Arab Gulf States (MPDS 2016; Toumi 2011). Marriage rates overall have declined in recent years and divorce rates have risen since 2001 (MDPS 2016) and are now one of the highest in the region. Women are expected to have children soon after marriage and it is important for them to demonstrate their fertility in this way, which is reflected in our cohort, of whom 73 per cent had children. The model of family promoted is one in which couples marry relatively young and begin having children immediately. Families are large and women are encouraged to have children throughout their reproductive years, with motherhood valued highly in Islam and Qatari society (Kilshaw 2020).

England England, part of the United Kingdom, has an overriding ideology of neoliberalism, which sees competition as the defining characteristic

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of human relations. Having children is encouraged in public discourse and linked to one’s perceived role in society, although there is increasing visibility and support for those who remain childless through choice or by circumstance. A number of state policies and funding measures support families, including generous maternity leave, the introduction of paternity and parental leave, and government-funded childcare and education. However, there is stratified encouragement of having children along certain lines, such as class, in order to cultivate and reproduce ideal reproductive citizens. Those dependent on welfare benefits have to navigate a two-child policy, whereas those not dependent in this way are faced with entirely different options with implications for loss. As Murphy (2019: 37) argues, motherhood is seen as something needing disciplining, with ideas around who makes appropriate mothers informing policy; miscarriage may thus be perceived as a solution for pregnant teenage women (Brady et al. 2008) because pregnancy in this group is seen as a social problem (Cook and Cameron 2015). Notions of appropriate reproduction impact experiences of loss, which is reflected in the cohort of interlocutors of predominantly ‘middle-class’ white women in their thirties. Although, as in much of Euro-America, England is seeing an increase in ‘engaged fathers’, childcare is often primarily seen as the mother’s responsibility and children a site of women’s ‘identity-work’ (Faircloth 2013). The percentage of births outside marriage or civil partnerships was 47.6 per cent in 2016, although many were born to parents who lived together. The family model aspired to by interlocutors is relatively small: two to three children born to women in their early thirties. The vast majority of participants were married and almost all were in long-term partnerships with the father of the pregnancy, although three separated within the year following the miscarriage. The TFR in England and Wales was 1.8 in 2014 and the average age of first-time mothers was 28.6 years in 2015 (Office of National Statistics [ONS] 2016). The number of women over forty having babies overtook the number of women twenty years and under for the first time in seventy years, a trend echoed across Europe. Women typically have fewer children and begin childbearing later than in Qatar. This is reflected in our cohort’s demographics: the average age of interlocutors was 34.5 years; 50 per cent remained childless (although 15 per cent were pregnant at the time of the interview and subsequently went on to give birth); of those who had children, the vast majority had one child, with only three interlocutors having two to four children.

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In the UK abortion is accessible, legal in a broad range of circumstances and relatively common, with approximately 20 per cent of all pregnancies currently ending in abortion; one in three women have had an abortion in their lifetime; and approximately 194,668 abortions took place in England and Wales in 2017. Christianity is the most widely practised religion in England and pervades the official social structure: 59.4 per cent Christian, 5 per cent Muslim and 3.7 per cent other religions in the 2011 census. Three interlocutors did not reveal their religion, a quarter described themselves as atheist, and the majority of those remaining described themselves as non-practising Christians. While the interlocutors from Qatar were representative, the English cohort was not: largely middle class, highly educated, white and, interestingly, non-religious or atheist, with social position contributing to their miscarriage experience. The composition of the cohort in England was due to site and recruitment techniques: interlocutors were recruited through a National Health Service (NHS) hospital, with ethics approvals demanding a passive form of recruitment. Additional participants were recruited through a popular miscarriage support forum as well as through social networks. Such recruitment techniques meant that the group was self-selecting; while not representative of the population of England as a whole, this group is representative of the dominant voice in popular discourse around miscarriage and, thus, provides an important insight as well as an opportunity for comparison with Qatari women.

Models of Normativity and Reproduction Qatar: Expectations of Disruption Women understand having children as a significant aspect of their role as Muslims and Qatari women. Interlocutors consistently spoke of the expectations of pregnancy and motherhood, with this tied to a woman’s social role as well as religious and national identity. State discourse emphasizes the importance of family and, particularly, motherhood in the development of the country; women consistently spoke about the extreme pressure to produce children. They spoke of pregnancy as an expected and ‘normal’ state for a married woman. Pregnancies were not planned; they were a natural consequence of sexual relations with one’s husband. Qatari women similarly described miscarriage as ‘normal’, unexceptional, a possible outcome and one of a number of possible reproductive

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difficulties. Miscarriage is managed with relative openness within cultural frameworks of modesty: women referred to being aware of the miscarriages of others (Kilshaw et al. 2017), at least in some social environments. Jameela, a 38-year-old interlocutor, describes miscarriage as: Something normal, I saw that lots of women miscarried this month. Also, my sister, just yesterday, she miscarried. The heartbeat also stopped. I saw a lot [of miscarriages] this month. Many women miscarry.

Describing miscarriage as ‘normal’, Jameela refers to other women she was aware of who had similar experiences. Interestingly, Jameela and Huda, below, refer to other women who had miscarried “recently” and by so doing emphasize commonality: this is something that happens to contemporary women like them, in the immediate time frame. Miscarriage is familiar to Jameela as it is to Huda, a 35-year-old working mother with three children, who knew other women, including her sister-in-law, a number of her friends, as well as her mother, who had miscarried: The first miscarriage was normal for me because my mum miscarried and many women who I know also had miscarriages and then they had kids.

Knowledge of her mother’s experience meant that when Huda first miscarried there was a framework normalizing it. In light of high fertility rates, it is anticipated that some pregnancies may not result in the birth of a healthy child.1 There has been a process of medicalization of pregnancy and childbirth in Qatar, which has meant a sharp significant decline in maternal, neonatal and perinatal mortality rates since the 1970s (Salameh et al. 2009). Between 1990 and 2012, Qatar’s maternal mortality rate dropped by 80 per cent and between 1975 and 2011 the relative risk of neonatal mortality in Qatar decreased by 87 per cent, despite the fact that the population increased ten-fold, and the number of deliveries 7.2-fold (Rahman and Badreldeen 2013). As part of a process of medicalization, women seek medical assistance in the early stages of pregnancy; the country’s antenatal coverage is 94 per cent; and 99.45 per cent of Qatari women have hospital deliveries (Rahman and Badreldeen 2013; see Green and Smith 2006 for similar in UAE), largely due to homebirth being illegal. Close monitoring means that foetal demise may be discovered

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during regular appointments. Women experiencing pain or bleeding generally present to the hospital and are commonly admitted for monitoring and management. With improvements in maternal and child mortality rates being relatively recent, the cultural memory of pregnancy as precarious likely persists. Miscarriage does not make women vulnerable to stigma or shame in most cases: the husband of Noora, a 41-year-old Bedouin mother of six who had recently miscarried for the first time, explained: When the woman doesn’t get pregnant and doesn’t have kids at all, we call her Aqueem (infertile). But when the woman miscarries once or twice, we consider her healthy and fertile.

A woman who miscarries is ‘healthy and fertile’; she is compared positively to infertile women, who are seen as particularly problematic and stigmatized because of their inability to produce children. Miscarriage demonstrates fertility, for conception was achieved. Similarly, Varley describes miscarriage in Gilgit, Northern Pakistan, as ‘half the battle won’: two or three miscarriages were viewed as normal, but more than five was ‘too much’, signalling cosmological imbalance (2008: 313). Miscarriage is not viewed as damaging to fertility, nor as harming perceptions of the woman as such; she is expected to conceive again. In Qatar there is a standard method of handling pregnancy remains, with all materials buried just as all human tissues and body parts are buried (Kilshaw 2017a), with most women not memorializing beyond this. Miscarriage is a normal event in a range of reproductive possibilities; women typically express optimism about future reproduction and confidence in their ability to conceive again, as do those around them. England: Rejecting Normalization Interlocutors in England spoke about the ‘decision’ to get pregnant, taking into account age, career, relationship status and/or financial situation. They planned pregnancies, often around weddings, holidays, work commitments and purchasing homes, describing a desire to be secure financially as well as romantically prior to pregnancy. Some plan conception around the academic year to avoid having a ‘summer baby’ due to the perception that these children will be at a disadvantage as the youngest in the year group. Regular income, suitable housing, having a partner and father for the child and ‘feeling ready’ were important elements of provisioning and being in a suitable position to have a child. Dow found

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among her interlocutors in Scotland, UK, that ‘deliberations about becoming a parent demonstrate the assumption that parenthood can, and should, be planned – that planning parenthood is a sign that one intends to be a good parent’ (2013: 37, emphasis in the original). The prevalence and accessibility of birth control, abortion and ARTs adds to the discourse of reproductive control and agency. An emphasis on planning resonates with the dominant ideology of socially appropriate childrearing in much of Euro-America, including England, characterized as ‘intensive parenting’ (Faircloth 2013; Faircloth, Hoffman and Layne 2013; Hays 1996) and which has reached backwards in time so that ‘parenting ought more properly to be viewed along a temporal continuum, extending even to the pre-conception period, as mothers attempt to perform “ideal motherhood” and in fact achieve “mother” status through pre-conception efforts’ (Faircloth, Hoffman and Layne 2013: 6). Relentless demands are placed on ‘pre-conception parents’ to optimize their lifestyles, bodies and environment to ensure the welfare of their children (Faircloth and Gurtin 2017: 13). It logically follows that those who feel they have fallen short of such demands may experience feelings of failure or worries of culpability when reproduction does not go to plan. Women’s efforts, which suggest motherhood status at the early or pre-conception stage, inform feelings of grief and loss. English interlocutors typically commemorate their miscarriage through a variety of activities, such as: tattooing their body, creating a burial site, planting a tree or plant and/or participating in remembrance ceremonies or awareness events, such as Baby Loss Awareness Week. Heloise describes miscarriage as a feminist issue, noting the need to oppose the silence around it, which led to her being unfamiliar with its prevalence because of a lack of dialogue about it. Women typically experience miscarriage as a silenced event, which they endeavour to combat with acts of dialogue and remembering (Kilshaw 2017b; Layne 2000). English interlocutors understood their miscarriage as rare and unusual and likely signifying underlying problems (see also Bardos et al. 2015). Liv, a 25-year-old mother of a two-year-old daughter who lives with her partner of seven years, was aware that medical professionals were pointing to the prevalence of miscarriage in an attempt to ‘make her feel better’ and assuage feelings of guilt, but this did not resonate with her reproductive experience, which included two miscarriages and a previous difficult pregnancy. Interlocutors focused on the unusualness of their particular case, such as a history of reproductive problems, including previous

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miscarriage. They resisted notions of (their) miscarriage as normal, as Liv explained: [They said:] ‘This is normal, it’s fine, it happens to one in four pregnancies’. You don’t want to hear that when you’re twenty-five. I don’t drive, I don’t smoke, I follow the book when it comes to pregnancy … and I eat fairly healthily. You don’t need to hear these things saying, ‘This is fair, one in four, this is fair’. It’s like no, no, no. … [The nurse] just kept saying, ‘Normal’. … ‘This is not normal!’

For Liv, the statistic was general, not applicable to her, as a relatively young woman and one who had managed risk by following guidelines and not partaking in certain behaviours such as smoking, driving or eating unhealthy foods. Expectations around pre-conception and pregnancy in England are relentless with risk a central discourse, with a focus on containing threats to one’s own health, and those threatening the well-being of the foetus (Lupton 1999: 59), which is linked to a wider discourse of individualization and risk-consciousness (Beck and Beck-Gernsheim 1995, 2002). In a ‘neoliberal’ era, with an emphasis on self-management, ‘good’ mothers are reflexive, informed consumers (Murphy 2003) who constantly monitor themselves and their environment. Such understanding implies that pregnancy can be made risk-free (Rothman 2014) and that risks can be effectively managed. Liv rejected the normalization of her miscarriage with particular reference to risk management by being a ‘good’ ‘pre-conception’ parent. A commitment to planning pregnancy is key to this, which itself is suggested as a means to minimize risk.

Miscarriage, Agency and Control Notions of reproductive choice and control are part of the broader landscape in which reproduction is embedded, subsequently informing women’s experience of miscarriage, including feelings of culpability and perceptions of fertility and future reproductive possibilities. Having planned her life including her pregnancy with meticulous care, 34-year-old lawyer Dulcie ‘found things not going according to plan very difficult’ when her 12-week ‘dating scan’ revealed that the foetus had died. Dulcie grieved for the loss of a life planned with her ‘child’. Interlocutors commonly spoke of shattered futures, lost dreams and unfulfilled plans; miscarriage was seen as a breakdown in expected life intentions and trajectory.

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Dulcie found the lack of control over the miscarriage and its aftermath particularly challenging, as did 33-year-old Heloise, who spoke about the miscarriage at seven weeks’ gestation of her baby with her live-in partner as an experience of a lack of control: I mean the other thing I realized … I have control over a lot of things in my life and this was just something I had no control over…

Heloise’s choice to have a baby was associated with a desired transformation of her life, to travel and work less and become more settled. Interlocutors described the ‘decision’ to get pregnant; they planned and negotiated timings of conception, which suggests expectations of a high degree of control. A ‘good mother’ in England plans her pregnancies, with miscarriage seen as a failure, as losing control over her body, plans and aspirations. Medical technology has increased expectations around pregnancy, with some believing that advances in biomedicine have eliminated pregnancy loss (Layne 1992; Melo and Granne, this volume). The realization that medicine cannot overcome such losses added to feelings of uncertainty and lack of control. ‘Failure’ emerges repeatedly as a trope in interviews with English women who commonly interpret miscarriage in this way. Vicky, a 35-year-old married woman now 23 weeks pregnant, explained that following her third miscarriage: I felt like I was failing … I had this real sense that there was something wrong with me and, yes, something just wasn’t right … It certainly felt to me that Josh had done his part, and he was alright, there was nothing wrong with him and it was me letting the side down, really.

Vicky perceives her miscarriage to be a sign that there is something wrong with her; her partner had successfully contributed to the conception, but she was unsuccessful in sustaining the pregnancy. Vicky had counselling and learned relaxation techniques to overcome depression and anxiety and had been signed off work for this pregnancy in order ‘to get to the 12-week scan’. Miscarriage is typically framed as failure of one’s body, one’s femininity and womanhood, self-regulation, plans and control. In contrast, Qatari women’s framing of miscarriage is informed by understandings of reproduction as not something one plans and is further embedded in broader societal understandings of one’s life as mapped out by God. Qatari women perceive miscarriage as being God’s will and part of God’s plan for them. Samia, a 33-year-old mother of four sons, explained that following her recent miscarriage:

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I cried and I didn’t accept it … the doctor said, ‘this is from Allah’. So, though I was shocked at the beginning, but being a Muslim and our faith that whatever happens to us is God’s will … God rewards.

Samia was initially upset and unaccepting but was comforted by the doctor’s reminder that it was due to God’s will. Interlocutors commonly express solace in the knowledge of miscarriage as part of God’s plan; Kholoud explained the role of Islam in such understandings: We believe in Allah ‘Subhanaho Wa taa’ la’ (The most glorified, the most high) and we work for the afterlife. This life is transient and what we do in this life should be intended for the afterlife. I kept my baby with Allah and Inshallah I will meet him later … You don’t know what your child will grow up to be: he may grow up to be disabled or a corrupted person or disobedient or he may kill his parents, so Allah didn’t want him to be born because he wants the best for you. We believe in this and this is why we stay strong when we have such experience.

Kholoud’s faith is central to her framing of miscarriage and its acceptance, for it is God’s will that this pregnancy began and his will that it ended. Had her baby been born, he may have caused more pain; the miscarriage is a form of God’s protection from further heartache. Women commonly explain miscarriage as part of God’s plan, and a trial, which shows God’s love and provides meaning in the loss, and this is reinforced by those around them, including doctors and nurses. While God’s will is the ultimate cause of miscarriage, more concrete aetiological notions may also be suggested or explored. Frameworks of meaning, notions of reproductive control and ideas around culpability are informed by notions of destiny, fatalism and/or religion or their absence. Interlocutors in England typically did not refer to religion in making sense of their miscarriage or its cause, nor did they reach for religious discourse to provide comfort. While religion did not play a significant role in the lives of the majority of interlocutors in England, it played a dominant role in Qatar, where faith enabled women to find meaning in their miscarriage, deflect feelings of culpability or blame, and provided a sense of certainty in reproductive futures. Faith provided an overarching framework in Qatar, which informed all aspects of the experience. Miscarriage is embedded in a broader system of agency/fatalism in the unfolding of one’s life. ‘Fate’ in Southern Arabia is a complex construction but is often incommensurable and sometimes even congruous with deep personal agency (Parkhurst 2014).

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Culpability and Blame While women in both contexts followed certain proscriptions around protecting their pregnancy and ensuring their health and safety (Kilshaw et al. 2016), for the English cohort the advice, guidelines and expected behaviours were far more detailed, numerous and unrelenting. As Murphy (2019) notes, for women seeking to make sense of reproductive loss, there is much fodder: UK NHS advice suggests pregnant women should not eat soft cheese with white rinds, soft blue cheeses, raw or partially cooked eggs, pate, liver, game and some types of fish (NHS 2017); women are also given advice about exercise, how much they should eat and which vitamins they should consume, as well as strict guidance about limiting alcohol consumption and the cessation of smoking. English women described such preparations and behaviours as typically extended to before one conceives. In most cases, the cause of a miscarriage remains medically unknown (Melo and Granne, this volume), leaving women and others to contemplate possible contributing factors. The majority of interlocutors2 (56 per cent) in England referred to ‘chromosomal abnormalities’ or ‘genetic problems’ with the foetus, with these being seen as free from culpability; women reported that health professionals emphasized this cause and linked it to the lack of blame or control in miscarriage. However, this did not prevent women in England excavating their memories in an attempt to identify possible causes, a search associated with feelings of guilt. Similarly, other scholars have found women interrogating their behaviour while pregnant to determine whether they were to blame for stillbirth (Murphy 2012) or their child’s disability (Landsman 2000). As Liv pointed out, either the medical professionals were ‘lying before’ by emphasizing preventative proscriptions or were ‘lying now’ when suggesting that miscarriage was beyond one’s control and not due to any misdemeanours. Women described a struggle between a guilt-inducing ‘irrational’ search for cause and ‘rational’ thoughts of the miscarriage being blameless, caused by bad luck, and/or by faultless congenital abnormalities. Liv articulated such feelings of culpability: I still blame myself. I know I shouldn’t and I’ve had doctors, nurses, family, friends, everyone tell me not to blame myself, but I think I will until I die.

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Jennifer, a 35-year-old married woman with no children after one miscarriage and two previous terminations, sifted through her memories to identify possible causes, focusing on instances where she had transgressed the risk-conscious behaviours and self-management of a good pre-conception or pregnant woman: Over Christmas I was quite poorly. I’d taken quite a lot of Sudafed and other cold and flu medication. And then, on the day before New Year’s Eve we’d gone to a friend’s house for a dinner and I had drunk rather a lot of champagne with my female friends, and then two days later found out I was pregnant. Then, of course, when we found out I’d miscarried and then they said, ‘We think the baby didn’t develop properly’, immediately I started going, ‘Well, there we go, I was just pregnant and I’m flooding my body with medication and alcohol. No wonder this didn’t develop properly’, and I tortured myself for a good couple of days.

In most cases, as we see with Jennifer, women worry about behaviour prior to knowledge of the pregnancy despite being model pre-conception mothers. Jennifer’s desire to understand is linked with attempts to make sense of her miscarriage and to exert control over her reproductive future through the management of risk: Because there is so little understood about what the causes really are, for me it’s that classic thing of you really want to find something. … I think that unknown … fed into those fears: ‘Well, if we don’t know what’s caused it, how do we stop it happening again?’ ‘I can’t fix this unless I know what caused it to begin with…’.

For Jennifer, the uncertainty of cause is particularly problematic and informs anxieties about future reproduction. Understanding the reason for the miscarriage would mean an ability to prevent another in the future: identifying cause is a means to manage uncertainty. Interlocutors in England suggested a number of possible causes of miscarriage, with half submitting problems with the woman’s body such as a misshapen uterus or the presence of fibroids, or problems with the cervix. While women acknowledged that difficulties in reproduction could be due to either partner’s contribution, most emphasized miscarriage as due to issues with their bodies, as Emma did: I’m faulty and I can’t do what women are supposed to be able to do. … You just feel that fundamentally you are broken as a woman.

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Emma suggested that something was wrong with her body: it did not function in the way it should; it failed at producing motherhood. British women typically understood miscarriage to be their fault, either the result of something they had done, such as consuming alcohol, being stressed, or because of a problem with their bodies or their selves. The aging body was a significant concern, with 41 per cent suggesting advanced age was a likely cause of miscarriage. There was some overlap in understandings of cause in England and Qatar, with both cohorts seeing stress or lifting a heavy object as a common cause. This resonates with research revealing that Americans understand miscarriage as being caused by a stressful event (76 per cent) and lifting a heavy object (64 per cent) (Bardos et al. 2015). Twenty-five per cent of Qatari interlocutors cited foetal and/or chromosomal abnormalities as the cause of miscarriage, which was further linked to ideas of destiny and God’s will. There were, however, significant differences in notions of causation, such as those linked to problems with the maternal body. Qatari participants were less likely to refer to such, with 5 per cent suggesting issues with the uterus as a cause of miscarriage. English interlocutors did not discuss diabetes as a risk, whereas 12 per cent of Qataris did, reflecting the high prevalence of the condition in Qatar, with 16.7 per cent incidence in the adult Qatari population (Bener et al. 2009). Advanced age did not emerge as a major concern or dominant theme in Qatar. Supernatural forces play a prevalent role in miscarriage causation in Qatar but were entirely absent from discussions with English interlocutors: 33 per cent of Qatari interlocutors referred to evil eye and all referred to God’s will as a common cause. Qatari interlocutors suggested that, ultimately, miscarriage is part of God’s plan and therefore out of their hands. Women found comfort in the knowledge that the miscarriage was destined for them and, thus, beyond their responsibility. This helped to deflect accusations that they were to blame, as some reported that they had been indirectly blamed for causing their miscarriage, as was the case with Dana, a 29-year-old mother of two children who had suffered a miscarriage and a stillbirth before experiencing a second miscarriage. Dana’s mother explained: [Dana] was telling us that her husband’s family accuses her of the miscarriage in an indirect way. Her mother in-law said; ‘what’s wrong with women nowadays? We used to get our babies without having any problems!’

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Dana had described to her mother that she felt her in-laws held her responsible for her miscarriage in an ‘indirect’ way, suggesting there was something ‘wrong’ with her along with her contemporaries. Notions of miscarriage cause are linked to wider discourses of Arab modernity and its impact on reproduction (Kilshaw 2020). Typically, indirect or general suggestions of blame are linked with suspicions that a woman may have transgressed norms of pregnancy or acted ‘carelessly’ by not resting or not effectively avoiding exhaustion. The mother of 23-year-old Nada, who had no children following a miscarriage, stated that in general a woman is considered culpable when she contributes to the miscarriage by not heeding medical advice or common guidelines for pregnancy health: If she carried something heavy, in this case she is guilty, or if she took a medication that may harm her and the baby, she is guilty, or if she didn’t follow the doctor’s recommendations, she is guilty too. But if she did all she can and followed the doctors’ recommendations and took the medications, in this case she is not guilty.

Carelessness, particularly around fatigue and exertion, emerges as a trope around culpability. While a number of Qatari women reported that they felt others (typically their husband’s family) might think they caused their miscarriage, expressions of guilt were uncommon, which differs from the English context where narratives of miscarriage typically include feelings of responsibility. Feelings of culpability among interlocutors in England focus on particular behaviours, but also wider life choices around planning reproduction, including a focus on advanced age. Age was a common factor in women’s decisions to try to conceive, and a concern when problems were experienced. Women expressed anxiety about the relationship between age and fertility, questioning whether miscarriage was linked to their decision to delay conception, expressing concern that their increasing age limited opportunities for reproduction. ‘Are we running out of time?’ worried 35-year-old Vicky. As Heloise explained: The other kind of fear … is how long will it be before I get pregnant again? Was that my only chance? … Am I going to be one of those people who has multiple miscarriages? It just opens a door to all kinds of uncertainties.

‘Uncertainty’ appears repeatedly: miscarriage results in ambiguity, particularly over one’s reproductive future. English interlocutors were anxious and pessimistic about their future fertility. They

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worried that this was their last opportunity to have children, reflecting the milieu of ‘anxious reproduction’, which emerges as new reproductive choices, burdens, responsibilities and accountabilities increase anxiety (Faircloth and Gurtin 2017). Qatari women had confidence in their fertility and a sense that their life is mapped in a way that is somewhat beyond their control. Qatari women’s lives are lived within a religious and cultural framework that limits notions of reproductive choice, and, as a result, miscarriage is seen as ultimately out of their control.

Approaches to Miscarriage: Practices in Flux Understanding the shaping of women’s experience of miscarriage is relevant given the hegemony of the Euro-American ‘dominant’ language of parenting and reproduction, which has begun to frame miscarriage as a significant loss to which grief and memorialization are the appropriate response. Health policy and medical practice in Qatar are influenced by Euro-American discourses and professionals in these fields come to the country from all over the world. Parenting has become a subject of state concern and has become tied to narratives of national identity and discourses of modernity, as articulated in the main state development strategies, including the Qatar National Vision 2030 (QNV), and as evidenced by a number of government initiatives (i.e. Doha International Family Institute, the Qatar Nanny Academy). Qatari women’s experiences of miscarriage may change as dominant discourses continue to infiltrate, as well as with societal changes, which see Qatari women marrying and having children later, producing fewer children and experiencing fewer pregnancies. Furthermore, with an emphasis on ‘women’s empowerment’ (Qatar General Secretariat for Development Planning 2011) in state discourse, including increased expectations and aspirations around work and education, it is possible that opportunities and requirements for reproductive choice will accompany such transformations. Hays (1996) noted that the intensification of motherhood in Euro-American settings was coterminous with women’s increased participation in the workforce, and in Qatar the state focus on motherhood and parenting has accompanied strategies to increase women’s participation in the workforce. However, forces in Qatar will contain, resist and shape these discourses. For example, the centrality of faith in the aftermath of miscarriage not only minimizes feelings of culpability

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and accusations of blame, but also reduces anxiety and feelings of uncertainty. The way miscarriage is framed is not stagnant, just as other aspects of fertility and reproduction may be in flux. There are a range of responses to miscarriage and differences within settings as well, just as there are similarities across contexts. In both contexts the approach to miscarriage is in flux: both seem to be shifting, but perhaps in opposite directions. The more individual the model of health and illness, the more one becomes culpable. The rise of women’s empowerment is, of course, a good thing, but there may be an impact in unexpected ways. As new reproductive choices, burdens, responsibilities and accountabilities increase, so does anxiety about one’s reproduction (Faircloth and Gurtin 2017). It appears that while miscarriage is normalized in Qatar, it may be becoming less so. In England, there seems to be a shift away from seeing miscarriage as individual and something to be experienced in silence to something more social through public acts of commemoration; women are rejecting the medicalization of miscarriage and are moving towards seeing it as more normalized.

Conclusions Women in Qatar and England describe sadness and suffering around miscarriage. Societal approaches to miscarriage and perceptions about its normativity impact women’s experience, including feelings of responsibility. With the tradition of silence surrounding Euro-American miscarriage, women are less exposed to others’ miscarriages, although with the increase in public disclosures of pregnancy loss this is now changing. In contrast, Qatari women report being aware of others who have miscarried or experienced other negative reproductive outcomes, particularly referring to their mother’s, sister’s, sister-in-law’s or friend’s pregnancy losses. High fertility rates mean there is greater exposure to unsuccessful reproductive events, with miscarriage being understood as not uncommon and not particularly anxiety-producing, unlike infertility. Demographic anxiety in the face of declining fertility rates, changes in family formation and overwhelming demographic imbalances, as well as Islamic emphasis on procreation, means fertility is highly prized, informing a view of miscarriage as a positive demonstration of fertility. While fertility rates have been declining, the TFR remains high, which informs understandings of miscarriage as

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relatively normative. While both settings stress the importance of having children, and infertility is a source of profound anxiety, in England there seems to be a collapsing of miscarriage and infertility, with both pointing to pathology, while in Qatar miscarriage is understood as evidence of fertility and health. The different landscapes of fertility within which pregnancy loss is embedded inform experiences of miscarriage. English interlocutors have a wider sense of control over their reproductive lives. They were more likely to be childless than those in Qatar. The lower TFR in England, higher average age at time of the birth of the first child, the increasing rates of women having children after forty and the smaller family model promoted mean that women are exposed to fewer pregnancies and are likely to invest heavily in each pregnancy. Furthermore, children have become a site of women’s ‘identity-work’ (Faircloth 2013), further informing feelings of grief and acts of memorialization. The latter are likely informed by performances of and the achievement of ‘mother’ status through pre-conception efforts and those of early pregnancy. As reproductive choices expand, the burdens, responsibilities and accountabilities around reproduction increase, resulting in anxiety (Faircloth and Gurtin 2017). Despite awareness of its prevalence, English women saw miscarriage, or at least their miscarriage, as unusual, perhaps understanding it as something that happens to other women, those who are not ‘good’ pre-conception parents or pregnant women. In the English neoliberal context, reproduction is seen in terms of success or failure, and with its emphasis on self-management, women typically blame themselves when a pregnancy does not continue as planned. Interlocutors in England experience a high degree of control over their reproduction: the use of birth control is common, and women have access to a wide range of reproductive choices and technologies, as reflected in our cohort, with four having had one or two terminations, including Liv and Jennifer, and six becoming pregnant following ARTs. Women plan conception and pregnancies, understanding their behaviours as having a high degree of influence on the outcome. Opportunities for choice and notions of fatalism impact the way miscarriage is understood and experienced. In Qatar, the prevalence of arranged marriage, the legal and cultural prohibitions around sex and sexuality, pressure to produce children, lack of access to birth control and the rarity of abortion all inform notions of reproductive agency. Perceptions of choice and agency impact how reproductive disruptions are experienced. A context that emphasizes choice

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and control over reproduction has the unintended consequence of heightening feelings of responsibility, accountability and anxiety when reproduction goes awry. Miscarriage is experienced as a lack of control resulting in feelings of uncertainty. Whereas women in England suggested their miscarriage was a failure in their role as a woman and in their bodies, Qatari women did not: instead a miscarriage demonstrates fertility and they express confidence that another pregnancy will occur in the near future. Qatari interlocutors reflected biomedical interpretations of miscarriage not as failure, but rather a normal process of reproduction: the elimination of something unviable or disordered (see Elliot; Melo and Granne, this volume). What is a comfort in Qatar – a suggestion that one will soon be pregnant again – is often an injury in England: words meant to comfort such as, ‘at least you got pregnant’ and ‘you can get pregnant again’ were hurtful. In England this was experienced as minimizing loss, disregarding the uniqueness of the baby, and did not resonate with women’s uncertainty about future fertility. In the English context there appeared to be a collapsing of infertility and miscarriage with little differentiation between the two, which differs from the Qatari context where the two are seen as significantly different.

Acknowledgements I am grateful to my collaborators and research team for their significant contributions to the research: Stella Major, Nadia Omar, Mona Mohsen (WCM-Q), Halima Al Tamimi and Faten El-Taher (HMC), Kristina Sole (University of Oslo) and Daniel Miller (UCL). In particular, I would like to thank Mona and Nadia who conducted most of the interviews in Qatar and translated them, with Nadia’s contribution spanning the entire project. This chapter is based on research produced out of a close collaboration with the research team and I am grateful for their involvement throughout the research including: data collection, input and discussions throughout the project. I am grateful to my FRSG colleagues, Soraya Tremayne and Philip Kreager, for their comments on the presentation which formed the basis of this chapter. Jane Derges and Erica van der Sijpt read early drafts and provided helpful comments. This study was funded solely by Qatar National Research Fund (QNRF) (a member of the Qatar Foundation) (http://www.qnrf. org), under NPRP grant [5–221–3-064]. QNRF did not have any

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additional role in the study design, data collection and analysis, interpretation of data, decision to publish, or preparation of the manuscript. Susie Kilshaw is a Wellcome Trust Principal Research Fellow in the Department of Anthropology, University College London. Her research interests are in reproduction and risk, compromised fertility and pregnancy endings. She has worked in Qatar and in the UK. Her current Wellcome Trust-funded research focuses on the practices around pregnancy endings in England. She has written two monographs, Pregnancy and Miscarriage in Qatar: Women, Reproduction and the State (I.B. Tauris, 2020) and Impotent Warriors: Gulf War Syndrome, Vulnerability and Masculinity (Berghahn Books, 2009).

Notes   1. Among the Qatari cohort, there had been three stillbirths, three neonatal deaths and one death of a one-year-old due to congenital abnormalities. Forty per cent of the miscarriage cohort had experienced one miscarriage; 30 per cent had two miscarriages; 15 per cent had three; 15 per cent had four to six. Thirty per cent of the pregnant cohort had experienced a miscarriage (one three miscarriages and one five miscarriages); two had experienced stillbirths.   2. Of the forty women interviewed, six did not comment on causation and, thus, these figures are based on the thirty-four women who did choose to discuss miscarriage causation.

References Bardos, J., D. Hercz, J. Friedenthal, S.A. Missmer and Z. Williams. 2015. ‘A National Survey on Public Perceptions of Miscarriage’, Obstetrics & Gynecology 125(6): 1313–20. doi:10.1097/AOG.0000000000000859. Beck, U., and E. Beck-Gernsheim. 1995. The Normal Chaos of Love. Oxford: Polity Press.  . 2002. Individualization. London: SAGE. Bener, A., and R. Hussain. 2006. ‘Consanguineous Unions and Child Health in the State of Qatar’, Pediatric and Perinatal-Epidemiology 20: 372–78. Bener, A., M. Zirie, I.M. Janahi, A.O.A.A. Al-Hamaq, M. Musallam et al. 2009. ‘Prevalence of Diagnosed and Undiagnosed Diabetes Mellitus and Its Risk Factors in a Population-Based Study of Qatar’, Diabetes Research and Clinical Practice 84: 99–106. doi:10.1016/j.diabres.2009.02.003.

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Landsman, G. 2000. ‘“Real Motherhood”, Class, and Children with Disabilities’. In H. Ragone and F.W. Twine (eds), Ideologies and Technologies of Motherhood: Race, Class, Sexuality, Nationalism. London: Routledge. Layne, L. 1992 ‘Of Foetuses and Angels: Fragmentation and Integration in Narratives of Pregnancy Loss’. In D. Hess and L. Layne (eds), Knowledge and Society: The Anthropology of Science and Technology, vol. 9. Greenwich, CT: JAI Press, pp. 29–58.  . 2000. ‘“He Was a Real Baby with Baby Things”: A Material Culture Analysis of Personhood, Parenthood and Pregnancy Loss’, Journal of Material Culture 5(3): 321–45. Lupton, D. 1999. ‘Risk and the Ontology of Pregnant Embodiment’. In D. Lupton (ed.), Risk and Sociocultural Theory: New Directions and Perspectives. Cambridge: Cambridge University Press, pp. 59–85. Ministry of Development Planning and Statistics. 2016. Woman and Man: Statistical Portrait 2014. Doha, Qatar. Retrieved 14 April 2018 from https://www.mdps. gov.qa/en/statistics/Statistical%20Releases/Social/GenrealSocialStatistics/ MenWomenProfile/2014/WomanAndMan2014_en.pdf. Murphy, E. 2003. ‘Expertise and Forms of Knowledge in the Government of Families’, Sociological Review 51(4): 433–62. Murphy, S. 2012. ‘Reclaiming a Moral Identity: Stillbirth, Stigma and “Moral Mothers”’. Midwifery 28(4): 476–80. doi: 10.1016/j.midw.2011.06.005.  . 2019. ‘“I’d Failed to Produce a Baby and I’d Failed to Notice when the Baby Was in Distress”: The Social Construction of Bereaved Motherhood’, Women’s Studies International Forum 74: 35–41. NHS. 2017. ‘Foods to Avoid in Pregnancy’. Retrieved 14 May 2019 from https:// www.nhs.uk/conditions/pregnancy-and-baby/foods-to-avoid-pregnant/. Office of National Statistics [ONS]. 2016. ‘Birth in England and Wales’. Retrieved 4 November 2019 from https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/livebirths/bulletins/ birthsummarytablesenglandandwales/2016. Parkhurst, A. 2014. ‘Genes and Djinn: Identity and Anxiety in Southeast Arabia’, Ph.D. dissertation. Department of Anthropology, University College London. Qatar General Secretariat for Development Planning. 2011. ‘Qatar National Development Strategy (QNDS)’, 2011–2016. Doha, Qatar. Retrieved 4 November 2019 from http://www.mdps.gov.qa/portal/page/portal/ gsdp_en/knowledge_center/Tab/Qatar_NDS_reprint_complete_lowres_ 16May.pdf. Rahman, S., and A. Badreldeen. 2013. ‘Perinatal Service in the State of Qatar’. Retrieved 4 November 2019 from https://www.omicsonline.org/perinatal-service-in-the-state-of-qatar-2157-7420.S11-012. php?aid=15234. Rahman, S., W. El Ansari, N. Nimeri, S. ElTinay, K. Salameh, T. Abbas, M.T. Yousafzai and A. Bener. 2012. ‘Have Neonatal Mortality Rates in the State of Qatar Become Static? A PEARL Study Analysis’, Eastern Mediterranean Health Journal 18(12): 1201–8.

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Rothman, B.K. 2014. ‘Pregnancy, Birth and Risk: An Introduction’, Health, Risk & Society 16(1): 1–6. doi:10.1080/13698575.2013.876191. Salameh, K., S. Rahman, H. Al-Rifai et al. 2009. ‘An Analytic Study of the Trends in Perinatal and Neonatal Mortality Rates in the State of Qatar over a 30-Year Period (1977 to 2007): A Comparative Study with Regional and Developed Countries’, Journal of Perinatology 29(11): 765–70. PMid:19641511. http://dx.doi.org/10.1038/jp.2009.89. Strathern, M. 1996. ‘Enabling Identity? Biology, Choice and the New Reproductive Technologies’. In S. Hall and P. Du Gay (eds), Questions of Cultural Identity. London: SAGE. Supreme Council of Health, Qatar 2014. ‘National Health Strategy 2011–2016’. Retrieved 16 May 2016 from http://www.nhsq.info/app/ media/1541. Toumi, H. 2011. ‘Fertility Rate Records Steady Decline in Qatar’, Gulf News, 13 April. Retrieved 4 November 2011 from http://gulfnews.com/news/ gulf/qatar/fertility-rate-records-steady-decline-in-qatar-1.791643. Tremayne, S., and M. Inhorn. 2012. ‘Introduction: Islam and Assisted Reproductive Technologies’. In Islam and Assisted Reproductive Technologies: Sunni and Shia Perspectives. Oxford: Berghahn, pp. 1–21. Van der Sijpt, E. 2014. ‘The Unfortunate Sufferer: Discursive Dynamics around Pregnancy Loss in Cameroon’, Medical Anthropology 33(5): 395–410. Van der Sijpt, E. 2013. ‘Complexities and Contingencies Conceptualized: Towards a Model of Reproductive Navigation’. Sociology of Health & Illness 36(2): 278–290. Varley, E. 2008. ‘Belaboured Lives: An Ethnography of Muslim Women’s Pregnancy and Childbirth Practices in Pakistan’s Embattled, Multi-Sectarian Northern Areas’, Unpublished Ph.D. thesis. University of Toronto.

Chapter 6

‘It Felt Like the Longest Time of My Life’ Using Foetal Dopplers at Home to Manage Anxiety about Miscarriage Aimee Middlemiss

I

n the early summer of 2017, I noticed Cara’s pregnancy was beginning to show as she led me down the stairs into her living room in Cornwall. Her toddler son was sleeping, and the windows were open to the sound of birdsong. The little house she and her husband had just finished building was big enough for two children, and she was 16 weeks pregnant. It would appear that life was all going to plan. But alongside the pregnancy there was a visible tension in her body, as she showed me the small grey box and transducer wand of the foetal Doppler that she was using in this, her sixth pregnancy: I went to work the other night, and I was really doing a lot of bending down and getting stuff out of the fridge, I was on the bar, and my hip flexors were really hurting at the end of the night, and I was a bit, just like ‘oh god, I hope everything’s alright’. And I just did it [listened to the foetal heartbeat using the Doppler] the next day, just as a bit of reassurance.

Four of Cara’s five pregnancies had ended in miscarriage. Two miscarriages in the first trimester came before the birth of her

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son, and since then there had been two ‘missed miscarriages’. In both these later pregnancies, foetal death had occurred around eight weeks but was discovered at the 12-week routine antenatal ultrasound scan. Cara had struggled to cope with the losses and had become increasingly anxious about her ability to carry another pregnancy to term. Money was tight, because of building the house, but she had spent £19 on eBay and bought herself a second-hand foetal Doppler, a device used in midwifery and obstetrics to assess the presence and rate of a foetal heartbeat, now widely commercially available in the UK (Hale 2007). For Cara, using the Doppler on her own body at home was a way of managing her anxiety about the outcome of this new pregnancy, and of avoiding the shock of another missed miscarriage discovered by medical staff: I’m not going to worry that I’m going to turn up to the [20-week] scan and they will tell me something’s gone wrong. Because that’s the main worry. I’ve been so nervous about going to my scans this time, thinking are they just going to say ‘sorry’ again.

Cara’s extreme anxiety about the precarity of the continuation and outcome of her wanted pregnancy was echoed by other women in Cornwall who shared their stories with me about their use of foetal Dopplers at home in pregnancy. Months or years after particular pregnancies had ended with the birth of a child, women still vividly recalled high levels of anxiety about the possibility of miscarriage, which prompted them to acquire and use Dopplers at home to listen to the foetal heartbeat in the early months of pregnancy. The impact that fear of miscarriage had on the lives of participants was considerable, during particular pregnancies, during subsequent pregnancies and in their personal narratives of their reproductive lives. Participants described how they had used domestic foetal Dopplers during pregnancy to gain repeated reassurance that their foetus had not died, as the most basic condition for the possibility of the pregnancy outcome they hoped for: the birth of a living baby.

Investigating Foetal Doppler Use in Cornwall The project from which these findings were drawn was a broader exploration of the use of foetal Dopplers by pregnant women at home in Cornwall, in the United Kingdom, in the context of public criticism of the practice. Handheld foetal Dopplers are electronic devices that can broadcast replicated foetal heartbeat movement as

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sound in real time. They have become widely commercially available in the last decade, alongside other electronic devices which claim to monitor the foetus, such as mobile phone apps. Concerns about the lay use of foetal Dopplers were first raised by doctors in the BMJ in 2009 (Chakladar and Adams 2009; Daniel 2009), based around a single case of possible misuse.1 They were then taken up by the campaigning pregnancy charity Kicks Count (Kicks Count 2017) and developed into a Private Member’s Bill in Parliament which aims to limit foetal Doppler sales to medical professionals (Fetal Dopplers (Regulation) Bill, 2017–19). There is therefore a recent history of criticism of lay foetal Doppler use in medical and policy contexts, and there are attempts to stop pregnant women having legal access to the devices at home. However, these discourses discouraging lay Doppler use exist alongside online promotion of the devices and their easy availability to buy or rent. There is also ambiguity about the role of foetal heartbeat listening in National Health Service (NHS) midwife-led antenatal appointments, which were attended by all the women in this study. For over forty years, generations of NHS midwives have offered foetal heartbeat listening, often using Dopplers, as part of antenatal care and during labour (Gültekin-Zootzmann 1975; Hod and Kerner 2003). In 2008, national guidelines declared that Doppler antenatal foetal heartbeat listening should not be routinely offered by midwives in the NHS in England (National Institute for Health and Care Excellence [NICE] 2008), but the practice is still common in midwife antenatal care. Therefore, for pregnant women, the use of foetal Dopplers and heartbeat listening in pregnancy is a normal and routine element of professional care. As a consequence, women make a choice about whether to acquire and use a foetal Doppler themselves at home in the context of competing discourses about the acceptability of the practice. This chapter explores how the choice to use foetal Dopplers at home can be understood by paying attention to the specific reproductive histories of women, particularly their histories of miscarriage or threatened miscarriage. The practices of Doppler use and the meanings it has for pregnant women who acquire and use the devices at home are shown to be attempts to control anxiety about pregnancy outcome through acquiring knowledge of the foetus in pregnancies perceived as at risk of miscarriage. Significantly for this research, a foetal Doppler is constructed with a separate transducer wand attached to a monitor by a coiled, expandable cord, allowing it to be easily used on one’s own pregnant body. This allows for the

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possibility of the use of the technology on oneself in a home setting, outside the antenatal clinic or labour room, in a domestication and demedicalization of the technology (Conrad 1992; Silverstone, Hirsch and Morely 1992). Similar to the commercialization of ultrasound imaging of the foetus in the UK (Roberts, Griffiths and Verran 2017), there are implications for control of the technology and for new family practices producing knowledge of the foetus. Furthermore, the usefulness of Doppler technology for pregnant women also rests on its ability to pick up foetal heartbeat sounds before foetal movement is usually felt, late in the second trimester of pregnancy. Some women were able to hear heartbeat sounds as early as the first trimester. A Doppler, therefore, is potentially able to provide evidence of the existence of foetal life, at home, under the control of the pregnant woman, at a stage of pregnancy when knowledge of the foetus and its existence is otherwise mediated by medical professionals in the antenatal care system. This situates home foetal Doppler use within feminist debates over whether reproductive technologies allow women to exert agency and control over their own reproduction, or whether they represent new forms of control over pregnancy (Ginsburg and Rapp 1991; Murphy 2012; Neyer and Bernardi 2011; Rothman 2014). The project sought to investigate women’s use of this technology in pregnancy by interviewing women who reported the experience of hearing foetal heartbeat sounds from within their own bodies, as produced by a Doppler at home. This was a theoretical sampling approach (Marshall 1996), which distinguished the project from other qualitative work on Doppler use in medical contexts in Mexico (Howes-Mischel 2016, 2017). The domestic, familial setting of Doppler use also situated the project within literature describing relational content and meaning produced by medical technologies that describe the foetus, such as foetal ultrasound (Han 2009; Harris et al. 2004; Mitchell 2001). Fifteen women were recruited through traditional and social media, and semi-structured interviews were carried out in homes in Cornwall, England. During the research, my own position as a local mother who had herself experienced miscarriage played a part in establishing trust and developing rapport. There were some significant vocabulary choices in the interviewing process, in that I chose to use the term ‘baby’ to refer to the foetus (Duden 1993; Rothman 1993), which was confirmed by participants’ use of the term ‘baby’ or sometimes the name of the child who was born from the pregnancy they were describing, since all the pregnancies in which women used the Dopplers resulted in

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live births. I used the term ‘foetal Doppler’ for the technology as the women themselves used this vocabulary, and the commercial descriptions of the technology also use that term. Ethical approval for the project was gained from the University of Exeter’s Ethics Committee. Interviews were audio recorded and transcribed, and participants were anonymized. Several passes were made through the data to consolidate themes, in an inductive approach to identifying patterns which has been used by other feminist researchers in the field of motherhood research (Malacrida 2007; Wall 2010). Data were also coded in NVivo. Modified Grounded Theory techniques (Charmaz 1990; Strauss and Corbin 1998) were used in analysis, and interviews were conducted until data saturation was reached in terms of new themes or concepts emerging from the data (Guest, Bunce and Johnson 2006). The women interviewed all lived in Cornwall, and identified as white British, which is typical of this remote, low-population, rural county in the west of England (Cornwall Council 2013). Although Cornwall has a strong traditional culture, only 10 per cent of the inhabitants identify their nationality as Cornish and there is substantial migration into the county (Cornwall Council 2013). Cornwall is characterized by relatively low levels of average earnings and areas of deprivation (Cornwall Council 2017) in an economy based principally on agriculture and tourism which also contains pockets of wealth, for instance in holiday rental ownership. Two participants did not work outside the home and the others had a variety of occupations, from low skilled, such as a waitress, to higher skilled, such as a nurse. They were aged twenty-three to fifty at the time of the interview, and all had used foetal Dopplers in pregnancies that had ended in live births during the last ten years. One participant, Cara, was pregnant at the time of the study. The women had an average of 2.3 children, but a range of between one and five. Of the thirty-five children born to study participants, a Doppler had been used on twenty-two of the pregnancies that had ended in live birth. Fourteen other pregnancies across the group had ended in miscarriage or missed miscarriage, or had been ectopic.

Foetal Doppler Use and Anxiety after Miscarriage During the fieldwork, as women explained their histories of pregnancy, it emerged that contrary to received opinion in medical and policy circles, home Doppler use was not a casual plaything

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thoughtlessly deployed, but was a considered response to the problem of anxiety and the need for reassurance in pregnancies perceived as precarious and at risk of miscarriage. It took place in the context of perceived limited access to reassurance from NHS antenatal care. Again and again, women spoke about anxiety and worry, about lack of control, concern about pregnancy outcome, the risk of miscarriage and the responsibility of pregnancy. Olivia, aged twenty-three, felt no foetal movement throughout her only pregnancy due to an anterior placenta and was ‘just always panicking’ about the possibility of foetal death and missed miscarriage. She described pregnancy as ‘the longest time of my life’: I didn’t have that whole fluffy, lovely pregnancy. I just didn’t enjoy it. And I didn’t even suffer morning sickness or anything like that, I just felt the whole thing so worrying [sic]. I didn’t like not knowing if he was ok. I was always on the ‘something’s going to go wrong’ rather than the ‘I’m going to have a lovely baby boy’.

For women in this study, all of pregnancy had become precarious and risky because of their specific personal reproductive history of previous miscarriage or threatened miscarriage, or, in the case of Jane and Nicki, because of their age increasing their miscarriage risk. This chapter describes the impact of increased perceived risk of miscarriage on women’s pregnancies, and how these experiences of anxiety about miscarriage disrupted women’s assumptions about pregnancy and reproduction resulting in living babies. Living with this uncertainty for the long months of pregnancy produced ongoing anxiety. The need to manage this anxiety prompted women to use foetal Dopplers on their own bodies at home as a partial solution to the fear of miscarriage; they reassured women that foetal death had not occurred by allowing them to hear replicated foetal heart sounds. This access to reassurance of continued foetal life through using the Doppler at home was under the control of pregnant women rather than their doctors and midwives. It was therefore partly an opportunity for personal agency reminiscent of ‘agency through objectification’ (Thompson 2007), in the context of reproductive technologies whereby women agentially consent to medical objectification when they feel this is the best way of achieving their personal goals of completed pregnancy. Yet Doppler use at home was also embedded in a model of pregnancy in which the experience is defined and validated by the biomedically detectable presence of a living foetus, situating it within the medicalization of childbirth and pregnancy (Arney 1982;

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Cahill 2001) and the prioritization of medical knowledge of the foetus over the embodied knowledge of the pregnant woman (see, for example, Duden 1993; Oakley 1984; Rothman 1993; Young 1990). Doppler use reinforces cultural ideas about pregnant women’s responsibility for the outcome of pregnancy as a healthy baby, in which home Doppler use is a monitoring of an ‘other’ being, the foetus, through surveillance (Foucault 1991; Lupton 2016). Foetal Doppler use is thus connected to the responsibility of mothers for the optimization of children and their physical and social well-being, a phenomenon that has been repeatedly noted in the social sciences (for example, Bordo 2003; Foucault 1998; Smith 1974). It is situated within the considerable literature that describes the expectation that a pregnant woman will take responsibility for the health of her unborn foetus (Longhurst 1999; Lupton 1999, 2012; Thomas and Lupton 2016; Weir 1996) in order to minimize perceived risk to the well-being of that foetus. The expectation that this risk can be managed, that pregnancy can be made risk-free (Rothman 2014), increases the pressure on pregnant women who have experience of pregnancies that ended without a living baby, in a cultural context that lays responsibility for risk management with the individual subject (Foucault 1998, 2003; Lupton 2016). The technology exists within, rather than challenges, dominant cultural forms, which marginalize, stigmatize and discount pregnancy ending in miscarriage (Layne 2003). This chapter therefore explains how and why participants turned to foetal Dopplers to provide reassurance in anxious pregnancies that felt precarious to them. It then discusses the limitations of this perceived agency, in relation to the limitations of the technology of the foetal Doppler.

Precarious Pregnancies Cara’s anxiety about her sixth pregnancy, after four missed miscarriages, and Olivia’s anxiety about foetal death because she felt no foetal movement, were typical of the reproductive histories of participants in Cornwall. Seven participants had a history of miscarriage, many experiencing multiple miscarriages. Sophie had had two miscarriages and then had experienced difficulty conceiving before her son and daughter were born in her thirties. Her miscarriages had been attributed to her bicornuate uterus, diagnosed in her early twenties:

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I’d had miscarriages before. And so I was just really worried. I’d been told that I sort of had, like a … my womb hadn’t developed properly at birth, you know, in the embryonic stage, and I may have problems. So I had a lot of anxiety based around that. I didn’t when I initially got pregnant. My first pregnancy, I got pregnant quite quickly, and it was about six weeks, the loss, and that took me by surprise, really knocked me for six. Then I got pregnant again, on our wedding night, which was wonderful, really exciting, and then again that went, again really quickly. And so, then, it took us a long time to get pregnant again after that … I was very anxious.

Like Sophie, many of the women had more than one reason for anxiety around their precarious pregnancies. Emily, nearly fifty when I spoke to her, had spent more than twenty years raising five children, having given up her job as a nurse to spend her time on her large and energetic family. She had experienced two miscarriages in her seven pregnancies, and she was also concerned about her age increasing her chances of miscarriage when she unexpectedly became pregnant at the age of forty-five. Her anxiety about pregnancy loss was further increased by the fact that a sibling had had a stillborn child. She explained how these reproductive experiences had changed her attitude to pregnancy: When I was pregnant with [first child], I thought, I’ll definitely have this baby, it’ll be fine, and then I lost one, and then you think, oh actually, things do go wrong.

The shock of unanticipated miscarriage and the consequent reproductive disruption was evident in women’s accounts of previous pregnancies. Cara’s experience of ‘missed’ miscarriages being discovered at scans by medical staff was familiar to other interlocutors. Many of the women described deliberately checking for a heartbeat with the Doppler before antenatal ultrasound scans so as to control any shock if foetal death had occurred. They were aware that if the foetal heart had stopped, there was nothing that could be done, but they wished to be prepared if there was a chance of being given this bad news by sonographers. And if they did find a heartbeat before the ultrasound scan, the anxiety of the scan experience was decreased by the knowledge that there had recently been a foetal heartbeat. Women’s awareness of the possibility of miscarriage and the precarity of specific pregnancies was accompanied by a sense of responsibility for its occurrence. Claire, aged thirty-two, had had two

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miscarriages in her mid twenties, before giving birth to a son and a daughter. When I visited Claire’s home, she sat on a sofa flanked by two video and sound baby monitors, one showing her sleeping toddler and one showing her sleeping baby, in their separate rooms upstairs. Claire had been a ‘mess of worry’ throughout both pregnancies with these children, because of two previous miscarriages and because the pregnancy with her son also involved repeated bleeds. She described herself as feeling very responsible for the safety and health of the sleeping children she was monitoring on the video screens, but also as having a responsibility for pregnancy outcome: One, you just think it’s a horrible misfortune, but when it happens two [sic], you start to worry that it’s something wrong with you. You start to worry there’s something wrong with your body and that it might happen again because of that.

Despite a likely medical reason for her miscarriages attributable to her bicornuate uterus, Sophie’s sense of responsibility for pregnancy outcome extended to her behaviour in pregnancy: I was really worried, like so, so worried all the way through my pregnancy with [first child after miscarriages]. Just, you know, about every little thing. I remember I drank a can of Coke one day because I just had these horrendous headaches … and I’d cut out caffeine, because obviously that’s what you do, and I’d done all those things, and I thought to myself one day, maybe it’s just the absence of caffeine, maybe I just need a can of it. Well, somebody told me off for drinking a Coke and I spent twenty minutes crying, and you’re just kind of, oh my God, you know, I’ve damaged my baby.

Cara had also worried that helping with lifting during the building of her new house might have prompted one of her miscarriages. The possibility of transgressing controls on women’s behaviour in pregnancy, particularly in relation to diet or bodily management, added to women’s anxiety about the possibility of miscarriage. There was also a sense of responsibility for the impact of miscarriage on others. Some participants had announced previous pregnancies which had then miscarried, and they felt responsible for the consequent emotional reactions of wider family and other children. Cara described having made her family happy with the announcement of a coming grandchild, only to have to withdraw it weeks later. She also had to manage the impact of the fourth miscarriage, a missed miscarriage discovered at 12 weeks, on her toddler, and she felt this to be a personal failure too:

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With the last pregnancy before this, we were so sure that everything was fine. I was still feeling ill, and we sort of mentioned it to him [young son], because he kept asking, is there a baby in your tummy? And I think once we sort of said yes. And I just felt so stupid afterwards. And he said afterwards, you know, when’s the baby coming out? And I said, oh, it won’t be for a long time yet…

Participants were also anxious about the threat of miscarriage when they had not directly experienced one but were aware of the signs and symptoms of miscarriage, or of factors increasing the risk of miscarriage. For example, Jane and Nicki were both very conscious of being classified as older mothers, in their late thirties, and of the consequent increased risk of miscarriage for their pregnancies. Several women had physical experiences which they understood as threatened miscarriage, such as vaginal bleeding and pain during early pregnancy. Anna’s whole approach to pregnancy was disrupted by the possibility of miscarriage in her fourth pregnancy at the age of thirty-five. Her third child had been born at home, deliberately without medical assistance, and she had considered herself to be anti-intervention and determined to avoid medicalizing her pregnancy. But she bought herself a Doppler after vaginal bleeding in her fourth, subsequent, pregnancy: All my previous pregnancies were like, absolutely fine and went swimmingly. And with her, I kept having bleeds. And we went for the scans and everything showed absolutely fine, but it just suddenly switched everything to, like, what if something’s wrong?

This understanding of their pregnancy as fragile and precarious, derived from embodied experience and bodily states such as age, was sometimes reinforced by social experience. Three women worked in fields where they had regular experience of extreme medical situations, as paramedics and a children’s hospice nurse, and Emily had trained as a nurse. These participants had working lives and medical knowledge, which increased their understanding of pregnancy as precarious. Hospice nurse Sarah had her own experience of a missed miscarriage, but also had a more general sense of the fragility of life from her work, which included caring for young babies who died from conditions detected in utero. She felt strongly that reproduction was a risky affair: I don’t think you can assume you’re going to fall pregnant. I don’t think you should assume you can have children, because actually

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quite a lot of people can’t. And it’s not that I’m a negative person, I would say that I’m a realist. I think with [first daughter], until she was actually with me, it was like, ‘this [pregnancy loss] can happen’.

For participants, therefore, whatever they did to manage pregnancy risk, whatever controls over their own behaviour they put in place, there was still the chance that their pregnancy might end in miscarriage.

Reassurance in the Precarious Pregnancy This anxiety experienced by participants about the possibility of miscarriage was the prompt for them to acquire and use foetal Dopplers at home. They knew about the possibility of foetal heartbeat listening from midwife antenatal monitoring in previous pregnancies, from online forums, television programmes or from friends. The widespread availability of the devices at a reasonable price online from major retailers or second-hand on resale websites meant that acquiring a Doppler was straightforward. Using it was modelled on experiences with midwives at antenatal appointments, or researched online on sites such as YouTube. Women valued the simplicity of the device, and the clarity of the information it gave them. Rather than using it as a medical professional might, paying attention to the heart rate shown on the Doppler screen, most of the women used it to simply assess the presence of the foetal heartbeat sound, which indicated the continuation of foetal life, and therefore the pregnancy. Musician Anna, whose previous pregnancies had been straightforward, described the importance of hearing the heartbeat sound using the Doppler in the pregnancy which she felt to be precarious: I guess it was quite monumental. Because I’d never bled before, I was totally convinced I was having a miscarriage, I even said ‘I think we’ve lost the baby’. And you know, it was really sad. Yeah, and then, I found a heartbeat. I was like, oh my God! It might be ok! So … it was a really big deal.

There was a clear feeling that although the Doppler could not relieve all pregnancy anxiety in terms of producing the desired outcome of a healthy baby at term, it could relieve the basic, day-to-day anxiety around miscarriage by providing evidence of life:

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It’s just such a relief, I think, an absolute relief to hear it, because you know pretty much everything’s ok. Obviously, there could be other abnormalities, but you know it’s there and it’s alive. (Claire)

Cara said that the Doppler provided sufficient information to relieve her repeated anxiety about miscarriage – she didn’t need her Doppler to do anything except provide evidence of a heartbeat: ‘a definitive answer that it’s alive is enough for me’. Furthermore, some of the women considered that the Doppler produced the best evidence of life available to them until birth. Although many of the women in the study stopped using their Dopplers once they felt foetal movement and gestation had progressed beyond the threat of miscarriage, a few continued throughout pregnancy to combine heartbeat listening with awareness of foetal movement or other ways of acquiring knowledge of the foetus. For those women, Doppler listening continued to provide very specific evidence of life. Emily compared visual knowledge of the foetus from ultrasound scan pictures with aural knowledge in real time produced by the Doppler: There’s something very special about a heartbeat, isn’t there, I think. That there’s something alive. And it’s a sign of life. Whereas you could be carrying a dead baby and you could have a picture of it.

The foetal Doppler, therefore, provided participants with specific information about the continued life of the foetus, which they valued as clear evidence that they had not, at that point in pregnancy, experienced foetal death and missed miscarriage.

Agency and Control in Precarious Pregnancies The timeframe over which Doppler reassurance could take place was important to the participants. Like many women in the UK, they knew that they were pregnant very early, through home pregnancy testing and antenatal ultrasound scans; in the context of anxiety over miscarriage, time seemed to go very slowly. Using the Doppler was a way of managing this very difficult stretch of time. I think, for me, I’m a bit of a control freak, and pregnancy’s one of those things you couldn’t control. The losses were one of those things you couldn’t control. And conception was one of those things I couldn’t control. And it was a way of giving myself some

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reassurance, some confidence that I knew what was going on … I wasn’t, you know, thinking along to genetic anomalies, or anything like that, you know … the chips would fall where they lay with that, really. But just to know something. (Sophie)

The use of Dopplers themselves carried an element of risk, of not finding the desired foetal heartbeat, but this was considered a risk worth taking for the sake of the real-time knowledge of the foetus and pregnancy which domestic listening could produce. Being prepared for the possibility of the emotional shock of miscarriage, particularly one discovered by medical staff, was very important, as Emily described: I mean it must be hideous if you put it on and there is something wrong, but even more hideous if you wait for your midwife appointment and it happened two weeks back and you’ve been, you know what I mean, thinking everything’s fine and it’s not been. So it gives you a bit of control, I guess. Into your body and your baby. Which I think you should be entitled to really, in a way.

The need for personal control over knowledge of the foetus and its continued life was a significant factor in the use of the domestic Dopplers. Participants did not use the Dopplers as a substitute for medical care, contrary to claims made by campaigners against domestic Dopplers (Kicks Count 2017). Even Anna, who had been ideologically opposed to what she perceived as the medicalization of her pregnancies during her third pregnancy, re-engaged with antenatal care when her fourth pregnancy was threatened by bleeding. However, women felt that access to medical care through the NHS in England was restricted, both in terms of financial investment from the NHS, and in terms of perceived pressure from medical and midwifery staff not to make a fuss, or be demanding, in their consumption of healthcare. This sense that they were unsupported by the NHS, especially after previous miscarriage, pushed women towards home Doppler use. In early pregnancy, women felt the NHS policy was to wait and see whether the pregnancy was going to be viable. I think that if I could have gone somewhere, I would not have been bothered about that [using a domestic Doppler], but it’s not really available to you, is it? I mean, they do the scan at 12 weeks but that 12 weeks feels like forever. (Claire)

Cara was upset about how the timing of her four miscarriages, in pairs either side of her son’s birth, meant she never qualified for

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recurrent miscarriage investigation under the NHS guideline of investigation after three in a row. Waiting for her 20-week scan when I spoke to her, she explained how the limited availability of antenatal midwife care could not solve her anxiety about miscarriage in the early part of pregnancy. The possibility of accessing knowledge of continued foetal life at home through the Doppler without having to bother midwives or make appointments gave women a sense of agency in pregnancies where they felt unsupported. Experiences of miscarriage in previous pregnancies were sometimes felt to have been discounted or insensitively managed by medical staff to whom they did not have the same significance. Sophie felt the shock of her first trimester miscarriages was compounded by a lack of medical solutions or concern: I think that when I had that miscarriage the first time, and I phoned up the maternity because I didn’t know what to do. I woke up and I was bleeding. And I phoned the maternity department and they kind of went, oh well, yeah, you’re just going to have to go to your GP. And it was a bit kind of like, oh my God, this is happening, you know, it’s horrendous! And they were kind of like, you know, oh you’ll just have to wait till tomorrow and you can go for a scan. You’re just sort of thinking, there’s nothing! There must be something someone can do! But of course, there isn’t. And I think that’s a snapshot into the day to day life of this person who’s worrying and you don’t have any emotional support.

For women who had had these experiences of miscarriage, mobilizing anything that gave them a sense of agency and control in their subsequent pregnancies was an obvious course of action. Women knew that foetal heart rate was monitored in labour, and therefore practices of foetal heartbeat listening were felt to have medical significance and meaning. It must be a useful practice, or, as 23-year-old Olivia said, why would the midwives be noting ‘FHH’ or ‘Foetal Heartbeat Heard’ in women’s maternity notes? The women in this study felt that their use of domestic Dopplers had a validity alongside the monitoring by professionals in the NHS, but that this was often not recognized by staff: I think the way that you’re treated when you go in and speak to the medical professionals about it is: ‘You’re just a bit silly. It is a bit pointless because it doesn’t really tell you if everything’s alright or not’. But of course, it does tell you everything’s alright … Your baby’s heart is definitely beating. So that kind of is enough, that was enough for me. (Sophie)

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Resisting the Medicalization of Pregnancy Using foetal Dopplers at home, therefore, was partly a form of resistance to medicalization, in which women could control knowledge about their own foetus unmediated by medical professionals. Because at the end of the day … you’re the one growing the baby and it’s all happening to you, isn’t it, so to have that little bit of control to just check on something without having to make phone calls and appointments and go in, and worry whether they think you’re just a fussy, over the top worrier person, yes it was nice. And I could do it instantly, you know, I could have a niggle or a pain or a worry and I could check it there and then, rather than having to wait three, four days. (Claire)

Furthermore, all the women emphasized the emotional meaning that the heartbeat sound contained for them and other family members. Echoing Howes-Mischel’s (2016) findings in medical contexts in Mexico, for these women in Cornwall the foetal heart sound was understood as the essence of life, of a person and of intimacy with that person: I just do think people see the heart as the essence of who people are, on so many levels, partly because of life and death, and actual being alive, but also their character and their soul is all embedded into that, is all mixed into that. (Sarah)

Women described time spent listening to the foetal heart, once its vital presence had been detected, as a form of interaction with the foetus. The Doppler listening thus operated on two levels, one that checked for basic presence and life, and one that allowed an imagined future baby to emerge during a pregnancy which felt so threatened by anxiety. However, there was a tension, described by several of the women, between using foetal Dopplers, as medical technology, and a relational, domestic, intimate approach to pregnancy, sometimes conceptualized by them as a ‘natural parenting’ approach. Anna was very conscious of her transition from an advocate of unassisted birth to someone who used a Doppler in the next pregnancy. Sarah, the hospice nurse, was interested in the paradox of using a medical technology to produce knowledge of the foetal body that was defined as medical, but which also had other meaning for her:

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[Pregnancy]’s a very medicalized thing, and so listening to a heartbeat is an extension of that, but also that in a pregnancy that you don’t really feel is your own, that you’re owned, the midwives and the doctors own your pregnancy, and tell you what you can and can’t do with your body, it’s an opportunity to do what you want in the confines of your own home. And to feel that you have some kind of link into your own body and pregnancy that perhaps you don’t otherwise have.

Limitations of Foetal Dopplers in Managing Perceived Miscarriage Risk Doppler use was therefore in part an act of agency and an attempt at risk control in pregnancies that women felt to be precarious because of their personal reproductive history of miscarriage or threatened miscarriage. However, the technology ultimately exists in a biomedical framework which requires women to have proof of pregnancy, centred around the body of the living foetus, and mediated through technologies of biomedicine that provide proof of health. Sophie described how she felt compelled to use biomedical technologies to gain evidence of pregnancy. She had experienced difficulty conceiving and repeated miscarriages due to her bicornuate uterus, which made her deeply anxious: It was almost like I was pregnancy testing up to when I could start the Doppler, and I used the Doppler until I could feel the baby.

In this sense, pregnancy as an embodied experience is actually further medicalized by the use of foetal Dopplers at home, through women’s internalization of the need for biomedical proof of foetal life. Ellie, who had experienced an ectopic pregnancy which she had believed to be viable until it was discovered by ultrasound at 12 weeks, explained how she came to trust the knowledge provided by the Doppler over knowledge gained from her embodied experience of pregnancy: It almost becomes like an OCD thing really, where you’ve got to make sure all the lights are turned off or every cooker knob is turned off before you go to bed. Even though you know you’ve done it, because you’re questioning yourself that little bit, you’ve still got to check. And that was what that was like, I suppose. Even though I’ve

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felt it, I will still check, because I don’t know, maybe it can move when it’s not alive, I don’t know.

Furthermore, the reassurance and usefulness of the Doppler in relation to miscarriage anxiety was only valid if it produced the knowledge that women were looking for, in other words if they could actually find a heartbeat sound that confirmed foetal life. This was recognized by women in the study, even though those who spoke to me had not experienced failure to find a heartbeat. Ellie, who sometimes felt compelled to use her Doppler, simultaneously knew that the technology could not actually solve pregnancy loss, but could only provide knowledge of whether it had occurred or not: If it’s gone, it’s gone, isn’t it? There’s nothing you can do. No matter how many times you wave that thing [the Doppler] around, if it’s not there, it’s not there. With pregnancy, what will be will be, won’t it? That’s what it comes down to.

The anxiety around miscarriage that women were working so hard to manage was therefore only relieved by the Doppler technology working in a particular way in particular circumstances. If the foetus was still alive, it could reassure in real time that missed miscarriage was averted for now. But if the foetus had died, it would at best give women notice of possible death that did not come from medical staff in a medical setting. Women would then have gone to medical staff for confirmation of pregnancy loss. In these circumstances, the usefulness of the Doppler in giving women control or in demedicalizing pregnancy would simply be in providing private, domestic notice of a likely ‘missed miscarriage’ or intrauterine foetal demise. A miscarriage occurring through spontaneous early labour would not be picked up by a Doppler at all. And the Doppler itself, or indeed any medical intervention, could do nothing to provide any control to a woman experiencing miscarriage once the process had begun.

Conclusion Women in Cornwall using foetal Dopplers at home were experiencing pregnancies dominated by the threat of miscarriage. Miscarriage or threatened miscarriage was a discrete event in a particular pregnancy, but it had repercussions in future pregnancies, sometimes

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many years later, because a history of miscarriage permanently shifted perceptions of pregnancy and reproduction towards uncertainty. Miscarriage was remembered years after it occurred as a central part of the narrative of women’s reproductive and emotional lives. Threatened miscarriage did not have to result in completed miscarriage in order to shock women into a fear of reproductive loss, and a sense of pregnancy as precarious. Where women experienced bleeding, or pain, or reduced foetal movement in pregnancy, the shock of potential foetal loss was enough to cast a shadow over the rest of that pregnancy and sometimes over future pregnancies too. For participants, therefore, pregnancy was a time of anxiety, of lack of control over the outcome of the pregnancy, and of the precarity of the very existence of a pregnancy, determined by the detectable presence of a living foetus within them. In the cultural context of medicalized pregnancy and the prevalence of biomedical technology, combined with the commercial availability of Doppler devices, using the devices to check for a foetal heartbeat was an obvious solution for these anxious women. The home use of foetal Dopplers by the pregnant women who listened to their own foetus’s heartbeat was therefore in part an act of agency and resistance to the medical control of knowledge of their foetus when they could check for themselves whether their foetus was still alive. This knowledge was so desired, as a solution to anxiety, that women were willing and active in their own objectification by medical technology where it provided what they were looking for, the sound of the foetal heart, so long as the foetus was actually alive and the heartbeat could be heard. However, this agency through objectification (Thompson 2007) was limited by several factors. The fact that the Doppler technology was not actually able to produce changes allowing women to avoid or solve miscarriage, that it could make no difference to whether that foetal heart was beating or not, was significant in understanding how it could only partially grant women agency. Objectifying oneself using the reproductive technology of a domestic Doppler cannot in fact reduce risk of miscarriage. It is a limited form of agency for women like Cara, pregnant and deeply anxious about yet another miscarriage, that in the worst case scenario she could gain knowledge before the professionals of the end of the pregnancy, or in the best case scenario she can just know, day to day, that she is inching towards her goal of a completed pregnancy. The only thing that self-objectification using a Doppler can change is the self, through alleviating the internal state of anxiety. Yet even

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this reassurance can only last so long, before it needs repeating. Therefore, women in this study were drawn into repeated practices of self-objectification and of surveillance of the foetus when those practices could not in fact produce the outcome they were seeking, but simply tell them it was still possible. Furthermore, the action on the self that was enabled by the Doppler relocated the responsibility for pregnancy outcome within the pregnant body, as if all the possibilities of pregnancy were only determined by the body in which it took place. This meant that while there was some limited degree of control and agency by pregnant women, there was also a greater degree of conformity to dominant cultural ideas about pregnancy as the responsibility of the individual woman, based in her individualized domestic unit, using commodities purchased in the marketplace. The domestic foetal Doppler was acting as a classic disciplinary technology, producing pregnant women who acted on themselves in attempts to conform to bodily norms (Foucault 1991, 1998; Sawicki 1999). In addition, the Doppler was not wholly demedicalized by its domestication in the context of anxiety about miscarriage. The foetal Dopplers in this study were not owned or used by medical staff, were located in a domestic space, and contained relational meaning for their users. But they only represented a full domestication or appropriation of the technology when they were used to build relational knowledge of the foetus separate to the medical knowledge they produced, when they focused on the symbolic meaning of the heartbeat sound. Where they were used to monitor and objectify the pregnant and foetal bodies in attempts to confirm the continuation of pregnancy, they were a form of medicalization of the home, producing docile pregnant and also docile foetal bodies. These practices actually shifted the clinic into the domestic space and exemplified Rothman’s internalization of the medical gaze (Rothman 2014) on the part of the pregnant women practising foetal listening. They pulled the previously unknown foetus into processes of medical normalization through surveillance. The shift of the technology from antenatal clinic to home carried with it the cultural values of the medicalized pregnancy, which focuses on the outcome and product of a living baby as the responsibility of the pregnant woman, enabled by medical surveillance of her body and the foetal body. In fact, it was commitment to those cultural values and the medical modelling of Doppler use as a meaningful practice that was instrumental in the women’s decision to acquire and use foetal Dopplers at home. Doppler use, whether practised at home

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by pregnant women or in the clinic by medical staff, still conformed to the perceived requirement for biomedical evidence of a living foetus during pregnancy. It conformed to the belief that pregnancy is not an experience or event that is of note to others unless it results in live birth. And it restated that the risk of not having a live birth is worth the adoption of all medical practices in all spaces of family and personal life, even if those medical practices cannot in fact guarantee the outcome you so desire. This focus on the outcome of a wanted pregnancy, while also the desperately wanted goal of the women involved in foetal Doppler listening in Cornwall, inevitably contributes to the marginalization of those pregnancies that do not produce a living baby and that end in miscarriage. Aimee Middlemiss read Social Anthropology at the University of Cambridge in the 1990s and then left academia to work in journalism as a news producer on BBC Radio Four, followed by teaching IB and A-Level Anthropology in Cornwall. She recently returned to study at the University of Exeter, completing an MRes in Science and Technology Studies in 2017, for which she carried out the research reported here. She is now undertaking an ESRC-funded Ph.D. at Exeter looking at women’s experiences of second trimester pregnancy loss in south-west England, under the supervision of medical sociologist Professor Susan Kelly and anthropologist of Britain Dr Katharine Tyler. The project also has the support of Sands, the stillbirth and neonatal death charity. This Ph.D. extends themes from Aimee’s work on domestic Doppler use, including conflicts between lay and medical discourses, intimate and domestic constructions of foetal personhood and kinship, and the materiality of bodies in pregnancy.

Note   1. Chakladar and Adams describe a case in which they claim a woman may have mistaken her own heartbeat for that of the foetus in late pregnancy, at 38 weeks’ gestation, but in fact the foetus had died, resulting in stillbirth (Chakladar and Adams 2009). The report of the case contains a number of caveats and flaws (Middlemiss 2018). For example, the authors themselves note that it is possible that the foetal death in this case may have been unavoidable, and that there is also poor evidence for using foetal movement as an indicator of foetal well-being as an alternative to heartbeat monitoring. Furthermore,

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they present no concrete evidence that the pregnant woman did not actually hear the foetal heartbeat at home in the days leading up to the foetal death, and do not address the fact that it was the pregnant woman being unable to find the foetal heartbeat at home which led her to seek medical care in the first place. Foetal death may well have already occurred at home, in which case Doppler use would not have made any difference to the outcome except for discovering it earlier. However, the authors still conclude in their article that the domestic use of foetal heart monitors poses safety risks to both pregnant women and all their foetuses, including the not yet viable foetus. On the basis of this single case, the Medicines and Healthcare Products Regulatory Agency expressed concern about untrained foetal Doppler use, and there were several articles in the press and online about the case.

References Arney, W.R. 1982. Power and the Profession of Obstetrics. Chicago: University of Chicago Press. Bordo, S. 2003. ‘Are Mothers Persons? Reproductive Rights and the Politics of Subject-ivity’. In S. Bordo, Unbearable Weight: Feminism, Western Culture and the Body. Berkeley and Los Angeles: University of California Press, pp. 71–97. Cahill, H.A. 2001. ‘Male Appropriation and Medicalization of Childbirth: An Historical Analysis’, Journal of Advanced Nursing 33: 334–42. Chakladar, A., and H. Adams. 2009. ‘Dangers of Listening to the Fetal Heart at Home’, British Medical Journal 339. Charmaz, K. 1990. ‘“Discovering” Chronic Illness: Using Grounded Theory’, Social Science & Medicine 30: 1161–72. Conrad, P. 1992. ‘Medicalization and Social Control’, Annual Review of Sociology 18: 209–32. Cornwall Council. 2013. 2011 Census: An Overview of the Headline Figures for Cornwall. Retrieved 5 June 2018 from https://www.cornwall.gov.uk/ council-and-democracy/data-and-research/data-by-topic/2011-census/.  . 2017. State of the Economy. Retrieved 5 June 2018 from https://www.cornwall.gov.uk/business/economic-development/ economic-intelligence/. Daniel, L. 2009. ‘Dangers of Pregnant Women Relying on Personal Fetal Monitors’, British Journal of Midwifery 17: 813. Duden, B. 1993. Disembodying Women: Perspectives on Pregnancy and the Unborn. Cambridge, MA: Harvard University Press. Foucault, M. 1991. Discipline and Punish: The Birth of the Prison. London: Penguin Books.  . 1998. The History of Sexuality, Vol. 1: The Will to Knowledge. London: Penguin Books.

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 . 2003. ‘Technologies of the Self’. In P. Rabinow and N. Rose (eds), The Essential Foucault: Selections from the Essential Works of Foucault 1954– 1984. New York: The New Press, pp. 145–69. Ginsburg, F., and R. Rapp. 1991. ‘The Politics of Reproduction’, Annual Review of Anthropology 20: 311–43. Guest, G., A. Bunce and L. Johnson. 2006. ‘How Many Interviews are Enough?’ Field Methods 18: 59–82. Gültekin-Zootzmann, B. 1975. ‘The History of Monitoring the Human Fetus’, Journal of Perinatal Medicine 3: 135–44. Hale, R. 2007. ‘Fetal Monitoring and the Use of Doppler’, British Journal of Midwifery 15: 449–52. Han, S. 2009. ‘Seeing Like a Family: Fetal Ultrasound Images and Imaginings of Kin’. In V.R. Sasson and J.M. Law (eds), Imagining the Fetus: The Unborn in Myth, Religion, and Culture. Oxford: Oxford University Press, pp. 275–90. Harris, G., L. Connor, A. Bisits and N. Higginbotham. 2004. ‘“Seeing the Baby”: Pleasures and Dilemmas of Ultrasound Technologies for Primiparous Australian Women’, Medical Anthropology Quarterly 18: 23–47. Hod, M., and R. Kerner. 2003. ‘Telemedicine for Antenatal Surveillance of High-Risk Pregnancies with Ambulatory and Home Fetal Heart Rate Monitoring: An Update’, Journal of Perinatal Medicine 31: 195–200. House of Commons. 2017–2019. Fetal Dopplers (Regulation) Bill. Retrieved 3 October 2019 from https://publications.parliament.uk/pa/ bills/cbill/2017-2019/0110/cbill_2017-20190110_en_1.htm. Howes-Mischel, R. 2016. ‘“With This You Can Meet Your Baby”: Fetal Personhood and Audible Heartbeats in Oaxacan Public Health’, Medical Anthropology Quarterly 30: 186–202.  . 2017. ‘The “Sound” of Life, or, How Should We Hear a Fetal “Voice”?’ In S. Han, T.K. Betsinger and A. Scott (eds), Anthropology of the Fetus: Biology, Culture, and Society. New York: Berghahn Books, pp. 252–75. Kicks Count. 2018. ‘Why Ditch the Doppler?’ Retrieved 3 October 2019 from https://www.kickscount.org.uk/ why-we-want-home-doppler-sales-to-be-regulated. Layne, L.L. 2003. Motherhood Lost: A Feminist Account of Pregnancy Loss in America. New York: Routledge. Longhurst, R. 1999. ‘Pregnant Bodies, Public Scrutiny: “Giving” Advice to Pregnant Women’. In E. Kenworthy Teather (ed.), Embodied Geographies: Spaces, Bodies and Rites of Passage. London: Routledge, pp. 77–89. Lupton, D. 1999. ‘Risk and the Ontology of Pregnant Embodiment’. In D. Lupton (ed.), Risk and Sociocultural Theory: New Directions and Perspectives. Cambridge: Cambridge University Press, pp. 59–85.  . 2012. ‘“Precious Cargo”: Foetal Subjects, Risk and Reproductive Citizenship’, Critical Public Health 22: 329–40.

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 . 2016. The Quantified Self: A Sociology of Self-Tracking. Cambridge: Polity Press. Malacrida, C. 2007. ‘Negotiating the Dependency/Nurturance Tightrope: Dilemmas of Motherhood and Disability’, Canadian Review of Sociology & Anthropology 44: 469–93. Marshall, M.N. 1996. ‘Sampling for Qualitative Research’, Family Practice 13: 522–25. Middlemiss, A.L. 2018. ‘The Fetal Dopplers Bill is Based on Limited Evidence about Pregnant Women’s Use of the Device’. Retrieved 20 August 2018 from http://blogs.lse.ac.uk/politicsandpolicy/fetal-dopplers-bill/. Mitchell, L.M. 2001. Baby’s First Picture: Ultrasound and the Politics of Fetal Subjects. Toronto: University of Toronto Press. Murphy, M. 2012. Seizing the Means of Reproduction: Entanglements of Feminism, Health, and Technoscience. Durham, NC: Duke University Press. National Institute for Health and Care Excellence. 2008. Antenatal Care for Uncomplicated Pregnancies. Retrieved 6 June 2017 from https://www.nice.org. uk/guidance/cg62/chapter/1-Guidance#fetal-growth-and-wellbeing. Neyer, G., and L. Bernardi. 2011. ‘Feminist Perspectives on Motherhood and Reproduction’, Historical Social Research 36: 162–76. Oakley, A. 1984. The Captured Womb: A History of the Medical Care of Pregnant Women. Oxford: Basil Blackwell Publisher. Roberts, J., F. Griffiths and A. Verran. 2017. ‘Seeing the Baby, Doing Family: Commercial Ultrasound as Family Practice?’ Sociology 51: 527–42. Rothman, B.K. 1993. The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood. New York: W.W. Norton and Co.  . 2014. ‘Pregnancy, Birth and Risk: An Introduction’, Health, Risk & Society 16: 1–6. Sawicki, J. 1999. ‘Disciplining Mothers: Feminism and the New Reproductive Technologies’. In J. Price and M. Shildrick (eds), Feminist Theory and the Body: A Reader. New York: Routledge, pp. 190–202. Silverstone, R., E. Hirsch and D. Morely. 1992. ‘Information and Communication Technologies and the Moral Economy of the Household’. In R. Silverstone and E. Hirsch (eds), Consuming Technologies: Media and Information in Domestic Spaces. London: Routledge, pp. 9–17. Smith, D.E. 1974. ‘Women’s Perspective as a Radical Critique of Sociology’, Sociological Inquiry 44: 7–13. Strauss, A.L., and J.M. Corbin. 1998. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. Thousand Oaks, CA: Sage. Thomas, G.M., and D. Lupton. 2016. ‘Threats and Thrills: Pregnancy Apps, Risk and Consumption’, Health, Risk & Society 17: 495–509. Thompson, C. 2007. Making Parents: The Ontological Choreography of Reproductive Technologies. Cambridge, MA: MIT Press. Wall, G. 2010. ‘Mothers’ Experiences with Intensive Parenting and Brain Development Discourse’, Women’s Studies International Forum 33: 253–63.

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Weir, L. 1996. ‘Recent Developments in the Government of Pregnancy’, Economy and Society 25: 373–92. Young, I.M. 1990. ‘Pregnant Embodiment’. In I.M. Young, Throwing Like a Girl and Other Essays in Feminist Philosophy and Social Theory. Bloomington: Indiana University Press.

Chapter 7

Miscarriage and Its Resulting Losses during Commercial Surrogacy in India Sayani Mitra

Introduction The practice of commercial surrogacy has turned India into a global ‘reprohub’ (Inhorn 2015). The country has been attracting prospective parents from all over the world to its low-cost modern biomedical infrastructure with its English-speaking doctors, flexible legal framework and easily available line-up of surrogates. India’s surrogacy venture has been at the centre of a series of bioethical debates concerning the future of kinship, commodification of bodies of ‘third world women’, and the plight of the unborn children stuck in legal limbo of changing transnational legislation. Despite much discussion on the nature of labour and the market economy surrounding commercial surrogacy in India (see Pande 2014; Rudrappa 2015; Sama 2012), an understanding of the practice remains incomplete without exploring those instances when the process gets disrupted and as a result fails to deliver what it set out to achieve. Failures during surrogacy can occur when a surrogate is unable to conceive a pregnancy despite an embryo transfer, or when a successfully conceived pregnancy leads to a miscarriage, abortion, foetal reduction1 or stillbirth. Commercial surrogacy in

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general, but particularly in the context of India, rests upon a narrative of success (Berend 2016; Mitra and Schicktanz 2016). These success stories are constructed by the fertility clinics, agencies and the global virtual surrogacy platforms to attract the intended parents and the surrogates towards surrogacy. Indian surrogates usually come from deprived socio-economic backgrounds and lack the knowledge or the literacy to read about and research the risks and challenges associated with the use of Assisted Reproductive Technology (ART). Unlike their counterparts in the US (Berend 2016), Russia or Ukraine, Indian surrogates do not use social media to share their queries and experiences with a community of experienced and potential surrogates. Their knowledge of the biomedical interventions is limited to the verbal information they receive from the local agents,2 who seldom caution them about any possible failures that technology cannot avert. Under such circumstances, it becomes interesting to examine how the Indian surrogates experience disruptive events such as miscarriages. Miscarriages are not unique to surrogacy, but several factors set apart the experience of miscarriage in this context. First, just as with other ART procedures such as In Vitro Fertilization (IVF) or Intra-Uterine Insemination (IUI), it is not just the lack of biological capacities to reproduce one’s own child that fails some of these women, but technology fails them as well. Second, surrogate pregnancies are non-sexual, technology-mediated pregnancies and hence lack any genetic link between the foetus and the surrogate. The woman undergoing the miscarriage is not the intended mother, and therefore in the traditional sense does not lose ‘her’ child-to-be. Third, the involvement of intended parents, surrogate, gamete donors (if used), doctors, agents and other staff gives rise to a fragmented nature of ownership over the pregnancy process and outcome. A pregnancy loss due to a miscarriage therefore holds varying stakes for each set of actors. Investigating the nature and types of losses that surrogates experience due to their miscarriages can thus bring to light the multi-layered stakes and elucidate how they understand these pregnancies. While conducting her web ethnography on US-based surrogacy support websites, Berend (2010) directs our attention towards the losses that surrogates undergo for failing to give a baby/foetus to the intended parents due to miscarriage, stillbirth and so on. She further challenges the failure of the surrogacy narrative to recognize the surrogates’ efforts and says that the cultural context of surrogacy is important to understand what the surrogates lose (Berend 2010). Experiences of

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pregnancy, childbirth and pregnancy loss are culture-specific and so is the practice of surrogacy. Hence, it is important to analyse the cultural meanings assigned to childbirth and miscarriage in India in order to fully grasp the surrogate’s experiences of pregnancies and miscarriages. Broadly, the aim of this chapter is to examine the impact of miscarriages on the surrogates and identify the nature of various forms of resulting losses. Based on an ethnographic study conducted for eight months between 2014 and 2015 at five fertility clinics – three in Delhi and two in Kolkata – I discuss how surrogates understand their own miscarriages. I conducted interviews and case studies with forty-five surrogates, fifteen Indian intended parents who were the commissioners of surrogacy, five doctors, seven agents (which included both local agents and agencies),3 four clinical staff and one surrogate home staff member. I also carried out non-participant observation at the clinics and surrogate homes. Surrogate homes are the communal accommodations where most surrogates in India live during their pregnancies. These vary from single-bedded rooms to dormitories where women live for nine months without their husbands and children, although children of surrogates (up to the age of seven or eight years) are sometimes accommodated in these homes. I was able to recruit four surrogates, two doctors and one agent to speak about their miscarriage experiences: this chapter is based on those accounts. I also use the findings from my encounters with surrogates, intended parents and agents who did not encounter a miscarriage, but whose experiences and expectations of the process inform my understanding of the nature of surrogate pregnancies. Gaining access to these clinics was extremely challenging due to the closed nature of the surrogacy industry in India, and also the negative press that the Indian surrogacy industry was experiencing at the time of fieldwork, with media and activists questioning the ethical nature of the Indian surrogacy contracts, apprehending malpractices similar to the Baby Gammy case that had just unfolded in Thailand.4 In addition, even after I secured access, discussions around reproductive disruptions and especially miscarriages were challenging, as the surrogate agents, doctors and clinical staff systematically silence any event that might be read as their failure to control the outcome. Nevertheless, the insights gained despite all limitations offer a valuable understanding about what is at stake for surrogates who miscarry.

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In the following sections, I begin by discussing the terminology used in India surrounding miscarriage. I then situate surrogacy miscarriages within the larger context of childbirth and miscarriage norms in India. Then I discuss how the unpreparedness of the surrogates to deal with miscarriage shapes the nature of their losses and their miscarriage experiences. Furthermore, I show how routine technological monitoring and surveillance in the form of ultrasound scans and tests make the pregnancies concrete and definite, as a result of which miscarriages become difficult to accept. I end the chapter by arguing that the nature of surrogates’ losses resulting from miscarriages can be explained by a lack of any clearly defined rights of surrogates in India.

Terminologies During my interviews, after I initiated a conversation about experiences of failure during surrogacy, those handful of surrogates and agents who shared their encounters with miscarriages referred to them as ‘pregnancies getting spoilt’, ‘child getting spoilt’ or ‘falling of the child’. Such expressions are popularly used in common parlance to refer to miscarriage in India. The vernacular equivalent of the word miscarriage in Hindi is Garvapath and in Bangla it is Garbhasrab, which is almost never used in spoken language. The surrogates whom I interviewed referred to the foetus as bacha, which in English literally translates to ‘child’. Lack of terminologies in the everyday vernacular usage to refer to the ‘embryo’/‘foetus’ as anything else but ‘child’ reflects the Hindu cultural belief of the people involved, who view foetuses as a ‘life at conception’ (Moad 2004; Murti and Derr 1998). These terminologies represent the meaning that is culturally assigned to pregnancies and foetuses. They need to be taken into account in order to understand how the surrogates assign meanings to their pregnancies and miscarriages.

Situating Miscarriages The pain or suffering associated with childbirth is naturalized in India and is considered as women’s way of deriving power or shakti (Van Hollen 2003). But the pain caused by caesarean section and advanced reproductive technologies is not viewed in the same light (Chawla 2006). The surrogates in my study described the pain and

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discomfort they underwent due to the administering of hormonal shots and vaginal ultrasounds as their ‘hard work’ towards earning a secure future. Just like the traditional birth narrative, pain is naturalized even within the surrogacy discourse, but by employing a completely different rationale. Thus, it is important to understand how surrogacy creates new pregnancy narratives and in what ways the surrogate miscarriages correspond to the traditional and contemporary birthing narratives. Pregnancy and childbirth in India are traditionally associated with the notion of sharam or shame (Chawla 2006), as are sexuality and menstruation. As a result, Indian women generally do not openly discuss matters concerning their pregnancy, menstruation or sexual health. Menstruation is concealed for being an event of pollution and defilement because of the ‘dirty’ menstrual blood (Jeffery and Jeffery 1996). Miscarriage also holds similar negative connotations and hence is concealed in everyday conversations. Historically, in some parts of India, conception itself was not considered as pregnancy. Women did not consider themselves to be pregnant until three months had elapsed from the time their menstrual cycle stopped, and they shared their news about pregnancy only after three months even with their nearest kith and kin (Jeffery and Jeffery 1996). In rural Bijnor, where Jeffery and Jeffery (1996) conducted their fieldwork, excess bleeding due to foetal loss during that period was considered to be ‘a blob of flesh passing down the drain’ (24), lacking personhood, and thus was not considered a miscarriage. Late miscarriages were also traditionally considered as the potential loss of a lineage (Patton 2002), which brought shame to women. These were the reasons why traditionally Indian women failed to garner much attention or sympathy in situations of both early and late miscarriages. In more recent times, due to the easy availability of pregnancy tracking technology, pregnancies are detected at an early stage, but the news of a successful conception is often concealed to avoid attracting threatening gazes from people around (Pinto 2008). Such practice of concealment of pregnancy and the tentativeness of its recognition due to fear of misfortune or evil gaze are also discussed by Kaveri Qureshi in her ethnographic account from the Pakistani Punjab in this book. As a result, pregnancies are still not openly discussed within Indian society, while miscarriages are silenced and shamed (Upadhya 2016). There are seldom any spaces within the family or larger society where women can express their accounts of pregnancy loss. In fact, testimonies of women bring out how they have been rudely treated

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by doctors and nurses after their miscarriage and denied any information or counselling post dilation and curettage (Upadhya 2016). Unlike non-surrogacy pregnancies, it is not possible for the surrogates to conceal their pregnancies from their doctors, agents, husbands, commissioning parents or fellow surrogates who travel with them or stay with them at surrogacy homes. This is because their bodies are constantly under various forms of technological surveillance (e.g. ultrasound scans, blood tests), and the rest of the actors are privy to their test results. For instance, the results of the beta human chorionic gonadotropin (beta hCG) test carried out to confirm the pregnancy are first conveyed by the doctor to the intended parents and then to the surrogates. Various individuals have access to information about the pregnancy and concerns about evil gaze seldom arise in this technology-dependent setting. The medicalized gaze (through biomedical methods of blood tests, urine tests and ultrasound) along with social surveillance of the body by the agents establish the realness of the pregnancy. Although surrogate pregnancies including miscarriages cannot be kept a secret, the past and present socio-cultural practices of silencing miscarriages from wider society continue to inform much of the surrogacy discourse in India, although for very different reasons. While miscarriages in India in general continue to be shrouded in secrecy (Upadhya 2016), surrogate pregnancies have another layer of secrecy attached to them. Surrogacy continues to be a taboo topic in India, due to the social stigma attached to pregnancy out of wedlock (for the surrogates who are not carrying their husband’s child), and the stigma associated with infertility (for the intended parents). Indian women, as in other cultures, feel incomplete and inferior (Widge 2005) if they are unable to conceive and give birth. As a result, most of the surrogates and intended parents that I met concealed their involvement in surrogacy from their friends and colleagues, fearing stigma. The surrogates felt that their neighbours or extended family might not understand that their pregnancy was technology-mediated (see also Pande 2014). Similarly, the intended parents feared that the child might face discrimination in the future. Pregnancies that are guarded from society prevent women from receiving any attention in the event of a miscarriage. The advent of biomedicine and the hospitalization of childbirth has complicated birthing cultures in India. It has also made the intersectionalities of women based on class, caste and gender more visible. Surrogates in India, who usually come from deprived backgrounds, are unable to access private medical facilities for their

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personal use during any form of healthcare needs, unlike those of higher social classes. But as surrogates they are able to use some of these modern healthcare services. Given their background, the surrogates do not have any independent access to these clinical spaces even during surrogacy, and any kind of interaction with the doctors is mediated by agents. After a miscarriage, as their surrogacy contract is repealed, they lose all access to these clinical spaces. In the event of any health issue post miscarriage, the surrogates cannot approach the doctors or clinical staff, whether directly or indirectly. Under such circumstances, it becomes pertinent to examine the kinds of losses that miscarriages bring to the Indian surrogates.

Unpreparedness to Face Miscarriages Although surrogate miscarriages are a known possibility, it is impossible to estimate their frequency in India due to the absence of any official database for ART pregnancies. Among the countries managing a flourishing industry of commercial surrogacy, the US is the only one that has guidelines for helping its surrogates cope with a high-risk pregnancy. According to the Center for Disease Control’s (CDC) data (Center for Disease Control and Prevention [CDC], American Society for Reproductive Medicine [ASRM] and Society for Assisted Reproductive Technology [SART] 2014) for the US, approximately 82 per cent of pregnancies resulting from ART cycles using fresh non-donor eggs or embryos lead to a live birth (59 per cent in a singleton birth and about 22 per cent in a multiple-infant birth). This means that about 18 per cent of pregnancies result in miscarriage, stillbirth, induced abortion or maternal death prior to birth. These statistics include the birth rates of other ART techniques as well as surrogacy, such as self IVF, IUI and Intra-Cytoplasmic Sperm Injections (ICSI), among others. These data highlight that post-conception pregnancy losses are common during all ART procedures, including surrogacy. It is also known that the use of stimulatory drugs and multiple embryo transfers increase the chance of spontaneous miscarriages (CDC/ASRM/SART 2014). As a result, the ASRM/SART (Practice Committee of the American Society for Reproductive Medicine and Practice Committee of the Society for Assisted Reproductive Technology 2015) clearly recommends proper psychological advance counselling and guidance of surrogates about the risks and ways of coping with miscarriages. It upholds the right of the surrogates to be informed about any possible risks of multiple

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pregnancies or pregnancy reduction and identifies the need for counselling them on their feelings about multiple pregnancy, bed rest, hospitalization and pregnancy loss (ibid.: 6–7). In the absence of any legislation overseeing the well-being of surrogates in India, similar psychosocial guidelines are not formulated, nor are any such steps followed. Even the guidelines from the Indian Council of Medical Research (ICMR) and the draft ART bills make no recommendations for dealing with miscarriages or counselling surrogates about the risks of miscarriages. I found that the doctors and agents in India systematically silence the possibilities of spontaneous miscarriages in order to keep the surrogates and the intended parents’ attention away from the risks associated with the process. Several surrogates in India become local agents. They may have witnessed their fellow surrogates undergo a miscarriage or other pregnancy complications, but they seldom discuss it once they return to the fold of the industry as an agent due to their obligation to recruit new surrogates for a living. When I asked a Kolkata-based agent named Kanti if she warns the women whom she recruits as surrogates about the possibilities of undergoing miscarriages or foetal reduction, she laughed and said that doing so would be impossible. This was because explaining the meaning of surrogacy to the potential recruits in itself is a challenging task. First-time surrogates mostly lack an understanding of the asexual nature of these pregnancies. It takes persistent explanations to convince them about the role of technology in assisting the pregnancies and to establish surrogacy as both morally acceptable and safe for them. Therefore, telling them about pregnancy complications would make it harder for them to trust the procedure. Although the possibility of a miscarriage might cross the agents’ minds, given the challenges of recruiting women into surrogacy they consciously refrain from sharing any information regarding the risks and uncertainties. Yet the way in which risks are managed and silenced during surrogacy is full of contradictions. Like any other ART pregnancies, surrogate pregnancies are termed ‘high-risk’ pregnancies within the clinical narrative in India. But these biomedical narratives of ‘risk’ are not a part of the local world of the surrogates, whose understanding of the procedure, as mentioned above, comes from their local networks. Although IVF and related ART procedures neither prevent nor increase the risk of miscarriage as compared to any ‘naturally’ conceived pregnancy (Richard 2005), multiple embryo transfers do create a high risk of miscarriage. However, surrogate

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pregnancies are technology-assisted. The intended parents and surrogates opt for the process only after being convinced about the ability of the technological procedure and expertise of the doctors to bring forth the pregnancy. Acknowledging the very possibilities or past instances of spontaneous miscarriages that are beyond their control could imply acknowledging the failure of the technology to assist a successful pregnancy. That would contradict the success narrative that these Indian surrogacy clinics construct as their marketing strategy. The agents and doctors thus warn the surrogates against any heavy household chores, unhealthy or unhygienic diet or accidental falls, which could potentially harm the foetus, without spelling out the frequency of miscarriages for surrogates. Such instructions echo traditional beliefs according to which pregnant women are forbidden to eat certain herbs and fruits, such as papaya, to prevent miscarriage (Van Hollen 2003). In this context, these instructions are meant to selectively caution women against pregnancy complications or loss that could occur due to their own carelessness or physical neglect, without spelling out the term miscarriage or its local equivalent. Moreover, within the clinical setting or at surrogate homes, there is hardly any mention of any past miscarriages that might have taken place due to a surrogate’s neglect. Thus, I observed that miscarriages within the surrogacy discourse are constructed and approached in two different ways. The first type could occur solely due to the surrogate’s non-adherence to the prescribed way of life, and hence are seen as avoidable by adherence. The other type are those that cannot be averted by any technological expertise or precaution, and are hence selectively silenced. Such categorizations are never spelt out, but surface from the strategic warning and silencing that are a part of the surrogacy industry’s surveillance of the surrogates. Given the uncertain nature of IVF, the intended parents require assurance to be able to place their hopes in surrogacy and gather the strength to initiate a whole new procedure, especially if they have tried and failed with IVF in the past. An intended father named Vijay who is based in Delhi mentioned: After so many miscarriages of my wife, we did not want to try anything else. But I read that surrogacy is a more advanced technique and even more reliable than IVF. Also, I have been reading on the internet [websites run by clinics and agencies] about other people’s experiences with surrogacy and I think this procedure is rather more reliable if you are with the right doctor and get a good surrogate. She

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is experienced in childbirth, my wife isn’t. So she will not have the complications that my wife has been suffering from during her IVF cycles.

Vijay’s words suggest that the information he gathered suggesting a higher possibility of success with surrogacy as compared to IVF offered the necessary impetus for his decision. His way of rationalizing resembled the arguments used by the online surrogacy platforms, as well as by the doctors and agencies during personal counselling sessions. Thus, any information that the doctors and the agencies communicate to the intended parents – verbally or through online platforms – becomes the basis for shaping their perceptions of surrogacy. The intended parents with whom I interacted were aware of the uncertain nature of ART as most of them had experienced failed IVF cycles. Some of them had recurrent miscarriages during their own IVF attempts and therefore perhaps had some idea about the risks of miscarriages associated with IVF pregnancies. But once they chose surrogacy, they adopted a conscious strategy to set aside this ‘uncomfortable knowledge’ (Rayner 2012: 111). Mr and Mrs Chaddha were intended parents from Delhi who had just commissioned a surrogacy when I met them. During our conversation, Mr Chaddha described in detail their years of struggle with infertility, and the hardships that his wife had encountered. But this time he seemed to have rested his hopes on the doctors and the surrogacy process. Me: Given that you have had such a long road, do you feel worried about this pregnancy? Mr Chaddha: We feel very hopeful this time. The rest is on the doctor and agents.

Despite their previous failures and history of miscarriages, Mr Chaddha and his wife were hopeful of a positive outcome. They had not factored in the risks of failure due to a pregnancy loss or other similar reasons. Such expectations of the intended parents are shaped by the hype that the Indian surrogacy industry creates about their success rates. A popular website previously advertising commercial surrogacy in India claimed thus: India’s success rates match or are sometimes better than US surrogacy success rates, the country is a popular destination for surrogacy. (Surrogacy Mumbai Wordpress)5

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The success rates for ART cycles that use gestational carriers are higher than the success rates for those cycles that do not. (Surrogacy Mumbai Wordpress)

The inflated success rates coupled with the absence of any discussion of unsuccessful pregnancies within the ART discourse leave the surrogates unprepared to deal with any disruptive events such as miscarriages. Moreover, the medical test reports and the ultrasound scans further contribute to their unpreparedness as these serve as evidence for the existence of a foetus and make the likelihood of a healthy birth seem real and achievable. Most surrogates that I met appeared very confident in their reproductive capacities. They felt certain of their ability to birth a healthy child simply by following the health regimen prescribed by the doctors and the agents. A surrogate named Parvati, whom I met in Delhi before her monthly ultrasound screening (which is a routine method of pregnancy check-up), was in the fifth month of her pregnancy. She said: I knew I could do it [conceive a surrogacy pregnancy]. I always have very non-complicated pregnancies. This one will also be the same.

While Parvati was confident about her reproductive capacity and ability to gestate an uncomplicated pregnancy, the general absence of any discussions on pregnancy complications possibly enabled her to uphold such personal beliefs. The systematic silence around the issue of pregnancy loss within the surrogacy discourse arguably keeps surrogates from consciously reflecting upon the risks associated with surrogate pregnancies.

Technology Establishing the Realness of the Pregnancy Surrogate pregnancies are heavily monitored. The surrogate’s movements, diet, lifestyle, intake of hormonal injections and pills are closely supervised by the agents or surrogate home staff. This is not standard practice for non-ART pregnancies. Ultrasonography scans are not a routine part of pregnancy for women in India, especially those from a lower socio-economic background such as that of the surrogates. Ultrasounds are private procedures and are used routinely by women visiting private maternity clinics. However, during surrogacy, close monitoring of their pregnancies by medical

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technology (scans and tests) and continued supervision by doctors, agents and surrogate home staff makes the pregnancies appear very achievable to the surrogates. Thus, a surrogate named Kunti whom I met at a clinic in Delhi emphasized the advantage of staying under the ‘care’ of the surrogate home staff because she felt that such routine adherence is likely to ensure the desirable outcome. Me: Do you know where you will be staying during your pregnancy? Kunti: I have told them that I will stay at home [surrogacy home or hostel]. Else it’s very inconvenient to get someone [a family member] to care for you while you are carrying someone else’s child. It is better to stay under their care and travel for tests and medical checkups with them. Then you don’t need to worry. If they would have not offered to keep me at home, I would not have done it.

Surrogate pregnancies are ‘conceptions in the heart’ (Ragone 1994). As imagined and highly desired entities, ‘these conceptions take place much ahead of its materialization, in the minds of the actors through their continuous planning, strategizing and participation during the preconception phase’ (Mitra and Schicktanz 2016: 2). After a pregnancy test confirms a conception, the technological mediation in the form of test results and ultrasound scans further establishes the realness of the pregnancy. An interview with Ravinder, an intended mother from Delhi, illustrates this: Me: Did you learn today that she [the surrogate] is pregnant? Ravinder: Yes, my husband saw her [the surrogate’s] scan today. He is still there inside and they are now confirming it. Earlier they had phoned me about the test report [beta hCG]. Me: Okay, so you knew for a while now? Ravinder: Yes and no. Till you see it you don’t believe it you know! Now we can be sure and start thinking a bit further…

Although Ravinder learnt about her surrogate’s pregnancy through the beta hCG test results, she wanted to wait until the fifth week ultrasound scan to rule out any chances of chemical pregnancy. After having undergone various failed IVF attempts and having commissioned unsuccessful surrogacy attempts, Ravinder relied on the ultrasound scan to be reassured about the progress of the pregnancy. Various intended parents that I interviewed similarly

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connected with the foetus through the visuals of the ultrasound scans. Ultrasound scans presented the visuals of a growing foetus that is soon to be born and encouraged the parents to begin planning for parenthood. An intended mother, Neetu, in Delhi told me: Neetu: I and my husband keep ‘WhatsApp-ing’ during the ultrasound scans. You know how it is … you feel excited and want to talk about it and want to plan … it’s such a great feeling. Me: What kind of plans have you made, if I can ask? Neetu: We are planning the future of the child of course. You can see the child. It’s almost there. So you have to start planning. I feel very ready. I have already decided which school I am going to send the child to. I have decided to switch to a part-time job and also keep a nanny.

Some of the surrogates also mentioned feeling the existence of the child-to-be through their ultrasound scans. A pregnant surrogate in Delhi, Shanti, said: Shanti: I could see everything while they were doing it. They turned the screen towards me and told me ‘see this is yours’. Me: And? How did you feel about it? Shanti: I was thrilled. It was a different feeling. I could see the baby growing and how it grows and everything. I wish I had the same privilege during my son’s birth.

Like Shanti, most surrogates lack any experience of foetal monitoring through ultrasound scans during their own childbirth. Through the monthly ultrasound scans, Shanti enjoyed this new experience of visualizing the growth of the foetus that she was embodying. In fact, most surrogates whom I met would eagerly wait for their monthly scans to learn not just about the foetal health, but also about the progress of their own performance as a surrogate. The importance given to ultrasound scans, weight and blood pressure check-ups and other routine tests serves as a continuous reminder of the growth of the foetal entity, which is soon to be born. These scans also signify their own achievement as a surrogate so far. Therefore, while technology establishes the progress of the pregnancy and becomes proof of the surrogates’ labour, a miscarriage brings a sudden end to their labour and any hopes of a financially secure future.

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The Multifaceted Losses While narrating her miscarriage experience, Rekha, a former surrogate in Delhi, said: A doctor there examined me and gave me a few injections. I was too scared and was already crying. I understood what was happening but just could not believe it. I kept asking the nurse what’s going on and if my child will be fine … but she just asked me to keep quiet. I was in too much pain and was bleeding profusely. They were taking my scan when I was put on sedative I guess. I got up after a few hours and was told that I had a ‘miscarriage’. I couldn’t believe it.

Rekha was in the second trimester of her pregnancy when she had a miscarriage. Her words reflect the shock and pain at the turn of events. She could not believe that the pregnancy for which she had worked so hard had failed so suddenly. Like Rekha, the other surrogates with whom I spoke also demonstrated a deep-seated feeling of pain and a sense of disbelief. Their losses were emotional as well as financial. In the event of a pregnancy loss through a miscarriage or abortion, the surrogates are denied 75 per cent of their compensation, which is granted only after a successful delivery and the relinquishment of the child (Sama 2012). They receive 25 per cent of their total remuneration in monthly instalments over the nine months of pregnancy (or in less time in cases of premature delivery). Each instalment is given to them after their monthly medical check-up. A miscarriage indicates a loss of the remaining instalments as well as the final 75 per cent payment. Surrogates who have had a miscarriage are unlikely to be accepted for surrogacy again. I learnt from the surrogacy agents in both Delhi and Kolkata that one of the strict criteria for surrogate recruitment is to select women without any history of pregnancy complications or miscarriages, either during their own childbirth or during their previous surrogacy attempts. So although surrogates are not informed about the risks and uncertainties that they are undertaking by opting for surrogacy, after miscarriage their bodies are considered ‘too risky’ to be trusted. Therefore, miscarriage also entails a loss of future livelihood opportunities as a surrogate. This loss of financial potential sets surrogacy miscarriages apart from regular miscarriages, as the latter might entail a loss of a child and one’s identity as a future parent or mother but not that of a worker. A pregnancy loss for the surrogates is not just a loss of a foetus or child-to-be but also a loss of their temporarily acquired status

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as surrogates. A miscarriage brings an abrupt end to the attention and recognition that they were receiving from a group of doctors, agents, intended parents and other fellow surrogates. Being able to gestate and carry a pregnancy to full term becomes important to them in order to earn their due remuneration and a better future for their families by using their reproductive capacities. The reproductive capacities of the surrogates whom I met are their biological capital on the basis of which they negotiate the regimented rules of the industry and ask for exceptions, passively resist authorities, earn their place within the surrogacy arrangement, and aspire to a better future. Surrogacy offers them an opportunity to change their lives by allowing their reproductive capacities to be financially productive – not just for themselves and their family but also for the intended parents. The remuneration of a successful surrogacy procedure holds the promise of securing the immediate future of the entire family of the surrogate. A miscarriage implies a loss of that opportunity. A former surrogate turned agent named Nandini, whom I met in Kolkata, had a miscarriage when she was in the first trimester of her pregnancy. When I met her a few months into my research, she opened up to me about her miscarriage experience. She had a miscarriage following a fall in her home. The hospital asked me to visit them only after my bleeding reduces a bit and I can walk … I went there after seven days and I was still bleeding. I could sense that the ‘flower like thing’ [referring to the embryo] had broken. The party [commissioning couple] was not there that day. Didi [nurse] told me that the party’s wife [intended mother] was crying a lot. I was initially not crying since I was still in a state of shock. But hearing this, I started crying. I was feeling like a failure. … My son was worried about my health … My mother said that ‘God gives you company yet takes it away every time…’.

Nandini and her son (who was taking care of her) encountered a rather helpless situation, since neither of them was aware of the possible consequences of a miscarriage for her health and future livelihood opportunities. Nandini had no prior instructions or information about what to expect, how to act, or who to reach out to in case of a miscarriage. Her son called the hospital for advice because as per the terms of the contract they were strictly forbidden from seeking medical treatment from any doctor but the assigned fertility clinic, irrespective of the ailment or nature of the emergency. Nandini told me that both she and her son were initially

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scared for her life. She also experienced a loss of control over her body and her reproductive capacities. Her inability to complete the task that she had set out to do led to a sense of defeat. When Nandini visited the hospital for a check-up and a possible dilation and curettage, her sense of loss intensified. Her physical and emotional trauma was furthered by a sense of failure at having let down the intended parents. The loss of this pregnancy also caused a loss of her opportunity to utilize her reproductive capacity to earn for her immediate future. Nandini’s sorrow at having failed the intended parents was also accompanied by a sense of guilt at having failed her own son and the rest of her family. Not only did this miscarriage lead to the loss of an opportunity to earn money and secure her family’s future, but it also put her in a difficult financial position. Although the fertility clinic prescribed her medications over the phone, her son had to buy them. Once she could walk and make her way to the clinic, the clinic performed a dilation and curettage procedure free of cost. But they did not offer her any immediate psychological or physical support to recuperate from the shock of her miscarriage. As discussed before, surrogates in India do not have any healthcare rights after a pregnancy loss or post-partum as per their surrogacy contract. The clinics are not legally obliged to offer them any medical support such as dilation and curettage. The lack of any clearly defined right to after-care is indicative of the nature of the surrogates’ loss. It places them at the mercy of the surrogacy agencies, agents, doctors or intended parents after a miscarriage. As a result, they are also at risk of being held responsible for medical bills, which they would not have been responsible for had they not been pregnant. Debika, a surrogate whom I met in Kolkata, mentioned that she was lucky to have her intended parents pay her initial hospital bills following her miscarriage. However, she had to return to hospital after a month, as her bleeding had not completely stopped, and she had to pay for this herself. Instead of making them financially secure as had been the intention, miscarriage resulted in additional costs to Debika and her husband. The impact of miscarriage is also felt by the extended family of the surrogate. For the surrogate to conceive and gestate a surrogate pregnancy, her family members reorganize their lives in several ways, the most obvious way being that many surrogates live apart from their families in surrogacy homes, while the rest remain in their regular home with their families. When surrogates live in their own houses during pregnancy, it is their husbands, mothers

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or mothers-in-law who take care of them. Even for surrogates who gestate while staying at surrogate homes, their husbands often get emotionally involved with their pregnancies. They often leave their jobs temporarily to care for their children so that the wives can carry on with their pregnancies undisturbed. It brings them a hope for a better future and they eagerly await the arrival of the childto-be. Therefore, miscarriage has an unrecognized impact on the wider family of the surrogate, as well as the surrogate herself. While narrating their miscarriage experiences, Kabita and Debika mentioned their husbands ‘breaking down’ at their plight. Although not the social or the biological fathers, the husbands of both these surrogates were very concerned about their respective wives’ health and affected by the loss of their wives’ hard labour. The surrogate’s family makes many sacrifices and adjustments in order to facilitate their participation in surrogacy. A miscarriage shatters the dreams of a better life for the family as a whole.

The Impact of the Pregnancy Loss on the Surrogates Scholars have often argued that miscarriage generates a unique sense of loss since the reason for its occurrence remains scientifically unexplained (Frost et al. 2007). In the case of surrogates, that uniqueness has multiple dimensions to it. The surrogates experience multiple losses from a miscarriage, including loss of identity, personal and economic relationships and most importantly an opportunity to earn. Thus, it remains difficult for surrogates like Rekha or Kabita to pin their losses down to just one factor over another. Rekha wanted another opportunity to become a surrogate after her miscarriage, but the agency representative began to avoid her calls and started ignoring her: I called him so many times. He did not answer my call. I went and sat at his office for hours. He even asked the guards [of this clinic] to not include my name in the list [of surrogates who could enter the clinic]. Guards know me very well. They told me.

It is these rejections and silencing that further contribute to the surrogates’ sense of loss. Once their pregnancies fail, the once fertile and desirable bodies become a liability for the surrogacy industry whose experiences need to be erased from the surrogacy discourse. Rekha’s narrative also reflects that she developed a sense of dissent

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towards the agents post miscarriage and felt disappointed with the kind of arrangement that she was in. Thus, what she encountered due to her failure to carry a child to term was not just a loss of a second opportunity but also of access and trust in an agent whom she had trusted previously. Moreover, these experiences of miscarriage make surrogates feel ‘inferior’ and envious of their fellow surrogates, who are able to complete their surrogacy to term. Nandini, for instance, mentioned how she could not meet the expectations that the doctors had set for her by offering her an opportunity to become a surrogate: I was unable to do what so many girls [surrogates] who I myself am recruiting now are doing. They are doing it and making us proud, making their families happy. But I could not.

Nandini’s words reflected her regrets about not being able to successfully carry a pregnancy to full term, which other women, whom she herself was recruiting, could achieve. Since surrogacy and infertility are taboo in India, most surrogates and intended parents share the fact of their involvement in surrogacy with a limited number of people, such as parents and at times a friend or a few trusted family members. As a result, they lack any social support to fall back upon in moments of crisis like that of a miscarriage. Studies on perinatal death have shown that lack of financial and material support during miscarriage conveys a clear message of non-legitimacy of such events and complicates mourning for those affected by it (Malacrida 1999). In the case of surrogacy, concealment of the arrangement from close ones along with the segmented nature of pregnancy and ownership complicates the recognition of the loss and grief for both the intended parents and the surrogates. The losses resulting from a miscarriage change the meaning of what surrogacy can offer. It leads to the severing of the hopes and dreams attached to the procedure. For the surrogates, a miscarriage reduces an extremely labour-intensive procedure, which had the potential to secure the future of their families, to an event of failure. Similarly, for the intended parents, an arrangement that held the promise of providing them with a child of their ‘own’ becomes an enormous loss while simultaneously furthering the ‘chronic sorrow’ (Olshansky 1962) of childlessness.

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Conclusion This chapter has discussed miscarriages in the context of surrogate pregnancies in India. Miscarriages in India are culturally silenced and shamed, and surrogate miscarriages are further silenced to hide the inability of the technology to deter any unwanted outcomes. Past occurrences of miscarriages are seldom acknowledged within the surrogacy narrative to hide any disruptive possibilities. However, as part of their disciplining technique, the agents and doctors selectively caution surrogates against pregnancy complications that could occur due to their non-adherence to their regimented prescribed life, without spelling out the term miscarriage or its locally equivalent terminology. Neither the surrogacy contracts nor any official ART guideline discuss the importance of counselling the surrogates about miscarriages or specify their rights in the event of a pregnancy loss. Thus, agencies and clinics do not counsel them about its possibilities. A narrative of success constructed by the surrogacy industry accompanies such systematic silencing of any past instances of failures such that the surrogates are left unprepared to experience miscarriages. As a result, surrogates are unsure about their rights once a miscarriage strikes. The testimonies of the surrogates reflect that continuous monitoring of the process and their bodies makes a healthy childbirth appear extremely achievable to them. As a result, they feel confident about their capacity and the technology’s expertise in assisting a successful childbirth. The visual technology of ultrasound and the regular test reports play a key role in solidifying the realness of these pregnancies both for the surrogates and the intended parents. Therefore, when a miscarriage takes place, their unpreparedness complicates the nature of their loss. Their losses are both emotional and financial. These losses are not just limited to the loss of a pregnancy but are also the loss of a life-changing opportunity to earn for one’s future, to receive full payment and a newly acquired status both at home and at work. Miscarriage also brings an abrupt end to the attention they were receiving from a range of actors – doctors, agents, intended parents or their own husbands. In addition, there is a loss of pride in one’s reproductive capacities, labour, dreams and hopes for a better life. Surrogates who have had a miscarriage are unlikely to be accepted for surrogacy again. This loss of financial potential sets these miscarriages apart from others. Moreover, since surrogacy continues to be a taboo topic in India, the guarding of surrogate pregnancies from society further

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prevents women from receiving any attention in the event of a miscarriage. The multifaceted nature of the surrogate losses incurred through miscarriage is caused by the lack of their rights as surrogates, and is also an outcome of the incomplete information they are given regarding the nature of risks and uncertainties attached to surrogacy. Since surrogates in India do not have any healthcare rights after pregnancy loss or post-partum, as per their contracts, a miscarriage could place them in a financially precarious position instead of securing their family’s future. The way in which miscarriages are dealt with during surrogacy, including the losses incurred as a result, brings to the fore the intense, personal and complicated consequences for the surrogates. Sayani Mitra is a sociologist with expertise in social studies of biotechnologies, ethics of reproductive technologies, global health, comparative health research and political economy. She is a postdoctoral researcher in the Department of Health Services Research, University of Liverpool, where she is working on a Wellcome Trust-funded project exploring a global governance model for assisted reproductive technologies. She received her Ph.D. from the Faculty of Social Sciences, University of Göttingen, Germany. Her Ph.D. thesis, titled ‘Disruptive Embodiments: A Study of Risks and Failures during Commercial Surrogacy in India’, examined the seldom discussed aspects of risks and disruptions during commercial surrogacy practices in India. Her recently co-edited book CrossCultural Comparisons on Surrogacy and Egg Donation: Interdisciplinary Perspectives from India, Germany and Israel (Palgrave Macmillan, 2018) offers a comparative insight into the diverse social, legal and ethical practices that constitute the global markets of assisted reproductive technologies.

Notes   1. Foetal reduction is also known as selective reduction, multifetal pregnancy reduction (MFPR) or selective termination. It is the practice of reducing the number of foetuses in a multifetal pregnancy, say quadruplets to a twin or singleton pregnancy.   2. Agents are grassroots-level recruiters of surrogates in India. They approach, counsel and recruit surrogates through their informal networks. Most agents are former surrogates and/or egg donors and belong to the same socio-economic strata as the surrogates.

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  3. Agencies, also known as ‘vendors’ or ART banks, are organizations that source surrogates and donors for the clinics, coordinate all mundane medical, legal and logistical arrangements during surrogacy, and even house the surrogate in their surrogate home.   4. Baby Gammy was abandoned by his Australian commissioning parents in Thailand. He was born in December 2013 with Down’s syndrome and a congenital heart condition, which according to his surrogate was the main reason that led to his abandonment, since she refused to undergo an abortion. The intended parents (IPs) had allegedly left for Australia with Gammy’s healthy twin, Pipah (BBC 2014).   5. See https://surrogacymumbai.wordpress.com/success-rates-of-surrogacy-in-india/ (accessed 8 May 2015).

References BBC. 2014. ‘Australian Couple Abandon Surrogate Down’s Syndrome Baby’, BBC News, 2 August. Retrieved 21 April 2017 from http://www. bbc.co.uk/news/world-asia-28617912. Berend, Z. 2010. ‘Surrogate Losses: Understandings of Pregnancy Loss and Assisted Reproduction among Surrogate Mothers’, Medical Anthropology Quarterly 24(2): 240–62.  . 2016. The Online World of Surrogacy. New York: Berghahn Books. Center for Disease Control and Prevention, American Society for Reproductive Medicine and Society for Assisted Reproductive Technology. 2014. Assisted Reproductive Technology National Summary Report. Atlanta: US Department of Health and Human Services. Chawla, J. 2006. Birth and Birthgivers: The Power behind the Shame. New Delhi: Har-Anand Publications. Frost, J., H. Bradley, R. Levitas, L. Smith and J. Garcia. 2007. ‘The Loss of Possibility: Scientisation of Death and the Special Case of Early Miscarriage’, Sociology of Health & Illness 29(7): 1003–22. Inhorn, M.C. 2015. Cosmopolitan Conceptions: IVF Sojourns in Global Dubai. Durham, NC: Duke University Press. Jeffery, P., and R. Jeffery. 1996. ‘Delayed Periods and Falling Babies: The Ethnophysiology and Politics of Pregnancy Loss in Rural North India’. In R. Cecil (ed.), The Anthropology of Pregnancy Loss: Comparative Studies in Miscarriage, Stillbirth and Neonatal Death. Oxford: Berg Publishers, pp. 17–38. Kennedy, R. 2005. ‘Risks and Complications of Assisted Conception’, British Fertility Society Factsheet. Leeds. Retrieved 10 October 2019 from http://citeseerx.ist.psu.edu/viewdoc/ download?doi=10.1.1.541.7070&rep=rep1&type=pdf. Malacrida, C. 1999. ‘Complicating Mourning: The Social Economy of Perinatal Death’, Qualitative Health Research 9(4): 504–19.

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Mitra, S., and S. Schicktanz. 2016. ‘Failed Surrogate Conceptions: Social and Ethical Aspects of Preconception Disruptions during Commercial Surrogacy in India’, Philosophy, Ethics, and Humanities in Medicine 11(1): 9. Moad, E.O. 2004. ‘Hindu Ethics on the Moral Question of Abortion’, Eubios Journal of Asian and International Bioethics 14(4): 149–50. Murti, V., and K.M. Derr. 1998. ‘Abortion is Bad Karma: Hindu Perspectives’, Feminism and Non-Violence Studies (Special Issue on Spiritual Diversity) 19(4). Olshansky, S. 1962. ‘Chronic Sorrow: A Response to Having a Mentally Defective Child’, Social Casework 43(4): 190–92. Pande, A. 2014. Wombs in Labor: Transnational Commercial Surrogacy in India. New York: Columbia University Press. Patton, L.L. 2002. ‘“Mantras and Miscarriages’: Controlling Birth in the Late Vedic Period’. In L. Patton (ed.), Jewels of Authority: Women and Textual Tradition in Hindu India. New Delhi: Oxford University Press. Pinto, S. 2008. Where There Is No Midwife: Birth and Loss in Rural India. New York: Berghahn Books. Practice Committee of the American Society for Reproductive Medicine, and Practice Committee of the Society for Assisted Reproductive Technology. 2015. ‘Recommendations for Practices Utilizing Gestational Carriers: A Committee Opinion’, Fertility and Sterility 103(1): e1–e8. Ragone, H. 1994. Surrogate Motherhood: Conceptions of the Heart. Boulder, CO: Westview Press. Rayner, S. 2012. ‘Uncomfortable Knowledge: The Social Construction of Ignorance in Science and Environmental Policy Discourses’, Economy and Society 41(1): 107–25. Rudrappa, S. 2015. Discounted Life: The Price of Global Surrogacy in India. New York: NYU Press. Sama. 2012. ‘Birthing a Market: A Study on Commercial Surrogacy’. Retrieved from 20 October 2019 from http://www.samawomenshealth.in/birthing-market/ and https://www.academia.edu/7885788/ Birthing_A_Market_A_Study_on_Commercial_Surrogacy_Sama_Resource_Group_for_Women_and_Health?auto=download. Upadhya, R. 2016. ‘For Indian Women Who Have Miscarriages, Grief Is Met with Silence and Shame’. Vice, 21 September. Retrieved 4 August 2018 from https://broadly.vice.com/en_us/article/8x49mb/for-indianwomen-who-have-miscarriages-grief-is-met-with-silence-and-shame. Van Hollen, C. 2003. Birth on the Threshold: Childbirth and Modernity in South India. Berkeley and Los Angeles: University of California Press. Widge, A. 2005. ‘Seeking Conception: Experiences of Urban Indian Women with in Vitro Fertilisation’. Patient Education and Counseling 59(3): 226–233.

Chapter 8

Unwitnessed Ceremonies Funeral Services for Pre-24-Week Pregnancy Losses in England Karolina Kuberska

Introduction The disposal of pregnancy remains has been a subject of some controversy in the UK media in recent decades. A number of independent investigations revealed storage and disposal practices of pregnancy remains in some hospitals that did not conform to a level of transparency expected of public institutions. These incidents were brought to public attention in the UK by official inquiries.1 According to such media sources, foetal remains were stored and incinerated without explicit consent. These reports, by emphasizing problematic practices without mentioning that many if not most hospitals handled human tissue respectfully, suggested that the issue of carefree storage and disposal of foetal remains was not only widespread in the UK, but also that nothing was being done to change these practices. That there are guidelines and policies around disposal of pre24-week pregnancy remains is relevant for this chapter in three main ways. First, they make it clear that pregnancy losses might be viewed differently by those who experience them and by the

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law. Specifically, the law of England and Wales requires the registration of stillbirths2 but not miscarriages, effectively formally only recognizing the existence of the former but not the latter (Fairbairn 2018). Second, without excluding other perceptions of miscarriage, these guidelines and policies are framed by a view that miscarriage is equal or at least very similar to the death of a baby and by an assumption that such a general approach offers the best chance of providing sensitive bereavement care. Third, these guidelines and policies legitimize treating pre-24-week pregnancy remains in the same way as post-24-week pregnancy losses (which are classified as stillbirths by law in England and Wales) or the remains of people who lived and died. In this chapter, I focus on funeral arrangements that frequently accompany hospital-arranged shared cremations and explore how the idea of ‘sensitivity’ inflects the forms of unwitnessed funeral ceremonies for pregnancy remains. The practitioners who organize these ceremonies may not intend the consequences that arise from the generalized conceptualization of ‘sensitivity’ informing their actions. I will show how these services can be interpreted within the anthropological framework of ritual theory, resulting in a normalization of a very specific social order where funerals for pre-24-week pregnancy losses come to be expected. However, as I demonstrate, although these rituals include elements, activities and values shaped by notions of ‘respect’ and ‘sensitivity’ to emphasize a certain view of foetal personhood as well as bias in the motivation behind such services, they are neither incontestable nor uncontested. The data analysed in this chapter come from semi-structured interviews with fifteen funerary industry professionals in England, including funeral directors, bereavement services managers at council cemeteries and crematoria, as well as representatives of national funerary industry institutions, and from observations of locations and services in three council crematoria and cemeteries in England. This information is part of a dataset collected between 2016 and 2018 for an Economic & Social Research Council (ESRC)-funded project ‘Death before Birth’. The project looked at perceptions of the law around disposal of pregnancy remains in England as well as the language used to talk about experiences of pregnancy loss in order to improve care and support for those experiencing such losses.3

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Note on Language In the funerary industry in England, pre-24-week pregnancy remains are referred to in a number of ways that fall into two main categories. Words emphasizing the personhood of the anticipated child, such as ‘baby’, ‘daughter’ or ‘son’, are used in contact with clients, as well as sometimes in informal conversations between crematorium or cemetery staff. These word choices are consistent with how such pregnancy remains are usually treated in the funerary industry. The second category includes an array of phrases that are confined to professional discourse – these phrases primarily emphasize the medical and legal status of pregnancy losses up to 23 weeks and 6 days, for instance, non-viable (NVF) or pre-viable foetus, foetal or pregnancy remains, pregnancy products or tissue, products of conception. In interviews, bereavement services managers at crematoria and cemeteries made vocabulary choices that belonged to both domains – they would say ‘baby’ with the same ease as foetus, pregnancy remains or NVF, depending on the context. It was clear that using the word ‘baby’ was the only acceptable, respectful and sensitive option when facing the family; bureaucratic requirements on the other hand mandated using language from the intersection of medicine and law in official notes and documents.4 In this chapter, depending on the context, I use both ‘pregnancy remains’ and ‘baby’ to refer to the material remains following pregnancy loss up to 23 weeks and 6 days.

Background Disposal of pregnancy remains is often in the background of bereavement care following pregnancy loss as more emphasis is given to acknowledging people’s feelings while offering support. This can be evidenced, for instance, by the frequent absence of information on the disposal of pregnancy remains in patient information leaflets on different kinds and aspects of pregnancy loss offered by NHS England hospitals (McGuinness and Kuberska 2017, Austin and McGuinness 2019). In professional literature related to bereavement care following pregnancy loss, the issue of disposal often receives insufficient attention. The most comprehensive guidelines available in the UK, the 500-page Pregnancy Loss and the Death of a Baby: Guidelines for Professionals (Sands 2016), features a twenty-page chapter titled ‘Funerals and Sensitive Disposal’5 that discusses this topic

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directly. As for the clinical perspective, the National Institute for Health and Care Excellence (NICE) guideline on management of miscarriage (that UK NHS healthcare providers rely on) does not mention disposal as part of care (NICE 2019b), although individual NHS trusts may have had policies on this matter even before national guidelines came into existence (Cameron and Penney 2005). However, the matter of disposal of pregnancy remains is far from insignificant or marginal given the number of miscarriages in the UK (estimated as over 20 per cent of all pregnancies, so between 200,000 and 250,000 [Savitz et al. 2002: 94]) and a slightly lower number of terminations6 (Department of Health [DoH] 2017; Information Services Division [IDS] and NHS Scotland 2017) that also involve disposal of pregnancy remains.7 In the case of miscarriages, depending on the geographical location, gestational stage and type of miscarriage management, women are offered different advice and options, despite attempts to standardize care quality (as evidenced by four editions of the Sands guidelines for professionals from 1991, 1995, 2007 and 2016;8 see also Moulder 1998: 16). In general, care in labour wards tends to approach loss of pregnancy as a loss of a baby; however, this is not always the case in gynaecology wards where earlier losses are usually attended to (Fuller et al. 2018). Women are accepted onto labour wards at different stages of pregnancy in different hospitals – various bereavement midwives9 interviewed explained that the entry threshold can be set at anywhere between 12 and 21 weeks. Nonetheless, given that most miscarriages take place either at home or in gynaecology wards, women are often left without adequate care or information, including details of disposal options (McGuinness and Kuberska 2017, Austin and McGuinness 2019). Attempts at providing guidance on the disposal of foetal remains following miscarriage have been taking place for over thirty years in the UK. This is at least partially due to the fact that funerary professionals’ institutions, such as the Institute of Cemetery and Crematorium Management (ICCM), the Federation of Burial and Cremation Authorities (FBCA) or the National Association of Funeral Directors (NAFD) set standards of industry through issuing of guidance documents or policy statements that follow legislation and include best practice standards as well as through offering official training for funerary professionals. The ICCM in particular has been making strides in allowing and encouraging cremation of all foetal remains since 1985, when the first policy on this matter was issued (ICCM 2015b: 3). Subsequent years brought consistent

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revisions of this policy; its most recent version, ‘The Sensitive Disposal of Fetal Remains: Policy and Guidance for Burial and Cremation Authorities and Companies’, was published in September 2015 (ICCM 2015b). The latest piece of guidance on this topic for England and Wales was issued in March 2015 by the Human Tissue Authority (HTA) as ‘Guidance on the Disposal of Pregnancy Remains Following Pregnancy Loss and Termination’, which allows a range of options that include individual or shared burial, individual or shared cremation, and sensitive incineration. The guidance document does not favour any of the disposal methods above others, emphasizing instead that each of them might be the most appropriate in different circumstances. Similar guidance documents have also been produced – before and after 2015 – by the Royal College of Obstetricians and Gynaecologists (RCOG 2005), the Royal College of Nursing (RCN 2018) and the Stillbirth and Neonatal Death Charity (Sands 2016), demonstrating the need for clear professional standards in the matter of disposal of pregnancy remains. The goal of this section was to outline the complex landscape of existing guidelines and provision in which the disposal of pregnancy remains takes place in England. Given that landscape, a degree of variation is inevitable in the way that disposal arrangements following pregnancy loss are organized in different places, although they are guided by the same principles of sensitivity and respect, often taking the form of shared cremations. In what follows, I will explore a phenomenon of ceremonial services preceding shared cremations for pre-24-week pregnancy losses.

Unwitnessed Ceremonies I begin with a description of a funeral ceremony preceding a shared cremation of pre-24-week pregnancy remains that I attended. Using data from interviews with bereavement professionals, I also discuss how such services are organized in some other crematoria in England. The focus on services offered in crematoria is justified by the fact that they are the most common in England (McGuinness and Kuberska 2017). The chapel was empty except for the Catholic nun who arranged the services on behalf of the hospital, the funeral director, and me. The nun wore a skirt suit and the funeral director wore a morning suit. There were fresh flowers in the vases at the front of the chapel and a

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tree-shaped candle stand with lit candles. The funeral director placed two small coffins on a catafalque. The coffins were white and shiny, and also very small – maybe a foot and a half in length, too small for a full-term baby. Three pale yellow service sheets were placed on the catafalque by the nun. The front page included a centrally placed colour photo of white and purple pansies and read ‘A Service for Hospital Babies’, the name of the crematorium and the date of the service. We gathered around the catafalque, standing close to the coffins. I was next to the funeral director, facing the nun who led the ceremony. First, we listened to a short piece of instrumental music in silence, then the nun began the ceremony by reading the brief welcome section from the service sheet, followed by a short prayer invoking the unfailing love of Christ our Lord. Next, she read a poem entitled ‘The Little Snowdrop’ that likened pregnancies and babies lost too soon to the inconspicuousness and short lifespan of snowdrops, a metaphor and a visual that can be found in discourse surrounding pregnancy loss support in the UK.10 A short piece of music was played and the ceremony continued with a reading from the New Testament about children belonging to the kingdom of God, a prayer directed to the gracious God who can heal broken hearts, two short poems, one about meeting again (presumably in heaven) and another about how each life is precious irrespective of its length. She invited the funeral director and me to join her in the recitation of the Lord’s Prayer, which we did in soft voices. The nun proceeded with the act of committal and a blessing; both mentioned God, Jesus, and eternal peace. We stepped away from the catafalque with our service sheets and a mechanical velvet curtain closed slowly around the little coffins. We slowly left the chapel to prepare for the next baby funeral. The whole ceremony lasted seven minutes.

It is important to emphasize here that while similar funeral-like services are offered by many crematoria for shared cremations of pregnancy remains, these ceremonies are not always religious. Nor do they necessarily involve any spoken words – in one crematorium I visited, pregnancy remains in plain white cardboard boxes were placed on a catafalque, a piece of instrumental music was played for about two minutes and the base of the catafalque was lowered in the act of committal. These shared services are usually unattended by parents but sometimes the midwife from the hospital and/or crematorium staff may sit in the pews. Funerary industry representatives I interviewed emphasized that such unattended ceremonies were no different from those where the mourners were present, although they might have been shorter as, during attended ceremonies, family members were offered some

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time to say their goodbyes before the committal. A number of participants also mentioned the importance of being able to tell the parents what the funeral looked like if they did not attend but wanted to know the details. Some bereavement managers interviewed suggested that holding a service in addition to a shared cremation and scattering of ashes in a specific area (often a garden of remembrance devoted specially to babies or a specific rose bed) increased the perception of sensitivity and respectfulness of the funeral arrangements by the bereaved but also those who cared for them. Finally, some funeral professionals also explained that every life deserved a respectful funeral, which seemed to motivate standardization of such shared cremation services, even in the absence of the bereaved. With funerary industry professionals emphasizing that these services were just like any other funeral, there was a clear message that the legally drawn 24-week limit was not of much significance when such loss and grief were involved. Funeral director Emily11 said: Sometimes, … there’s just nobody there, so you would just follow the ritual in exactly the same way. I’d say it would happen for any aged person, unless somebody was very specific that they wanted nothing.

John, another funerary industry professional, went even further: [A woman has] gone through a loss and if she believes she’s lost her baby even – in that sample – if there’s no foetal tissue, it [the baby] should still be buried or cremated to give that lady peace of mind.

Losing a baby to miscarriage can be a difficult time for many, and research shows that sensitive support adjusted to people’s needs is crucial for dealing with this experience (see, e.g., Corbet-Owen and Kruger 2001; Jurkovic, Overton and Bender-Atik 2013; Moulder 2001). The question of disposal of pre-24-week pregnancy remains or funeral arrangements presents different challenges as, in many cases, it takes place without the direct participation of the bereaved (as in the case of unwitnessed ceremonies). Nonetheless, the way in which these services are organized suggests recognition of the presence of an invisible mourner who is a parent (who was perhaps in too much pain to be there, or who had been told that they could not attend a shared ceremony, or who had not been told that they could attend one). Keeping standards of service irrespective of attendance may intuitively seem respectful. However, what these

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standardized services entail in practice could be considered problematic by the bereaved parents or people who lost or terminated pregnancies, as well as potentially the general public. In the next section I will examine a range of intertwined issues that help to foreground potential frictions, for example between expectations and the reality of funerary arrangements. I will discuss religious aspects of the service, the role of participants in both a ritual and in unwitnessed ritualized events, using notions of respect and sensitivity to further a specific worldview, as well as the potential bias in transparency and standardization – given that routinization of such ceremonies is an expression of a specific worldview. By highlighting misunderstandings, disappointments or conflicting expectations articulated by research participants, I hope to shed some light on the complexity of the widespread practice of unwitnessed ceremonies for pre-24-week pregnancy remains.

Religious Elements of the Service The ceremony described in the vignette above was broadly Christian,12 with one secular poem about snowdrops and two poems invoking Christian ideas of the afterlife and God’s love. Interestingly, a patient information leaflet from the NHS Trust that employed the nun stated that the service ‘[would] be suitable for those of all beliefs’. However, it is possible to predict that a shared funeral ceremony for people with different religious affiliations and preferences could cause some friction. The most immediate issue in this situation is the impasse created by the impossibility of reconciling the needs or preferences of those who have some religious beliefs with the needs and preferences of those who hold no such beliefs when it comes to organizing funeral services. The leaflet distributed at that particular hospital offered parents a wide range of options regarding funeral arrangements, including contact with appropriate religious officials. Most of these choices were at no cost to the parents, meaning those who wanted a specific kind of service, such as an individual religious ceremony, could be best accommodated. At the same time, the 2015 HTA guidance on the disposal of pregnancy remains allows people to opt out of making a decision about the disposal of pregnancy remains, placing the responsibility for the disposal/funeral arrangements on the hospital and permitting the hospital to dispose of the pregnancy remains in any way accepted by law, with the most common

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method being shared cremation (McGuinness and Kuberska 2017). If someone opts out of making the decision, they are still allowed to enquire about the procedure at a later date, either at the hospital, crematorium or cemetery, in which case it is relevant to ask whether a ceremony with explicitly religious elements is appropriate. However, it is not clear whether this particular detail of the service would always be disclosed to those who ask a general question of what happened to their baby – as in the case of the service described above and the patient information leaflet that did not mention the religious character of the service. Of course, it could be said that opting out of decision-making protects the hospital from liability for any potential dissatisfaction on the part of the parents. On the other hand, it could be argued that an institution such as a hospital – despite providing chaplaincy services – should not be expected to arrange religious funeral services. Moreover, many people who choose hospital-arranged funeral arrangements in the form of shared cremation, a particularly common situation in the case of pregnancy loss in the first trimester, also decide not to attend the ceremony. In interviews, both funerary industry professionals and bereavement midwives flagged up that people who experienced pregnancy loss may not necessarily be informed about the religious aspects of the service or might only be informed about it in broad terms (‘sensitive’, ‘respectful’, ‘appropriate’); alternatively, the bereaved might not have expressed an explicit wish about a religious service. Furthermore, if these disposal arrangements are funded from the NHS budget, it is perhaps worth questioning the appropriateness of paying for even only broadly Christian services from such a source, especially given the fact that the identities of parents or people who lost pregnancies (and thus their religious affiliations if any) in the context of a shared cremation are concealed from crematorium staff and sometimes the funeral director. I spoke to Anna, a bereavement services manager with decades of experience in the funerary industry. She described tension between a crematorium where she used to work and a local hospital that had a contract with the crematorium regarding the religious aspect of the shared services: Another thing that concerned me with how the hospital did it here was that the service was quite religious. … I feel it needs to be not religious ’cause not everybody that loses a baby is religious and therefore won’t get comfort from what the priest is saying necessarily. …

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You know, where they would get comfort from a poem or a well-chosen piece of music. [KK: And is it because the area is predominantly Christian?] It’s just the way that the hospital does it. … We were a bit concerned about it being a bit too religious and spoke with them. Our local Sands group were happy to get involved and read poems or help in any way with the service and the hospital didn’t want that. I don’t understand why. Because these [Sands group members] are people that have lost the baby themselves and very much know how people are likely to be feeling and could have given some comfort. But for some reason our local hospital didn’t want that.13

When Anna uses the word ‘hospital’, she refers to the person responsible for handling the arrangements for disposal. These duties can be assumed by different members of staff in different hospitals, but it is usually a member of the bereavement team or the chaplaincy (like the Catholic nun in the vignette above), who may use their personal judgement or preferences when setting local standards for disposal and funeral arrangements. In the quote above, it was clear that Anna and the hospital staff members’ judgements about what is appropriate at a shared ceremony were not in agreement. Sometimes in such situations, the contract between a crematorium and a hospital may not be renewed or the new contract may not include the disposal of pregnancy remains via shared cremations, especially if there is a different crematorium in the area willing to assume this responsibility. General advice from perinatal loss charities suggests that ceremonies accompanying shared cremations should be either non-denominational or that their religious character ought to be made clear to parents: ‘The shared funeral ceremonies are non-denominational, so they are for parents with no religion as well as those who are’ (Tommy’s 2017); ‘In most places, shared funeral ceremonies are non-denominational, for parents of all faiths and none’ (Sands 2014, leaflet); ‘When a hospital arranged funeral is offered and parents want this information, they should be told whether the funeral that will be arranged will be an individual or shared funeral and whether it is religious or non-denominational’ (Sands 2016: 345). Such attitudes were expressed by multiple interviewees. Valerie, another bereavement services manager, said: [What] was important in our decision-making was that we were aware that the mother could have been of any faith group and that

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was emphasized in the agreement when talking to the mother. This was what the hospital’s responsibility was. To make it clear to the mother that there would be no religious ceremony.

David, a bereavement services manager, described changes to the previously religious décor of the chapel: Our burial chapel became very neutral. One of the things I did get a little bit of stick over – although I did speak to one of the funeral directors and ministers about it before we did it – was that we had an eight-foot cross above the catafalque. Now, you couldn’t properly see this cross because of the committal curtain. And because humanists wanted all religious artefacts covered up, we had curtains before 2004 put up on either side of the cross so it actually looked like a window – it didn’t look like a cross. So once we had the chapel repainted and refurbished, I’d agreed to have the cross removed. What we do now is more a little platform above the curtains at the back of the catafalque where there is like a shelf for any religious artefact to go on. … Now we don’t cover up religious artefacts – we bring out what is required.

These excerpts from the interviews show that religious elements of the service or religious objects in the chapel may be inappropriate at times.

Shared Coffins In a shared cremation, various sets of pregnancy remains, each in an individual opaque container labelled with a patient number, are placed in either larger coffins or coffin-like cardboard boxes before being transported to a cemetery or crematorium chapel for the service preceding shared cremation, sometimes also referred to as communal cremation. While the adjective ‘communal’ might evoke the idea of communal graves, the details of each shared cremation, together with information about the standardized funeral service that preceded the cremation, are appropriately preserved in crematorium or cemetery records and auditable. This method of disposal of pre-24-week pregnancy losses is allowed and recognized by the HTA, which regulates tissue removal, storage and use in England, Wales and Northern Ireland (HTA 2015), and is also approved and recommended by the national funerary industry organizations, such as ICCM and FBCA (FBCA, ICCM, CSGB and APCC 2016). Some parents who selected this option explained that they liked

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the idea of their baby being with other babies (Sands 2016: 332). This choice was also acknowledged in interviews with bereavement support staff. Becky, a bereavement midwife at a large specialized hospital, said: Occasionally, somebody will say: ‘I like the fact that baby will be cremated with other babies’.

Ritual and Its Participants In classic anthropological ways of looking at rituals, those who undergo the process of social change are just as important as those who lead them through it and as those who witness the whole event14 (e.g. Grimes 2014). In other words, participants of a ritual may have different roles that complement each other in meaningful ways. A ritual transforms the person who undergoes it as long as there are witnesses to the fact or perhaps some sort of a formal record of the event (or both) (ibid.). That a funeral is a ritual does not need arguing, although it is worth pointing out that the usual participants involve both the dead and the living. A useful theoretical framework for analysing events at the core of this chapter can be found in Catherine Bell’s ([1992] 2009) crucial work on ritual theory. Bell focuses on ‘“ritualization” as a strategic way of acting. … When analysed as ritualization, acting ritually emerges as a particular cultural strategy of differentiation linked to particular social effects and rooted in a distinctive interplay of a socialised body and the environment it structures’ ([1992] 2009: 7–8; original emphasis). While the significance of ritualization is not always interpreted by the participants in the same way (according to Bell, allowing for both continuity and change of the ritual [ibid.: 169]), strategies of ritualization are concerned with the ‘construction of particular forms of power relations’ (ibid.: 170). Therefore, by means of a ritual, such strategies control, legitimize and eventually normalize a specific social order. In the case of unwitnessed ceremonies, obvious tensions are apparent – the status of the baby that died before the beginning of the twenty-fourth week of pregnancy is questioned by the law but recognized in the ritual event and the living are not there but the record is preserved. At the same time, the funerary rite (or funeral-like rite, such as the type discussed in this chapter) obscures these tensions by emphasizing a particular interpretation of the meaning of pre-24-week

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pregnancy loss, one in which it is a loss of a baby that deserves (or even requires) a funeral. An unattended funeral may connote disappointment, perhaps pity for the dead who failed to make significant connections in life, maybe even sorrow for a kind of loneliness of not being accompanied in death rites. The ceremonies analysed in this chapter, however, unattended as they may be, may not immediately cause such feelings (many people I spoke to were surprised by their existence) – although they may be quite emotional, evoking children’s deaths, unfairness, or loss of future potential, hopes and dreams. At the same time, the fact that they are usually witnessed only by bereavement professionals suggests that there is something about these ceremonies that does not quite fit into existing cultural bereavement scripts in England. There are many reasons for the ceremonies to be unattended, both of administrative and circumstantial character. In some cases, the relationship between the council crematorium and hospital lacks effective communication and parents/patients are not routinely informed of the time and date of the service. If, in such a location, the costs of private arrangements are high, parents may prefer to leave the arrangements in the hands of the hospital. In this case, shared cremation is the most likely option to be offered for pre-24-week pregnancy losses. Different trusts have different policies regarding how and when (and sometimes if) parents should be informed of the funerary arrangements. In some locations, a hospital’s concern for not breaching patient confidentiality was quoted as the reason for not informing parents about the time and date of the shared service. Moreover, some ceremonies take place at a time that may make it difficult for people to attend (e.g. rush hour or when they take their other children to school), some people may know about the ceremony but do not want or cannot bring themselves to attend,15 while some hospitals inform parents about the ceremony after it has already taken place.16 Crematorium bereavement services managers I interviewed emphasized that it was important to them that each shared cremation was accompanied by a funeral service, however short, irrespective of attendance. They justified it by wanting to be able to tell what the service was like if a parent who did not attend the ceremony asked about it at a future date and, perhaps more fundamentally, by their conviction that every human, no matter how young, deserved a funeral.

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Valerie, a bereavement services manager, described a typical service preceding a shared cremation in the following way: The hospital chaplain would attend the service. We’d put a nice pall over the catafalque and some flowers we have, and so make sure the chapel looked nice. We made sure the organist or the music was played, irrespective of whether the parents were attending or not. The mother is advised that their baby’s funeral service will take place. [Parents] don’t need to give us any advance warning if they’re going to attend or not attend or change their mind. But … the important thing I think that we were undertaking [was] a caring and dignified funeral service irrespective of [whether] anyone was there or not. ’Cause we felt it was important that for whatever reason the mother might not be able to attend – she might want to but she might not be able to – and so that she may then in a week, a month, a year or several years down come to the crematorium and say: I wasn’t able to attend but what happened? So we wanted to have the assurance that we actually undertook a caring, dignified funeral service for the baby, irrespective of whether the parents were there.

Rob, another bereavement services manager at a large crematorium and cemetery, explained: The parents are invited to attend if they wish to and if they do attend then we will allow them to stay there up to half an hour. The block – the booking – is from 9 to 9:30 and we would allow them to stay there until 9:30. We would just close the curtains too, the music would continue to play and we’d just allow them to say their last goodbyes. [KK: If there are no parents, is there anyone sitting in the chapel?] Yes, I would [or] one of our team will sit in the chapel and one of the team from the [local hospital bereavement team] will be in there. We check the identity codes that are on the actual boxes and the cards that they apply and the paperwork that we’ve got. And then also it’s just a mark of respect that we do it the same that we would with any other funeral. They’re coming through the front doors [to the chapel]. The coffin or the casket will be placed onto the catafalque and music will be played. [Original emphasis]

Another factor contributing to nonattendance is linked to the way miscarriage is sometimes perceived in wider society: as a nonevent or an event of minor impact (although, as academic research has consistently been showing for more than four decades, it is often far from insignificant for those who experience it – see, e.g.,

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Layne 2003; Moulder 1998; Silverman and Baglia 2015). It should be acknowledged that perceptions of pregnancy losses are changing due to consistent efforts of various stakeholders such as the Miscarriage Association and Sands as well as innumerable people who have shared their experiences and feelings with others. Nonetheless, wider social recognition of miscarriage as a cause for bereavement cannot be taken for granted. Furthermore, information that such ceremonies are organized for early pregnancy losses often comes as a surprise, however welcome, emphasizing that they do not easily fit into existing social scripts of the consequences of pregnancy loss. Even those who have experienced bereavement following miscarriage may still wait to announce their subsequent pregnancies once the first trimester concludes, they may still notice the immateriality of pregnancy loss in the eyes of others, they may still conceal their grief from others for fear of an even unintentionally dismissive or hurtful comment.17 The bereaved may be apprehensive of inviting family and friends to a funeral service if they have not announced their pregnancy. At the same time, some of them regret their decision in retrospect. Mary held a funeral for her baby after terminating a pregnancy following a diagnosis of foetal anomaly. She said: I look back and think: Well, maybe I would’ve liked to have my extended family there for support at the funeral but at the time I was just like: no, this is not normal. This is not right. No one wants to – no one will wanna be there. I don’t want anybody there!

A similar reflection was shared by Steph, whose daughter was stillborn at 25 weeks: And then, the day of the funeral, I hadn’t invited anybody. My mum and dad were gonna come but I hadn’t invited anybody else. ’Cause I thought that I knew I was gonna be such a state – but again, that’s another regret I have because now I wish I’d have invited loads of people.

It should become increasingly clear that while these shared funeral services preceding shared cremation might not be attended by the parents or people who lost pregnancies and their families and friends, they are by no means informal events. In fact, crematoria keep specific records of shared cremations of pre-24-week pregnancy remains, although the information recorded is limited. More specifically, because the legal status of pregnancy remains classifies them as tissue from the pregnant person (rather than ‘human

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remains’ that require a burial or cremation by law) (Human Tissue Act 200418), a crematorium office handling a shared cremation is only supplied with a list of identifying numbers for each set of pregnancy remains (rather than names of patients and/or babies). In case of individual cremations requested by the family (or the hospital on behalf of the family), names of the baby (including pre-24-week losses) and the parents would be routinely recorded. Crematoria are obligated to keep such records as a requirement for maintaining the Environmental Protection Agency emission standards. These records are often kept in perpetuity at the crematorium; however, it should be noted that hospital patient records to which crematorium records are linked are preserved for a limited number of years (usually twenty-five). What is significant here is that these records confirm the existence of these pre-24-week babies, securing a place for them in the bureaucratic system for all to see, providing some kind of official recognition. This fact may be particularly significant in the absence of any formal records (such as a stillbirth register) of such pregnancy losses. It is possible to look at the function of these records as witness testimonies, separated from the funeral service by the gap between people and bureaucracy. Shared funeral services discussed in this chapter have much in common with funeral ceremonies for people who lived and died, especially in terms of symbolic meaning framed as a rite of passage that is a funeral. At the same time, because the recognition of the status of foetus in pregnancy is socially ambiguous at best and changes through time, these rituals do not carry the universal significance accorded to funerals for those who lived and died. When asked about the challenges of conducting such services, including individual ones, funeral directors described the difficulty of talking about the baby in more specific terms; some of them said that they ask the parents about the hopes and dreams they had for the baby in order to be able to personalize the service for the parents. A shared ceremony, even an attended one, makes such individualization nearly impossible. Furthermore, funerary industry professionals emphasized the importance of trying to make all funeral services similar to each other, that is, making services for babies born before the twenty-fourth week of pregnancy much like services for stillborn babies, which in turn are to resemble services for children who lived and died. While this intention is analytically interesting and points to a way of viewing the foetus as a person from the earliest stages of pregnancy, what is relevant here is the perceived function of the funeral ritual.

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Importantly, a funerary rite, while impinging on death, also implies life – a trait that miscarried babies are somewhat refused through their legal status, common concealment of miscarriage events, and lack of a widely shared public view on what constitutes a baby. Furthermore, although pregnancy losses up to 23 weeks and 6 days cannot be formally registered in the UK currently,19 a funeral service and a subsequent cremation or burial ensure a certain type of public record. In the case of shared ceremonies, such a record is likely to include few details individualizing the pregnancy remains; nonetheless, its bureaucratic existence grants irrefutability to some kind of human existence. At the same time, because these records are confined to the crematorium where the cremation took place, and because they often only contain a number that can be linked to another number that can be linked to a specific patient (but only for as long as the hospital keeps the patient records), a degree of ambiguity surrounding these ceremonies does not disappear. This ambiguity is paralleled by the differences between shared and individual funeral services. With the exception of twins and mothers and babies who died in childbirth, it is usually not possible to place more than one body in a single coffin.20 This restriction does not apply to shared cremations of pre-24-week losses. Different crematoria have different standards limiting the maximum number of sets of pregnancy remains to be placed in one coffin; this number may also depend on the gestational stages of losses due to their size. Another dimension of the ambiguity is related to the contents of shared coffins. More specifically, depending on geographic area (i.e. existence of abortion clinics outside of local hospitals and availability of sensitive incineration as a disposal option), shared coffins may contain pregnancy remains from miscarriages and pre24-week terminations. Those NHS hospitals that conduct abortions routinely ask their patients about their choice of disposal method. Some patients might either opt out of making a decision or agree to the hospital-arranged disposal. If the local crematorium does not charge for shared cremation (or the charge is relatively small, e.g. £20 per each shared coffin), the hospital might very well use shared cremation as a default disposal option. While information on the provenance of pregnancy remains is never revealed to crematorium staff, a couple of the interviewees expressed an opinion that they would rather not have details of this kind for fear of some staff not

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being able to treat all remains with the same level of sensitivity and respect. Rob, a bereavement services manager, explained: The council as an entity is not aware of what’s in those [containers with pregnancy remains] – we don’t even look at them as NVFs, to be honest. It’s just another cremation, you know, and that’s how it’s treated, with reverence, with respect. And everything comes in through the front door [and] goes onto the catafalque through into the crematory and then it’s treated with respect.

Bereavement services manager Lynn described the competing bureaucratic priorities and the necessity to anticipate potential tensions among staff members: [Some] people are making a judgement that [pregnancy remains from terminations] shouldn’t be cremated. [But] I don’t want that [information] – I just wanna know the baby was under 24 weeks. I don’t need to know how or what. Because if we don’t know and we follow the procedures in that we’ve just got the hospital number, it just means we don’t make judgements. I personally don’t make judgements, but I know people do.

Sensitivity, Dignity and Respect All guidance documents that set standards for the disposal of pregnancy or foetal remains emphasize the importance of such disposal being sensitive, respectful and dignified. These values are underpinned by recognition of the meaning of loss to the parents as well as an acknowledgement that while the legal status of pre-24-week pregnancy remains is that of tissue from a living human (Human Tissue Act 2004), people who lose pregnancies may view these events in a fundamentally different way. In other words, disposal of pregnancy remains should be sensitive and guided by parents’ choices because it is recognized that pregnancy remains are symbolic of a person that did not get a chance to breathe, of a potential of a life, despite their insignificant legal status.21 The perceived parallel between pregnancy remains and human remains is perhaps the most potent here as principles of respectful treatment of human remains are transferred onto ideas about pregnancy remains: what (or who) they are/were and how they should be disposed of. In this way, shared cremations – and funeral services that precede them – become not just appropriate, but the

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most appropriate way of handling pregnancy remains. This view was expressed consistently by funerary industry professionals I interviewed, although some of them were accepting of methods of disposal that did not accord the pregnancy remains a special status (i.e. sensitive incineration). What I would like to draw attention to, however, is the power of that perceived parallel between pregnancy and human remains to restrict or usurp the notions of sensitivity, dignity and respect when it comes to disposal. While many miscarriages are thought of as deaths of babies, research shows that it is not always the interpretation of those who have had such an experience (Reagan 2003). A parallel perception may be found among those who have decided to terminate a muchwanted pregnancy and who saw it as a loss of a much-wanted baby.22 Because miscarriages and pre-24-week terminations are not always interpreted as baby loss, and because the tissue from such losses (i.e. falling under the legal category of ‘pregnancy remains’) does not have the same legal status as tissue from pregnancy losses occurring after the beginning of the twenty-fourth week (i.e. ‘human remains’), legal regulations regarding the disposal of pregnancy remains are appropriately broad, acknowledging a variety of experience by allowing different disposal methods. When we look at how pregnancy remains are dealt with (with ‘sensitivity’, ‘respect’, ‘dignity’), what methods of disposal are the most common (shared/individual cremations), what bereavement professionals say about these methods (they opt for the most sensitive), the emerging pattern suggests that a sensitive disposal is one where pregnancy remains are treated similarly to human remains. This in turn privileges viewing them in a way that takes foetal personhood for granted. A considerable body of feminist academic literature has analysed the cultural character of the foetus in depth. Works by Newman (1996), Taylor (2008), Morgan and Michaels (1999) and Roberts (2012) have explored the culturally constructed and reified notions of what/who a foetus can be. In a cultural context such as England (and by and large in the Euro-American world), a foetus is a number of things at the same time, from a part of the woman’s body to a baby, embodying the ambiguity between the stances of different social perceptions, law, and scientific medicine’s technological insights. This ambiguity is appropriately mirrored in the case of the disposal of pregnancy remains, escaping unidimensional definitions through a variety of available disposal options that reflect the meaning of the pregnancy remains to those from whom they came.

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Various campaigns on raising awareness about pregnancy loss are underpinned by the recognition of loss as the fundamental principle of offering support. Unwitnessed funeral ceremonies accompanying shared cremations seem to be underpinned by the same principle, although the recognition that they symbolize is not reaching those who experienced the loss, at least not in a direct way. While it is clear that the services are well intentioned on the part of those who provide them, the prevalence of such services also reflects a wider political and social climate in England as well as changing understandings of foetal personhood. Normalizing unwitnessed ceremonies accompanying shared cremations as proper funerals can become a double-edged sword. On the one hand, it helps to reiterate the idea that mourning a pregnancy loss can be more than justified. On the other hand, it obscures situations in which no special significance is accorded to pregnancy remains, suggesting that such stances are less ‘respectful’ because they are unaccompanied by ritualized disposal.

Conclusion Pregnancy losses constitute analytically rich ground. The disposal of pregnancy remains, an aspect of which has been the subject of this chapter, is particularly interesting. It is a space where different priorities intersect and clash: bureaucratic requirements and sensitive support might have very different timelines, the decomposition of the body and having time to grieve simply do not go hand in hand. Given the efforts of the UK perinatal loss support organizations and of their beneficiaries, it is not surprising that emerging policies – in hospitals, the funerary industry and elsewhere – largely reflect their official positions on how people who have experienced pregnancy loss should be supported. At the same time, it is possible to note that the unwitnessed ceremonies may stand for more than a dignified funeral. There is no doubt that availability of cremation and burial for pre-24-week pregnancy losses (as part of a broader campaign to recognize pregnancy loss bereavement) has helped many people in the UK to deal with their reproductive losses. Nonetheless, shared unwitnessed ceremonies, the details of which are not always revealed to those who opt for them, might more effectively capture the attitudes of a funerary industry than ideals of parent-centred bereavement care. Scholars focusing on ways in which rituals

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define social norms emphasize the importance of remaining critical when faced with rituals. Lukes (1975: 301) pays particular attention to the affective power of ritual: ‘[ritual] helps to define as authoritative certain ways of seeing society: it serves to specify what in society is of special significance, it draws people’s attention to certain forms of relationships and activity – and at the same time, therefore, it deflects their attention from other forms, since every way of seeing is also a way of not seeing’. Respect, sensitivity and dignity, when ritualized and moulded in the form of unwitnessed ceremonies, might be well intentioned but can also impose a very rigid framework for what should be done with pregnancy remains and – more importantly – why they should be treated in a certain way. More specifically, rather than relying on the perceptions of the person who lost the pregnancy, the streamlining ethics of unwitnessed ceremonies for pre-24-week pregnancy losses articulates a view that it was babies that died and that they deserve a funeral. It should be noted that for many people a funeral ceremony, individual or shared, may be the most appropriate, sensitive and helpful choice. But perhaps it should also be considered that a mandatory funeral service might be as oppressive as the impossibility of having one.

Acknowledgements I would like to thank Susie Kilshaw, Katie Borg and anonymous reviewers for their helpful and insightful comments. I am also indebted to my research team colleagues, Danielle Fuller, Jeannette Littlemore, Sheelagh McGuinness and Sarah Turner, for inspiring discussions, reading earlier drafts of this chapter and their thoughtful feedback. Last but not least, I owe a debt of gratitude to the participants of the Death Before Birth research project who shared their expertise, reflection and heartbreak with me. Karolina Kuberska is a medical anthropologist with a special interest in maternal and reproductive health. She received her Ph.D. from the University of St Andrews. She has previously worked with indigenous highland migrants to lowland Bolivia, concentrating on the relationships between emotions, sociality and well-being as well as understandings of the body that incorporate traditional and biomedical notions. Between 2016 and 2018 she was a member of a research team working on an ESRC project Death before Birth at

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the University of Birmingham, UK, that explored socio-legal intersections of decision-making processes in the experiences of miscarriage, termination and stillbirth in England. Currently, she is a Research Associate at The Healthcare Improvement Studies (THIS) Institute at the University of Cambridge where she is involved in a range of projects aiming to strengthen the evidence base for improving healthcare.

Notes  1. The 2001 Redfern report investigated Alder Hey Children’s Hospital for unauthorized practice of retaining human tissue (The Royal Liverpool Children’s Inquiry 2001). Similar topics were covered in the mass media, for example in 2014 Channel 4 television programme ‘Dispatches – Exposing Hospital Heartache’, presented by Amanda Holden, set out to expose incineration as an inappropriate disposal method.  2. Registration of stillbirths is required by law in England and Wales on the basis of Births and Deaths Registration Act 1953 section 41 as amended by the Stillbirth (Definition) Act 1992 section 1(1). The amendment lowered the gestational age from which a baby born without signs of life was considered stillborn from 28 to 24 weeks (Fairbairn 2018: 6), which meant that pregnancy losses occurring between 24 and 27 weeks and 6 days that had been previously considered miscarriages started to be classified as stillbirths, requiring official registration.  3. ESRC grant identifier: ES-N008359 (www.deathbeforebirthproject. org).  4. The funerary industry guidance mirrors this dichotomy well. The document called ‘The Sensitive Disposal of Fetal Remains’ (my emphasis) states: ‘The baby they were expecting has died and their grief can be profound and long lasting, therefore when speaking to parents the term “baby” must be the only term used’ (ICCM 2015b; my emphasis).   5. It should be noted that a chapter on this aspect of bereavement care was included in all previous editions of these guidelines (Sands 1991, 1995, 2007). The chapters differ in sections explaining contemporary legal provisions regarding the disposal of pregnancy and baby remains.   6. The Department of Health (2017: 5) report states: ‘There were 190,406 abortions for women resident in England and Wales in 2016’. The IDS and NHS Scotland (2017: 5) report states: ‘The number of terminations of pregnancy in Scotland in 2016 was 12,063’.  7. The first guideline on Abortion Care published by the National Institute for Health and Care Excellence (NICE) in September 2019

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includes providing women with information about the different options for disposal of pregnancy remains as part of care (NICE 2019a).   8. The first and second editions had fewer than one hundred pages; the fourth edition from 2016 is nearly 500 pages long, almost doubling the volume of the third, 2007 edition (271 pages).  9. All midwives were employed in NHS England trusts at the time of the interview. 10. The popularity of the snowdrop may be linked to a poem ‘Little Snowdrop’ (author unknown), often quoted on various websites about bereavement following pregnancy or baby loss (see, e.g., Oxfordshire Sands 2019). 11. Interviewees’ names are pseudonyms. 12. It is important to note that similar shared ceremonies for pre-24-week pregnancy losses are organized by different professionals (e.g. bereavement midwives or nurses, or funeral directors), not all of whom favour explicit religious elements in the services. 13. Quotations from linguistic transcripts have been modified for ease of reading by adding punctuation and removing linguistic markers. 14. See also Bailey (2012) for an analysis of funeral rites in contemporary Britain with a particular focus on the participants. 15. Jane, one of the women interviewed, said: ‘I decided … not to go. … There … was something about the idea of – kind of – standing there with – I don’t even know – if there would have been other people there – but standing there with other kind of people … going through the same and watching…’. 16. Interestingly, a number of interviewees said that they became upset when they received an email or a telephone call about the time and date of the shared funeral service – most of them explained that they had not anticipated such an email or call or that the tone of the message had not been appropriately sensitive. 17. See, for example, Bueno (2019) for a comprehensive overview of attitudes to miscarriage in contemporary UK. 18. Human Tissue Act 2004, section 53. http://www.legislation.gov.uk/ ukpga/2004/30/section/53 (accessed 4 October 2019). 19. Formal steps have been undertaken to consider changing this rule and to allow formal registration of pre-24-week pregnancy losses via Pregnancy Loss Review (Department of Health and Social Care [DHSC] 2018). The consultation aimed to determine whether such registration would be mandatory or voluntary and whether there would be a lower threshold of gestational stage for stillbirth. As of November 2019, there is no provision for formal registration of pre-24-week pregnancy losses. 20. ICCM’s Q&As, ‘Questions People Ask about Burial and Cremation’, states: ‘The aperture through which the coffin passes in the cremator and the cremation chamber are of dimensions that will only safely

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accept one coffin. However, exceptions can be made in the case of a mother and baby or small twin children, so long as the next of kin or executor has made this specific request. There have been a small number of instances where elderly couples have died within a day or two of each other both being cremated in the same coffin. This is not unlawful provided that the applicant for cremation has made this request’ (ICCM 2015a: 4–5). 21. ‘Although under the HT Act [Human Tissue Act 2004], consent is not required for the disposal of pregnancy remains, the particularly sensitive nature of this tissue means that the wishes of the woman, and her understanding of the disposal options open to her, are of paramount importance and should be respected and acted upon’ (HTA 2015: 2). 22. If a pregnancy is terminated before the 24-week threshold, the pregnancy remains have the same legal status as the tissue from miscarriage; terminations after the beginning of the twenty-fourth week must be registered as stillbirths (HTA 2015).

References Austin, L. and S. McGuinness. 2019. ‘Reproductive Loss and Disposal of Pregnancy Remains’, Northern Ireland Legal Quarterly 70(1): 131–53. Bailey, T. 2012. ‘Going to Funerals in Contemporary Britain: The Individual, the Family, and the Meeting with Death’, Ph.D. dissertation. University of Bath. Bell, C. 2009 [1992]. Ritual Theory, Ritual Practice. New York, Oxford: Oxford University Press. Bueno, J. 2019. The Brink of Being: Talking about Miscarriage. London: Virago. Cameron, M.J., and G.C. Penney. 2005. ‘Are National Recommendations Regarding Examination and Disposal of Products of Miscarriage Being Followed? A Need for Revised Guidelines?’, Human Reproduction 20(2): 531–35. Corbet-Owen, C., and L.-M. Kruger. 2001. ‘The Health System and Emotional Care: Validating the Many Meanings of Spontaneous Pregnancy Loss’, Families, Systems, and Health 19(4): 411–27. Department of Health and Social Care (DHSC). 2018. ‘The Pregnancy Loss Review: Care and Support when Baby Loss Occurs before 24 Weeks Gestation. Terms of Reference’. March 2018. Retrieved 11 October 2018 from https://assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/file/693820/Pregnancy_ Loss_Review_ToR_gov.uk.pdf. Department of Health (DoH). 2017. ‘Abortion Statistics, England and Wales: 2016’. Retrieved 11 October 2018 from https://assets.publishing. service.gov.uk/government/uploads/system/uploads/attachment_data/ file/679028/Abortions_stats_England_Wales_2016.pdf.

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Fairbairn, C. 2018. ‘Briefing Paper: Registration of Stillbirth’. House of Commons Library, 1 February. Retrieved 11 October 2018 from https:// www.parliament.uk/documents/commons-library/Registration-of-stillbirth-SN05595.pdf. FBCA, ICCM, CSGB and APCC. 2016. ‘Policy Statement – For Infant Cremation – England and Wales’. Retrieved 15 May 2018 from http:// www.iccm-uk.com/iccm/library/Joint%20Infant%20Cremation%20 Policy%20Statement.pdf. Fuller, D., S. McGuinness, J. Littlemore, K. Kuberska, S. Turner, L. Austin and M. Burgess. 2018. ‘Preliminary Project Findings for Meeting with Representatives of the Department of Health and Social Care’, University of Bristol/University of Birmingham, 24 August. Retrieved 11 October 2018 from https://testprojectwebsiteblog.files.wordpress.com/2018/08/ summary-of-death-before-birth-findings-for-dhsc.pdf. Grimes, R.L. 2014. The Craft of Ritual Studies. New York: Oxford University Press. Human Tissue Authority (HTA). 2015. ‘Guidance on the Disposal of Pregnancy Remains Following Pregnancy Loss and Termination’. Retrieved 15 May 2018 from https://www.hta.gov.uk/sites/default/files/Guidance_on_the_disposal_of_pregnancy_remains.pdf. Information Services Division (IDS) and NHS Scotland. 2017. ‘Termination of Pregnancy Statistics: Year Ending December 2016’. Retrieved 11 October 2018 from http://www.isdscotland.org/Health-Topics/Sexual-Health/ Publications/2017-05-30/2017-05-30-Terminations-2016-Report.pdf. Institute of Cemetery and Crematorium Management (ICCM). 2015a. ‘Questions People Ask about Burial and Cremation’. Retrieved 28 June 2018 from https://www.iccm-uk.com/iccm/library/QUESTIONS%20 PEOPLE%20ASK%20ABOUT-1.pdf.  . 2015b. ‘The Sensitive Disposal of Fetal Remains: Policy and Guidance for Burial and Cremation Authorities and Companies’. Retrieved from 4 October 2019 from https://www.iccm-uk.com/iccm/library/ Fetal%20Remains%20Policy%20Updated%20Sept2015%20.pdf. Jurkovic, D., C. Overton and R. Bender-Atik. 2013. ‘Diagnosis and Management of First Trimester Miscarriage’, British Medical Journal 346(7913): 34–37. Layne, L.L. 2003. Motherhood Lost. A Feminist Account of Pregnancy Loss in America. London: Routledge. Lukes, S. 1975. ‘Political Ritual and Social Integration’, Sociology 9(2): 289–308. McGuinness, S., and K. Kuberska. 2017. ‘Report to the Human Tissue Authority on Disposal of Pregnancy Remains (Less than 24 Weeks’ Gestational Stage)’. University of Bristol/University of Birmingham, ISBN: 9780956838988. Morgan, L.M, and M.W. Michaels (eds). 2008. Foetal Subjects, Feminist Positions. Philadelphia: University of Pennsylvania Press.

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Moulder, C. 1998. Understanding Pregnancy Loss: Perspectives and Issues in Care. Basingstoke: Macmillan.  . 2001. Miscarriage: Women’s Experiences and Needs. Abingdon: Routledge. National Institute for Health and Care Excellence (NICE). 2019a. ‘Abortion Care’. NICE guideline. Retrieved 14 October 2019 from https://www. nice.org.uk/guidance/ng140.  . 2019b. ‘Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management’. NICE guideline, April 2019. Retrieved 4 October 2019 from https://www.nice.org.uk/guidance/ng126. Newman, K. 1996. Foetal Positions: Individualism, Science, Visuality. Stanford, CA: Stanford University Press. Oxfordshire Sands. 2019. ‘Remembrance Poems’. Retrieved 4 October 2019 from https://www.oxfordshiresands.org.uk/remembrance-poems/. Reagan, L.J. 2003. ‘From Hazard to Blessing to Tragedy: Representations of Miscarriage in Twentieth-Century America’, Feminist Studies 29(2): 356–78. Roberts, J. 2012. The Visualised Foetus: A Cultural and Political Analysis of Ultrasound Imagery. Farnham: Ashgate. Royal College of Nursing (RCN). 2018. ‘Managing the Disposal of Pregnancy Remains: RCN Guidance for Nursing and Midwifery Practice’. Retrieved 4 October 2019 from https://www.rcn.org.uk/-/ media/royal-college-of-nursing/documents/publications/2018/december/007321.pdf. Royal College of Obstetricians and Gynaecologists (RCOG). 2005. ‘Disposal Following Pregnancy Loss before 24 Weeks of Gestation’ (Good Practice No. 5). Retrieved 15 May 2018 from http://www.aogm.org.mo/assets/ Uploads/aogm/Guidelines/RCOG---UK/No-5-RCOG-Disposal-Following-Pregnancy-loss-Before-24-weeks-of-Gestation.pdf. The Royal Liverpool Children’s Inquiry. 2001. Report/The Royal Liverpool Children’s Inquiry. London: The Stationery Office. Sands. 1991. Guidelines for Professionals: Miscarriage, Stillbirth, and Neonatal Death. London: Sands.  . 1995. Pregnancy Loss and the Death of a Baby: Guidelines for Professionals. London: Sands.  . 2007. Pregnancy Loss and the Death of a Baby: Guidelines for Professionals. London: Bosun Press.  . 2014. ‘Deciding about a Funeral for Your Baby’. Retrieved 28 June 2018 from https://www.sands.org.uk/sites/default/files/DECIDING%20 ABOUT%20A%20FUNERAL%20SINGLE%20PAGE%20LINKED.pdf.  . 2016. Pregnancy Loss and the Death of a Baby: Guidelines for Professionals. 4th ed. London: Sands. Savitz, D.A., I. Hertz-Picciotto, C. Poole and A.F. Olshan. 2002. ‘Epidemiologic Measures of the Course and Outcome of Pregnancy’, Epidemiologic Reviews 24(2): 91–101.

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Silverman, R.E., and J. Baglia (eds). 2015. Communicating Pregnancy Loss: Narrative as a Method for Change. New York: Peter Lang. Taylor, J. 2008. The Public Life of a Foetal Sonogram: Technology, Consumption, and the Politics of Reproduction. New Brunswick, NJ: Rutgers University Press. Tommy’s. 2017. ‘Planning a Funeral for Your Stillborn Baby’. Retrieved 28 June 2018 from https://www.tommys.org/pregnancyinformation/pregnancy-complications/pregnancy-loss/stillbirth/ planning-funeral-your-stillborn-baby#.

Conclusions Susie Kilshaw

B

y making use of miscarriage as a lens, the authors have explored central anthropological issues such as the categories of personhood and thresholds of humanity, the boundaries of life and death, and notions of gender, women and motherhood. Throughout the book we have highlighted how miscarriage is typically surrounded by ambiguity and uncertainty, with definitions, categories and understandings in flux and negotiable. We have explored how boundaries, including those of the body, are problematized in pregnancy and miscarriage, with pregnant bodies often thought to be vulnerable, at risk or permeable. As such, body boundaries require monitoring and protection during pregnancy, with problems occurring when these are traversed. The way in which a society understands pregnancy and the pregnant body impacts how women experience the end of a pregnancy. Furthermore, category borders such as those demarcating miscarriage from other pregnancy endings impact experience. Medico-legal-religious constraints define these categories and inform women’s experiences; reproduction occurs within these constraints but there are opportunities, negotiations and subversions, as women and their carers navigate ambiguities, resisting particular framings and endorsing others. The landscape around miscarriage shifts as legislation continues to change, just as categories around foetuses, their value and notions of personhood are flexible and changing. Definitions are multiple, fluid and flexible. This book has provided detailed examples of the way in which pregnancy and, by extension, miscarriage are embedded in wider social and historical relationships, with cultural and historical resonances profoundly shaping experience.

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Advances in biomedical technology have had a significant role in shaping the way pregnancy, miscarriage, embryos and foetuses are understood and experienced. The global reach of reproductive technologies such as widely available birth control and assisted reproductive technologies (ARTs) has informed how we think of reproduction, informing a broader rhetoric of agency and choice. Sensitive and inexpensive home pregnancy tests, ultrasound technology, ARTs and foetal Doppler monitors have impacted ideas of control over reproduction, creating a prevailing view in many contexts that pregnancy timing can and should be chosen and that one can reduce risks and prevent pregnancy loss. Neoliberal settings and those that are technologically advanced may increase notions of personal guilt and a sense of failure in the face of reproductive loss. Notions of control over reproduction may exacerbate feelings of anxiety, yet personal guilt may not be a feature in some women’s experience and miscarriage may not always be framed as failure. In some contexts, miscarriage may be framed as a positive demonstration of fertility; a woman who miscarries is seen as healthy, for a pregnancy loss is evidence of the ability to conceive. In such understandings, the body is acting as it should by preventing the development of an unviable pregnancy or flawed foetus. Framing miscarriage as the body operating as it should rather than pathology is found in biomedical interpretations where miscarriage is framed as a natural process of quality control. Advances in reproductive technologies have also played a role in how we imagine foetuses, babies, children, parents and families, while also adding weight to notions of foetal personhood, particularly bringing forward thresholds of humanity in many contexts. This may contribute to feelings of loss and framing miscarriage as the loss of a child or baby requiring grieving or memorialization. The ritualization of pregnancy loss and the cultural response to miscarriage shed light on diverse cultural notions of personhood as well as understandings about motherhood. Practices often reflect the moral ambiguity around that which is produced by a miscarriage, with practices pointing to the liminal nature of these beings. Miscarriage provides an opportunity to explore the foetal subject, including legal, medical and religious categories that grapple with definitions of life before birth and what value is attributed to an embryo, foetus or pregnancy tissues. A plethora of relational values inform what these materials are, how they are regarded and meanings ascribed to them. While miscarriage as the loss of a baby is not universal, the dominance of Euro-American discourse which

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frames it as such must be noted. The book has revealed that miscarriage may not be recognized as a significant loss or one that requires demonstrations of grief in some contexts, pointing to the range of possible appropriate responses to a pregnancy end. The eroding silence around miscarriage in Euro-American contexts along with dominant discourses of miscarriage as significant loss may result in some experiences being muted, ignored or, worse still, pathologized. Thus, our book has presented miscarriage in a variety of historical and cultural contexts to provide additional voices to scholarly work on pregnancy loss.

Index

abortion 59–69, 72–75, 79–81 accusations 10, 11, 96, 98, 101 categories of 13, 20–21 and foetal disposal 1 induced 6, 10 law 35, 92–93, 108, 139 numbers 141 in Pakistani Punjab 118–19, 127, 130 practices 8, 93, 96–98, 108, 109, 144 suspicions 88, 92, 94, 96–100, 102, 106–107 terminology 11 Abortion Act (1967) 61, 65, 74 accusations 4, 10 age gestational 34–35, 37 male 37–38 maternal 37, 44, 49, 165, 167, 169 agency limitations of 166, 177, 178 in pregnancy 163, 171, 173, 175, 177 reproduction and 19, 137 through objectification 165, 177 alcohol 37–39, 45 ambiguity of categories 7, 87–89, 96–98 of cause 22, 88 of early pregnancy 7, 87–89 of the foetus 7, 8, 9, 87, 105–107

of language 10, 94, 96–98 of pregnancy loss 87–89, 92, 101–102, 105–107, 151 amniotic fluid 39 anaesthesia general 41 local 41 anembryonic miscarriage 37, 47 Angiogenesis 44 antenatal access to care 165, 172 care 162, 172 monitoring 170, 173 (see also foetal surveillance; foetal ultrasound imaging) anxiety about miscarriage 45–47, 161, 165, 167, 168, 170, 177 ‘anxious reproduction’ 19, 23, 151–52 assisted reproductive technology (ART) development 15, 18, 19, 38, 48 in England 144 failure of 193–94 in India 198 in Qatar 138 risks/challenges of 185 technology mediated 8, 185, 188–92, 195–96, 202 biomedicine advances in 12, 15–16, 20

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integration with ethnomedicine 118, 132 seeking help from 113 shift in approach to pregnancy loss 1, 2 blame/culpability 113–14, 122–26 causes of miscarriage 21 from family members 129, 150–51 feelings of 10, 137, 148, 152 bleeding risk of 33 vaginal 36, 40, 169, 172, 173, 177 blighted ovum. See anembryonic miscarriage blood 87, 95, 99 Body mass index (BMI) 38 burial. See disposal of foetal tissue caffeine 39 calcium 71 Cameroon 4, 7, 21, 89–92, 94–96, 98–102, 106–107, 108 causes of miscarriage 4, 148–51 God’s will (Islam) 21, 147 cerebral palsy 35 cervix 36, 41 chance 113–14, 122–26 chemotherapy 39 Childbearing desire 91–92, 94, 96 norms 91–94, 98, 102, 107 meaning 90, 93 strategies 91–92 chromosomal abnormalities 37, 39, 72–73 clinical gaze 116, 131–32 commemoration 102–106 complete miscarriage 36 conception 38, 44–45, 50–51 conjuncture 101, 107 Contraception (birth control) 60, 75 control by/of pregnant women 163, 165, 168, 170–73

Index

of technology 163 Cornwall docile bodies foetal bodies as 178 pregnant bodies as 178 cousin marriage 113, 138 cremation 209–10, 218–22 attendance 211–12, 214, 218–20 communal/shared 210–12, 214, 215–17, 218–19, 220–22 consent to 209, 222 cost 213, 218 record of 216, 220–22 See also disposal of foetal tissue culpability/blame 88, 94, 97, 99, 102, 106, 113–14, 122–26 causes of miscarriage 21 from family members 129, 150–51 feelings of 10, 137, 148, 152 cultural construction of miscarriage 117–19 death maternal 34, 40 neonatal 35 in utero 35 demographic context 5 depression 45–46 postpartum 46 diet (including nutrition) 61, 71, 80, 81, 122 Diethylstylbestrol 72, 80 discourse 89, 98, 107 political 92–94, 97 religious 93–94, 96–98, 100–101, 103–107 of suffering 98–101, 106, 109 disposal of foetal tissue burial 1, 18, 143, 210, 221 cremation 18, 24 distress and 78–79 following termination 209, 213, 220, 222–23, 224 funeral ceremony 210–12, 213, 218–19, 221

Index239

guidance on 1, 208–10, 213–14, 223 incineration 1, 17 regulation 206–07, 209–10, 216–17, 220–21, 224 sensitive 1, 207, 208, 210, 212–14, 222, 223–24, 226 donor egg 44 insemination 48 Doppler. See foetal Doppler Down syndrome 39 drugs 38–39, 41, 50 early pregnancy 39–40, 47, 51 loss 35, 39 unit (EPU) 40 ectopic pregnancy 175 egg 34, 36–38, 43–44, 48, 50 donor 44, 48 See also oocyte embryo 43–44, 47, 49 implantation 43–44 quality 38, 43 embryology 73, 87, 94–96 embryonic miscarriage 37 emergency gynaecology 34 emotions 61–63, 76–77 grief 79 history of 63 trauma 79 employment, female 68 endometrium 38, 43–44 eugenics 73 fallopian tube 43 female factor infertility 37, 48 feminism 63, 66, 82 feminist debates about reproductive technology 163 research 164 understandings of pregnancy 163 fertility 60, 61, 66 rate/Total Fertility Rate 5, 90, 93, 139, 140, 153, 154 fertilization 43–44

foetal evidence of life 163, 165, 170–1, 172, 175–6 surveillance 166, 178 foetal death. See missed miscarriage foetal Doppler commercialization of 161, 162, 170, 177 demedicalization of 163, 178 design of 160, 161, 162, 170 domestication of 161, 163, 165, 173, 178 medical concerns about 162, 179–80 NHS use 161, 162, 170, 173 online availability of 162, 170 online demonstration of 170 regulation of 162 used for reassurance 16, 165, 167, 170–1, 172, 175, 177 foetal heartbeat as evidence of life 160, 161, 167, 170, 171, 176, 177 kin listening to 174 on maternity notes 173 medical monitoring of 161, 162, 170, 173 production of sounds of 161 sounds in real time 162, 171, 172, 176 foetal movement 163, 165, 166, 171, 177 foetal personhood/person categories 6–9 in funeral practices 25, 217, 221, 224–25 heart sound and 174, 178 notions of 18, 60, 69, 207 provisional 120–21 use of technology 15–17 foetal ultrasound imaging. See ultrasound scans foetus 34–35, 42–45, 114–15 demise 34, 36, 39, 44, 50 foetal remains 206, 208, 209, 220, 223, 224 heartbeat 36, 51

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in utero 87, 94–96, 103 legal status/rights 13, 208, 221 perception of 206, 212, 213, 218, 219, 221 post-mortem 102, 103–105, 109 terminology for 118 viability 35, 40 folic acid 45 Foucault, Michel 166, 178 funerals arrangements 78, 210, 211–15, 218–20 services 207, 209, 212, 216–18, 220–22, 223–24 genes foetal 42, 50 genetic mutations 38 genetics (including chromosomal abnormality, karyotyping) 72–74 gestational sac 35, 37, 39, 47 guilt 39, 46 haemorrhage 40 home, medicalization of 174, 178 hormones (androgens, oestrogens, progesterones) 71–72 hospital 64, 66, 67, 68, 77–78 Human chorionic gonadotropin (hCG) 46, 47, 48 beta-subunit 46 Human Fertilization and Embryology Authority (HFEA) 49 Human Tissue Act (2004) 220–21, 223 Human Tissue Authority (HTA) 1, 210, 213, 216 humourism 122–26 immune system 42, 44 implantation 43–44, 48 in vitro fertilization (IVF) 44, 48–50 incineration 1, 17 incomplete miscarriage 36 India 4, 7 surrogacy and 184–94, 199, 201–03

Index

induction of labour 35 inevitable miscarriage 36 infection 33, 35, 40–42, 72 infertility 23, 50, 143, 154 female 37, 48 male 37 intentionality 10, 11, 88, 96–100, 103–106 intracytoplasmic sperm injection (ICSI) 48 intrauterine foetal demise 176. See also missed miscarriage intrauterine insemination (IUI) 48 Japan 17 Jeffery, Patricia on diet 122 on expectant mothers 126 on marital home 124 person categories 7, 22, 115–16, 119–20, 131–33 Kicks Count 162, 172 kinship 90, 91 late miscarriage 35 Layne, Linda 3 luteinizing hormone (lh) 45 malevolence 126–32 management of miscarriage conservative 40–41 surgical 2, 40, 42 marriage 90–93, 96, 101–102, 106, 108, 113, 114, 138 media 39, 45, 51 medical gaze. See clinical gaze medical research 71–72 meiotic nondisjunction 37 memorialisation miscarriage 1, 144 stillbirth 17 metaphors, miscarriage 117–19 midwives copying of 162, 170 limited access to 172–73 Ministry of Health 65

Index241

miscarriage/ (early) pregnancy loss 88, 106–107 aetiology 88, 96, 99, 101, 107 approaches to/shifts 1, 2, 153 as failure 19, 144, 146 impact on kin of 168 increased risk of 165, 169 meaning 87, 91–92, 94–96, 99–100, 107 medical investigation of 173 normalisation of/normativity of 2, 141–42 as positive; as evidence of fertility 19, 143 presentation 92, 96–97, 99 registration of/certificates of life 1, 12, 13 rejection of normalisation of 145 as social problem 14 terminology 88, 94–98, 107 uncertainty 4 See also pregnancy loss Miscarriage Association, The 2, 76, 77 Misoprostol 41 missed miscarriage 36 anxiety about future pregnancies 165, 166, 167, 169 Doppler use 161, 164, 171, 176 and family 168 mortality (infant, neonatal, maternal) 60, 65–67, 70, 82 motherhood 18, 141, 154 pre conception motherhood 149 National Health Service (NHS) 33, 59, 162, 165, 172, 173 National Institute for Health and Care Excellence (NICE) 36 natural selection 43–44 navigation 88–89, 92, 98–107, 108 Neo liberalism 19, 145 obesity 38 oestrogen 38 oocyte 38, 43 quality 38

ovulation 38, 44–45, 48 pain, in pregnancy 169, 174, 177 Pakistan 4 patri-virilocal marriage 114 Pinto, Sarah 116, 131–33 placenta 37, 39, 41 post-maturity 35 pre-eclampsia 44 pre-implantation genetic diagnosis (PGD) 49 preconception parents 144, 145, 149 planning 44 pregnancy biochemical 35, 46–49 ectopic 40, 47–48 first trimester of 160, 163, 173 focus on live birth in 179 medicalization of 165, 172, 174, 178 ongoing 40, 43 second trimester of 163 test 35, 40–41, 46–48 tissue 33, 36–37, 39–42 pregnancy disclosure 87, 92 pregnancy loss bereavement care 208–9, 214, 217, 225 lack of registration 207, 221 non-viable foetus (NVF) 208, 223 pre-24 weeks 206–7, 208, 212, 216–18, 220–21, 222, 223–24 recognition of 207, 218, 219, 221, 222, 224, 225 pregnancy testing 15, 75, 120–21, 131–32 pregnant woman reproductive history of 165, 166, 175, 177 responsibility of 165, 166, 168, 178 prenatal. See antenatal Qatar 4, 17, 18, 137, 138–39 Qatar National Vision 138, 152

242

rear-mirror methodology 89 religion 18, 147, 152 Christianity 18, 141 Islam 138, 147 reproduction and agency 19, 137 and anxiety/’anxious reproduction’ 19, 23, 151–52 notions of control over/planning of 137, 143–44, 145–46, 149, 154; lack of control 141 rhetoric of choice 18, 136, 154 reproductive loss 177 as disruption 4, 136 as experienced by LGBTQ people 3 memorialisation of 17 during surrogacy 3 resistance, to medicalization of pregnancy 177 retained pregnancy tissue 33, 36, 40–41 ritual 17–18, 213, 217–18, 226 critique of 212–13, 217–18, 222, 224, 225–26 funeral 207, 210–12, 214–16, 217, 218, 220, 221 Romania 4, 17, 21, 89–90, 92–94, 96–98, 102–106, 108, 109 Royal College of Obstetricians and Gynaecologists 65, 78 screening, in pregnancy 73, 81 secrecy 88, 89, 92, 93 self-help literature 61, 76 semen volume 38 sepsis 34, 40 silence, trope of silence 1, 3, 8, 24, 89, 92, 94, 98, 105–107, 137, 144 smoking 37, 45 social sex selection 49 sperm 38, 43, 48–49 concentration 38 count 38 DNA fragmentation 38 motility 38 spiritual contagion 126–31

Index

spiritual healer 113, 125–26, 128–29 spontaneous miscarriage 35, 40 stillbirth causes of 37 definition 35 discourse 10 experience of 64, 81, 167, 220, 221 guidance on 77–78 memorialisation 17 rates of 66, 70, 82, 139 Stillbirth and Neonatal Death Society 77, 210 Stillbirth (Definition) Act (1992) 12–13, 207 subfertility 38, 48, 51 surrogacy business of/commercial aspect 184, 190, 193 contract 186, 190, 198–99, 202–203 in India 23–24, 184–94, 199, 201–03 loss during 3, 185–94, 197–203 medical costs during 199 miscarriage and; disruption/ disruptive 184–86, 194, 202; as failure 185, 187; pregnancy loss 185–86, 188, 190–91, 193–94, 197, 199–200; as shame 188, 202; silencing of 188, 191, 192, 194, 202; status as surrogate 9, 14, 185, 202 tactics 89, 98, 101–102, 106–107 Taiwan 17 technology biomedical 175, 177 commercialization of 161, 162, 163 demedicalization of 163, 178 domestication of 163, 178 reproductive 165 See also foetal Doppler Teratogenic 38

Index243

termination of pregnancy 35, 209, 213, 220, 222, 224 terminology abortion 11 for foetus 118 miscarriage/(early)pregnancy loss 34–35 Thompson, Charis 165, 177 threatened miscarriage 36, 162, 175, 177 tobacco 38 toxins 39

uncertainty of intentionality/cause 11 of reproduction 151 United States of America (USA) 2, 3, 17

UK 4, 17, 161 England 137, 139–40, 144 ultrasound scans 12 week 161, 172, 175 20 week 161, 173 dating 36 and foetal Doppler use 163, 167, 171, 176, 178 in Pakistani Punjab 120–21, 132 technology 15–16, 24, 81 transvaginal 36 use of 35–36, 40–41, 47, 51, 75–76

war Boer War 66 First World War 66, 67, 68, 69–70 War Cabinet Committee 68 Women’s Co-operative Guild 62, 65, 69–70 World Health Organization (WHO) 34

vaginal bleeding, in pregnancy 36, 40, 169, 172, 173, 177 Varley, Emma 115, 118, 123, 128, 143 viability 67, 77–78 vitamin E 71, 80

x-ray 39 zygote 43