A Catholic Framework for Women’s Health
What is needed is a critique to challenge the standard paradigm of “women’s reproductive health.” But a critique must come from somewhere, some stable ground that provides a basis for evaluation—which in this case is a Catholic vision of reality. Working from a Catholic framework, my main contention is this: What is often presented as women’s “reproductive health” actually pathologizes natural biological realities that are unique to women, namely: fertility, pregnancy, and childbirth.
There is an underlying, hidden premise at work in this paradigm of pathology, which prevails in both feminist rhetoric and the medical establishment: women, to be “healthy” and “free,” must function, biologically speaking, as much like men as possible. What is uniquely female, then, is pathologized, seen as a condition that needs to be treated, a problem that needs to be solved. This tendency toward pathology is expressed in two key areas of women’s health: fertility and childbirth.
But first, here is where I am coming from:
The cosmic egg is one of my favorite images of the Catholic worldview. The image comes from a vision of St. Hildegard of Bingen, a 12th century abbess, musician, mystic, theologian—and physician. The universe, including the human person, is a harmonious and orderly whole. In fact, the order and harmony of the human body is a microcosm, or miniature reflection, of the cosmos.
This harmonious whole has a divine significance, because it was brought into being and is held in being—right now, in this very moment—by a loving God. This is important to note: God is not simply a creator God in the past, at the beginning of cosmic history; in every moment, the continued existence of the world is dependent upon the will and action of God.
Furthermore, the cosmos is not merely an object of God’s creation, but is also part of God’s self-revelation, his attempt to break into our world and form a relationship with us. In this way, the physical world serves a sacramental function. This is an important Catholic principle: the visible reveals the invisible. The material world, even our bodies, serves as signs and icons of the hidden God.
This is crucial: in the Catholic vision, the human body is good. The female body is good. The male body is good. This very maleness and femaleness, in fact, is part of the body’s sacramental meaning. All through Christian revelation, scripture and tradition, the primary metaphor we are given for understanding God’s relationship to humankind is the symbol of sexual, conjugal union. The capacity for a human man and a human woman to join together and form a complete reproductive whole—thus creating the possibility of new life—is a mirror for our capacity for union with God, a union that is likewise abundant and life-giving.
According to the sacramental principle, then, all of creation has intrinsic meaning and significance—and the human being above all, because the human being alone is created in God’s image and likeness. The human person, in a unique and unparalleled way, reveals the reality and person of God. Moreover, it is this very form—the form of the human being—that God himself adopts in the Incarnation, when his descent into our reality reaches its apex in the Resurrection of the person of Jesus Christ. The Christian witness of these two truths—the Incarnation of Christ and human beings as image-bearers—leads to a second principle of the Catholic vision: the principle of innate human dignity.
Every human being, no matter his or her circumstances, abilities, or stage of development, has infinite worth and dignity from conception until death—from womb to tomb. A Catholic vision of reality, then, is sacramental, incarnational, and affirms innate human dignity and the goodness of the human body.
Now, let us take a crack at defining “women,” because we strangely live in a time when there is no longer a shared understanding of what that word means. For some, the idea of “woman” is entirely a social fiction, a construct, a bundle of cultural myths and stereotypes that are projected onto, and subconsciously enacted by, the female body. This would be the view of Judith Butler, for example, the matriarch of contemporary gender theory. For others, being a “woman” is a subjective inner state, a deeply-felt conviction, that may or may not “align” with embodiment. To be a woman is not a bodily reality, but more of a question of the psyche or soul.
I could dwell at length on these definitions, their merits and flaws, but for my purposes here, I am going to propose instead a definition that is in accord with both Catholic theology and, I would argue, the biological sciences: A woman is the kind of human being whose physiology is organized around a capacity to generate and gestate human life. The terms “male” and “female,” and their human-specific correlates, “man” and “woman,” name what is fundamentally a reproductive identity.
Let me quickly respond to an obvious objection to my definition, which is perhaps surfacing in some of your minds. What about infertile women? Am I saying they are not really women? Absolutely not. You will notice my definition uses the word “capacity.” A synonym you could substitute here is “potential.” A woman is a human being who has the innate potential for pregnancy; when a woman is unable to get pregnant, she is called “infertile.” We do not say, however, that a man who cannot get pregnant is infertile, because a man does not have that potential to begin with. The very category of infertility, then, is sex-specific, and reinforces a definition based on reproductive potential—a definition that includes infertile woman, as well as pre-pubescent and post-menopausal women.
This topic of infertility highlights another important aspect of reality that I have not yet explicitly named—the darker side of the cosmos we inhabit. We live in a sacramental, orderly cosmos, yes—but a cosmos that is also marred by disorder: illness, suffering, and death. The downside of being material beings is that matter is not eternal, and as material beings, we are mortal. Our bodies are sacred, but they are also weak and vulnerable, prone to decay and disease.
The term “health” has dual etymological roots—a word in Old English that means “wholeness” and a word in Old Norse that means “holy or sacred.” Health, then, is wholeness—when the order and harmony of the body is in good working condition, when all is functioning as it is supposed to be. The work of healing is a restoration of wholeness. And there is something sacred about that very harmony and order, about restoring the natural processes of the body.
If we draw together all these definitions, we have the beginnings of a framework for a Catholic vision of women’s reproductive health: one that sees female physiology in terms of wholeness rather than pathology, and works with—not against—the natural order of the female body.
Fertility as Pathology
It is not a risky bet to wager that “birth control” is the first phrase that spring to mind when I say “women's reproductive health.” A 2019 special report in Scientific American on “the science of women’s reproductive health” provides an apt illustration with its background picture—a neat row of images of various birth control methods, as if women’s reproductive health is fundamentally about one thing: contraception.
The Scientific American report makes pains to affirm the standard triumphalist line—contraception makes women free!—but only as a disclaimer. The bulk of the report offers surprising critiques of the medical establishment’s enthusiastic attitude toward birth control, and how that enthusiasm can be an impediment to women’s health: “Clinicians tend to wield synthetic hormones like a hammer, liberally prescribing the birth-control pill for all kinds of pain—which is partly why serious diseases of the female organs such as endometriosis take an average of eight years to be diagnosed.”
The first article in this special report—“What is the Point of a Period?”—highlights the dearth of knowledge about the natural functions of the female reproductive system and cycles, particularly the menstrual cycle. In the rush to bring so-called “reproductive freedom” to women, pioneers of the birth control pill in the mid-20th century—Margaret Sanger, Gregory Pincus, John Rock—“appear to have ignored the implications of shutting down a woman’s natural cycle. [They] figured out how to supplant periods long before they began trying to understand why they work the way they do.” This dearth of knowledge among medical practitioners and researchers is shared by women themselves, who are routinely prescribed medication that disrupts or entirely suppresses fertility, but are rarely educated about how to better understand and “read” their own bodily indicators of fertility.
To most in the medical establishment, the pill is seen and prescribed as a magic bullet for all kinds of physical issues and irregularities. As Jonathan Schaffir, professor of obstetrics and gynecology at Ohio State puts it in Scientific American, “the pill is the closest thing we have to a panacea in women’s health.” But Elizabeth Kissling, professor of women’s and gender studies at Eastern Washington University disagrees: “The pill isn’t a treatment for [menstrual irregularities], it’s a way of refusing to treat them . . . Doctors are so quick to prescribe the drug to teenagers reporting bad cramps without investigating to see if there is an underlying cause.” Kissling, like myself, is concerned with the trend of prescribing the pill for long-term period suppression, in the absence of adequate knowledge about the potential ramifications. This trend, she says, is “the largest uncontrolled medical experiment on women in history.”
The most widely used and prescribed methods of birth control, such as the use of synthetic hormones and/or an intra-uterine device (IUD), work by disrupting the normal functions of a woman’s reproductive system, intentionally making it malfunction, in order to prevent pregnancy. Unsurprisingly, the disruption of one organ system can disrupt the equilibrium of the entire organism, which leads to increased risks for serious disease.
According to the National Cancer Institute, a metanalysis of 54 studies concluded that women who are using oral contraceptives have a 24% increased risk of breast cancer. A 2017 Danish study indicated that women with current or recent use of oral contraceptives had a 20% higher risk of breast cancer overall, and depending on the specific kind of pill, a risk as high as 60%. Moreover, the risk of breast cancer increased the longer oral contraceptives were used. The Danish study is particularly noteworthy, because it focuses on recent formulations of the birth control pill, rather than older versions with higher doses of synthetic hormones. Use of oral contraceptives also increases the risk of cervical cancer—and the longer the usage, the higher the risks. With five or fewer years of use, the elevated risk is 10%. With 5-9 years of use, the risk increases to 60%, “and a doubling of the risk with 10 or more years of use.”
On the other hand, use of oral contraceptives actually lowers the risk of endometrial and ovarian cancers by at least 30%. Do these relative risks then equal each other out? That is one way of reading it, perhaps. But it is worth noting that the protective value against ovarian cancer is due to a reduction of the overall ovulations and menstrual periods a woman experiences in her lifetime—a reduction that can be naturally accomplished by the processes of pregnancy, childbirth, and lactation, those very processes that the pill tries to suppress.
Pregnancy and breastfeeding, in fact, not only lower the risk of ovarian and endometrial cancers—they also lower the risk of breast cancer. A history of breastfeeding, moreover, increases the survival rates of women who do develop breast cancer. Avoiding oral contraceptives and experiencing the normal physiological processes of pregnancy, birth, and lactation, then, provide the optimal combination: a lowered risk of cancers across the board.
Hormonal birth control also increases the risk of developing depression, according to a 2016 study of over a million women living in Denmark. The risk was higher with progesterone-only forms of contraception, including the IUD: “That the IUD was particularly associated with depression in all age groups is especially significant, because traditionally, physicians have been taught that the IUD only acts locally and has no effects on the rest of the body. Clearly, this is not accurate.” The risk of depression was most elevated for adolescents. And, let us be honest, we do not need to make the experience of being a teenager harder than it already is.
These increased risks for serious, debilitating conditions, like cancer, depression, as well as blood clots and stroke, are accompanied by other common side effects—migraines, weight gain, decreased libido, mood swings. No wonder many women abandon their chosen method of artificial birth control after several years. According to the Contraception CHOICE project cited in the same Scientific American May 2019 issue mentioned above, a cohort study of 10,000 women aged 14-45, “69% of the women who had chosen oral contraceptives, injection, the vaginal ring or the skin patch had given up on them after three years.” Even the IUD, which seems better in comparison, has drop-out rates of close to 50% within five years, largely due to side effects such as bleeding, pain, or because the IUD perforated the uterus and was expelled from the body.
These statistics clearly indicate women’s widespread dissatisfaction with available birth control methods, belying the standard triumphalist line that contraception is the panacea to women’s reproductive health and freedom. But what is the alternative?
According to a 2012 study by researchers at UCSF cited by the Scientific American reproductive health issue, the top three features women desire in a birth control method are:
- lack of side effects
The study concludes that “that combination does not exist”—but in fact, it does, in natural forms of birth control, known as Fertility Awareness Methods (FAMs), or as it is known in Catholic circles, Natural Family Planning (NFP). According to the Scientific American report, FAMs are one of the only birth control methods “whose popularity is on the rise.”
FAMs have no physiological side-effects, because they do not seek to disrupt a woman’s reproductive system; they are affordable, requiring no ongoing prescriptions or medical procedures, and they are effective, as affirmed by multiple peer-reviewed studies. I will give just two examples:
- A 2008 study on the Marquette Method of NFP found a correct-use effectiveness rate of 99.4%
- A March 2019 study on the effectiveness of the Dot Period and Fertility Tracker app found a perfect-use failure of 1-percent, and a typical-use failure of 5 percent.
The conclusions of these studies show that FAMs, when used properly, are just as or more effective than artificial methods of birth control.
Despite the continual rhetoric about women’s freedom, control, and agency, there seems to be a deep mistrust among doctors toward relying more heavily on women’s agency when it comes to planning pregnancies. Instead, there is a marked preference to medically alter a women’s reproductive system, rather than trust women to read their own fertility, and, armed with that knowledge, make behavioral choices to either achieve or avoid pregnancy.
Speaking personally, I have never personally heard FAMs (NFP) suggested as a viable birth control option by a medical professional. When I became interested in natural birth control, I learned about it by talking to other women and doing my own independent research. And any conversations I have had with doctors about my choice to use FAMs invariably result in pressure to switch to a method that alters my normal physiology, like the pill or an IUD.
Just hours after the birth of my last child, the doctor came into my hospital room to offer a hearty congratulations before immediately asking about my plans for birth control. The conflicting implicit message seemed to be: “Congratulations on the birth of this beautiful baby! How thrilled you must be! Now . . . what can we do to make sure this never happens again.” She was not happy when I told her that I would be using fertility awareness methods.
FAMs do require, as the name suggests, a heightened and active awareness of bodily processes on the part of women. This is not a passive form of birth control, like popping a pill once a day, or inserting a piece of metal in the womb. But I do not see this as a bad thing. The more aware a woman is of her normal cyclical pattern, the sooner she will notice if something is amiss, which can indicate the presence of a condition that actually requires medical attention (unlike, say, simply being female). Moreover, I think women who are actively conscious of themselves as potentially fertile beings are in a better position to make healthy and informed decisions about when and with whom to have sex.
The use of passive birth control methods—those that work on a woman’s physiology without her conscious awareness—can alter a woman’s sense of herself as a fertile being, instead cultivating a consciousness of assumed sterility. This, in turn, could result in riskier sexual behavior and increased contraceptive failure rates. In other words, one psychological effect of using contraception could be a reduced awareness of the need for contraception. This reduced awareness of one’s capacity for pregnancy could be a contributing factor in the high rate of unplanned pregnancies in the U.S.—a rate that persists despite the widespread use of contraception. Shockingly, almost half of all pregnancies in the U.S. are unintended.
The key distinction between synthetic methods of birth control and fertility awareness methods is this: one seeks to prevent pregnancy by altering a woman’s physiology, so that it malfunctions and fails to do what it is designed to do. The other can be used either to avoid or achieve pregnancy through a deeper understanding of a woman’s physiology, which allows a woman to adapt her behavior to be in harmony with her physiology. In brief: one works by changing the normal functions of a woman’s body; one works by empowering a woman with greater knowledge of her body.
The current medical paradigm that sees the birth control pill as a panacea of woman’s health is a paradigm that pathologizes female fertility, viewing a woman’s potential for pregnancy as an adverse condition to be medically managed. This “medical management” entails disrupting the wholeness of a woman’s body, rather than restoring it, and in this way, is not in accord with the basic definition of health.
Childbirth as Pathology
A Catholic vision of women’s health and family planning, in contrast, would educate medical practitioners and women themselves in methods of fertility awareness, methods that work in harmony with a woman’s body, rather than disrupting it. This vision, in contrast to the Pathology Paradigm, provides a fertility-positive approach to women’s health, an approach that does not see a woman’s body as a threat to her freedom and happiness, but rather as something good and meaningful, worthy of deeper understanding and respect. This brings us to another realm of female embodiment that is pathologized by current medical practices: childbirth.
The most commonly performed major surgical procedure in the United States is a cesarean section. There are, of course, instances where C-sections are medically necessary. According to the World Health Organization, an optimal C-section rate should be around 10% of all births. The U.S. rate is currently three times this: in 2017 nearly a third of all babies born in the States were delivered by C-section.
According to a 2019 special report in U.S. News and World Report, “since the early 1970s, the likelihood of a mother undergoing a cesarean in the United States has skyrocketed by 500%.”
Here are some highlights—or perhaps we should say lowlights—from the report:
- “Although cesareans are designed to rescue babies from danger, rates of survival and brain injury among infants born close to their expected delivery date have not changed. Mothers have not benefited either—in fact, the opposite has occurred. Americans today are 50% more likely to die in the period surrounding childbirth than their own mothers were, a risk that has remained consistently three to four times higher for black mothers compared with white mothers.”
- “For mothers, birth complications such as hemorrhage, infection and organ injury are three times more likely to occur with a cesarean compared with a vaginal delivery—risks that increase with each subsequent cesarean a mother has.”
A 2018 systematic meta-analysis of 80 studies found the following long-term risks associated with cesarean delivery: Women with previous C-section deliveries have increased risks for placenta previa, when the placenta blocks the cervix; placenta accreta—a condition where the placenta grows through the walls of the uterus and can cause severe bleeding and death; placental abruption, when the placenta separates from the uterus prematurely; and uterine rupture. When compared with women who had a previous vaginal delivery, women with a previous C-section have higher odds of miscarriage, ectopic pregnancy, and stillbirth—as well a hysterectomy and antepartum hemorrhage.
Babies born as a result of a C-section are at higher risk for conditions such as asthma, allergies, and diabetes. A C-section delivery can also interfere with mother-infant bonding, successful breastfeeding, and contribute to post-partum depression.
The key to lowering the overall C-section rate is reducing the chances of that initial C-section, because once a woman has a C-section, it is much more difficult to give birth vaginally in subsequent pregnancies. In 2016, only 12.4% of women delivering with a previous C-section delivered vaginally. In 87.6% cases, then, a previous C-section led to a subsequent C-section. That first C-section has a cascading effect, leading to more C-sections and increasing risks of adverse conditions.
One major precipitating factor is the “cascade of interventions”—invasive steps by physicians to usher labor along, which often lead to subsequent interventions that can culminate in the need for a C-section. The U.S. News and World Report profiles one example:
Eryn McCraw-Smith, a 21-year-old student from Alexandria [Louisiana], was sent to Rapides Women's and Children's Hospital last year from her 37-week prenatal checkup because her blood pressure was high. Her obstetrician came to see her that night and decided she would be induced the next day.
“This is going to end with you cutting me open. I don't want this,” McCraw-Smith remembers telling her nurse. The next morning, her obstetrician gave her the labor-inducing drug Pitocin and broke her water. Less than 12 hours later, her doctor decided to perform a cesarean because McCraw-Smith wasn't progressing quickly enough. The surgery went smoothly, but her son ended up in the neonatal intensive care unit for three weeks with underdeveloped lungs.
He's healthy now, but McCraw-Smith often replays that day in her mind. She says she “will always feel like (delivery) could have waited until my baby was safer and not struggling to breathe.”
“I was scared because . . . I could feel that my body just wasn't ready,” she says. “But I mean, it really wasn't up to me at that point.”
Eryn’s story illustrates the “cascade of interventions” that can greatly increase the chance of a C-section delivery. As soon as artificial inductions are used, the chances of a C-section skyrocket to 50/50. Pitocin is often the first intervention, a synthetic form of oxytocin used to jumpstart a labor that has not even begun, as in Eryn’s case, or to speed up a labor that is not progressing quickly enough. Pitocin contractions, however, tend to be more intense and prolonged than natural contractions, increasing the chance of fetal distress, which can lead to an emergency C-section. In Eryn’s case, the doctor also broke her water—and as soon as the waters break, the clock starts ticking, as the risk of infection increases in the baby is not born within 24 hours. By taking this step, the doctor ensured a C-section would happen if Eryn did not give birth quickly enough.
As I write this, I am three weeks away from the birth of my fourth child. This is a high-risk pregnancy for several reasons, and for the first time I am facing the prospect of a labor induction if I do not give birth spontaneously before my due date. My main source of apprehension about induction is that I will be “put on the clock,” forced onto an artificial timeline for labor progression.
Carla Keirns, a physician and clinical ethicist, wrote about her own experience of childbirth in the journal Health Affairs, describing how her doctors seemed much more preoccupied by watching the clock, rather than their patient, pressuring her to have a C-section when her labor had “failed to progress” in a timely fashion. “Failure to progress” is the most common reason for a first C-section in the U.S. This is often when the cycle of subsequent C-sections begins. But, as Keirns notes, “judgments on what constitutes a slow or stalled labor are often subjective.”
Furthermore, “the criteria for assessing labor progress” is woefully outdated, “derived from observations of women in labor in the 1950s.”
Keirns cites a 2010 retrospective study of 62,000 women with successful vaginal births that found a much slower cervical dilation rate than the 1950s studies—50% slower, in fact. Many of the laboring women granted that golden ticket to a C-section—failure to progress—simply have not been given enough time.
There are also other factors—non-medical factors—at work that might explain why many doctors are in such a hurry to perform unnecessary surgeries: convenience. Doctors earn more from C-sections, they can schedule a surgery at their convenience, and they can control the timing and duration of delivery.
Holly Kennedy, a professor of midwifery at the Yale School of Nursing, puts it this way: “As an obstetrician told me . . . ‘You're going to pay me more [to do a C-section], you're not going to sue me and I'll be done in an hour.’” C-sections might be better for doctors, but they are worse for women and their babies.
The sky-high cesarean rates in the US reveal a medical culture that pathologizes natural childbirth—which often proceeds slowly—by the use of unnecessary and invasive interventions that lead, more often than not, to unnecessary surgeries. This is a medical culture that is more doctor-centered than patient-centered, that defers to the doctor’s authority to decide when and how birth should happen, rather than relying on more careful—and patient—attention to the woman herself, and her laboring body.
There is a familiar pattern here: an impulse to rely more on physician control than female agency, and to technologically manage and disrupt the natural processes of women’s bodies, rather than to better understand and work in harmony with those very processes.
With its many adverse risks for women, a medically unnecessary cesarean section does not meet the standard of health as a “restoration to wholeness.” And the bias toward efficiency, convenience, and profit reveals a consumerist attitude toward women’s bodies, rather than an attitude of dignity and respect. There are, however, positive changes afoot.
The American College of Obstetricians and Gynecologists has published updated recommendations for clinical practices with an eye toward reducing the C-section rate. These guidelines redefine the threshold of active labor from 4 cm of cervical dilation to 6 cm, emphasizing that a woman in prolonged latent labor should not be considered as “failing to progress.” A more recent opinion from 2017 states that “obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor.” The upshot of these revised recommendations is that doctors should give women more time and fewer interventions. Let a woman do what her body is designed to do.
This simple idea—that the procreative capacity of the female body is good—is not taken for granted in the dominant paradigm of women’s reproductive health. In that paradigm, “health” is not a vision of wholeness. Rather, is it a vision of resistance and control, one that sees the natural processes of women’s bodies as problems that need to be solved, and femaleness as something from which women should be freed.
A Catholic vision of women’s health, in stark contrast, sees the unique generative power of the female body as a divine gift, rather than a threat. This approach is unapologetically body-positive, birth-positive, fertility-positive, and life-affirming, because the Catholic worldview is one where bodies matter and are holy—because bodies speak the language of God and reveal to us the person, the woman, who is made in God’s image.
EDITORIAL NOTE: This essay was adapted from the 2019 Bioethics Lecture delivered at Franciscan University of Our Lady in Baton Rouge, LA on October 4, 2019.