A response to Kate Manne on pregnancy

On the importance of well-reported data

I have written a lot about how investing in the science behind female health and fertility-enabling tech would be a game-changer for our society and should be a top priority for feminists. I also recognize the disproportionate burden that childbirth and childcare places on women and the sacrifices this important and dare I say, large, segment of society has to make for what is in effect a social good. One of my most read articles is indeed based on the very premise that in their 30s women are often faced with a race against time: often having to choose between permanently falling behind in their careers and a closing fertility window. Since publishing that piece, I received many messages from women describing their struggle to conceive after having delayed childbirth to establish a career. I find these stories heartbreaking.

But my reaction to this is that of trying to find a solution, a way to reduce, if not completely eliminate, these trade-offs: investing in technology that would advance female health and increase the fertility span to allow women more choice over their reproduction. After all, across developed countries, family and children are consistently found to score at the top for sources of meaning among adults of both genders. This suggests to me that what we should aim for is to make it easier for women to combine their career ambitions with achieving their family goals, since the latter seem to matter a great deal when it comes to living a meaningful life (with career often coming as a close second).

Having mentioned all this (and sorry to my frequent readers, who by now, know all this stuff), I consider pieces like

Kate Manne

’s “Don’t have children” to be catastrophizing and moving us away from a positive vision for the future. For this reason, I wrote a long thread on twitter, in which I debunk some of the claims in her article, including those related to the danger of pregnancy in the US. Since then she has doubled down on previous claims, with another article:

Pregnancy is (Currently, in the US) Too Big of a Gamble

She specifically references my thread by saying:

I was accused on X of catastrophizing vis-à-vis the risks of pregnancy: the chance of dying are, after all, on par with that of being struck by lightning. But I don’t go out and stand around during thunderstorms either. It is perfectly reasonable when contemplating pregnancy, much as with any elevated-risk activity, to insist that conditions are tolerably safe and oriented to protecting you properly before going through with it. More: it is fair to want pregnancy in particular to be as safe as it can be, given the ostensible moral good of producing children for our society.

Yet I maintain her initial article was catastrophizing! If I were to be very pedantic, I would point out that the chances of dying in pregnancy are 10x less than that of being struck by lightning. But, more importantly, the absolute risk of dying due to pregnancy is small: 1 in 100,000. Despite this very small risk, she seems to at least in part base her argument on the idea one should not have children specifically because in US death rates from motherhood are higher than in other developed countries. In her article, Kate says:

Pregnancy is not just far more likely to result in preventable death than it should (comparing the US, again, to other developed nations). It is also far more likely to result in long-term as well as acute sickness, suffering, and a subsequent sense of precarity. It is hard to get decisive figures on the matter, but an estimated 8% of pregnancies involve complications “that could result in harm to the mother or baby if they are not treated.” And treatment is often woefully lacking. I heard from reader after reader who catalogued not death but near-death, as well as forms of pain, suffering, and long-term ill health that were the result of two things: (a) pregnancy, and (b) inadequate health care during and after the process. This is both very bad in and of itself, and it is also an injustice that one may quite fairly balk at. Moreover, it can result in a sense of vulnerability, helplessness, and trauma even if the very worst outcomes do not materialize. The sense that you could have died, and that nobody would have saved you, is bad over and above any lasting health consequence

But this argument, even if we accepted that US maternal deaths are higher than in other countries, does not really make sense to me. Firstly, life is not about minimizing risk. We need to balance this against the positives! Secondly, whether mortality rates from pregnancy are slightly higher in your country than another one, when very small in the absolute, should not detract you from doing something as life-changing as having a child. It’s the equivalent of making choices based on comparing yourself to others instead of some internal sense of what is, on aggregate, good for you.

Leaving aside these moral considerations, however, I do not think the argument is correct factually, mostly because it’s not even clear US has higher maternal mortality rates than other countries. As this excellent article from

Saloni Dattani

points out (I recommend reading the entire piece), the recent apparent rise in maternal mortality in the US is down mostly to changes in measurement:

To follow the ICD-10 definition and make sure that maternal deaths weren’t going uncounted, the United States added the “pregnancy checkbox” to death certificates, starting in 2003. The US used an automated system to code deaths as maternal deaths if the checkbox was ticked for women between the ages of 10 and 54, for deaths caused by medical conditions, regardless of other information on the death certificate.⁸

(…)

The researchers also estimated what the maternal mortality ratio from 2003 to 2017 would have looked like under two hypothetical scenarios: (a) if all states adopted the checkbox simultaneously, or (b) if none of them did. In both scenarios, they estimate that there would have been no change in maternal mortality ratios between 2003 and 2017. In other words, the rise in maternal mortality is largely explained by the staggered adoption of the checkbox.¹³ The researchers also noted that the impact of the change in measurement was greatest among older women and non-Hispanic black women.¹⁴ The checkbox increased the ability to detect pregnancy-related deaths that would have been missed otherwise, but in some cases, it also resulted in overcounting deaths from other causes.

Saloni also brings compelling evidence that other developed countries are underreporting maternal deaths:

While the United States has used the checkbox to automatically code deaths as maternal if it is ticked¹⁹, this practice is not followed in several other countries.²⁰ There is strong evidence that maternal mortality, as defined in the ICD, is underreported in national statistics in many countries.²¹ One reason is that some countries do not use data from the checkbox to identify potential maternal deaths, or do not routinely conduct additional investigations to identify unreported maternal deaths.²⁰ Some countries have implemented systems separate from their vital registries to investigate potential maternal deaths further.²² These systems include “enhanced surveillance”, which involves an additional system for more detailed monitoring, and “confidential inquiries”, which are private investigations into individual cases. These investigations have been conducted infrequently, and the maternal deaths identified through these systems are not necessarily counted in vital registries for national statistics and given to the WHO.²³ Research finds that the number of maternal deaths from vital registries tend to be lower than equivalent definitions from these other surveillance systems.²⁴ In low- and middle-income countries — where death certificates and vital registries are often lacking — other sources of data are used to determine maternal deaths, including hospital records, and verbal autopsies.

Her recommendation and conclusion?

To help identify missed deaths, the United States introduced a “pregnancy checkbox” on death certificates, and deaths of women with this box ticked would be coded as maternal deaths in most age groups.While this helped identify maternal deaths that would have been missed, it also led to some misclassification and false positives from women who had not been pregnant or had died from other incidental causes. Because of this, the US changed its coding system in 2018 to disregard the checkbox for deaths of patients under 10 or over 45 years old. Researchers have also recommended that additional quality-assurance measures are used to verify potential maternal deaths before they are compiled in US national statistics. In other high-income countries, there is strong evidence that maternal mortality is underreported in national statistics (…) By improving data collection and surveillance of maternal deaths further, the world can have a better understanding of where and why mothers are dying, mobilize resources and policies to save lives, and reduce maternal mortality further.

Other arguments Kate brings up are related to complications related to pregnancy — yet again, it’s not clear these are more frequent in the US than in other places. Otherwise, yes, we should make female health more of a priority, which is exactly what I am advocating for.

As for the abortion related bans that she mentions, I have repeatedly mentioned my stance: as someone coming from an ex-communist country where contraceptives of all kinds were literally banned, I have a strong, visceral repulsion to all forms of reproductive control and I am strongly pro-choice. However, I am not sure about the relevance of these bans to this specific discussion. Presumably Kate wrote the article arguing against having kids for women who are deciding whether to have them or not, which means they are presumably in control of their fertility, not for women who are in the unfortunate and tragic situation of being forced to bear a child due to lack of access to proper medical care and lack of options. Furthermore, it seems strange to me that one would make a life decision as important as whether to have children or not based on whether Trump is president or not (or any other political event).

Pregnancy and childbearing is not for everyone and women should be generally appreciated much more for what they are doing when they take on the task of bringing children into the world — here I suspect me and Kate agree. I also agree with her that nobody should feel “obligated” to give birth — it’s entirely a personal choice. But other than that, I still think that many of the arguments in these posts are based either on poor data or on stuff that’s not that relevant, like who happens to be President at a given point in time. Unless that affects you directly, e.g. via a large decrease in net worth because the economy is dwindling, I do not think important life choices should be influenced by whether your preferred candidate is in power or not.

And to end all this this, I would add that the right response is that which I always emphasize in my articles. If you want to help women, get involved in initiatives to study fertility and women’s health, raise funds for such research, start companies around it, raise awareness of current fertility preservation strategies (e.g. egg freezing and so on). The header image of this post is a Gustav Klimt painting of a pregnant woman called “Hope”. There is a literal reading here: pregnancy is the essence of hope, the way in which life regenerates itself. And a metaphorical one: we should approach the challenges that women face with hope for a better future, without forgetting what a unique moment we are living in: for the first time in the existence of humanity, we are armed with the tools of science to achieve this.