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310 CHAPTER 11
Parenthood as an Option
What are the pros and cons of being parents or remaining child-free?
Becoming Pregnant
What are some of the causes of male and female infertility?
What are the current articial reproductive technologies? How do
they work?
Spontaneous and Elective Abortion
How can a miscarriage affect a woman and couple emotionally?
What factors most inuence a country’s abortion rate?
What procedures are used for abortion?
How have laws regarding abortion changed since Roe v. Wade?
The Experience of Pregnancy
How does pregnancy affect sexuality?
A Healthy Pregnancy
How does the fetus change in each trimester of pregnancy?
What factors can harm the fetus during pregnancy?
Childbirth
What occurs in each of the three stages of childbirth?
After Childbirth
What are advantages and disadvantages of breast-feeding?
What criteria should a couple use to decide when to resume
intercourse?
310
Michael Krasowitz/Getty Images
11
Conceiving Children:
Process and Choice
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Conceiving Children: Process and Choice311 311
I’ve been an expectant” father twice, but my role was drastically different the
second time because of changes in obstetrical practices. During my first child’s
birth, it was the classic scene of Dad pacing the waiting room floor while my
wife was in the delivery room. In my second marriage, the pregnancy was our
pregnancy” from the beginning. I went to doctors appointments and saw our
baby’s ultrasound pictures. Seeing his heart beat so early in the pregnancy gave
me a feeling of connection right from the start. We attended prepared childbirth
classes together, and I was there from start to finish during labor and when she
delivered our baby. I went with him to the nursery for all the weighing, measur-
ing, and cleaning, then brought him back to his mother in the birthing suite. I
wish I’d had those experiences with my first child’s birth. (Authors’ files)
One of the most important decisions we will probably make in our lifetime is whether
to become a parent. In this chapter we address the pros and cons of parenthood. We
also discuss the processes of conception, pregnancy, and birth and some of the emo-
tions that accompany them from the viewpoints of the parents. We encourage peo-
ple who desire further information to seek more extensive references or to consult a
health-care practitioner. As a starting point, we look at the option of parenthood and
some of the alternatives that are available for people who want to become parents.
Parenthood as an Option
More couples and individuals than in the past are choosing to be kid-free. In 1975
about 9% of 40- to 44-year-old women did not have children; in 2010 almost 19%
were childless (U.S. Census Bureau, 2010). Remaining childless has many potential
advantages. Individuals and couples have much more time for themselves, more finan-
cial resources, and more spontaneity with regard to their recreational, social, and work
patterns. The personal importance placed on leisure time may be especially important,
as one study found that women who valued leisure time more put less importance on
motherhood than did women who rated motherhood as more important (Mcquillan
et al., 2008). Nonparents can more fully pursue careers, creating more opportunity for
fulfillment in their professional lives. At the same time, there is usually more time and
energy for companionship and intimacy in an adult relationship.
In general, childless marriages are less stressful, and some studies show that they are
happier and more satisfying than marriages with children, especially in the years following
a rst child’s birth (Doss et al., 2009). Not having to worry about providing for the physical
and psychological needs of children can make a dierence, because conict about who does
what for the children is a major source of disenchantment for many couples (Vejar et al.,
2006). Note, however, that the reduced marital satisfaction after children may be because
many unhappily married couples remain together because they have young children.
Becoming parents of adopted or biological children also has many potential advan-
tages. A national representative sample found that 98% of fathers and 97% of mothers
agreed with the statement, “e rewards of being a parent are worth it, despite the costs
and work it takes (Martinez et al., 2006, p. 28). Children give as well as receive love,
and their presence can enhance the love between couples as they share in the experi-
ences of raising their ospring. Successfully managing the challenges of parenthood can
also build self-esteem and provide a sense of accomplishment. Parenthood is often an
opportunity for discovering new and untapped dimensions of oneself that can give ones
life greater meaning and satisfaction.
Conceiving Children
Process and Choice
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312 CHAPTER 11
e potential rewards of either becoming parents or remaining childless can be
romanticized or unrealistic for a given person or couple, and some people experience
considerable ambivalence (Eibach & Mock, 2011). As one writer put it, having children
changes your life—but so does not having them (Cole, 1987).
Becoming Pregnant
In the remainder of this chapter, we look at some of the developments, experiences,
and feelings involved in the physiological process of becoming parents, starting with
becoming pregnant. This first step can be difficult for some couples.
Enhancing the Possibility of Conception
Choosing the right time for intercourse is important in increasing the probability of
conception. Conception is most likely to occur within the 6-day period ending on the
day of ovulation. It is difficult to predict the exact time of ovulation, but several meth-
ods permit a reasonable approximation. Ovulation predictor tests, which measure the
rise in luteinizing hormone (LH) in urine before ovulation, can accurately identify the
best time for conception and can be purchased over the counter. Otherwise, the mucus
method, body temperature, and the principles of the calendar method can also be used
to estimate ovulation time, as discussed in Chapter 10.
Some individuals and couples are interested in enhancing the possibility of conceiv-
ing a child of a specic sex, as discussed in the following Sexuality and Diversity section.
SEXUALITY and DIVERSITY
Preselecting a Baby’s Sex: Technology and Cross-Cultural Issues
The desire to have a child of a certain sex has existed since ancient times. Superstitions
about determining the sex of a child during intercourse are part of Western folk tradi-
tion—for example, the belief that if a man wore a hat during intercourse, he would
father a male child or that if a man hung his trousers on the left bedpost, he would sire
a girl.
Couples sometimes try low-tech methods to conceive a boy or girl. Timing inter-
course closer to ovulation (to conceive a boy) or further from ovulation (to conceive a
girl), making the vaginal environment more acidic or alkaline by douching with water
and vinegar (girl) or water and baking soda (boy), or using dierent intercourse posi-
tions such as man on top (girl) or rear-entry (boy) are among the techniques that
couples may try. However, there is no scientic consensus as to whether any of these
methods are eective.
An eective technique for sex selection, pre-implantation genetic diagnosis (PGD),
creates embryos in the laboratory. e sex of the embryos is tested, and a physician sub-
sequently inserts the embryos of the desired sex into the womans uterus. e approx-
imately $20,000 procedure oers almost 100% certainty of the baby’s sex (Dayal &
Zarek, 2008). Less certain results occur with more commonly used laboratory tech-
niques that can separate X-chromosome–bearing sperm from Y-chromosome–bearing
sperm. Once the laboratory separation process is complete, the desired X or Y portion
is introduced into the vagina by articial insemination. Success rates are about 90%
for female babies and 70% for male babies. However, the rather unromantic” nature of
semen collection and articial insemination will probably limit the use of sex selection
techniques unless parents have compelling reasons to conceive a child of a particular sex.
SEXUALhEALTh
The rst stage of pregnancy: Only one
of the sperm surrounding this ovum
will fertilize it.
Photo Researchers/Getty Images
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Conceiving Children: Process and Choice313 313
Sex preselection oers benets to couples at risk for passing on X-chromosome–linked
diseases to their children, and research indicates that the public strongly favors its use
for that purpose (Kalfoglou et al., 2008).
In China, India, and South Korea, the preference for a son is particularly strong,
and selective abortion of female fetuses and the killing of infant girls are common. In
India a woman can obtain an ultrasound for about $12 to determine the sex of the
fetus, and if it is a girl have an abortion for about $35 (Power, 2006). Consequently,
an imbalance in the numbers of boys and girls has occurred: For every 100 girls there
are 120 boys in China and 109 in India. e imbalance is most severe in wealthier
regions where couples can aord the ultrasound tests (Halarnkar, 2011; Hvisten-
dahl, 2011). Overall, there are currently 100 million more males than females in Asia
(Ferguson, 2011).
Economic and cultural factors contribute to the importance of sons in many Asian
cultures. Sons provide for parents through their old age, oering security in the absence
of governmental social support. In Hindu and Confucian religious traditions in Asia,
only sons can light their parents funeral pyres and pray to release the souls of dead
parents. Sons will bring future earnings to their parents, but daughters are a nancial
liability to their families when they require the expense of a dowry. Womens work will
also contribute to the family into which they marry instead of to their birth family
(Garlough, 2008). ese traditions are so strong that even Asian couples who have
immigrated to the United States are using medical technology to have sons instead of
daughters. Interviews with immigrant Indian women who pursued fetal sex selection
found that 40% of the women had terminated prior pregnancies with female fetuses
and that 89% of women carrying female fetuses in their current pregnancy pursued an
abortion (Puri et al., 2011).
Infertility
Sixty percent of couples become pregnant within 3 months, but if attempts at impreg-
nation are unsuccessful after 6 months, a couple should consult a physician. It has
been estimated that about 12% of U.S. couples attempting pregnancy experience fer-
tility problems, defined as not conceiving after at least 1 year (Bell et al., 2012; Han-
non, 2009). Because approximately 40% of infertility cases involve male factors (20%
involve both male and female factors), it is important that both partners be evaluated
(Rabin, 2007a). We usually think of infertility as the inability to conceive any children,
but secondary infertility—the inability to conceive a second child—occurs in 10% of
couples (Diamond et al., 1999).
Infertility is a complex and distressing problem (Greil et al., 2011). It can have a
demoralizing eect on the infertile individual’s sense of self and on the couples sense
of their integrity as a healthy unit (Galhardo et al., 2011; Wischmann et al., 2009).
Its causes are sometimes dicult to determine and remain unidentied in many cases.
However, between 85% and 90% of infertility cases can be treated with drug therapy or
surgical procedures (Hannon, 2009).
Infertility’s Impact on Sexual Relationships
Most people grow up believing that they can conceive children when they decide to
begin a family. Experiencing infertility is an unanticipated shock and crisis (Wilkes,
2006). As their infertility becomes more evident and undeniable, a couple may feel a
great sense of isolation from others during social discussions of pregnancy, childbirth,
and child rearing. As one woman who has been unable to conceive stated,
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314 CHAPTER 11
Coffee breaks at work are the worst times; everyone brings out their pictures of
their kids and discusses their latest parental trials and tribulations. When one of
the women complains about having problems with something like child care, I
just want to shout at her and tell her how lucky she is to be able to have such a
“problem. (Authors’ files)
Problems with infertility can have profoundly negative eects on a couples relation-
ship and sexual functioning (Keskin et al., 2011). Partners can also become isolated
from each other and believe that the other does not really understand. Each partner
might feel inadequate about his or her masculinity or femininity because of problems
with conceiving. Each may feel anger and guilt and wonder, Why me?” Finally, both
may feel grief over life experiences they can never have—namely, pregnancy, birth, and
conceiving and rearing their own biological children (Steuber & Solomon, 2008).
Intercourse itself can evoke these uncomfortable feelings and can become an emotion-
ally painful rather than pleasurable experience, fraught with anxiety and sadness about
failing to conceive. Studies have found that most infertile couples
experience some sexual dissatisfaction or dysfunction at one point or
another (Mahoney, 2007). In addition, the medical procedures used
in fertility diagnosis and treatment are disruptive to the couple’s sex-
ual spontaneity and privacy. Sex can become stressful and mechanical,
resulting in performance anxiety that interferes with sexual arousal
and emotional closeness.
In contrast, 20% of men and 25% of women report that infer-
tility helped their marriage. e determining characteristics were
whether men actively communicated their feelings instead of avoid-
ing conversations about pregnancy and burying themselves in work.
In addition to increasing closeness in the relationship, couples who
communicated with each other about the infertility also reduced
their overall individual stress by doing so (Aaronson, 2006).
Female Infertility
A woman can have difficulty conceiving or be unable to conceive for
a number of reasons. Problems with ovulation account for approxi-
mately 20% of infertility (Urman & Yakin, 2006). Increasing age
reduces fertility significantly (Brandes et al., 2011; Schmidt et al.,
2012): A womans fertility peaks between ages 20 and 24 and begins
to decrease rapidly after age 30. Fertility rates in women ages 35 to
39 are up to 46% lower, and in ages 40 to 45 are 95% lower than
women at their peak fertility (Fritz & Speroff, 2010). Women over
age 35 are twice as likely to have unexplained infertility than are
younger women (Maheshwari et al., 2008).
Hormone imbalances, severe vitamin deciencies, metabolic
disturbances, poor nutrition, genetic factors, emotional stress, or
medical conditions can contribute to ovulatory problems. Ovula-
tion, and thus pregnancy, can also be inhibited by a below-normal
percentage of body fat, which results from excessive dieting or exer-
cise. Being even 10–15% below normal weight is sucient to inhibit
ovulation. Women who smoke cigarettes are less fertile and take
longer to become pregnant than nonsmokers, and alcohol and drug
abuse reduces fertility in women. Environmental toxins—including
Some fertility specialists think that celebrity moms who
have babies later in life, such as
Tina Fey, give the false
impression that conception at any age is easy.
HRC WENN Photos/Newscom
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Conceiving Children: Process and Choice315 315
chemicals in carpets, food packaging, nonstick cookware, and pesticides—may also
impair female fertility (Fei et al., 2009; Hannon, 2009). Ovulation problems can some-
times be treated with a variety of medications that stimulate ovulation. Although often
successful and generally safe, these drugs can produce certain complications, including a
greatly increased chance of multiple births.
If tests indicate that the woman is ovulating and that her partner’s semen quality is
satisfactory, the next step often is a postcoital test to see whether the sperm remain via-
ble and motile in the cervical mucus. A womans cervical mucus can contain antibodies
that attack her partners sperm, or it can form a plug that blocks their passage (Ginsburg
et al., 1997). Intrauterine insemination (placing semen directly into the uterus) can be
helpful in some cases.
Infections and abnormalities of the cervix, vagina, uterus, fallopian tubes, or ovaries
can destroy sperm or prevent them from reaching the egg. Scar tissue from old infec-
tions—in the fallopian tubes or in or around the ovaries—can block the passage of
sperm and eggs. Sexually transmitted infections (STIs) are a common cause of these
problems. Tubal problems can sometimes be resolved by surgically removing the scar
tissue around the fallopian tubes and ovaries.
Male Infertility
Most causes of male infertility are related to the presence of too few sperm to fertilize
an egg or to abnormal sperm shape or motility (the vigor with which sperm cells propel
themselves) (American Society for Reproductive Medicine, 2008). A major cause of infer-
tility in men is a damaged or enlarged vein in the testis or vas deferens, called a varicocele
(Abdel-Meguid, 2012; Zohdy et al., 2011). The varicocele causes blood to pool in the
scrotum, which elevates temperature in the area, impairing sperm production (Mishail et
al., 2009). Infectious diseases of the male reproductive tract can alter sperm production,
viability, and transport. For instance, mumps, when it occurs in adulthood, can affect the
testes, lowering sperm output, and infection of the vas deferens can block the passage of
sperm. Infections caused by STIs are another major cause of infertility. Smoking, alcohol,
and drug use and abuse reduce fertility as well (Springen, 2008). Cocaine use decreases
spermatogenesis, and marijuana impedes sperm motility. Environmental toxins, such as
chemicals, pollutants, and radiation, can also produce low sperm counts and abnormal
sperm cells. Sperm absorb and metabolize environmental toxins more easily than do other
body cells, which can also result in birth defects. Environmental factors are the likely cause
for the worldwide drop in sperm counts in the last 50 years (Joensen et al., 2009).
To improve the quality of sperm, research indicates that ejaculating daily is helpful
(Henderson, 2007). In contrast, when the sperm count is low, to increase the concentra-
tion of sperm, the optimal frequency of ejaculation during intercourse is usually every
other day, beginning 6 days before ovulation and during the week that the woman is
ovulating. A man with a low sperm count might also want to avoid taking hot baths,
wearing tight clothing and undershorts, and riding bicycles long distances, because these
and similar environments subject the testes to higher than normal temperatures.
For poor semen quality or quantity, intracytoplasmic sperm injection (ICSI) can
result in pregnancy. ICSI involves injecting each harvested egg with a single sperm and
is one of the advances in reproductive technology we discuss in the next section.
Reproductive Alternatives
Various alternatives have been developed to help couples overcome the problem of
infertility. Artificial insemination is one option to be considered in certain instances.
In this procedure, semen is mechanically introduced into the womans vagina or cervix
SEXUALhEALTh
varicocele
A damaged or enlarged vein in the
testis or vas deferens.
intracytoplasmic sperm injection
(ICSI)
Procedure in which a single sperm is
injected into an egg.
articial insemination
A medical procedure in which semen
is placed in a woman’s vagina, cervix,
or uterus.
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316 CHAPTER 11
or, in some cases, directly into her uterus, a procedure called intrauterine insemina-
tion. If the man is not producing adequate viable sperm or if a woman does not have
a male partner, artificial insemination with a donor’s semen is another option. More
than a million people who are alive today in the United States were conceived by donor
insemination (Egan, 2012).
Perhaps the most unique pregnancy by articial insemination is that of the preg-
nant man, omas Beatie. omas was born female but had sex reassignment proce-
dures including testosterone supplementation and chest reconstructive surgery. He is
legally recognized as a male. However, he did not alter his female genitals and repro-
ductive organs. When his wife, Nancy, was unable to conceive, the couple decided
that he would try to become pregnant. He stopped his testosterone supplementation,
used semen purchased via the Internet for articial insemination, and conceived on
the second insemination. eir healthy baby girl, Susan, was born in July 2008. ey
wanted more children so omas became pregnant two more times, and they now
have three children.
A surrogate mother is a woman who is willing to be articially inseminated by the
male partner of a childless heterosexual, lesbian, or gay couple or to undergo in vitro
fertilization using eggs and sperm from a couple. She carries the pregnancy to term,
delivers the child, and gives it to the couple for adoption. In the last 30 years, surrogate
mothers in the United States have given birth to approximately 25,000 children, and
surrogate births rose to 1,000 in 2007, compared to 260 in 2006 (Ginty, 2008b).
Surrogacy can be done anonymously through an attorney or privately by arrange-
ment between the woman and the couple. Some states have made surrogacy illegal,
while others permit it but allow only nominal payment to cover medical and incidental
expenses (Apel, 2011). In the few states that allow surrogate mothers to be compen-
sated, they typically receive a fee between $20,000 and $30,000. Individuals and couples
from European and Middle Eastern countries where surrogacy is illegal travel to the
United States and India for surrogates. Surrogacy in India costs 10% of what it costs in
the United States and generates $445 million in yearly revenues (Bates, 2010).
e techniques of extrauterine conception are referred to as assisted reproductive
technology (ART). e worlds rst test-tube baby was born in England in 1978. More
than 2 million women and couples worldwide have children conceived through IVF, and
in the United States about 48,000 women each year deliver babies that were conceived
in a laboratory of one of 430 reproductive technology centers
(Evans, 2009). In in vitro fertilization (IVF) the ovaries are
stimulated by hormonal fertility drugs to produce multiple
ova. e mature eggs are removed from the womans ovary and
are fertilized in a laboratory dish by her partner’s sperm. After
2 or 3 days several fertilized eggs are then introduced into the
womans uterus. Excess embryos are often frozen so that if the
rst implantation does not take place, the procedure can be
repeated. If this procedure is successful, at least one egg will
implant and develop. Research had found that couples initially
seeking medical help for infertility tend to overestimate the
success rates of treatment (van den Boogaard et al., 2011). e
success rate of live births from IVF is between 50% and 72%.
Live births are twice as likely when the mother is under age 35
(Boyd, 2009). Research on ways to increase the pregnancy rate
from IVF is ongoing (Devroey et al., 2009).
Variations on IVF involve transferring fertilized ova to a
fallopian tube rather than to the uterus, a procedure known as
Thomas and Nancy Beatie at home
in May 2008 prior to the birth of their
rst child.
Kristian Dowling/TB/Contributor/Getty Images
After a two-year, bicoastal search of fertility clinics and egg
donors, Doug Okun, 38, and
Eric Ethington, 37, became parents
to twins
Elizabeth and Sophia thanks to a surrogate mother.
AP Photo/Jeff Chiu
surrogate mother
A woman who is articially insemi-
nated by the male partner in a child-
less couple, carries the pregnancy to
term, delivers the child, and gives it to
the couple for adoption.
assisted reproductive technology
(ART)
The techniques of extrauterine
conception.
in vitro fertilization (IVF)
Procedure in which mature eggs are
removed from a womans ovary and
fertilized by sperm in a laboratory dish.
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Conceiving Children: Process and Choice317 317
zygote intrafallopian transfer (ZIFT). In gamete intrafallopian transfer (GIFT),
the sperm and ova are placed directly in the fallopian tube, where fertilization normally
occurs.
Donated ova can be used for IVF when the woman does not have ovaries, does not
produce her own ova, or has a heritable genetic disease. Donation of ova is analogous to
donor articial insemination. Donors are usually women in their 20s, a sister or friend
of the infertile woman, or another woman undergoing IVF who donates her ova to
another woman wanting the IVF procedure. In cases in which both partners are infer-
tile, IVF can be done with both donated sperm and donated ova.
Financial and Health Costs of Assisted Reproductive Technologies
Assisted reproductive technologies are expensive. One IVF procedure costs an average
of $12,000 and up to $15,000, and more than one attempt is often needed. Donor eggs
or sperm, ICSI, and any other additional procedures add to the cost (Gurevich, 2011).
Preliminary research on single births has found a twofold increase in heart prob-
lems, cleft lip and palate, and abnormalities in the esophagus or rectum in infants con-
ceived with IVF compared to infants conceived naturally. However, since these birth
defects are rare to begin with, this increase is small. For example, in the United States
cleft lip typically occurs in one out of 950 births, whereas the risk for infants conceived
with IVF is one in 425 (Reefhuis et al., 2008).
Multiple embryos are usually implanted during IVF to increase the chances of con-
ception (Roberts et al., 2011). Consequently, the twin birth rate rose by 76% from 1980
to 2009. In 1980, one in every 53 babies was a twin, compared to one in every 30 in
2009. One third of the increase is attributed to more women having babies later in life
instead of IVF (Martin et al., 2012). e triplet-or-more birth rate increased by 380%
during a similar period (Martin et al., 2009). Any multiple pregnancy increases the
danger to babies, with greater incidence of prenatal and postnatal death, prematurity,
low birth weight, and birth defects (Wadhawan et al., 2011). For mothers the risks of
cesarean deliveries, high blood pressure, and other birth complications, including death,
increase with multiple births (MacKay et al., 2006). In some cases one or more fetuses
are removed during the pregnancy to increase the likelihood that at least one or two
others will survive and be healthy (Stone et al., 2008).
e rate of multiple births following IVF decreased in the late 1990s after the
American Society for Reproductive Medicine published guidelines for reducing the
number of multiple births (Martin et al., 2009). Other countries have strict regulations:
Some European countries have laws instead of guidelines limiting IVF to one or two
embryos (Gibbs, 2008).
Legal, Ethical, and Personal Dilemmas Associated
With Assisted Reproductive Technologies
Assisted reproductive technologies have given rise to unprecedented ethical and legal
dilemmas. Extra embryos often result from the assisted reproductive process, and
some couples generously put their surplus embryos up for adoption, to be implanted in
another woman. Other women and couples donate the embryos for stem-cell research.
One study found that 60% of couples were willing to donate their surplus embryos
to research, 22% were willing to donate to another couple, and 24% would discard
them (Kliff, 2007). Other situations result in controversy, as when a divorcing couple
disagrees about what to do with the embryos they froze before they ended their mar-
riage. By 2000, more than 20,000 frozen embryos were the subjects of such disputes
(Silvertsen, 2000).
Critical Thinking Question
Do you think children conceived by donor
sperm and/or egg insemination should be
told about this? Why or why not?
zygote intrafallopian transfer (ZIFT)
Procedure in which an egg is fertilized
in the laboratory and then placed in a
fallopian tube.
gamete intrafallopian transfer (GIFT)
Procedure in which the sperm and
ovum are placed directly in a fallopian
tube.
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318 CHAPTER 11
Further ethical questions arise regarding selling embryos and paying
women for their ova and men for their sperm. Unlike the United States,
Canada and China prohibit paying women for ova, resulting in a shortage of
eggs and embryos for IVF. Women with sucient nancial resources resort to
“international reproductive travel”—going to other countries to purchase ova
or embryos for IVF (Heng, 2009).
Pre-implantation genetic diagnosis of embryos is currently available
and is used to screen for serious genetic problems. Genetic alteration prior
to implantation might be implemented in the near future (Geary & Moon,
2006). Genetic alteration could give parents with a known genetic defect—
predisposing them to developing Alzheimers, breast cancer, cystic brosis, or
another illness—the ability to have their eggs and sperm genetically altered to
remove the illness-causing genetic material prior to in vitro fertilization and
implantation (Begley, 2001). Nine months later the couple’s baby will be born
without the legacy of family genetic problems. Many bioethicists support this
development, which can shield children from disabling and life-threatening
genetic problems. Others oppose this technology because it could be used to
genetically engineer designer babies, selecting for characteristics such as hair,
eye, and skin color (Moses, 2009).
Reproductive technology has made it possible for women past the age of
menopause to become pregnant, carry the pregnancy, and deliver their babies.
e postmenopausal womans own ova are not viable, so ova from a younger
woman are fertilized in vitro, usually with the sperm from the older womans
husband. With hormonal assistance, the womans uterus can maintain a preg-
nancy. Women as old as 70 have had babies by means of ART (Caplan, 2008).
In the future, younger women may have their ova preserved by freezing to oer them
some protection against the decline in fertility with aging (Stoop et al., 2011).
Should elderly parents who may die before their children reach adulthood be denied
the use of reproductive technology? Some believe that the welfare of current and future
children should be taken into account, but others maintain that it is unethical to deny
women the opportunity to conceive on the basis of age alone (Murray, 2009). Current
guidelines from the American Society for Reproductive Medicine state that fertility
programs can withhold services only if they have well-substantiated judgments that the
woman or couple cannot provide adequate child rearing (Rubin, 2009).
Fifty years ago assisted reproductive techniques were found in science ction stories
instead of at the numerous assisted reproductive centers in the United States. Assisted
reproduction is currently a $3 billion a year industry (Coeytaux et al., 2011). Financial
incentive and technological advancements will continue to expand the options for repro-
ductive technologies as well as the legal, ethical, and personal quandaries that invariably
accompany them. e director of the Project on Biotechnology in the Public Interest at
the Center for Genetics and Society summarizes:
Responsible federal oversight of the fertility industry, in ways that protect reproduc-
tive rights and actually improve appropriate access to fertility, is not only possible
but long overdue. Comprehensive policies have been adopted in Canada, the United
Kingdom, and elsewhere. It’s time for the United States to catch up and move beyond
its reputation as the Wild West” of assisted reproduction. (Reynolds, 2009, p. 3)
Pregnancy Detection
The initial signs of pregnancy can provoke feelings from joy to dread, depending on
the womans desire to be pregnant, her partner’s feelings, and a variety of surrounding
Janise Wulf, who is 62 years old, holds her
4-day-old baby boy,
Adam, born in February
2006.
The newborn is her 12th child.
AP Photo/Mercy Medical Center Redding, Michael Burke, HO
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Conceiving Children: Process and Choice319 319
circumstances. Although some women have either a light blood flow or spotting (irreg-
ular bleeding) after conception, usually the first indication of pregnancy is the absence
of the menstrual period at the expected time. Breast tenderness, nausea, vomiting, or
other nonspecific symptoms (such as extreme fatigue or change in appetite) can also
accompany pregnancy in the first weeks or months.
Any of these clues might cause a woman to suspect that she is pregnant. Medical
techniques such as blood or urine tests and pelvic exams can make the determination
with greater certainty. e blood and urine of a pregnant woman contain the hormone
human chorionic gonadotropin (cohr-ee-AH-nik goh-na-duh-TROH-pun) (HCG),
which is secreted by the placenta. Sensitive blood tests for HCG have been developed
that can detect pregnancy as early as 7 days after conception. Commercially available
at-home pregnancy urine or saliva tests can detect pregnancy shortly after a missed
menstrual period. Because elective home pregnancy tests can yield both false-positive
and false-negative results, a health-care practitioner should conrm the results.
Spontaneous and Elective Abortion
Not every pregnancy results in a birth. Many pregnancies end in spontaneous or elec-
tive abortion.
Miscarriage and Stillbirth
Even when pregnancy has been confirmed, complications can prevent full-term devel-
opment of the fetus. A miscarriage is a spontaneous abortion that occurs in the first
20 weeks of pregnancy; many occur before the woman finds out that she is pregnant.
At least one in seven known pregnancies ends in miscarriage (Springen, 2005).
Table
11.1 gives the most common causes of miscarriage, but in many cases doctors are
unable to determine the specific cause (Kaare, 2009).
Early miscarriages can appear as a heavier than
usual menstrual ow; later miscarriages might involve
uncomfortable cramping and heavy bleeding. Fortu-
nately for women who desire a child, one miscarriage
rarely means that a later pregnancy will be unsuccess-
ful, although many women and couples worry about
the possibility of having another miscarriage in a sub-
sequent pregnancy.
When a fetus dies after 20 weeks of pregnancy, it is
sometimes referred to as a stillbirth. About 26,000 fetal
deaths occur each year in the United States, and rates
of fetal death are higher for teenagers and women age
35 and older, and for twin and other multiple births
(MacDorman & Kirmeyer, 2009). As with miscar-
riage, the causes of stillbirth are often unknown. Prob-
lems with the placenta or umbilical cord, the baby’s
health or development, and maternal health problems
such as diabetes or high blood pressure are some of the
known factors.
Miscarriage and stillbirth can be a signicant loss
for the woman or couple. Couples may need to grieve
the loss of this pregnancy and baby for several months
At a Glance
TABLE 11.1 Prime Suspects: Possible Causes of Miscarriage
Maternal age greater than 35 years
More than 5 alcoholic drinks per week
Smoking tobacco
More than 375 mg of caffeine per day (2–3 cups of coffee)
Rejection of abnormal fetus
Cocaine use
Damaged cervix
Chronic kidney inammation
Abnormal uterus
Infection
Underactive thyroid gland
Autoimmune reaction
Diabetes
Emotional shock
Aspirin and nonsteroidal anti-inammatory drugs early in pregnancy
Obesity
SOURCES: Baba et al. (2011), Lash & Armstrong (2009), and Speroff & Fritz (2005).
human chorionic gonadotropin
(HCG)
A hormone that is detectable in the
urine of a pregnant woman within
1 month of conception.
spontaneous abortion (miscarriage)
The spontaneous expulsion of the
fetus from the uterus early in preg-
nancy, before it can survive on its own.
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320 CHAPTER 11
before pursuing another pregnancy. Some parents who lose an unborn child nd it
meaningful to create a memory book of the pregnancy and baby and hold a memorial
ceremony of some kind. With a stillbirth, parents may nd it important to have photos
and footprints of the baby (Price, 2008).
Elective Abortion
In contrast to a spontaneous abortion, an elective abortion involves a decision to ter-
minate a pregnancy by using medical procedures. Each year, nearly half of all pregnan-
cies of women in the United States are unplanned. Women who are 18 to 24 years old,
poor, and cohabiting have two to three times the national rate (Finer & Zolna, 2011).
Many of the unplanned pregnancies become welcome and wanted. However, about 4
in 10 of these unplanned pregnancies are terminated by abortion. In 2008, 1.2 million
women had an abortion, and an estimated 33% of women in the United States will
have had an abortion by age 45 (Guttmacher Institute, 2011a).
Recent statistics nd that women in their 20s have more than half of all abortions,
and teenagers have 18% of abortions. About 61% of women having abortions each year
have one or more children. Among women having an abortion, 37% identify themselves
as Protestant and 28% as Catholic (Guttmacher Institute, 2011a).
How Women Decide
After a woman confirms that she is pregnant (assuming that she was not trying to con-
ceive), she must then decide whether to carry the pregnancy and keep the child, give the
child up for adoption, or have an abortion. Abortion is a last resort for women who are
faced with pregnancies they did not want. Research indicates that women rely on practi-
cal and emotional matters to make their decisions about their dilemma (Wind, 2006).
Concern and responsibility for others is a frequent reason for choosing to terminate the
pregnancy. Women without children often say they are unprepared for motherhood,
and women who already have one or more children cite their desire to be a good parent
and the difficulties in meeting their current responsibilities as a mother as their primary
reason for needing an abortion (Guttmacher Institute, 2011a; R. Jones et al., 2008).
In the United States two thirds of women who have abortions say their primary
reason is that they cannot aord a child, and 60% of abortions occur among those with
an annual income below $28,000 for a family of three (Boonstra et al., 2006). Unfor-
tunately, in part because of the erosion of government-funded contraceptive services
between 1994 and 2008, low-income women were considerably more likely to have an
unplanned pregnancy than are higher-income women (Wind, 2006). After President
Obamas election in 2008, his administration increased government-funded family
planning services to help reduce rates of unplanned pregnancy and abortion (Slaetan,
2009). However, by 2012 tens of thousands of teenagers and low-income women lost
access to subsidized contraception as many states with Republican-led legislatures cut
or reduced funding for family planning services (Simon, 2012).
Shared Responsibility
A couple can share responsibility for the decision about whether to have an abortion
and for the abortion itself, if that choice is made, in several ways. First, the man can
help his partner clarify her feelings and can express his own regarding the unwanted
pregnancy and how best to deal with it. Important topics for a couple to discuss include
each persons life situation at the time, their feelings about the pregnancy and each
SEXUALhEALTh
elective abortion
Medical procedure performed to ter-
minate pregnancy.
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Conceiving Children: Process and Choice321 321
other, the pros and cons of the possible choices, and their future plans as individuals
and as a couple. If the man and woman disagree on what to do, the final decision rests
with the woman: Male partners do not have a legal right to demand or deny abortion
for the woman. Research has found that most partners of single and married women
who have abortions know about and are supportive of the decision. However, women
were unlikely to disclose the pregnancy and abortion to partners who had been physi-
cally abusive to them prior to the pregnancy (Jones et al., 2010).
Psychological Reactions to Abortion
Choosing to have an abortion is usually a difficult decision for a woman and her partner.
It means weighing and examining highly personal values and circumstances. Even when
the pregnancy is unwanted, one or both partners may feel loss and sadness. Research
found that women who felt that the abortion was not primarily their decision and did
not feel clear emotional support after the abortion had some emotional distress fol-
lowing abortion (Kimport et al., 2011). However, well-designed studies of psychologi-
cal reactions following abortion have consistently found that the risk of mental health
problems is no greater than for women who continue their pregnancies. Ongoing feel-
ings of sadness, guilt, regret, and depression after an abortion are uncommon (American
Psychological Association, 2008; Munk-Olsen, 2011; Steinberg & Finer, 2011).
Pregnancy Risk Taking and Abortion
In many cases an unwanted pregnancy is clearly a matter of contraceptive failure.
About 54% of women who have had an abortion were using contraception when they
became pregnant (Guttmacher Institute, 2011a). For other women or couples seeking
abortions, the pregnancy can be traced to contraceptive risk taking—that is, not using
contraceptives consistently or reliably, sometimes because of inconvenience, side effects
of certain methods, or perceived low risk of pregnancy (Perlman & McKee, 2009).
Being under the influence of alcohol or drugs reduces judgment and greatly increases
contraceptive risk taking, unless the woman is using a method such as the pill or IUD.
Women who feel guilty about sex may not proactively use contraception because doing
so acknowledges their intent to engage in intercourse. Women may also not be asser-
tive about contraception if they fear alienating a partner by asking for his cooperation
in planning and using birth control.
Rates of Abortion
The United States has one of the highest abortion rates in the developed world. Each
year, 21 out of every 1,000 women of reproductive age have an abortion (Guttmacher
Institute, 2012a). In contrast, abortion rates in western Europe of 12 per 1,000 women
are the lowest in the world. Differences in many social policies contribute to the lower
abortion rates in other developed countries, including comprehensive sex education in
schools and easy access to inexpensive or free birth control and emergency contracep-
tives. In addition, these countries assist mothers by providing maternity leave, health
care, education and training, an adequate minimum wage, and other social services. In
contrast, from 2001 to 2009 the Bush administration strongly opposed and restricted
funding for these policies despite the fact that they result in lower abortion rates. How-
ever, to the extent possible given Republican opposition, the Obama administration
reestablished these kinds of programs that have helped reduce abortion rates in other
developed nations (Bendavid et al., 2011).
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322 CHAPTER 11
Worldwide, about one in ve pregnancies ends in abortion (Guttmacher Institute,
2012a). e very highest abortion rates are in countries that severely restrict abortion
but do not provide the social services, sex education, and access to contraception that
Western European governments do. For example, each year, 56 out of 1,000 women in
Peru have abortions, compared to 8 out of 1,000 in the Netherlands (Boonstra et al.,
2006). In the developing world, abortion rates are lowest in subregions where contra-
ceptive use is high (Barot, 2011).
Procedures for Abortion
Several different abortion procedures are used at different stages of pregnancy. In the
United States, 62% of legal abortions occur within the first 8 weeks of pregnancy, and
92% of abortions are done in the first 12 weeks (Mugge, 2011). Early abortion is very
safe. The risk of dying from a surgical abortion is 0.1 per 100,000 women, while the
risk of pregnancy fatality is 11.8 per 100,000 (Zielinski, 2006). The most common
procedures are medical abortion, suction curettage, D and E, and prostaglandin induction.
Medical abortion uses pills instead of surgery to end a pregnancy (Templeton &
Grimes, 2011). A woman can have a medical abortion within days of a missed period
and up to 9 weeks into a pregnancy. e medication mifepristone, commonly known as
RU 486, became available in 2000 to women in the United States. Medical abortion has
been available in European countries since 1980—20 years earlier than in the United
States. Decades of anti-abortion political action against the U.S. manufacture and dis-
tribution of medications for abortion caused the delay (Jones & Henshaw, 2002). Medi-
cal abortions account for about 13% of all elective abortions in the United States (Ginty,
2008b). Women with 12 years or more of education are more likely than women with
less than a high school education to have medical abortions (Yunzal-Butler et al., 2011).
A medical abortion is 99% eective in ending pregnancies of less than 7 weeks and
91% eective in the 8th week of pregnancy (Spero & Fritz, 2005). It is safer than the
abortion procedures done later in pregnancy and safer than childbirth itself. In addition,
a woman who opts for a medical abortion can see her family doctor at an oce instead
of going to another facility (Quindlen, 2009b).
Medical abortion works by blocking the hormone progesterone, which causes the
cervix to soften, the lining of the uterus to break down, and bleeding to begin. A few
days later the woman takes a second medicine that makes the uterus contract and expel
the grape-size embryonic sac.
Figure 11.1 shows how a medical abortion works. Side
eects can include cramping, headaches, nausea, or vomiting, but many women experi-
ence no physical side eects (Hausknecht, 2003).
Suction curettage is a surgical technique used 7 to 13 weeks past the last menstrual
period. A suction curettage is performed by physicians at clinics or hospitals and takes
about 10 minutes. During the procedure local anesthetic is used and a small plastic tube
is inserted through the cervical os into the uterus. e tube is attached to a vacuum
aspirator, which draws the placenta, built-up uterine lining, and fetal tissue out of the
uterus. Rare complications include uterine infection or perforation, hemorrhage, or
incomplete removal of the uterine contents. Research data indicate that a rst-trimester
abortion does not have a signicant eect on subsequent fertility, pregnancy or health of
the newborn (Guttmacher Institute, 2011a).
If a pregnancy progresses past approximately 12 weeks, the suction curettage proce-
dure is no longer as safe, because the uterine walls have become thinner, making perfora-
tion and bleeding more likely. For pregnancy termination between 13 and 21 weeks, a
D and E, or dilation and evacuation, is the safest and most widely used technique. A
combination of suction equipment, special forceps, and a curette (a metal instrument
medical abortion
The use of medications to end a preg-
nancy of 7 weeks or less.
suction curettage
A procedure in which the cervical os
is dilated by using graduated metal
dilators or a laminaria; then a small
plastic tube, attached to a vacuum
aspirator, is inserted into the uterus,
drawing the fetal tissue, placenta,
and built-up uterine lining out of the
uterus.
dilation and evacuation (D and E)
An abortion procedure in which a
curette and suction equipment are
used.
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Conceiving Children: Process and Choice323 323
Uterus
Ovary
Ovary
Uterine
wall
Vagina
Cervix
Day 1: After a physical exam,
woman takes first pills.
Day 14: Posttreatment exam
ensures that patient is healthy.
Doctor appointments
Day 3: Woman takes second
tablets.
How pregnancy occurs
Egg* is released from
ovary and produces
hormone
progesterone
Egg attaches itself to
swollen uterine wall
to develop into a fetus
Medical abortion
Used to end pregnancy
within seven weeks of a
woman's last menstrual
cycle. Involves a com-
bination of two drugs and
three visits to the doctor.
Here's how it works:
The dose: When
tablets go into the system,
they block receptors of
progesterone, a hormone
needed to maintain
pregnancy.
The reaction:
Medicine softens and
opens up the cervix.
As a result of these
changes, the fertilized
egg is prevented
from clinging to the
uterine wall.
Abortion: Two days
later, two tablets of
a hormonelike
substance cause the
uterus to contract and
expel any remaining
fetal tissue.
1 2 3
2
3
1
Fallopian tube
Sperm fertilizes
egg in fallopian
tube
Female
reproductive
system
Progesterone
signals uterus
to swell
used to scrape the walls of the uterus) is used. General anesthesia is usually required,
and the procedure is riskier. About 8.9 women out of 100,000 will die from an abor-
tion after 20 weeks of pregnancy—still less than the rate of 11.8 out of 100,000 who
die from a full-term pregnancy (Zielinski, 2006). Women who are more likely to have
abortions at 13 weeks or later have some characteristics in common. ey have less
education and are more likely to be African American than are women who have rst-
trimester abortions. ey have also experienced three or more disruptive life events in
the past year, such as being a victim of a crime, becoming unemployed, having a medical
problem, or experiencing the death of a friend or family member (Jones & Finer, 2011).
Teens are more likely than older women to delay having an abortion until after 15 weeks
of pregnancy (Guttmacher Institute, 2011a).
Second-trimester pregnancies can also be terminated by using compounds such as
prostaglandins, hormones that cause uterine contractions. e prostaglandin is intro-
duced into the vagina as a suppository or into the amniotic sac by inserting a needle
through the abdominal wall; the fetus and placenta are usually expelled from the vagina
within 24 hours. Complications from procedures that induce labor contractions include
nausea, vomiting, and diarrhea; tearing of the cervix; excessive bleeding; and the pos-
sibility of shock and death.
Late-term abortion, or intact dilation and evacuation, is done after 20 weeks and
before viability at 24 weeks gestation. It is reserved for situations when serious health
risks to the woman, or severe fetal abnormalities, exist. In this procedure the cervix is
dilated, the fetus emerges feet rst out of the uterus, and the fetal skull is collapsed to
Figure 11.1 How medical abortions work.
prostaglandins
Hormones that are used to induce
uterine contractions and fetal expul-
sion for second-trimester abortions.
late-term abortion (intact dilation
and evacuation)
An abortion done between 20 and 24
weeks when serious health risks to
the woman or severe fetal abnormali-
ties exist.
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324 CHAPTER 11
permit passage of the head through the cervix and vagina. Although late-term abortions
after 21 weeks of pregnancy are rare, comprising 1.3% of all abortions in the United
States, they continue to be the focus of intense political controversy (Mugge, 2011).
Opponents of abortion rights call this procedure partial-birth abortion, and the media
have adopted this term instead of dilation and evacuation despite its imprecise meaning
and absence from medical texts (Pollitt, 2006). In 2003 Congress approved a ban on
late-term abortion, and President George W. Bush signed the bill. In 2007 the Supreme
Court upheld the legislation, creating the rst-ever federal ban on a medical procedure
(Guttmacher Institute, 2009b).
Illegal Abortions
An estimated 21.6 million unsafe abortions occur yearly, resulting in 47,000 deaths
and millions of women left with serious health problems and infertility (Guttmacher
Institute, 2012a). More than 95% of abortions in Africa and Latin America are per-
formed under unsafe conditions. Desperate to end unwanted pregnancies, women
attempt to self-induce abortions by drinking turpentine, bleach, or tea made with live-
stock manure. They insert herbal preparations into the vagina or cervix and push a
stick, coat hanger, or chicken bone through the cervix into the uterus (Guttmacher
Institute, 2008c). Illegal abortionists typically insert a sharp instrument or object into
the uterus to induce contractions.
Laws that make abortion illegal do not decrease the incidence of abortion. In fact,
higher rates of abortion are found in countries where abortion is illegal, primarily because
of the unavailability of contraception. ere is a worldwide trend toward legalization of
abortion. Since 1997 only three countries—El Salvador, Nicaragua, and Russia—have
increased legal restrictions on abortion, and 17 countries have legalized or broadened
the grounds for legal abortion during the same period (Guttmacher Institute, 2012a).
The Abortion Controversy
Elective abortion continues to be a highly controversial political
issue in the United States and many other countries (Kulczycki,
2011). Beliefs regarding the beginning of life, womens right to
reproductive choice, and the role of government influence the stand
individuals take regarding elective termination of pregnancy.
Abortion: Historical Overview
Laws regulating abortion have changed over time. In ancient China
and Europe, abortion early in pregnancy was legal. In the 13th cen-
tury, St. Thomas Aquinas delineated the Catholic Churchs view
that the fetus developed a soul after conception—after 40 days for
males and 90 days for females. Centuries later, in the late 1860s,
Pope Pius IX declared that human life begins at conception and is
at any stage just as important as the mothers. The Roman Catho-
lic Church still maintains this position, although 58% of American
Catholics believe one can be a good Catholic and disregard the churchs teachings on
abortion (L. Miller, 2008).
Early American law, based on English common law, allowed abortion until the preg-
nant woman felt quickening, or movement of the fetus. During the 1860s, abortion
became illegal in the United States, except when necessary to save the womans life.
Reasons for this change included the belief that population growth was important to
Abortion supporters and opponents usually believe very
strongly in their positions.
Mark Wilson/Getty Images
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Conceiving Children: Process and Choice325 325
the country’s developing economy and, perhaps, the male-dominated
political systems unease about the emerging movement of middle-
class White women seeking independence and equality (Sheeran,
1987). Consequently, women who had enough money would travel
to a country where abortion was legal or persuade an American physi-
cian to perform a safe, illegal abortion. Women without the money
to pursue such options may have been fortunate enough to nd one
of the skilled underground abortion providers working for free or for
little compensation. Otherwise, they resorted to desperate measures:
back alley” abortions using unsafe, unskilled, and unsanitary proce-
dures, or self-induced abortions, sometimes using a wire coat hanger,
douching with bleach, or swallowing turpentine (Solinger, 2005). e
momentum for legalizing abortion arose from these circumstances.
Roe v. Wade and Beyond
By the 1960s, advocacy groups were lobbying for change and had
begun to win a few battles on the state level. In 1973, based on the
constitutional right to privacy, the U.S. Supreme Court in Roe v. Wade
legalized a womans right to terminate her pregnancy before the fetus
has reached the age of viability. Viability is defined as the fetuss ability
to survive independently of the womans body—an ability that devel-
ops by the 6th or 7th month of pregnancy. Roe v. Wade voided the remaining state laws
that treated abortion as a criminal act for both the doctor performing the abortion and the
woman undergoing the procedure.
Figure 11.2 shows the decline in deaths from abor-
tion following the repeal or reform of laws against abortion in 15 states and the Court’s
ruling in Roe v. Wade that made abortion legal in all states.
However, the legalization of abortion in 1973 did not end the controversy. In 1977
Congress passed the Hyde Amendment, which restricted the use of federal Medicaid
funds for abortions, leaving millions of low-income women of reproductive age, who
obtain their health care through Medicaid, without this resource (Boonstra & Son-
eld, 2000). States may use their own funds for this purpose, but only 17 states pay
for abortions for low-income women. Consequently, many poor women either sacri-
ce their rent, food, and clothing money for themselves and their children to pay for
an abortion, or bring another child into already dicult circumstances (Boonstra et
al., 2006). e abortion rate among poor women (those living below the federal pov-
erty level) rose 18% between 2000 and 2008 (Jones & Kavanaugh, 2011). Availabil-
ity of low-cost contraceptive services and methods is essential in reducing these rates
(ompson et al., 2011).
Since the Hyde Amendment, the Supreme Court has made additional rulings that
allow states to place restrictions on abortion. ese regulations impede, and often
eliminate, womens access to abortion. e Sex and Politics box discusses current state
restrictions on abortion and their impact.
The Current Debate
The abortion controversy centers on the debate between the pro-choice and the anti-
choice, or right-to-life, positions. Recent polls have found that equal numbers (47%)
of people in the United States identify themselves as pro-choice or right-to-life (Saad,
2011). Pro-choice advocates maintain that safe and legal abortion is a necessary last
resort and oppose government control over a womans right to make her own reproduc-
tive decisions. They want women faced with the dilemma of an unwanted pregnancy to
be free to decide that terminating it is their best alternative (National Abortion Rights
Number of abortion-related deaths
Year
0
20
40
60
180
160
140
120
100
80
200
’83’80’77’74’71’68’65 ’86 ’95’92’89 ’98 ’01
1970: 15 states reformed or
repealed anti-abortion laws
1973: Roe v. Wade, made
abortion legal nationwide
Figure 11.2 Deaths from abortion declined dramatically
after legalization.
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326 CHAPTER 11
Action League, 2009). One columnist has stated, Mothering is so critical and so chal-
lenging that to force anyone into its service is immoral” (Quindlen, 2003, p. 26). Many
prestigious organizations, including many associated with religious institutions, have
made public statements opposing anti-abortion legislation: Catholics for Choice, the
National Academy of Sciences, the American Public Health Association, the American
Medical Association, and the American College of Obstetricians and Gynecologists. Of
the American public, 64% want Roe v. Wade to remain in place (Marcus, 2009).
Antichoice advocates believe that once an ovum has been fertilized, it is a human
being whose right to life supersedes the womans right to choose whether to continue
Abortion Restrictions at the State Level
SEX &
POLITICS
The Supreme Court cases Webster v. Reproductive Rights
in 1989 and Planned Parenthood v. Casey in 1992 gave
states the right to pass laws to restrict women’s access
to abortions. By 2009 only seven states (Maine, Mary-
land, New Hampshire, New York, Oregon, Vermont, and
Washington) remained free of such restrictions. Legisla-
tors and voters in all other states have established myriad
restrictions, and states enacted 80 abortion restrictions in
the rst half of 2011 (Guttmacher Institute, 2011d). Some
make abortion more expensive (Crary, 2012; Joyce, 2011).
For example, some states prohibit private insurance from
covering abortion procedures, and others restrict insur-
ance coverage of abortion for public employees. About
20 states that require counseling also mandate a waiting
period of up to 24 hours between receiving counseling
and undergoing abortion, adding to child-care and travel
costs and loss of income due to time taken from work (G.
Robertson, 2011). In 2012 the legislature in Utah estab-
lished a waiting period of 72 hours for women seeking an
abortion (Gryboski, 2012).
Thirty-ve states require a minor to notify and/or
obtain the consent of one or both parents before she can
have an abortion, or to obtain a judges permission to do
so without parental consent.
Parental consent laws can
delay teens’ access to abortion:
Research has found that
increased rates of second-term abortions occur after states
have established parental notication laws (Joyce et al.,
2006).
Although most adolescents do discuss their preg-
nancy options with their parents, laws that require parental
notication and consent assume that all parents have their
daughters’ best interests at heart. Sadly, this is not the case
for abusive and neglectful parents. It is ironic that parental
consent is not required for a pregnant young woman to
have the baby and take on the responsibilities of parent-
hood, but it is required if she decides not to become a
mother (Stotland, 1998). For these and other reasons, many
leading medical groups oppose mandatory parental con-
sent requirements—groups such as the American Medical
Association, the American Academy of Pediatrics, and the
American Academy of Family Physicians.
Mandatory counseling sessions are an especially
controversial issue because of the faulty information
that some of the 34 states require abortion providers to
present to women prior to an abortion. This misinforma-
tion can include the claim that abortion endangers future
pregnancies and poses signicant risks of death, breast
cancer, long-lasting psychological problems, or suicide. In
South Dakota, an abortion provider is required to tell any
woman seeking an abortion that abortion ends a human
life (Ewing, 2011). The goal of these requirements is to dis-
suade women from having abortions rather than provide
accurate medical information to help the woman make a
well-informed decision. Further, this type of “counseling”
forces health-care professionals to either disregard the eth-
ics of informed consent and medical practice or break the
state law (H. Hall, 2009; Lazzarini, 2008).
Although an ultrasound is not routinely medically
necessary for a rst-trimester abortion, laws and legislative
bills in more than 27 states require health-care providers
to offer women seeking abortions the opportunity to have
an ultrasound of the fetus and listen to its heartbeat: Seven
states require the provider to conduct an ultrasound and
offer the woman the opportunity to see the image (Gutt-
macher Institute, 2012b).
It would seem logical to assume that states that
restrict abortion would provide increased resources for
the children who are born into difcult circumstances
because abortion was not an option. However, states with
the most legal restrictions on abortion also provide the
fewest resources to facilitate adoption, the least assistance
to children in low-income families, and the lowest funds
to educate children (C. Cooper, 2008). Former president
Jimmy Carter, a devout Baptist, states, “Many fervent
pro-life activists do not extend their concern to the baby
who is born, and are the least likely to support benevolent
programs that they consider ‘socialistic’” (2005, p. 94).
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Conceiving Children: Process and Choice327 327
I loved being pregnant. My face glowed for nine months. I felt like a kindred
spirit to all female mammals and discovered a new respect for my body and its
ability to create life. The bigger I got, the better I liked it. (Authors’ files)
If I could have babies without the pregnancy part, I’d do it. Looking fat and
slowed down is a huge drag. (Authors’ files)
her pregnancy. Consequently, advocates believe that abortion is immoral and constitutes
murder of a pre-born child. Anti-abortion organizations and advocates want to see Roe
v. Wade overturned and want Congress to pass the Life at Conception Act or to amend
the U.S. Constitution with the Paramount Human Life Amendment, both of which
establish the fertilized egg as an independent being entitled to equal protection under
the law (National Pro-Life Alliance, 2009). Another anti-abortion group continues to
attempt to pass personhood amendments in several states that dene a fertilized egg
as having legal rights (Cohen, 2012b; Raasch, 2012). All of the 2012 Republican candi-
dates for the U.S. presidency ran on platforms to overturn Roe v. Wade and to eliminate
federal funding for abortion (White, 2012).
Extreme anti-abortion activists have gone beyond legal means to restrict abortion—
blocking clinic entrances; harassing patients, physicians, and sta; and burning or bombing
clinics. In 2008, about 57% of non-hospital facilities that provide abortion experienced
some kind of harassment. Levels of harassment are highest in the Midwest and the
South (Jones & Kooistra, 2011). Pro-life extremists have resorted to killing physicians
and sta who work in abortion clinics, believing that these murders are justied to save
unborn babies. In May 2009 a pro-life extremist shot and killed Dr. George Tiller as
he entered his church for Sunday services. He had previously escaped death in 1993
when an anti-abortion extremist shot him in both arms and claimed at her trial that she
had done nothing wrong in her attempt to kill a physician who performed abortions
(Kissling, 2009). Doctors and clinics that provide abortions must implement stringent
security measures: metal detectors, alarms, and bulletproof glass and vests (Joe, 2009;
National Abortion Rights Action League, 2009). e abortion debate will remain
passionate and bitter because of fundamental dierences in beliefs and worldviews of
people with strong commitments to one side or the other. However, most people experi-
ence considerable ambivalence about abortion (Kli, 2010). Many people who believe
abortion is wrong also believe that any woman who wants an abortion should be able
to obtain it legally.
The Experience of Pregnancy
Pregnancy is a unique and significant experience for both a woman and her partner. In
the following pages, we look at the experience and the effect it has on the individuals
and the couple. Many of the experiences are encountered by heterosexual and lesbian
couples alike. In this section the heterosexual couple is used as a frame of reference.
The Woman’s Experience
Each woman has different emotional and physical reactions to pregnancy, and the same
woman may react differently to different pregnancies. Here are two reactions at the
opposite ends of the continuum:
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328 CHAPTER 11
Factors influencing a womans emotional reactions can include how the decision for
pregnancy was made, current and impending lifestyle changes, her relationship with
others, her financial resources, her self-image, and hormonal changes. The womans
acquired attitudes and knowledge about childbearing and her hopes and fears about
parenthood also contribute to her experience. Positive support and attention from her
partner are helpful in creating a happy pregnancy.
Women sometimes feel that they should experience only positive emotions when
they are pregnant. However, pregnancy often elicits an array of contradictory emotions.
One study of 1,000 women found a wide range of feelings about pregnancy: 35% loved
being pregnant, 40% had mixed feelings about it, 8% hated it, and the remainder had
dierent experiences with each of their pregnancies. e researchers concluded that the
degree of physical discomfort a woman experiences during the 9 months of pregnancy
greatly inuences her feelings about being pregnant (Genevie & Margolies, 1987). For
some women pregnancy is a very dicult period; about 12% of women experience sig-
nicant depression during pregnancy (Stewart, 2011).
The Man’s Experience
An expectant father obviously does not experience the same physical sensations that a
pregnant woman does (although occasionally a pregnant father” reports psychosym-
pathetic symptoms, such as the nausea or tiredness his partner is experiencing). How-
ever, the experiences of pregnancy and birth are often profound for the father. What
exactly does the male pregnancy involve?
Like the woman, he often reacts with a great deal of ambivalence. He may feel
ecstatic but also fearful about the womans and the baby’s well-being. It is common
for a man to feel frightened about the impending birth and about whether he will be
able to keep it together. He may feel especially tender toward his partner and become
more solicitous. At the same time, he may feel a sense of separateness from the woman
because of the physical changes that only she is experiencing. However, prenatal ultra-
sonography allows fathers to see the fetus growing in the uterus and can create greater
feelings of involvement (Sandelowski, 1994). Most men feel concern over the impend-
ing increase in nancial responsibility. In all, the expectant father has special needs, as
does his partner, and it is important that the woman be aware of these needs and be
willing to respond to them.
Sexual Interaction During Pregnancy
In pregnancies with no risk factors, the woman and couple can continue sexual activ-
ity and orgasm as desired until the onset of labor (C. Jones et al., 2011). A womans
sexual interest and responsiveness will likely change throughout the course of her preg-
nancy. Nausea, breast tenderness, and fatigue can inhibit sexual interest during the first
3 months. A resurgence of sexual desire and arousal occurs for some women in the sec-
ond trimester, with increased vasocongestion of the genitals during pregnancy heighten-
ing sexual desire and response. However, most research shows a progressive decline in
sexual interest and activity over the 9 months of pregnancy (Bogren, 1991). Some of
the most common reasons women give for decreasing sexual activity during pregnancy
include physical discomfort, feelings of physical unattractiveness, and fear of injuring the
unborn child (Colino, 1991).
e partner’s feelings also aect the sexual relationship during pregnancy. Reac-
tions to the womans changing body and to the need for adjustment in the couples
sexual repertoire can vary from increased excitement to inhibition for the partner.
SEXUALhEALTh
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Conceiving Children: Process and Choice329 329
During pregnancy a couple will need to modify intercourse positions. e side-by-
side, woman-above, and rear-entry positions are generally more comfortable than the
man-above position as pregnancy progresses. Oral and manual genital stimulation as
well as total body touching and holding can continue as usual. In fact, pregnancy is
a time when a couple can explore and develop these dimensions of lovemaking more
fully; even if intercourse is not desired, intimacy, eroticism, and sexual satisfaction can
continue. Open communication, accurate information, mutual support, and exibility
in sexual frequency and activities can help maintain and strengthen the bond between
the partners.
A Healthy Pregnancy
Once a woman becomes pregnant, her previous lifestyle and her health habits and
medical care during pregnancy play an important part in the development of a healthy
fetus (Melhado, 2011).
Fetal Development
The 9-month (40-week) span of pregnancy is customarily divided into three 13-week
segments, called trimesters. Characteristic changes occur in each trimester.
First-Trimester Development
As with all mammals, a human begins as a zygote (ZYE-goht), a united sperm cell
and ovum. The sperm and egg unite in one of the fallopian tubes, where the egg’s fin-
gerlike microvilli draw the sperm to it. The zygote then develops into the multicelled
blastocyst (BLAS-tuh-sist) that implants on the wall of the uterus about 1 week
after fertilization (
Figure 11.3). Growth progresses steadily. By 9–10 weeks after a
womans last menstrual period, the fetal heartbeat can be heard with a special ultra-
sound stethoscope known as the Doppler. By the beginning of the 2nd month from
the time of conception, the fetus is 0.5 to 1 inch long, grayish, and crescent shaped.
During the 2nd month, the spinal canal and rudimentary arms and legs form, as do
the beginnings of recognizable eyes, fingers, and toes. During the 3rd month, internal
organs, such as the liver, kidneys, intestines, and lungs, begin limited functioning in
the 3-inch fetus.
(a) (b)
Endometrium
Blastocyst
Blastocyst
Figure 11.3 The blastocyst implanted on the uterine wall, shown (a) in diagram and
(b) in photo taken by a scanning electron microscope.
© Dr. Y. Nikas/Phototake. All rights reserved.
zygote
The single cell resulting from the
union of sperm and egg cells.
blastocyst
Multicellular descendant of the united
sperm and ovum that implants on the
wall of the uterus.
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330 CHAPTER 11
Second-Trimester Development
The second trimester begins with the 4th month of pregnancy. By now the sex of the
fetus can often be distinguished. External body parts, including fingernails, eyebrows,
and eyelashes, are clearly formed. The fetuss skin is covered by fine, downlike hair.
Future development consists primarily of growth and refinement of the features that
already exist. Fetal movements, or quickening, can be felt by the end of the 4th month.
By the end of the 5th month the fetuss weight has increased to 1 pound. Head hair can
appear at this time, and subcutaneous fat develops. By the end of the second trimester,
the fetus has opened its eyes.
Third-Trimester Development
In the third trimester, the fetus continues to grow, developing the size and strength it
will need to live on its own (
Figure 11.4). It increases in weight from 4 pounds in
the 7th month to an average of over 7 pounds at birth. The downlike hair covering its
body disappears, and head hair continues growing. The skin becomes smooth rather
than wrinkled. The fetus is covered with a protective creamy, waxy substance called the
vernix caseosa (VER-niks ka-see-OH-suh).
Prenatal Care
Some of the problems with fetal development are genetic and unpreventable, but the
mother’s own general good health, good nutrition, adequate rest and exercise, and
abstinence from alcohol and recreational drugs are crucial to providing the best envi-
ronment for fetal development and for her own physical well-being during pregnancy
and childbirth (Hannon, 2009). The Your Sexual Health box, Folic Acid and Fetal
Development, describes what every woman of childbearing age needs to be doing right
now for the health of a future pregnancy.
orough prenatal care also involves health care and childbirth education. It is impor-
tant for a woman to have a complete physical examination and health assessment before
becoming pregnant, or as soon as she knows she is pregnant. She should also have a test
to determine her immunity to rubella (German measles), a disease that can cause severe
Fetal development at 9 weeks. The
fetus is connected to the placenta by
the umbilical cord.
© Dr. G. Moscoso/Photo Researchers, Inc.
vernix caseosa
A waxy, protective substance on the
fetus’s skin.
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Conceiving Children: Process and Choice331 331
fetal defects if the mother contracts it while she is pregnant. An HIV test should also
be done before or during pregnancy, because HIV can be transmitted to the developing
fetus during pregnancy, and therapies are available to prevent mother-to-child transmis-
sion of HIV and to improve maternal and infant health (Lalleman et al., 2011).
Unfortunately, in the United States many babies are born without adequate prenatal
care, a situation that increases the chance that problems will occur, including low birth
weight, lung disorders, brain damage, and abnormal growth patterns. ese problems
can have lifelong eects (Lundgren et al., 2011). Women most likely to delay obtaining
adequate prenatal care are unmarried African American or Hispanic American indi-
viduals under age 20 who have not graduated from high school and are uninsured or on
Medicaid. ey typically live in low-income neighborhoods with crowded clinics and a
shortage of doctors oces (Bloche, 2004).
Furthermore, statistics indicate that three to four times as many African Ameri-
can women as Hispanic American or White women die from childbirth complications
(S. Johnson, 2011). Because of the poor access to health care for people without health
insurance or adequate government-funded clinics, the United States compares unfavor-
ably with other countries in maternal and infant mortality rates. Forty-nine countries
have lower maternal mortality rates and 41 have lower infant mortality rates than does
the United States (Larsen, 2007).
e fate of pregnant women in developing countries is severe: A total of 99% of all
maternal deaths occur in developing countries, mainly in sub-Saharan Africa and South
Placenta
Cervix
Vagina
Fetus
Uterus
Bladder
Clitoris
Figure 11.4 Pregnancy in the 9th month. The uterus and abdomen have increased in
size to accommodate the fetus.
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332 CHAPTER 11
Asia. For every 1,000 births, 74 women in developing countries die, compared to 7 in devel-
oped countries (World Health Organization, 2009). Afghanistan has the worlds highest
rate of maternal mortality, and more than 85% of women give birth with no medical help;
1 in 19 babies dies in the rst month of life (Streib, 2011). Substandard health-care ser-
vices, poverty, lack of education, womens underlying poor health, and gender-related fac-
tors resulting in womens lack of decision-making power in their families all contribute to
these high mortality rates (UN Department of Public Information, 2010).
Risks to Fetal Development
The rapidly developing fetus depends on the mother for nutrients, oxygen, and waste
elimination as substances pass through the placenta (a disk-shaped organ attached to
the wall of the uterus, shown in
Figure 11.5). The fetus is joined to the placenta by
the umbilical cord. The fetal blood circulates independently within the closed system
of the fetus and the inner part of the placenta. Maternal blood flows in the uterine walls
and through the outer part of the placenta. Fetal blood and maternal blood do not nor-
mally intermingle. All exchanges between the fetal and maternal circulatory systems
Women can prevent several devastating birth defects by
taking folic acid, a B vitamin, throughout their childbear-
ing years. Folic acid assists the body in making new cells
and helping the fetus’s neural tube develop into the brain
and spinal cord. A lack of folic acid can cause conditions
in which the brain is partly missing or improperly formed,
resulting in fetal death or severe permanent disability. Folic
acid also helps prevent cleft lip and palate and several seri-
ous pregnancy complications, including premature birth
(Boulet et al., 2008).
A woman must be taking folic acid before becoming
pregnant for the baby to benet fully from it.
The baby’s
brain and spinal cord develop in the rst 3 to 4 weeks of
pregnancy—before women know they are pregnant—so
enough folic acid must be in the body before conception.
Folic acid also provides health benets to men and non-
pregnant women. Studies show that folic acid may lower
the risks of heart disease, stroke, Alzheimers disease, and
some kinds of cancer (Centers for Disease Control, 2009b).
Where do I get folic acid and how much do I need?
Many cereals, breads, pastas, and grain products are
fortied with folic acid; about 30 breakfast cereals have
100% of the daily amount a person needs when not preg-
nant. (
The nutrition label on the side of the box will tell you
whether the product contains folic acid and how much of
the daily recommended value it contains.) Other foods that
are high in folic acid are asparagus, green vegetables, nuts
and dried beans, oranges, and bananas.
Taking a supple-
ment or a multiple vitamin with 100% of the daily require-
ment will ensure you are getting an adequate amount of
folic acid. Government guidelines recommend that during
the childbearing years—whether or not a woman is intend-
ing to become pregnant—she needs at least 400 micro-
grams (mcg) of folic acid each day. When a woman is trying
to get pregnant and for the rst 3 months of pregnancy, she
should take 1,200 mcg daily. For the remainder of the preg-
nancy, she should take 600 mcg, and during breast-feeding,
500 mcg each day (Centers for Disease Control, 2009b).
Folic Acid and Fetal Development
YoUR SEXUAL
HEALTH
Folic acid helps prevent spina bifida, a
birth defect in the development of the ver-
tebrae that leaves a portion of the spinal
cord exposed.
Biophoto Associates/Photo Researchers, Inc.
placenta
A disk-shaped organ attached to the
uterine wall and connected to the
fetus by the umbilical cord. Nutrients,
oxygen, and waste products pass
between mother and fetus through
the cell walls of the placenta.
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Conceiving Children: Process and Choice333 333
occur by passage of substances through the walls of the blood vessels. Nutrients and
oxygen from the maternal blood pass into the fetal blood vessels; carbon dioxide and
waste products from the fetus pass into the maternal blood vessels, to be removed by
maternal circulation.
e placenta prevents some kinds of bacteria and viruses—but not all—from pass-
ing into the fetal circulatory system. Many bacteria and viruses, including HIV, do cross
through the placenta. Certain prescription medications, legal drugs such as tobacco and
alcohol, and illegal drugs are dangerous to the developing fetus. Tobacco and alcohol
aect a far greater number of babies each year, with more signicant health conse-
quences, than do illegal drugs (Yuan et al., 2001).
Approximately 13% of U.S. women continue to smoke throughout their pregnan-
cies; smoking reduces the amount of oxygen in the bloodstream and thereby increases
the chances of miscarriage, low fetal birth weight, and other pregnancy complica-
tions that can result in fetal or infant death (Fifer et al., 2009). Children of moth-
ers who smoked during pregnancy have more respiratory diseases, have a 50–70%
greater chance of having a cleft lip or palate, and have signicantly lower developmen-
tal scores and an increased incidence of reading disorders compared with matched
children of nonsmokers (Williams, 2000). Research in Denmark found that prenatal
tobacco exposure was correlated with hormonal changes in adolescence and adult-
hood. Males had smaller testicles, lower total sperm counts, impairment in testicular
function, lower adult height, and a higher adult fat to body size ratio (Ravnborg et al.,
2011). Daughters of women who smoked 10 or more cigarettes a day began menstru-
ating almost three months earlier than daughters of nonsmoking mothers (Shrestha
et al., 2011).
Maternal blood vessels
Placenta
Umbilical
cord
Uterus
Amniotic sac
Amniotic fluid
Maternal
blood
Fetal blood
vessels
Umbilical
cord
Umbilical artery
Umbilical vein
Uterine
lining
Maternal
portion
of placenta
Fetal portion
of placenta
(a) (b)
Figure 11.5 The placenta exchanges nutrients, oxygen, and waste products between the maternal and fetal circulatory
systems. (a)
The placenta attached to the uterine wall. (b) Close-up detail of the placenta.
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334 CHAPTER 11
Alcohol easily crosses the placental membranes into all fetal tissues, especially brain
tissue. Fetal alcohol syndrome (FAS) is the leading cause of birth defects and devel-
opmental disabilities in the United States. Because a safe level of alcohol consumption
is unknown, the Food and Drug Administration has advised women to abstain com-
pletely from alcohol use during pregnancy to avoid the risk of damage to their babies.
One drink per day has been associated with adverse birth eects, and binge drinking
(ve or more drinks per occasion) is extremely toxic to the fetus. Alcohol use can cause
intrauterine death and spontaneous abortion, premature birth, congenital heart defects,
damage to the brain and nervous system, and numerous physical malformations of the
fetus. e eects of FAS persist through childhood; children with FAS continue to be
smaller than normal and developmentally delayed and to have behavior problems (Will-
ford et al., 2006). Perhaps as a result of public health educational eorts, fewer women
drink alcohol during pregnancy: In 2004, 12% of pregnant women drank alcohol, com-
pared to 30% in 1989 (Grant et al., 2009).
e babies of mothers who regularly used illegal addictive drugs, such as amphet-
amines and opiates, during pregnancy are often born premature and have low birth
weight. In addition, after birth these babies experience withdrawal from the drug: ey
have tremors, disturbed feeding and sleep patterns, and abnormal muscle tension, and
they often require hospitalization in neonatal intensive care units. ese children can
experience permanent birth defects and damage to sensory, motor, and cognitive abili-
ties that continue past infancy (Zambrana & Scrimshaw, 1997).
In a number of tragic situations, children have been damaged by prescription and
over-the-counter medications taken by their mothers during pregnancy. For example,
the drug thalidomide, prescribed as a sedative to pregnant women in the early 1960s,
caused severe deformities to the extremities. Some grown children of women who were
given diethylstilbestrol (DES) while pregnant have developed genital tract abnormali-
ties, including cancer (Koren, 2009). Antibiotics need to be prescribed selectively dur-
ing pregnancy because tetracycline, a frequently used antibiotic, can damage an infant’s
teeth and cause stunted bone growth if it is taken after the 14th week of pregnancy.
Many over-the-counter medications, such as ibuprofen, aspirin, and histamines, can be
detrimental to the fetus, and eects are unknown for many other nonprescription drugs
and herbs. A woman and her health-care provider should carefully evaluate medications
used during pregnancy (Mitchell et al., 2011).
Pregnancy After Age 35
An increasing number of women delay having children until after 35 years of age:
Almost twice as many women between the ages of 35 and 44 become pregnant now
than was the case in 1980. Women who have their first baby when older appear to have
some psychological advantages. They are more resilient, report their partners are less
controlling, and report lower symptoms of depression and anxiety during pregnancy
than their younger counterparts (McMahon et al., 2011).
e greatest risk women and their partners face when they postpone having a
child until the woman is in her mid-30s or older is that her fertility decreases with age.
Women who have the nancial resources to do so can have their eggs retrieved and fro-
zen (a procedure called oocyte cryopreservation) when they are younger and more fertile,
to increase their chances of becoming pregnant after their fertility declines with age
(Stoop et al., 2011). e approximate cost is $15,000 plus a yearly storage fee of $400
(Lehmann-Haupt, 2009).
Healthy older women have no higher risk than younger women of having a child
with birth defects not related to abnormal chromosomes. However, the rate of fetal
fetal alcohol syndrome (FAS)
Syndrome in infants caused by heavy
maternal prenatal alcohol use; char-
acterized by congenital heart defects,
damage to the brain and nervous sys-
tem, numerous physical malformations
of the fetus, and below-normal IQ.
Moderate exercise usually contributes
to a healthy pregnancy and delivery.
A pregnant woman should consult
her health-care provider for guidelines
specic to her situation.
© Leland Bobbe/Getty Images
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Conceiving Children: Process and Choice335 335
defects resulting from chromosomal abnormalities (such as Down syndrome) rises with
maternal age. For example, Down syndrome rates for children of mothers ages 40 to
54 are about 14 times higher than those for women younger than age 30 (Martin et al.,
2009). For women between the ages of 35 and 44, prenatal testing for chromosomal
birth defects and elective abortion reduce the risk of bearing an infant with a severe
birth defect to a level comparable to that for younger women (Yuan et al., 2000).
Pregnancy in women over age 35 poses additional increased risks to the mother
and fetus. Slightly higher rates of maternal death, premature delivery, cesarean sec-
tions, and low birth-weight babies occur (Homan et al., 2007). Most physicians nd
that pregnancy for a healthy woman over age 35 is safe and not dicult to manage
medically because chronic illnesses such as diabetes and high blood pressure play a
greater role than age itself in problems with labor, delivery, and infant health (Yuan et
al., 2000).
Fatherhood After Age 45
Although men maintain their fertility much longer than women do, increasing evi-
dence is showing that later-in-life fatherhood may carry some increased risk of birth
defects for their children. Scientists have found changes in the DNA of older mens
sperm. Some studies suggest that single-gene mutations may be four to five times
higher in men age 45 and older compared to men in their 20s. Increases in rare birth
defects, autism disorders, and schizophrenia have been associated with higher paternal
age (Rabin, 2007b).
Childbirth
The full term of pregnancy usually lasts about 40 weeks from the last menstrual period,
although there is some variation in length. Some women have longer pregnancies; oth-
ers give birth to fully developed infants up to a few weeks before the 9-month term is
over. The experience of childbirth also varies a good deal, depending on many factors:
the womans physiology, her emotional state, the baby’s size and position, the kind of
childbirth practices used, and the kind of support she receives.
Contemporary Childbirth
Before the 1970s, fathers were not allowed in the delivery room while their babies were
being born (Larsen, 2007). Today’s parents-to-be can expect to work as part of a team
with their health-care provider in preparing and planning for the physical and emo-
tional aspects of childbirth. Obstetricians are medical doctors and midwives are nurses
who specialize in pregnancy and childbirth care. In the United States during the last 20
years, the number of hospital births attended by midwives has increased to about 10%
of births. Midwives typically work with women who have low-risk pregnancies and
uncomplicated births, and often help coach the woman throughout her labor (Cantor,
2012; North American Registry of Midwives, 2008). Physicians have additional train-
ing in managing medical complications during labor and childbirth, and women who
work with midwives need to have this care readily available.
Parents-to-be often participate in prepared childbirth classes that provide thor-
ough information about medical interventions and the process of labor and birth. e
classes also provide training for the pregnant woman and her labor coach (either her
partner, family member, or a friend) in breathing and relaxation exercises designed to
prepared childbirth
Birth following an education process
that can involve information, exer-
cises, breathing, and working with a
labor coach.
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336 CHAPTER 11
cope with the pain of childbirth. Research has found that women assisted
by a birth attendant during labor had fewer cesarean sections, less pain
medication, shorter length of labor, and greater satisfaction with the
birth experience (Campbell et al., 2006).
Approaches to contemporary childbirth began to develop when
Grantly Dick-Read and Fernand Lamaze began presenting their ideas
about childbirth in the late 1930s and early 1940s. ey believed that
most of the pain during childbirth stemmed from the muscle tension
caused by fear. To reduce anxiety, they advocated education about the
birth process; relaxation and calm, consistent support during a womans
labor; breathing exercises; and voluntarily relaxing abdominal and peri-
neal muscles.
Stages of Childbirth
Despite variations in childbirth, there are three generally recognizable
stages in the process (see
Figure 11.6). A woman can often tell that labor
has begun when regular contractions of the uterus begin. Another indi-
cation of beginning first-stage labor, the gradual dilation of the cervix to
10 centimeters, is the bloody show” (discharge of the mucus plug from
the cervix). The amniotic sac can rupture in the first stage of labor, an
occurrence sometimes called breaking the bag of waters. Before the
first stage begins, effacement (flattening and thinning) of the cervix
has usually already occurred, and the cervix has dilated slightly. The
cervix continues to dilate throughout the first stage. The first stage is
the longest of the three stages, usually lasting 10 to 16 hours for the
first childbirth and 4 to 8 hours in subsequent births.
Second-stage labor begins when the cervix is fully dilated and the infant descends far-
ther into the vaginal birth canal. Usually the descent is headrst, as shown in Figure 11.6b.
e second stage often lasts from half an hour to 2 hours—although it can be shorter
or longer. During this time the woman can actively push to help the baby out, and many
women report their active pushing to be the best part of labor:
I knew what “labor” meant when I was finally ready to push. I have never
worked so hard, so willingly. (Authors’ files)
The second stage ends when the infant is born.
Third-stage labor lasts from the time of birth until the delivery of the placenta,
shown in Figure 11.6c. With one or two more uterine contractions, the placenta usually
separates from the uterine wall and comes out of the vagina, generally within half an
hour of the birth. e placenta is also called the afterbirth.
Delivery by Cesarean Section
A cesarean (sih-ZEHR-ee-un) section, or C-section, in which the baby is removed
through an incision made in the abdominal wall and uterus, can be a lifesaving sur-
gery for the mother and child (Ananth & Vintzileos, 2011). Cesarean birth is rec-
ommended in a variety of situations, including when the fetal head is too large to
pass through the mothers pelvic structure, when the mother is ill, or when there
are indications of fetal distress during labor or birth complications, such as a breech
Prepared childbirth classes help prepare expectant
mothers and fathers for childbirth.
REUTERS/Chip East/Landov
rst-stage labor
The initial stage of childbirth in which
regular contractions begin and the
cervix dilates.
effacement
Flattening and thinning of the cer-
vix that occurs before and during
childbirth.
second-stage labor
The middle stage of labor, in which
the infant descends through the vagi-
nal canal.
third-stage labor
The last stage of childbirth, in which
the placenta separates from the uter-
ine wall and comes out of the vagina.
afterbirth
The placenta and amniotic sac follow-
ing their expulsion through the vagina
after childbirth.
cesarean section (C-section)
A childbirth procedure in which the
infant is removed through an incision
in the abdomen and uterus.
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Conceiving Children: Process and Choice337 337
presentation (feet or bottom coming out of the uterus first).
Mothers who experience a C-section often have anesthesia that
allows them to be awake to greet their baby when he or she is
born. In many hospitals fathers remain with the mothers during
cesarean births.
A decade ago, one in ve babies was delivered by C-section:
Currently one out of three babies is delivered by C-section
(Hunter, 2011). Some maintain that high rates reect better use of
medical technology. Others believe that cesarean sections are used
too readily. An analysis of birth data found that 11% of C-sections
for a rst pregnancy and 65% of repeat C-sections may not have
been necessary (Kabir, 2005). Intensive fetal monitoring, aggres-
sive malpractice lawsuits if serious problems follow a vaginal birth,
and maternal and physician preference are three reasons for the
increase (Hunter, 2011).
Uterus
Placenta
Umbilical cord
Vagina
Cervix
Placenta
Uterus
Placenta being
detached
Umbilical cord
First stage
Dilation of cervix, followed by
transition phase, when baby’s
head can start to pass through
the cervix
(a)
Second stage
Passage of the baby through
the birth canal, or vagina, and
delivery into the world
(b)
Third stage
Expulsion of the placenta,
blood, and fluid (“afterbirth”)
(c)
Figure 11.6 The three stages of childbirth: (a) first-stage labor, (b) second-stage labor,
and (c) third-stage labor.
Petit Format/Photo Researchers, Inc.
Second-stage labor is usually the highlight of the birth
process.
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338 CHAPTER 11
After Childbirth
The first several weeks following birth are referred to as the postpartum period. This
is a time of both physical and psychological adjustment for each family member, and it
is likely to be a time of intensified emotional highs and lows. The new baby affects the
roles and interactions of all family members. The parents can experience an increased
closeness to each other as well as some troublesome feelings. Both partners may want
extra emotional support from each other, but each may have less than usual to give. The
time and energy demands of caring for an infant can contribute to weariness and stress.
Conflict about the division of household and child-care labor can become problematic in
the early months and years of the child’s life (Cowan & Cowan, 1992). A good support
system for the new parents can be immensely helpful. Understanding that these feelings
are a common response to adjustments to the new baby may help new parents cope with
the stresses involved.
Postpartum depression (PPD) aects 15% of mothers (Routh, 2000). Unlike the
more common baby blues”—tearfulness and mood swings lasting up to 10 days that
about 75% of new mothers feel—PPD involves classic symptoms of depression, includ-
ing insomnia, anxiety, panic attacks, and hopelessness (Knudson-Martin & Silverstein,
2009). At its most extreme, women suering from PPD lose interest in their babies
or develop obsessive thoughts about harming themselves or their babies. Such reac-
tions may be partly due to the sudden emotional, physical, and hormonal changes fol-
lowing birth. Sleep deprivation from waking many times in the night to care for the
newborn also is stressful and diminishes emotional and physical reserves. Fortunately,
PPD can be eectively treated (Beck, 2006). However, evidence demonstrates racial
and ethnic disparities in rates of postpartum depression treatment. In a study of low-
income women who received Medicaid funds for treatment, African American women
and Latinas were less likely than White women to initiate treatment and continue care
for PPD (Kozhimannil et al., 2011).
Breast-Feeding
After childbirth the mother’s breasts first produce a yellowish liquid, called colos-
trum, which contains antibodies and protein. Lactation, or milk production, begins
about one to three days after birth. Pituitary hormones stimulate milk production in
the breasts in response to the stimulation of the infant suckling the nipples. If a new
mother does not begin or continue to nurse, milk production subsides within a mat-
ter of days.
Breast-feeding has many practical and emotional advantages. For the infant, breast
milk provides a digestible food lled with antibodies and other immunity-producing
substances (J. Hall, 2009). Research has revealed that babies who are breast-fed are less
distressed than other infants when experiencing pain or stress (Shah et al., 2006). Breast-
feeding through the 6th month also reduces the risk of sudden infant death syndrome
by about 50% (Vennemann et al., 2009). A study in Ireland found that breast-feeding
was associated with higher reading and writing scores among 9-year-olds, even after
controlling for variables in child, maternal, socioeconomic, and socio-environmental
characteristics (McCrory & Layte, 2011). For the mother, breast-feeding can be a posi-
tive emotional and sensual experience and an opportunity for close physical contact
with the baby. Nursing also induces uterine contractions that help speed the return of
the uterus to its pre-pregnancy size. Research indicates that breast-feeding may also
reduce maternal stress levels (Hahn-Holbrook et al., 2011).
postpartum period
The rst several weeks after childbirth.
postpartum depression (PPD)
Symptoms of depression and possi-
bly obsessive thoughts of hurting the
baby.
colostrum
A thin uid secreted by the breasts
during later stages of pregnancy and
the rst few days after delivery.
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Conceiving Children: Process and Choice339 339
I love seeing the contentment spread over my baby’s face as she fills her tummy
with milk from my breasts. It’s an awe-inspiring continuation of our physical
connection during pregnancy to see her growing chubby-cheeked from nour-
ishment my body provides her. (Authors’ files)
Nursing can temporarily inhibit ovulation, particularly for
women who feed their babies only breast milk. However, as we saw
in Chapter 10, nursing is not a reliable method of birth control.
Estrogen-containing birth control pills should not be used during
nursing because the hormones reduce the amount of milk and aect
milk quality. Nonhormonal contraception, including the IUD, is an
option for postpartum contraception (Glazer et al., 2011).
Nursing also has some short-term disadvantages. For one, nurs-
ing causes reduced levels of estrogen, which conditions and maintains
vulvar tissue and promotes vaginal lubrication. As a result, the nurs-
ing mother may be less interested in sexual activity, and her genitals
may become sore from intercourse (Barrett et al., 2000). e womans
breasts may also be tender and sore. Milk may be ejected involuntarily
from her nipples during sexual stimulation—a source of potential
amusement or embarrassment. It is often easier to share child-care
responsibilities by bottle-feeding than by nursing; the father can have
a greater role in holding and feeding the infant. However, a nursing
mother can use a breast pump to extract her milk so that it is available to her partner or
another caregiver for bottle-feeding the baby (Rasmussen & Geraghty, 2011).
e Centers for Disease Control and Prevention has set a goal for 75% of mothers
in the United States to nurse their babies, and the American Academy of Pediatrics
and the World Health Organization recommend exclusive breast-feeding for the rst
6 months (Norton, 2009). In the United States, 80% of women begin breast-feeding
after birth. Six months later, only 15% of women continue breast-feeding exclusively,
while 45% continue some degree of breast-feeding (Allers, 2011; Rochman, 2012).
Women most likely to have breast-fed were college graduates in the highest income
level, and women least likely to have breast-fed were at the lowest education and income
levels, residents of the South, teenage mothers, African American mothers, and smok-
ers (Ruowei, 2002). Most common reasons for not nursing are medical issues, returning
to work, diculty with nursing, and concern that the baby is not getting enough food
(Springen, 2007). Social bias and negative attitudes against women who breast-feed
may also be factors (J. Smith et al., 2011). Breast-feeding rates in Sweden are signi-
cantly higher than in the United States, due in large part to generous parental leave of
16 months at 80% of their wages for each parent (Streib, 2011). Of all the industrialized
countries, only the United States and Australia lack laws that require paid parental leave
with a guaranteed return to work (Jeery, 2006).
Sexual Interaction After Childbirth
Couples are commonly advised that intercourse can resume after the flow of the red-
dish uterine discharge, called lochia (LOH-kee-uh), has stopped and after episiot-
omy incisions or vaginal tears have healed, usually in about 3–4 weeks. However, the
most important factor to consider is when intercourse is physically comfortable for
the woman. This depends on the type of birth, the size and presentation of the baby,
For a woman who decides to nurse, breast-feeding is
another opportunity for close physical contact with her baby.
Maxim Tupikov/Shutterstock.com
lochia
A reddish uterine discharge that
occurs after childbirth.
episiotomy
An incision in the perineum that is
sometimes made during childbirth.
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340 CHAPTER 11
the extent of episiotomy or lacerations, and the individual womans rate of healing.
The postpartum decrease in hormones, especially pronounced with breast-feeding,
can cause discomfort during intercourse. After a cesarean birth the couple needs to
wait until the incision has healed enough for intercourse to occur without discomfort.
Other sexual and affectionate relations can be shared while waiting.
A new baby brings signicant changes in daily life that can aect sexual intimacy
(Botros et al., 2006). Research has found high levels of sexual diculties after childbirth.
Before pregnancy, 38% of the study participants reported experiencing sexual problems,
but 80% experienced one or more sexual problems in the rst 3 months after delivery. At
6 months, 64% were still having diculty. e most common concerns were decreased
sexual interest, vaginal dryness, and painful intercourse. As would be expected, women
who experience postpartum depression often have less sexual arousal, orgasm, and sat-
isfaction than nondepressed women (Chivers et al., 2011). A researcher, who has writ-
ten books about pregnancy and the rst year of motherhood, warns women and their
partners to be prepared for their sex lives to be downright crummy” for up to a year:
Mother Nature is using her entire arsenal of tricks, from hormones to humility, to keep
you focused on your baby and not on getting pregnant again (Iovine, 1997, p. 158).
Women and their partners, whose sexual activity has been disrupted by pregnancy and
birth, may feel out of practice in their sexual relationship. It is often helpful to resume
sexual activity in an unhurried, exploratory manner.
Summary
Parenthood as an Option
An increasing number of couples are choosing not to be
parents.
e realities of parenthood or child-free living are dicult
to predict.
Becoming Pregnant
Timing intercourse to correspond to ovulation enhances the
likelihood of conception.
About 12% of couples in the United States have problems
with infertility, and a cause is not found in many infertile
couples.
Failure to ovulate and blockage of the fallopian tubes are
typical causes of female infertility. Low sperm count is the
most common cause of male infertility.
Alcohol, illegal drug use, cigarette smoking, and sexually
transmitted infections reduce fertility in both women and
men.
e emotional stress and the disruption of a couples sexual
relationship from infertility can result in sexual problems.
e legal and social issues related to articial insemination,
surrogate motherhood, and assisted reproductive technolo-
gies are complex and will continue to create controversy.
e rst sign of a pregnancy is usually a missed menstrual
period. Urine and blood tests and pelvic examinations are
used to determine pregnancy.
Spontaneous and Elective Abortion
Spontaneous abortion, or miscarriage, occurs in approxi-
mately one in seven known pregnancies. Most miscarriages
occur within the rst 3 months of pregnancy.
Elective abortion is a highly controversial social and political
issue in the United States today. Medications, suction curet-
tage, D and E, and prostaglandin induction are the medical
techniques used to induce abortion.
Contraceptive method failure is a major contributor to
womens having repeat abortions.
Contraceptive failure or contraceptive risk taking often pre-
cede an unplanned pregnancy and consequent abortion.
In 1973 the U.S. Supreme Court legalized a womans
right to decide to terminate her pregnancy before the fetus
reaches the age of viability. In 1977 the Hyde Amendment
restricted the use of federal Medicaid funds for abortion and
limited low-income womens access to abortion. Since then,
many state legislatures have imposed further limitations on
the availability of abortion.
SEXUALhEALTh
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Conceiving Children: Process and Choice341 341
The Experience of Pregnancy
Women have a wide range of psychological reactions
to pregnancy, including 20% who experience signicant
depression.
Men have become increasingly involved in the prenatal,
childbirth, and child-rearing processes.
Although changes of position may be necessary, sensual and
sexual interaction can continue as desired during pregnancy,
except in occasional cases of medical complications.
A Healthy Pregnancy
Pregnancy is divided into three trimesters, each of which is
marked by fetal changes.
Nutrient, oxygen, and waste exchange between the woman
and her fetus occurs through the placenta. Substances
harmful to the fetus can pass through the placenta from the
mothers blood.
Smoking, alcohol, illegal drugs, and certain medications can
severely damage the developing fetus.
More women are deciding to have children after age 35.
ese women have decreased fertility and a higher risk of
conceiving a fetus with chromosomal abnormalities.
Childbirth
Prepared childbirth, popularized by Fernand Lamaze and
Grantly Dick-Read, has changed childbirth practices. Most
hospitals now support participation of the womans partner and
a team approach to decision making about the birth process.
Second-stage labor is the descent of the infant into the birth
canal, ending with birth. e placenta is delivered in the
third stage.
e rate of cesarean sections has increased signicantly
in the United States, with continuing debate about the
procedure.
After Childbirth
Many physical, emotional, and family adjustments must be
made following the birth of a baby. Postpartum depression
aects up to 15% of new mothers.
Both breast- and bottle-feeding have advantages and
disadvantages.
Intercourse after childbirth can usually resume once the ow
of lochia has stopped and any vaginal tearing or the episi-
otomy incision has healed. However, it may take longer for
sexual interest and arousal to return to normal.
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America, and Lamaze International.
Media Resources
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