Open Access
Unfit Mothers Only: Medical Gatekeeping of Second‐ and Third‐Trimester Abortion in France
by Raphaël Perrin
ABSTRACT
Background
In France, abortion is available without restriction as to reason until 14 weeks of pregnancy. Beyond this limit, medical authorization is required and “medical termination of pregnancy” is permitted for fetal malformation or serious danger to the woman’s health, including from “psychosocial distress.” Little is known about how professionals interpret psychosocial distress criteria and which women are deemed eligible.
Methods
This study is based on 6 months of ethnographic fieldwork (2021–2022) in two French university hospital maternity wards. Data collection included observations of abortion care, 12 multidisciplinary team meetings, and interviews with 25 healthcare professionals (gynecologists, general practitioners, psychiatrists, psychologists, social workers, and midwives). Analysis of case files from 27 past medical termination of pregnancy requests provided additional data.
Results
Healthcare professionals pathologized reproductive nonconformity by constructing certain women as unfit for motherhood based on intersecting marginalization—class, racialization, age, disability, and family structure. Approval depended on intersecting characteristics distancing women from the “good mother” norm: poverty, violent relationships, incarceration, substance use, and psychiatric diagnosis. Professionals medicalized social inequality while regulating abortion seekers’ emotions and behaviors. Gynecologists invoked fetal interests to refuse requests and conditioned approval on long-acting contraception or sterilization. Professional hierarchies shaped decisions, with gynecologists dominating.
Conclusions
Medical gatekeeping of second- and third-trimester abortion care reinforces reproductive stratification by granting access primarily to marginalized women judged incapable of motherhood while subjecting them to contraceptive coercion. Physicians construct reproductive legitimacy through collective practices, transforming social and political issues into medical problems.
From the Introduction
As of January 2024, 77 countries permitted abortion with no criteria beyond gestational duration, 12 allowed abortion based on social or economic grounds, 47 allowed abortion for “therapeutic” reasons (fetal malformation or threats to the pregnant person’s mental or physical health), and 44 others permitted abortion if the woman’s life is at risk. In nearly all cases, physicians enforce the criteria defined by law—whether gestational duration, socioeconomic distress, fetal malformation, or health threats.
In France, as in other countries with ostensibly liberal abortion laws, access follows a dual track. Before 14 weeks of pregnancy, abortion is available without restriction as to reason to “pregnant women who do not wish to continue a pregnancy.” Beyond this limit, abortion remains legally possible without gestational duration restrictions but requires medical authorization. This is known as medical termination of pregnancy (MTP), authorized by the 1975 law and supplemented by the July 4, 2001 law “either when continuing the pregnancy poses a serious danger to the woman’s health, or when there is strong probability that the child-to-be-born will be affected by a condition of particular severity recognized as incurable at the time of diagnosis.” French law provides neither a list of the fetal pathologies nor a clarification of what constitutes serious danger to the woman’s health. A 2020 amendment to the bioethics bill explicitly stated that the danger could “result from psychosocial distress,” but did not define the term. The amendment was ultimately rejected on grounds that psychosocial distress was already considered in evaluating these requests and that explicitly specifying it might suggest its primacy over other maternal grounds for MTP.
However, the law does define the overarching process and which professionals may authorize MTP. In an October 2019 statement, the French National College of Obstetricians and Gynecologists—the profession’s main scientific organization—recalled that the MTP law implicitly included “psychosocial causes” and urged obstetric-gynecology departments to accept MTP requests from “women in situations of personal danger, violence, major psychological difficulties, or extreme precariousness making continuation of pregnancy impossible.” The following year, the College’s president wrote in an opinion piece that beyond the legal abortion limit, “requesting is no longer sufficient; psychosocial reasons must convince the medical team,” and that “the precise definition of psychosocial distress is left to physicians’ judgment.”
Abortion seekers presenting after 14 weeks without fetal malformation can thus request MTP for psychosocial distress. In most French facilities, including the two maternity wards studied here, this entails a complex process involving four separate consultations—with a gynecologist, psychologist, social worker, and psychiatrist—spanning several weeks. Because neither the law nor clinical guidelines specified decision criteria, professionals interpreted the category locally and on a case-by-case basis. After individual consultations, they convene in multidisciplinary team meetings to decide whether to authorize MTP. During these meetings, they articulate, discuss, and sometimes debate what constitutes the psychosocial distress that would, in their view, justify second- or third-trimester abortion. An analysis of health insurance data estimates that 250-300 MTP for psychosocial distress were performed in France 2023.
Before 14 weeks of pregnancy, the principles of universal access and women’s autonomous decision-making are given primacy; beyond that point, case-by-case assessment and physician gatekeeping prevail… (continues at length, e.g. discussing “unfit mothers…).
SOURCE: https://onlinelibrary.wiley.com/doi/full/10.1111/psrh.70095?campaign=wolearlyview