Conception and Birth

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Conception and Birth

Human reproduction, from conception to birth, would seem to be one of the few historical constants across cultures and the centuries. While the basic biological features of reproduction have changed little over the last two millennia, the cultural understanding and social management of this fundamental human experience have varied enormously.

From the earliest records in the ancient world onward, birth attendants and parents sought to control fertility and to improve the experience and outcome of childbirth itself. While male philosophers and physicians starting with the Greek philosopher Aristotle (384322 b.ce.) theorized about the nature of conception and embryological development, it was women as mothers and midwives who were ultimately believed to have authority over the practical aspects of conception and birth. But beginning in the seventeenth century, European male "natural philosophers" and doctors began taking a more active interest in the world of reproduction by exploring the microscopic world of conception and by beginning to practice routine midwifery in the British Isles, France, and North America.

By the late eighteenth century, men's incursions into these arenas led to the professional marginalizing of female midwives and the denigration of popular beliefs about reproduction. Physicians, biologists, and other researchers laid claim to knowledge of reproductive anatomy, fertilization, and embryological development in the nineteenth century and to heredity and hormones in the twentieth. As male scientists and doctors asserted their authority over conception and birth in the nineteenth and twentieth centuries, they influenced public and political opinion, which ultimately led to the state regulation of abortion, birth control, out-of-wedlock births, midwifery, obstetrics, and prenatal and infant welfare.

The twentieth century witnessed phenomenal technological and social developments, from the invention of hormonal contraception in the 1950s and the legal right of Western women to terminate their pregnancies in the 1970s to the practice of surrogate motherhood and the surgical ability to repair fetal defects in utero in the 1980s. The spiritual and moral dimensions of conception and birth, such as when a fetus acquires a soul and whether the life of a mother or a fetus holds greater value, have been the subjects of debate for centuries. Yet twentieth-century scientific knowledge about reproduction, deep as it was, hardly resolved any of these issues. The extraordinary technological advances of the twentieth century only complicated the ethical, medical, and political questions regarding individual rights; the roles of the medical profession, the state, and the marketplace; and the question of when human life begins.

The Biology of Reproduction

Although it has been known in the West for centuries that both males and females contribute formative biological materials to a future child in the act of sexual intercourse, much beyond that remained mysterious. Exactly when and how peak fertility occurred in females, for instance, was not known until 1827 when the Estonian embryologist Karl Ernst von Baer discovered an ovum in a female dog and charted female ovulation. His work, combined with the late-eighteenth-century experiments of the Italian physiologist Lazzaro Spallanzani proving that sperm was necessary for fertilization, led to the insight that conception occurs when sperm from a male successfully fertilizes an ovum or ova released by the ovary of a female when she is ovulating.

The determination of the sex of the future child remained one of the great mysteries of human conception until the early twentieth century. While some classical authorities maintained that the male's left testicle held female seed and the right held male seed, the second-century Greek physician Galen argued that a not-yet-gendered fetus resting on the right side of the uterus would become male and one on the left would become female. For centuries, both popular and learned authors claimed that astrological forces, certain foods, and a woman's feelings during sexual intercourse could influence the future child's sex. According to the medical researchers Patrick Geddes and J. A. Thomson in 1889, there were at least five hundred distinct theories explaining sex determination by the nineteenth century. Though many of these theories argued that women somehow determined sex, it is in fact the father's sperm cells that carry the X and Y chromosomes that control sex, a discovery made in 1916 by the American biologist Calvin Bridges.

Sex ratios, however, are not perfectly even and can have significant geographic and historical differences. In late-twentieth-century Europe and North America about 105 boys were born for every 100 girls, but in Korea and Gambia that ratio was 116 to 100. At the turn of the twenty-first century it remains disputed why more boys are naturally born after wars, and why more firstborns are male.

In the vast majority of pregnancies, women have singletons. Twins and other multiples occur naturally either when more than one ovum is released and separately fertilized or when the fertilized ovum splits into genetically identical zygotes. Rates of multiples vary across ethnic and age groups, although on average in the 1990s in Europe and North America about one of every eighty-five pregnancies resulted in twins, with about a third of those identical. Multiples became more common in the West from the 1980s onward as more women delayed childbearing until their later thirties and forties (when their ovaries function less efficiently and more frequently release more than one egg per cycle) and as more women underwent assisted reproduction, a process that usually involves the implantation of more than one embryo.

The reproductive cycle in human beings, from the first day of the last menstrual cycle to the delivery, lasts approximately forty weeks. Conception occurs shortly after ovulation, usually about two weeks after the beginning of that month's menstrual cycle. The developing, multiplying cells are medically termed first as a zygote from conception to twoweeks, then as an embryo from two to eight weeks, and fromthen until birth as a fetus. As soon as the zygote is implanted about ten days after fertilizationand the woman is now considered pregnantwhatever nutrients and other substances she intakes can affect the viability and health of the fetus. In 1959 the first medical reports appeared demonstrating that the sedative thalidomide caused severe fetal deformities, and by 1972 several researchers reported a high correlation between smoking in pregnancy and low birth-weight. Especially during the first trimester, the pregnant woman can experience nausea, exhaustion, and tenderness throughout her body. At the same time, the fetal organ systems begin developing and maturing from two weeks to birth, with the basic structure of all the organ systems forming in the first six weeks.

In the late 1960s, animal researchers discovered that labor is launched by hormonal changes, first in the fetus and then the mother. When a normal fetus is nearly ready for birth, its pituitary gland is stimulated by the hypothalamus to begin secreting elevated levels of adrenocorticotropin (ACTH) and cortisol. These hormones help both to prepare the fetal lung tissue for breathing outside the uterus and to create enzymes that convert the mother's uterine progesterone into estrogen. This in turn triggers a cascade of maternal hormones that lead to labor: estrogen helps to increase oxytocin, secreted by the mother's pituitary glands and by the mother's mammary glands. Estrogen, oxytocin, and prostaglandins in the uterus ultimately trigger uterine contractions. The first stage of labor is this active phase when the uterine muscles powerfully contract to force open the cervix to ten centimeters. This can take several hours or even days. The second stage occurs as the baby exits the birth canal, a much shorter process of a few hours or less.

In about 97 percent of singleton pregnancies, the fetus presents itself upside down, often with its head facing toward the back of the mother, a position from which it is easiest to deliver. As the cervix thins and dilates and the uterine muscles contract, the head of the child drops into the birth canal; in the second stage of labor, the head turns through the pelvisa mechanical process discovered independently by an Irish and a Scottish obstetrician in the 1740s. In about 3 percent of pregnancies, the fetus is positioned in difficultto-deliver positions including a breech, in which the fetus's bottom is tucked into the pelvic basin. Before the twentieth century, attendants intervened in complicated births by performing internal or external version the manual turning of the full-term fetus in utero; by introducing the attendant's hands or obstetrical forceps into the mother's birth canal to apply mechanical leverage during the delivery; or by changing the mother's position in labor to aid in delivery. In the late twentieth century, especially in the United States, obstetricians tended to resolve breeches and other obstructed deliveries with cesarean sections.

After the child is born, the umbilical cord is cut and the placenta, which has provided nourishment during the entire pregnancy, is delivered during a third stage of labor. In the twenty-first century, as in the past, attendants immediately examine and clean the newborn. In 1953 the American obstetrician Virginia Apgar developed a scoring system based on the infant's physiological signs to assess its condition; if the child appears to be in distress, neonatal specialists intervene. After delivery, the mother is cared for and allowed to rest. Before the twentieth century, the postpartum ideal in western Europe and North America was for a mother to rest and recuperate during at least an entire month of "lying-in" while her relatives and friends managed the household and cared for the newborn and the rest of the family.

Delivery Practices

Before the twentieth century, most mothers in the Western world were attended by female midwives in their own homes. The professional transition among birth attendants from female midwives to male obstetricians occurred first and most dramatically in the British Isles, the United States, and France during the eighteenth century, mostly among elite and middle-class families. Male doctors were far less successful in taking over pregnancy and childbirth in Catholic countries such as Italy and Spain. But despite their early success among an elite female clientele, male obstetricians have never delivered the majority of newborns in Europe, and in the United States they began to deliver the majority only after 1900. While obstetricians have firmly established themselves in modern Americamanaging from 95 to 99 percent of pregnancies in the 1990sand while they handle complicated and high-risk pregnancies in all Western nations, it is only in the United States that midwives are no longer considered routine practitioners.

Before the late seventeenth century, medical men were usually called to births only in cases of severe complications requiring surgical intervention. But from the seventeenth century onward, male doctors developed techniques that improved the likelihood of survival among mothers and babies in some protracted labors. The most important and lifesaving included the obstetrical forceps, developed by the seventeenth-century Chamberlen family of physicians in England, and cesarean sections. Though cesarean sections had been attempted for centuries, until the 1880s few medical men had performed ones that resulted in the survival of both mother and child.

Obstetric medicine became increasingly associated with pain relief during labor. Beginning in the 1840s, British and American obstetricians began administering ether and chloroform as anesthesia during childbirth, and by the early 1900s, a full panoply of pain-reducing interventions had been deployed. By 1950, many techniques, such as spinal and epidural nerve blocks, were greatly improved, and some American obstetricians were commonly using continuous caudal anesthesia for use during vaginal labor and delivery. It became common practice by midcentury for women to be completely unconscious during labor and the birth of their children.

By the late 1950s, a handful of doctors in the Soviet Union and Europe and many women began arguing against this extreme "medicalization" of childbirth, including especially the administration of amnesiacs and anesthesia. Grantley Dick-Read's Childbirth without Fear (1944) and Ferdinand Lamaze's Painless Childbirth (1956) were instrumental in educating mothers about their bodies and the possibility of reducing pain during delivery without the use of drugs. By the 1990s, U.S. hospitals began incorporating "natural childbirth" education in prenatal courses, allowing women more control over the birth experience, and permitting partners to attend the birth. Yet a majority of American mothers in the late twentieth century continued to ask for pain relief; as of 2003, 60 percent of U.S. mothers requested epidural anesthesia during labor. This is not surprising given that research in the physiology of pain in the 1970s and 1980s showed that though Lamaze's methods can reduce discomfort by 30 percent on average, most mothers will still experience significant pain.

Obstetricians most successfully established nearly complete control over reproduction in the United States, especially as professional American medical groups helped to limit and even outlaw the work of midwives in the twentieth century. In Europe, however, midwives remain professionally powerful, fully trained and incorporated in hospital and clinical medicine. At the turn of the twenty-first century, about 75 percent of European births are attended by midwives, who are allowed to intervene medically in ways that only obstetricians are permitted in the United States. For instance, midwives are permitted to perform episiotomies and administer anesthesia in such countries as Great Britain and the Netherlands.

In the eighteenth century, medical men helped transform the experience of birth by establishing specialized "lying-in" hospitals in the British Isles and North America. These hospitals were initially reasonably safe places to give birth because female midwives handled most of the births, and, unlike doctors, they did not perform autopsies or attend other patients with contagious diseases. In the nineteenth century, however, as doctors increasingly attended hospital births, hospital mortality rates rose precipitously. La Maternité, a Paris hospital, for instance, saw the death of more than 180 mothers out of every 1,000 in the early 1860s. The American gynecologist Oliver Wendell Holmes (18091894) in 1842 and the Hungarian obstetrician Ignaz Semmelweis in 1847 observed how the disinfecting of birth attendants' hands reduced the spread of puerperal or childbed fever, but unfortunately their recommendations were little heeded until after the 1870s with the advent of modern germ theory.

Until the 1920s and 1930s, the American and European women who gave birth in hospitals were usually poor or objects of charity. Middle-class and elite mothers turned to hospital births beginning in the 1920s, first because of the growing reputation of medicine as an effective scientific discipline, and, second, because rapid urbanization and migration eroded traditional female networks that enabled mothers adequate social support to give birth at home. Paradoxically, however, maternal mortality rates were higher in hospitals than in home births throughout the 1920s and 1930s. Hospital mortality rates dropped only after 1935 with the introduction of sulfonamides and other antibiotics.

From the 1950s onward in the United States, the development of private, for-profit insurance and hospitals, plus the rise in plaintiff lawsuits, all influenced medical and hospital practices with controversial results. For instance, rates of cesarean sections increased dramatically starting in the 1970s, in part because surgical childbirths are more efficient, convenient, and even profitable for practitioners and hospitals than natural childbirths. The raised expectations of parents, combined with large jury settlements in some malpractice cases, have also led obstetricians to intervene in slow or difficult labors earlier and more aggressively. Less than 5 percent of U.S. births were cesareans before the 1970s, but by the 1990s, about 25 percent were. This contrasts with a rate of 15 percent in England and Wales and 40 percent of hospital births in Brazil and Chile in the same period.

At the turn of the twenty-first century, medical debate continues over whether an elective cesarean or vaginal delivery is safer for mother and child. In either case, maternal mortality rates are historically very low, running from 1 to 4 American mothers out of 10,000 dying in the 1990s depending on whether the delivery was vaginal, cesarean, routine, or emergency. Compared with mortality rates of nearly 70 mothers out of 10,000 dying as late as 1920 in the United States, the modern expectation that almost no women will die in childbirth is one of the most profound alterations in all of human history.

Popular Reproductive Beliefs

All cultures have sought to explain the mysteries of reproduction and to control the outcome of pregnancy. There have been thousands of various and contradictory cultural beliefs regarding sex determination, the explanation for fetal abnormalities, and every other imaginable aspect of conception and birth. Many Western beliefs rely on cosmological theories connecting macrocosmic forces such as astrological patterns with the microcosmic and invisible development of the fetus inside the mother's uterus. Other customs were based on the logic of resemblances; for instance in early modern Europe midwives and doctors recommended mothers wear an "eagle's stone"a little rock that contained loose bits of mineral in the interior that were audible when shaken. This was said to prevent accidents that would lead to miscarriage, to prevent pain, and to help draw the child out during labor.

Most midwifery texts before the nineteenth century argued that a woman had to experience sexual pleasure during intercourse because if ejaculation after an orgasm was required for a man to impregnate a woman, so must a woman reach climax in order to release an egg or other material vital to conception. While such a theory endorsed female sexual pleasure, the idea also made it impossible for a woman to persuade most jurists that she had been raped if she became pregnant, because it was believed conception resulted from her enjoying the sexual encounter.

Both laypeople and the learned tried to explain negative outcomes. One of the most prevalent explanations for birth defects was maternal imagination, the belief that a mother's desires or fears could imprint themselves on her unborn fetus. Being startled by a rabbit could result in a baby having a harelip, for example, or strongly craving strawberries could mark the baby with red birthmarks. The most phenomenal case demonstrating the widespread belief in maternal imagination occurred in 1726 when a poor peasant woman persuaded much of the English nation that she had given birth to seventeen rabbits after being startled by a hare during pregnancy.

Reproductive Research

Aristotle, the Hippocratic Corpus, Galen, and other classical authorities offered a rich but contradictory range of theories about gender difference, conception, fetal development, and birth. Many of their ideas, such as the importance of bodily humors, survived among the learned well into the eighteenth-century Enlightenment. But beginning with the sixteenth-century Italian Renaissance, artists and anatomists, such as the Belgian anatomist Andreas Vesalius, producer of De humani corporis fabrica (1543), focused on revealing the secrets of the human body. Several physiological aspects of conception and birth were discovered, including the discoveries of the fallopian tubes by Gabriele Falloppio in 1561 and of the foramen ovale, a hole between the chambers in the fetal heart that almost always fuses shut by birth, by Giulio Cesara Aranzi in 1557. Yet despite their focus on laying bare human physiology, anatomists were still heavily influenced by ancient theories and popular assumptions, such as the complementarity of the sexes. In Vesalius's 1555 dissections of the female body, he identified what are now called the ovaries as the "female testicles," basing his terminology on the assumption that the sexes were physiologically inside-out versions of each other.

The seventeenth century witnessed a flourishing of research into the beginnings of life and the nature of embryological development. Thanks to technical advances in microscopy, the Dutch naturalist Antoni von Leeuwenhoek and others discovered that male semen was filled with countless tiny, swimming sperm. Leeuwenhoek and his acolytes argued that each sperm cell carried if not a fully formed human, then all of the necessary rudiments of a future human. Although human ova were not actually seen until the nineteenth century, ovists contrarily maintained that female eggs housed miniature, fully formed humans. Others argued that both mothers and fathers contributed fundamental reproductive materials that allowed a future child to emerge epigenetically. These theorists proposed that living creatures were not preformed in either ova or sperm, but that once an egg was fertilized, unknown processes allowed unformed material to develop incrementally and gradually into different organ systems.

One important area of nineteenth-century research focused on embryological development. Von Baer, who had discovered the ovum in 1827, also observed how different layers developed sequentially in the zygote and embryo, showing how these different "germ layers" gave rise to different organ systems. The most significant developments in reproductive knowledge occurred from the 1890s onward in the burgeoning field of endocrinology, which charted the function of hormones as chemical messengers. Mid-nineteenth-century experiments showed that testes contained a material capable of preventing atrophy of the comb in castrated roosters, and in the 1890s Viennese researchers established the existence of female hormones when they triggered ovulation in spayed rabbits that had been implanted with ovarian tissue. By the 1910s, several researchers uncovered the hormonal changes involved in the female menstrual cycle and reproduction. Between 1923 and 1936 scientists isolated, synthesized, and determined the structure of the various female and male hormones. The discovery of the hormone human chorionic gonadotropin (HCG), which is present in the urine of pregnant females, led to the development of the first reliable pregnancy test (the Ascheim-Zondek test) in 1928.

At the same time that endocrinologists made these foundational discoveries, biologists began penetrating the nucleus of the cell, showing the genetic material and cellular processes of reproduction. Belgian Edouard van Beneden, for instance, demonstrated in 1883 that the fused gametes reduced their chromosome count by half so that the zygote contained the proper amount of genetic material. The most important contribution in this area was that of the Austrian monk Gregor Johann Mendel, whose 1866 work establishing the laws of heredity was rediscovered in 1900.

The Reign of Technology

Midwives and doctors offered advice for centuries to mothers telling them what signs to look for that showed the fetus was developing normally, such as feeling active movement of the fetus from about twenty weeks forward, when it was said to "quicken." Midwives and doctors could also usually determine by feeling a mother's belly the position of a full-term fetus. But the first advance that allowed an attendant to learn more about the fetus in utero was with the application of the French physician René Laënnec's invention of the stethoscope in the 1810s, which the French midwife Marie Anne Victoire Boiven Gillian and the Swiss surgeon François Mayor both independently used to detect the fetal heartbeat at about five months.

Other diagnostic developments included the application of X rays, discovered by the German physicist Wilhelm Conrad Röntgen in 1895, to diagnose the fetal position and detect such abnormalities as spina bifida and anencephaly. In the 1930s, American researchers used X rays to classify a woman's pelvic type and used such information to recommend whether she have a vaginal delivery or a cesarean section. Only in the 1950s did the medical profession recognize the dangers of excessive radiation, especially to the developing fetus, and obstetricians turned toward other diagnostic tools.

In 1958 Ian Donald of Glasgow University introduced ultrasound, a noninvasive and harmless technique used to visualize the fetus. Ultrasound has been routinely used since the 1960s to estimate the size of the fetus, gauge its position, determine whether it has certain abnormalities, and monitor its heart rate, oxygen intake, and sleep and gasp patterns. In the 1950s, European researchers developed amniocentesis, in which a needle is inserted through the abdominal wall to withdraw amniotic fluid, which can then be examined for its cellular and biochemical content. Among other uses, this technique was used to determine the sex of the fetus beginning in 1953 and to diagnose Down syndrome by 1968. Because of the sharply elevated rates of Down syndrome and other chromosomal defects in pregnancies of mothers thirty-five and older, amniocentesis became routine for this group of women starting in the 1970s. Other prenatal diagnostics include fetoscopy, which involves inserting fiber optical technology in utero to examine the fetus, and chorionic villus sampling, in which tissue from the chorion, which develops into the placenta, is removed and examined for chromosomal abnormalities and sex.

During the second half of the twentieth century, many once-fatal complications began to be routinely treated. For example, mothers whose blood is negative for the rhesus (Rh) factor, but who carry a Rh-positive fetus, produce antigens that threaten the life of any subsequent Rh-positive fetuses; since the 1970s, such women have been treated with anti-D globulin to halt the production of antibodies. Since 1963, surgeons have also been able to perform intrauterine blood transfusions on the fetus, and in the 1980s, several specialists pioneered in utero surgery to repair spina bifida, hydrocephalus, diaphragmatic hernias, urinary tract obstructions, and other complications.

Hospitals have likewise dramatically helped to reduce newborn mortality rates through neonatal intensive care units, the first of which was established in 1960 at Yale-New Haven Hospital in Connecticut. These units have helped save the lives not only of many critically ill full-term newborns but also of extremely premature infants. In 1984 the Baby Doe amendment to the Child Abuse Prevention and Treatment Act was passed by the U.S. Congress and signed into law by President Ronald Reagan, making it illegal for doctors to do less than the maximum to save all neonates, no matter how premature. In 1990, only 40 percent of babies born at twenty-six weeks survived, but by 2000, 80 to 90 percent did, with the majority developing into normal children. Many of these babies have life-threatening respiratory problems, including respiratory distress syndrome (RDS), in which the lungs are too immature to function on their own. Synthetic hormones given to the baby after birth can treat RDS, but researchers also discovered in 1972 that glucocorticoid treatments given to mothers in preterm labor or having elective cesareans could prevent RDS. Thanks to ongoing new medical discoveries, "the edge of viability" has dropped substantially. At the turn of the twenty-first century, even "super-preemies" born before twenty-four weeks are in some cases able to survive, but most can expect enormous and expensive developmental and permanent complications.

Assisted Reproduction

In the 1990s, one-sixth of American couples were estimated to be infertile, that is, unable to conceive successfully without medical or technological intervention. Viable solutions to assist reproduction reach back at least to 1790 when the Scottish anatomist John Hunter performed the first successful case of artificial insemination. The first use of donated sperm occurred in the nineteenth century, and the concept of a sperm bank was developed in 1866, although the technology to preserve human semen was introduced only in 1953. By 1995, approximately five hundred thousand children had been born through artificial insemination in the United States, and the majority of these were conceived via donor insemination.

Women's fertility problems, such as blocked fallopian tubes, are far more difficult to remedy than male impotence or low sperm count, both of which can often be resolved through artificial insemination. The key breakthrough for women's infertility occurred in 1978 when Patrick Steptoe and Robert Edwards of Britain announced the birth of the first "test-tube baby," Louise Brown, conceived through in vitro fertilization (IVF). IVF involves retrieving mature ova from a woman who has often been given hormones to induce the production of several ova. In IVF the retrieved eggs are fertilized and kept in a laboratory for two to five days and then implanted in the uterus. By 1991 the pregnancy rate per retrieval was less than 20 percent in IVF, compared to an 80 percent success rate with artificial insemination. In the United States, for each attempt at IVF, medical, laboratory, and travel expenses typically ranged in the 1990s from $4,000 to tens of thousands of dollars, and in a significant proportion of cases in which implantation succeeds, the procedure results in multiples. Sometimes, especially in cases of triplets and more, parents choose "selective reduction"that is, the termination of some of the pregnancies, an obviously highly controversial aspect of assisted reproduction.

As semen can be donated, so can ova, at least since 1983. The uterus also can be donated through surrogate motherhood. In biological surrogacy, a woman agrees to use her ova, which are fertilized through IVF, to carry the resulting fetus to term, and to surrender the child to another individual or couple. In gestational surrogacy, a woman carries a fetus that is conceived from another woman's ovum through IVF. By 1993, approximately four thousand babies had been born through surrogacy in the United States since the late 1970s.

Birth Control and Abortion

While many couples have sought medical and technological means to reproduce successfully, so too have women and men sought for millennia to limit their fertility. For example, the ancient Egyptians used various herbal concoctions placed on vaginal pessaries during intercourse to block sperm from reaching the uterus. But the most dramatic leaps in manufacturing widely available, effective birth control did not occur until the nineteenth century with the vulcanization of rubber, used to make condoms and vaginal barriers including cervical diaphragms. Research in endocrinology in the twentieth century led to the contraceptive pill, made commercially available in 1960. Other contraceptive methods include injected and implanted hormones, introduced in the 1980s, and intrauterine devices (IUDs), in use since the 1960s. Permanent forms of contraception, including vasectomies in males and tubal ligations in females, were developed in the nineteenth century but did not become widely and electively chosen until the 1960s.

In scholarship published in the late twentieth century, Janet Farrell Brodie and Angus McLaren both argued that birth control existed on a continuum with early term abortion until the nineteenth century in the United States and Europe. Evidence suggests that herbal abortifacients, violent exercise, and even mechanical means were used for many centuries, in many societies, and among all classes and religions to terminate pregnancies, especially in the first trimester of pregnancy. Abortifacients were widely discussed (often in condemning detail that would enable their use) and also advertised as medications to release "obstructions" from the seventeenth century onward.

Demographic data of the dramatically declining size of nineteenth-century middle-class families in the United States, the British Isles, and France strongly suggests that married couples were turning to abortion when contraception failed. Popular belief until the nineteenth century maintained that though a woman might apprehend that she was pregnant in the first month or so, the fetus was not really "alive" until the moment of "quickening," which occurred at approximately four months into the pregnancy. Medical, legal, and even some religious texts well into the eighteenth century also endorsed this position that fetal life really began only once the mother herself experienced quickening, implying that the termination of an early pregnancy was not morally equivalent to a later term abortion.

Though abortion was never officially condoned, legislatures began criminalizing abortion for the first time in the nineteenth century, beginning with the British government's making abortion a statutory felony in 1803. In the United States, laws against abortion were passed piecemeal through state legislatures, and by 1900 all states had come to prohibit the practice. Historians of the subject have widely argued that the male medical profession drove antiabortion legislation as they sought to gain control over family's reproductive health and marginalize "irregular" practitioners"quacks" and midwives. In so doing, they saw themselves as moral arbiters for society. The most stringent laws against abortion were enforced in Nazi Germany and Vichy France in the early 1940s, when providing abortions became a capital offense.

In the twentieth century, some advocates pushed for women's expanded access to abortion, first for reasons of physical and mental health. For instance, in 1927 German women could have abortions for therapeutic reasons (although this law was repealed under the Nazis), and some other European nations also passed similar legislation from the 1930s onward. In the 1960s several feminist groups, Protestant churches, and medical practitioners lobbied to repeal antiabortion laws in the United States, and by 1973, four states and the District of Columbia permitted elective abortions.

In 1973 the U.S. Supreme Court decided the landmark case of Roe v. Wade, with the majority stating that the right of privacy included a woman's right to abortion in the first trimester. From 1973 forward, states passed a wide range of laws that generally further expanded most adult women's access to abortion, for instance in later trimesters. Yet both Congress and certain states passed laws that limited many women's practical access to abortion, including mandatory waiting periods and parental consent for women younger than eighteen. The Hyde Amendment, first passed by Congress in 1976, annually prohibited federal funding of abortion, except in cases of rape or incest. In Europe, access to abortion was liberalized in most countries from the 1970s forward, but by the turn of the twenty-first century, most of these countries limited abortion by request to the first trimester or sixteen weeks of pregnancy.

In the United States, Roe v. Wade was deeply controversial, immediately leading to, on the one hand, advocates of abortion pushing states and the federal government to expand abortion rights, and, on the other, opponents lobbying for a repeal of abortion rights. In western Europe, a "prolife" movement has had little cultural or legal impact. But in the United States, both sides of the abortion debate have affected access to abortion, as in the case of RU-486, or mifepristone, a hormonal antiprogestin that halts gestation and is designed to be taken within nine weeks of the first day of the last menstrual period. Invented in France in 1980, RU-486 became available in France, Britain, and Sweden in 1989. RU-486 was not approved by the U.S. Food and Drug Administration until September 2000 after twelve years of strong lobbying by both sides.

A historical analysis of reproductive topics does not necessarily resolve these modern debates, but the varieties of accepted practices across time ultimately undermine any claim that there is a transcendent truth about the reproductive body or the ethics of reproduction. For instance, the high frequency of abortion for centuries challenges claims among late-twentieth-century opponents that the practice results from the rise of modern feminism and the secularized state. On the other hand, that abortion was widely condemned not only by the church and the state, but also by early modern midwives and nineteenth-century feminists, challenges some assumptions among present-day pro-choice advocates that pro-life attitudes have been bred exclusively by the modern, male-dominated medical professions or by twentieth- and twenty-first-century conservative, special-interest groups.

See also: Fertility Drugs; Obstetrics and Midwifery; Sonography .


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Lisa Forman Cody