This volume showcases the work of leading anthropologists, sociologists, bioethicists, and fertility specialists, providing insight into the moral and ethical negotiations people undertake in their quests for children, the provision of assisted reproductive technologies (ARTs) in low-income settings, and challenges for appropriate professional practice of serving culturally and linguistically diverse patients. The third phase of ARTs to which the volume’s title refers is the stage at which ARTs become incorporated as part of the standard repertoire of medical assistance for infertility and reproductive health care. As the authors in this book attest, increased accessibility and acceptability of ARTs, more public funding for ART treatments, developments in low-cost assisted reproduction, and the recognition of infertility as a disease rather than a moral blight or misfortune mean that ARTs are becoming “naturalized” as another means of conceiving children for “new constituencies as defined by socio-economic status, ethnicity and geography” (p. 12). The contributors to this volume explore the social impact and clinical practice and policy implications of this extension of ARTs to new populations. Geographically, the case studies concentrate on the Middle East, Africa, South Asia, and the United Kingdom.
In their introduction, the editors identify three themes characterizing this third phase: the fertility–infertility dialectic, globalization, and “the bricolage of bioethics” that characterize the adoption of ARTs in various settings. The fertility–infertility dialectic refers to the fact that infertility within populations is often highest where fertility is also the highest. This is a result of poor reproductive care, low rates of contraceptive use, and high prevalence of sexually transmitted infections. Coupled with strong expectations of fertility, an inability to conceive can be socially devastating for women and men, resulting in grave stigma and even ostracism from their communities. The use of ARTs in these settings is usually not prioritized in health care, with more emphasis placed on other priorities such as family planning, reducing maternal and child mortality, and lowering the incidence of infectious diseases. The advent of low-cost options is crucial for relieving the suffering of infertility in such communities.
The second characteristic of the third phase is the global distribution of ARTs. Across the world, tools, personnel, and information regarding ARTs are increasingly moving across state boundaries. A growing market is also spawning wider methods of delivering and practising ARTs within diverse cultural legal, demographic, and policy contexts. The third characteristic is the new moral dilemmas created by the increased circulation of ARTs, including bioethical re-evaluations to reframe infertility and the use of ARTs as an acceptable option.
These three characteristics appear throughout the various case studies in the book. The first section of the book offers a series of chapters exploring the reception of ARTs in the diverse local moral worlds of contemporary Islam. Detailed chapters on ARTs in Lebanon (Clarke), among Pakistani Sunni Muslims in England (Simpson, Blell, and Hampshire), and among Shias in Iran and the United Kingdom (Tremayne) underscore a set of negotiations and accommodations to these technologies and reveal a variability that belies any claim of a singular Islamic bioethics or consensus.
The second part of the book covers low-resources settings. In her introduction to this part, Trudie Gerrits argues that there is a need for situated studies of ARTs as they spawn new stratifications and forms of biological citizenship. This is followed by a chapter by Willem Ombelet, who advocates for the rights of infertile patients to receive the benefits of ARTs as part of comprehensive reproductive health care. Ombelet describes the development of low-cost ART equipment and protocols for low-resource settings that promise to decrease the costs of building an IVF laboratory by 80%. Case studies of care seeking in Bangladesh (Nahar), Botswana (Bochow), and Mali (Hörbst) follow. The case studies highlight the new forms of discrimination, gendered negotiations, and subjectivities posed by the quest to access ARTs, and they document the continued stigma and shame and secrecy surrounding infertility and its treatment.
In Bangladesh, Nahar explores urban middle-class use of ARTs and the religious and cultural dilemmas involved in the use of gamete donors or surrogates. For rural women, access remains limited due to cost and social barriers, as ARTs continue to be seen as morally suspect. As a consequence, rural women continue to face divorce and abandonment from husbands who would marry another wife rather than admit their inability to afford ARTs. In Botswana, Bochow describes the experiences of two generations of middle-class and elite women seeking fertility treatment. In the past, women could only access treatment when and if they traveled to the United States or Europe. In contrast, Bochow argues, the current generation has more biological health knowledge and is more aware of treatment options as informed “biological citizens.”
The Mali case study by Hörbst describes gendered negotiations surrounding ART use. Affording ARTs has become a new financial burden for middle- and upper-class women who insist on not being financially dependent on their husbands. However, these women are dependent on their husbands’ willingness to cooperate with treatment, something largely contingent on whether the men already have children from previous relationships.
The U.K.-focused final section of the book contains chapters examining the needs of ethnically diverse communities for culturally appropriate care. The chapter by Sangeeta Chattoo examines the views of oncology health professionals and their patients’ responses when told that while their cancer treatment might impair their fertility, fertility preservation options were available. She finds that while white patients are assumed to be culture-free individuals, generalizations about South Asian patients tend to view them as constrained by culture and religion, with consequences for the provision (and in some cases withholding) of appropriate counseling on fertility treatments. In their chapter, Nicky Hudson and Lorraine Culley present on third-party gamete transaction and anonymity for a variety of South Asian ethnic groups. They raise important questions about access, policies, and practices and their effects on diverse populations applicable to many countries. The final chapter (Navarro and Orcutt) explores how culturally competent care is actually translated to clinical practice, and it highlights the need for education in cultural competencies to be embedded within medical training.
This is a stimulating and accessible book for those with an interest in reproductive health, ethnicity, and health, or the social implications of new technologies. Its strength lies in the diverse, empathetic case studies of ART use in different regions and among a variety of groups. These case studies provide a balance of in-depth ethnographic studies and sensitive appraisals of the workings of health systems for diverse communities, with a broader vision of a future in which high-quality, culturally competent care is available for all and low-cost ART protocols allow access for people in low-resource settings to receive effective treatment for their infertility.