A life-course approach to human reproduction

A life-course approach is a multi-disciplinary area of study that makes sense of people's experiences, their decisions and their understandings of life events within a framework which places these in their appropriate social, structural and cultural settings. Writing specifically about human reproduction, Brown and Webster (2004) explore its complexity and highlight the need for a wide-lens view:

‘The arena within which reproduction takes place is no longer that of kinship and biomedicine alone but the wider domains of industrialisation, information innovation, product development and the political machines … that endeavour to order it’.

A RCOG (Stephenson et al., 2011) opinion paper makes a strong case for a life-course perspective in managing reproductive health pointing out the significance of this approach for understanding health risks, tackling health issues and the provision of personalised health care. Moreover, the paper stresses the importance of understanding past reproductive experiences in order to make sense of current health needs.

A life-course approach recognises that decisions and events do not just provide the context for people's lives but serve to shape people's experiences. This approach assumes that there are (a) recognised stages in a person's life (for example, childhood, youth, adulthood and later life); (b) transitions or rites of passage (for example, transition from young person to adult or student to professional) and (c) specific life events (for example, birth, marriage and death). These life stages, transitions and events are often understood to be part of ‘normal’ life and this serves to structure how people understand the world and their role in it.

Life is expected to progress in a timely, staged and linear fashion and experiences of fertility and reproduction – to include planned conceptions, straightforward pregnancies, ‘natural’ births and wanted, healthy children – are an anticipated part of this normality (Earle & Letherby, 2007). Of course, people's lives do not always follow an expected life course and the unexpected, for example, infertility, can disrupt an anticipated and desired trajectory. Hockey and James (1993) argue that an individual's path through life always has ‘false starts, changes in direction and hidden obstacles’.

Fertility issues and reproductive loss – in all its forms – can be experienced as devastating, since reproductive success is often seen to be an essential part of satisfactory transition across the life course (Earle et al., 2008). While much research in this field has focused on women's experiences, it is increasingly recognised that disruptions to the reproductive life course are significant for women and men, as well as the wider network of family members such as siblings and grandparents (for example, see McCreight, 2004; Nehari et al., 2007).

This special edition introduces a life-course approach to human reproduction bringing together the latest thinking and research in this multi-disciplinary field. The 14 papers in this issue cover a wide range of topics from a number of social science disciplines and have adopted a variety of methodological approaches. Some of the papers draw on new empirical research, whereas others provide critical academic commentary on existing work, pushing forward new thinking in the field.

The first selection of articles within the special edition explore infertility and assisted reproductive technologies (ARTs) examining how these challenge a normative life-course trajectory. As Nicola Cunningham notes, infertility is often experienced as an unanticipated disruption to the life course. The article Lost in Transition draws on a qualitative project carried out in the United Kingdom where women kept treatment diaries that enabled reflection on their experiences of infertility prior to, during and after treatment. Cunningham suggests that the infertility clinic is a critically important space and place that can provide support to women who are in transition during this difficult time. In ‘The BCRA Clock is Ticking!’, Lisa Rubin and colleagues explore another issue that is ethically and morally complex, that of preimplantation genetic diagnosis (PGD). Using a combination of qualitative interviews and case studies with BRCA1/2 mutation carriers who sought a consultation for and/or attempted PGD in the United States, Rubin and her colleagues suggest that a range of factors are often at play influencing how individuals with BRCA mutation understand risk and make decisions about ART. This article also highlights the extent to which reproductive ‘choices’ are influenced by the healthcare context and issues of financial privilege. The issue of financial privilege and inequalities in reproductive health is further explored in the next two articles. In Assisted Reproduction IVF Treatment in Ireland, Evelyn Mahon and Noelle Cotter describe the experiences of 34 Irish couples who had in-vitro fertilisation (IVF) treatment. The article, which is based on a longitudinal qualitative study at a private fertility clinic, suggests that infertility treatment should be understood within a framework of ‘money, power and time’ but where individuals and couples often participate actively in their quest to become parents. In another article to focus on reproductive agency, Kylie Baldwin and colleagues explore the current debates and research in social egg freezing. Still considered experimental in some countries, and sometimes recommended only on medical grounds, in Reproductive Technology and the Life Course, the authors argue in the article that while there is considerable public debate about the use of such technology by women who wish to delay childbearing, very little empirical evidence actually exists on the subject. Moreover, they argue that there is mistaken faith in the ability of ART to overcome declining or problematic fertility and that the notion of delayed childbearing as being the sole product of women's choice is also problematic and untrue.

There is further reflection on ideas about reproductive choice and delayed childbearing in the article How Teen Girls Think about Fertility and the Reproductive Lifespan. In this article, Fiona Kisby Littleton, who draws on exploratory qualitative research and on interviews and focus group methods with teenage girls in an English school, explores the significance of promoting positive reproductive health across the life course. In her article, Littleton argues that current sex education focuses on ‘damage and disease’ rather than a broader perspective which enable young people to be better informed and thus better enabled to make reproductive decisions throughout their lives.

Two of the articles in this special edition focus specifically on non-Western understandings of reproduction and the life course. In the first of these, Women in Limbo, Marida Hollos and Bruce Whitehouse explore the consequences of infertility in Nigeria's southern Niger Delta. Building on demographic and anthropological research, they argue that women usually bear the consequences of infertility. In pronatalist societies, they suggest that women who do not bear children or who are seen as ‘sub-fertile’ are marginalised throughout their lives. In Passing Children’ and Precarious Pathways, Erica van der Sjipt reports on an anthropological study of ‘reproductive mishaps’ in a Gbigbil village in Cameroon. Here Sjipt argues that progression through an anticipated life course is not straightforward but is often fluid and contingent on a range of factors. She argues that the management of the reproductive life course requires the management of social norms and personal feelings as well as management of the reproductive body. Any reproductive loss, the author argues, can jeopardise a woman's standing as a wife and mother, as well as her very womanhood.

As highlighted by the articles written by van der Sjipt, and Hollos and Whitehouse, issues of reproduction and fertility are often seen to be more important for women than for men. Social science research on men's reproductive life course is actually quite limited and often extrapolated from research on or about women. However, the next two articles focus specifically on men's experiences of reproduction and the life course. Drawing on a psychological approach, in his article, ‘Bang one day you're married…’, Gareth Terry explores men's views on vasectomy in New Zealand. Using qualitative research data, Terry argues that the notion of a ‘normal’ life-course trajectory actually provides men with a way in which they can make sense of their reproductive lives within the context of limited contraceptive choices. Also drawing on a psychological approach, the work of Maeve Dooley and colleagues, The Psychological Impact of Infertility and Fertility Treatment on the Male, uses a questionnaire design to explore the factors that might predict infertility distress in men in Ireland. The authors contend that the psychological distress associated with infertility can be as severe as that experienced by individuals with cancer, heart disease or other conditions. Furthermore, they argue that certain factors do closely correlate to infertility distress including satisfaction with relationships and ideas about what it is to be masculine. Dooley and colleagues conclude by making recommendations that might support men within the clinical environment.

The next two articles focus on different aspects of perinatal loss. In the first of these two articles, ‘By-the-way Knowledge’, Sam Murphy and Kerry Jones take a life-course approach a little wider to focus on the implications of perinatal loss for grandparents. Drawing on sociological perspectives, Murphy and Jones argue that, like fathers, who are often marginalised from experiences of reproductive loss, grandparents too are often the ‘forgotten mourners’. The authors point to the fact that little is known about how grandparents feel about perinatal loss but that experiences of perinatal death may affect mental health, ageing and co-morbidity. In the second article on perinatal loss, Griefwork Online, Gayle Letherby and Deborah Davidson draw on auto-biography and netography (online ethnography) to explore the use of social networking and online networks following perinatal loss. Letherby and Davidson argue that perinatal loss disrupts the life course but – as highlighted by Murphy and Jones – although it is a loss that can cause profound grief, it is one that is often minimised or ignored by wider society. The authors conclude that online networks can support those who experience loss and often provide an informal opportunity to enhance health and wellbeing.

Taking the reproductive life-course trajectory even further, the following two articles explore reproduction and the life course in relation to menopause and post-menopause. In Defining What is Normal at Menopause, Helen Rubinstein discusses the medicalisation and subsequent demedicalisation of this life event. Reviewing the literature on what women and clinicians actually know about the menopause, Rubinstein argues that uncertainty about which experiences are a ‘normal’ part of life and which are abnormal and/or require treatment can lead to very different understandings of the same experience. This can influence the way in which women experience health and ill health and affects treatment and care. Notions of what is ‘normal’ or not are at the core of a life-course approach. In Assisted Reproduction for Postmenopausal Women, Merryn Ekberg argues the case for ART for post-menopausal women, suggesting that this is simply an extension of reproductive autonomy and procreative rights. In her defence of ART, Ekberg reviews the ethical arguments in the context of increased longevity, an ageing population and advances in reproductive technologies to conclude that there should be no restriction on ART for post-menopausal women.

The final article in this special edition, Midwives’ Personal Experiences of Pregnancy and Childbirth, written by Sarah Church, takes a very different approach to the life course and considers how practice can be influenced by both personal and professional knowledge. Church draws on a qualitative auto-biographical study of midwives’ experiences in the United Kingdom to consider how midwives seek to promote agency and autonomy in their professional work while navigating their own reproductive experiences of pregnancy, birth and reproductive loss. As highlighted by Rubinstein in her article on knowledge and defining what is normal at menopause, Church's work is useful in bringing to the fore the significance of different types of knowledge as well as the importance of a life-course perspective for those who give, and receive, care.