Blessing unintended pregnancy

Religion and the discourse of women’s agency in public health

Don Seeman, Iman Roushdy-Hammady, Annie Hardison-Moody, Winnifred W. Thompson, Laura M. Gaydos, Carol J. Rowland Hogue

Abstract

Within public health and medical anthropology research, the study of women’s agency in reproductive decision making often neglects the role of religion and women’s spirituality. This article is based on ethnographic research conducted at a shelter for homeless (mostly African American) mothers in the southeastern United States. We explore the inadequacy of rational choice models that emphasize intentionality and planning, which our research shows are in tension with the vernacular religious and moral ethos of pregnancy as a ‘blessing’ or unplanned gift. Our findings confirm that young and disadvantaged women may view pregnancy and motherhood as opportunities to improve their lives in ways that mediate against their acceptance of family planning models. For these women, the notion of ‘blessing’ also reflects an acceptance of contingency and indeterminacy as central to the reproductive experience. We also question the increasingly popular distinction between ‘religion’ and ‘spirituality’ in contemporary public health.

Photo credit: ‘-11’ by J.K. Califf on Flickr

This article is based on ethnographic research among African American mothers at a homeless shelter in the southeastern United States.[note 1]The ethnographic research is described in detail in the next section.
 Most of the women we interviewed say that they became pregnant unintentionally or despite contraceptive measures. In several cases, getting pregnant was, by their own account, among the reasons they became homeless. Yet these women nevertheless tended to frame motherhood as either a catalyst for positive change or as a ‘blessing’ whose very nature defies human planning and control. Our ethnography began as part of an interdisciplinary study of the role of spirituality and religion in reproductive decision making among low-income women.[note 2]Fieldwork for the ethnographic portion of this study was conducted primarily by Iman Roushdy-Hammady and Annie Hardison-Moody with supervisory participation by Don Seeman. In addition, survey data (not included in this article) were collected at a separate health department location.
 As the ethnographic component of this research unfolded, however, we began to feel that a more basic consideration of concepts related to planning, control, and reproductive agency was needed.

Planning and intentionality are contested focal points in contemporary public health practice (O’Dougherty 2008; de Bessa 2006; Esacove 2008). Academic researchers, advocacy groups like Planned Parenthood, and governmental authorities like the US Department of Health and Human Services (2010) have all emphasized the correlation between unintended pregnancy and factors like maternal depression, decreased rates of breastfeeding (US Department of Health and Human Services 2010), late entry into prenatal care, maternal smoking, child abuse and developmental delays (Collier and Hogue 2006), low birth weight (Sable and Wilkinson 2000), and maternal impoverishment (Lifflander, Gaydos, and Hogue 2007). Interventions tend to focus broadly on the promotion of ‘family planning’ and ‘choice’, which includes access to counseling, increased access to long- and short-term contraception, and health education (James and Rashid 2013; Spain et al. 2010; US Department of Health and Human Services 2010). At the same time, researchers have begun to recognize that binary taxonomies of intended and unintended pregnancy may elide important distinctions between unplanned, unwanted, or merely mistimed pregnancies, and that alternative descriptive frameworks must be found to accommodate the mixed intentions and ambivalence, contingency (Bledsoe 2002; Cornwall 2007), and sociocultural or religious constraints (Lifflander, Gaydos, and Hogue 2007; James and Rashid 2013; Teman, Ivry, and Goren forthcoming) that characterize many women’s reproductive experiences (Wu et al. 2008). ‘Reproduction’, it has been noted (Johnson-Hanks 2005, 263), ‘offers a particularly appropriate locus for the study of intentionality and its limits’, because ‘“planning”, “intending” and “trying” are at once indispensable and insufficient modes of understanding social action around childbearing’.

Our study contributes to this body of knowledge by reframing the discussion of reproductive agency through attention to ‘vernacular religion’ (Primiano 1995; Albanese 2007; Flueckiger 2006), or everyday religious discourse, practices, and experiences that may disrupt or lend nuance to the binary distinction between intended and unintended pregnancy. Vernacular religious concepts like ‘blessing’ that were invoked by our informants call attention to a view of reproductive contingency that is often beyond planning, as well as to fields of agency that transcend individuals. We believe that we are better able to make sense of our informants’ reproductive experiences when we turn our attention to what anthropologists have called ‘agentive capacities’ (Coole 2005) that may be distributed across a social field rather than simply assuming, as in rational choice theory, that agency represents a unique capacity of bounded individuals. The women in our study sometimes spoke about agentive capacities concentrated in the hands of state or medical institutions that they experienced as inimical to their interests, but they also experienced divine blessing as a kind of life-giving and life-affirming agency beyond their control. We suggest that ‘blessing’ is an important prism through which we might begin to reexamine the construct of intentionality within reproductive health, as well as the increasingly popular (yet in our view, somewhat tenuous) analytic distinction between religion and spirituality (see Bender 2010, 46, 182–83). Statistics indicate that only slightly less than one-half of pregnancies in the United States today can be described as planned (Finer and Henshaw 2006). While black and Hispanic women do have higher rates of unintended pregnancies than white women, according to survey data (Kost et al. 2008; Mosher, Jones, and Abma 2012), it should also be emphasized that poor women report unintended births and abortions ‘at five times the rate of their counterparts in the highest income category’ (Finer and Henshaw, 2006, 94; see also Finer and Zolna 2011). Our research contributes to an understanding of the complex experiential and religious contexts in which some poor African American women decide – or resist having to decide – whether and when to have children.

Naomi’s House: The sense of new beginnings

Naomi’s House is an urban shelter specializing in care for families (mostly single mothers) with young children in the southeastern United States.[note 3]Names and identifying information for all informants have been changed. While we received permission to use the shelter’s actual name and location, we have chosen to withhold these as well, following standard research practice.
 Research was conducted over the course of fourteen months between November 2007 and December 2008. This included traditional participant observation of everyday shelter life (including classes and discussion groups organized by the shelter), a focus group initiated by the researchers, semi-structured interviews with shelter staff members, and life-history interviews with sixteen (out of about thirty-eight) female shelter residents between the ages of eighteen and thirty-seven. In the focus group, participants were asked about their reproductive health decisions (for example: Were your pregnancies planned? How did you feel when you found out you were pregnant? Do you use contraceptives? Why or why not?), religious and spiritual life (What does the term ‘religion’ mean to you? Can you be both religious and spiritual?), and questions about the intersection of religion and reproductive health (Have you learned anything from your religious community about reproductive health? Does how you take care of your body have a moral or spiritual element?). Life-history interviews were open-ended and included questions about the life course such as: Were you religious or spiritual growing up? What have you learned from your religious community or tradition about reproductive health? How has your faith or spirituality affected your decisions to have or not have sexual intercourse, have a child, use contraception, or carry a pregnancy to term? What do you wish that you had learned growing up about sexuality or women’s health? Researchers also attended church outside the shelter with two of the interviewees. All the participants in the study were African American women who had had their first child before the age of twenty-five and were residents at Naomi’s House during the research.

This study was part of a larger project, including surveys and focus groups conducted at another location, which brought together public health researchers, medical anthropologists, and religion scholars to examine the intersection of religious experience and women’s reproductive decision making. The goal of the ethnographic component conducted at Naomi’s House was to explore the everyday ways that women navigated and talked about their experiences of pregnancy, childbirth, and the challenges of homelessness. Although we focused on Naomi’s House residents, researchers also spent time with shelter staff in an effort to learn about the ethos, institutional culture, and rhythms of the establishment. Naomi’s House was founded in 1990 by a consortium of sixteen Christian and one Jewish faith-based organization, but staff members insisted that counselors receive no special religious or spiritual training and that on-site counseling is religiously neutral. There were no religious prerequisites for seeking shelter at Naomi’s House during the period of our fieldwork, but some of the programs that residents were required to attend did have religious or other ideological overtones. Most residents also participated in an optional weekly ‘Faith and Empowerment’ session led by volunteers from a local evangelical church. Despite the nonsectarian character of the shelter therefore, local religious institutions and religious ideas did contribute to the ethos of shelter life.

Even more pronounced than any specific doctrinal influence however was the pervasive emphasis on personal responsibility and self-management, including adherence to a set of relatively rigid shelter rules. Residents were obligated to participate in daily chores such as cooking lunch or cleaning bathrooms, to attend weekly counseling sessions and frequent group meetings (as many as three to four times per week), and to return to the shelter each night by 6:00 PM. ‘Planning’ was a self-conscious focus of many Naomi’s House programs that dealt, for instance, with money management or with balancing work and motherhood. Such messages were not, however, always clearly internalized by Naomi’s House residents. At one group meeting that members of our research team attended, women were asked by the facilitator to choose between a hypothetical night job offering more money or a day job in which they earned less but had hours that allowed them to take care of their children, as required by Naomi’s House rules (the shelter provides free child care during the day). Several women expressed consternation at having to make a choice, insisting that they would have to find some way to take both jobs, but without being able to offer any specific plans for doing so. This response can be viewed as a failure of – or resistance to – the planning discourse so prevalent at the shelter, but it also resonates with the commitment to ‘make a way out of no way’ (to persevere, with God’s help, despite serious obstacles) that womanist theologian Monica Coleman (2008) has described as an important feature of many African American women’s lives.

The Naomi’s House program was designed to provide clients with a temporary residence and childcare alongside educational opportunities to help them become economically and emotionally self-reliant. The average length of stay at the shelter was nine months, and residents worked with case managers to find a suitable future home. While women came to Naomi’s House for different reasons, they often described their arrival as an act of decisive personal agency, even if it was occasioned by an unforeseen event like pregnancy. ‘I didn’t have to come to the shelter’, insists Tiffany. ‘I could have … stayed with family and with friends, but I didn’t want to… . I needed to start over; I needed to better myself for my children. I needed to stop and break the pattern, so I went there’. Starting over was part of a complex set of meanings associated with pregnancy and blessing that came up in a variety of ways throughout our research. Yet even though starting over at the shelter was seen as an agentive act, the women from Naomi’s House did not idealize shelter life or minimize the problems associated with homelessness. Tiffany, for example, worried that homelessness would scar her children. ‘When you’re in a shelter’, echoed Janine, ‘it’s a reality check. You’re homeless. You have nowhere to go’. Still, the women viewed their predicament within a context of limited and frequently worse options that could make homelessness and pregnancy look better by comparison. Though they did not actively seek to become pregnant in most cases, this larger context allowed women to look back on their pregnancies as blessings rather than failures or catastrophes. 

Unintended blessings

Public health research has begun to recognize the role of ambivalence in women’s reproductive decisions (Schwarz et al. 2007; Lifflander et al. 2007; Stanford et al. 2000; Brückner et al. 2004; Crosby et al. 2002; James and Rashid 2013; Lessard et al. 2012), which may render simple binary oppositions between intended and unintended pregnancies unworkable. The women in our study frequently expressed ambivalence with respect to the very notion of human control over reproductive contexts. Three women at Naomi’s House had undergone abortions. Two of them invoked economic necessity to explain their decision to terminate, while a third described her own decision as a regretful act, ‘not forgiven by the Lord’. Yet all three women regarded the unintended pregnancies they subsequently carried to term as either ‘meant to be’, or ‘a blessing’. Whitney, one of only two women in our study who chose to have a tubal ligation, likewise expressed sadness and anxiety over the finality of her decision:

I believe in God, you know. And that’s the one thing that depressed me when I made the decision to get my tubes tied. I wanted to wait on menopause, but because I don’t [think] man has the right to decide what’s best. You know what I’m saying? In some aspects, medical decisions, you know – I don’t think, you know, you should – I just didn’t believe in getting my tubes tied because it wasn’t based in the Bible.

Whitney wanted to wait for menopause not just because tubal ligation is ‘unbiblical’, but because it represented for her an arrogation of the divine prerogative to send children into the world (see de Bessa 2006; O’Dougherty 2008). Yet she did undergo the ligation procedure in the end, despite her ambivalence. Such perceptions of tension or contradiction between human and divine agency were evident in multiple interviews, and they did not lead to a predictable outcome in women’s decision making. We refer here neither to articulated ‘health beliefs’ of the kind once posited by medical anthropologists (critically discussed in Good 1994, 1–24) nor do we assume that women’s reproductive experiences can be clearly derived from particular religious doctrines. Rather we are pointing to a vernacular sensibility that helps to shape women’s intuitive sense of well-being or ‘rightness’ in relation to the pull of different and sometimes seemingly opposed features of lived possibility: the existential tug between human and divine agency in becoming a mother, for example, or between planning and contingency more broadly.

This ambivalence emerged most powerfully in women’s accounts of becoming pregnant while using contraception; fully one-third of our interviewees reported that they had actually been using birth control at the time of conception. Eva’s account of her conversations with another woman after she became pregnant helps to demonstrate the social context in which perceptions of human agency and its limits are negotiated:

Everybody keep telling me that, saying that ‘Eva you don’t know and we don’t know’. You know, nobody knows but God what he had planned for you, you know what I’m saying? So she was like, ‘Just because you was on the birth control you probably got pregnant for a reason. You don’t know that reason right now because it’s just a learned process that you’re going through’. 

While this exchange certainly seemed to have been occasioned by attempts to comfort Eva regarding her contraceptive failure, her own retelling emphasizes that reproduction cannot be wholly scripted and that human attempts to do so are frustrated not just by caprice or bad planning but by the transcendent purposes and plans of divine agency.

The extent to which the vernacular perception of limited human agency may also contribute to positive outcomes for some women has not been sufficiently explored. Lisa told us that she was surprised when she became pregnant, despite the fact that she had been having unprotected sex, and admitted that she was hesitant to share the news of the pregnancy with her great-grandmother, a preacher in a local nondenominational church. She was however surprised at the outpouring of support she received when she eventually did tell her grandmother:

When my great-grandmother, she was – she put, like, that stamp of approval [on it]. You know – even though that happened – it was out of wedlock. [But, she told me] ‘It’s not the end of the world and you won’t have an abortion because of it, you won’t be ashamed of her because of it’. You know, ‘It’s not a mistake. Nothing’s by chance’. So she really, you know, let me know that it’s OK and ‘you will survive and you’re going to make it with this baby’. You know, Rebekah was a very joy, you know, she was.

Lisa’s great-grandmother and the religious community in which she preached supported Lisa in part by affirming that her pregnancy was God’s decision and could not, therefore, be considered a mistake. Their disapproval of abortion, significantly, was not articulated in abstract terms about when precisely life begins or how the rights of fetuses should be balanced against those of mothers (frequent subjects in the political debate over abortion rights in North America), but rather through an assertion of almost reflexive and visceral respect for divine initiative in creating life.

Naomi’s House residents frequently described pregnancy or motherhood as effectively beyond their control yet simultaneously emphasized that motherhood provided the context for them to start over, receive blessings, or triumph over adversity. Eva, for example, refused to allow two unintended pregnancies to prevent her from finishing high school:

I didn’t use that [having a child] as an excuse at the time … because of the fact that I had a child and another one on the way, and I was only eighteen, and I told myself, ‘Oh, there’s no way I’m not graduating and I’m not walking down that hall’. So I put every effort that I had, even though it was hard because I had a son. I was coming home from school to look after him, feed him, bathe him, and also do my homework. So, I mean, it was hard, but it was a learning experience; it taught me to grow up.

Whitney similarly described how having a child immediately after high school forced her to take stock of her situation:

I had him so young. I thought – I did everything with that boy. When I graduated, I had to carry him across the stage with me; I had to work to provide for him… . I didn’t want to be tied down; I didn’t want to be another statistic. I didn’t want to be another black girl – like so many of them here, not just here in the shelter but in society, period – with all these children and no fathers, you know. And I didn’t want to be like that. So I figured until I was able to afford children, after my son I was not having any more.

Another resident, Demetria, also went back to school for her GED in order to show her daughter that ‘Without education, it’s not making it’. Each of these women described motherhood as the primary reason that they managed to reframe their lives around achievement and success rather than endless struggles and disappointment. Our research supports findings by other scholars that women in vulnerable populations may view motherhood as an important form of leverage to improve their situation (Lucker 1997; Herrmann 2006; Edlin and Kefalas 2007).

Deshauna describes her decision to have a child at the age of sixteen as an opportunity to leave her abusive childhood home and get off drugs:

Now I feel like it was a – a reason for me to have kids. Because the way that I was. I was just outrageous, it’s like kicked down to jail and, you know, different things like that. So, I feel like it was, you know, helping me out to have a child because it slows me down from doing all the other things that I used to do, you know.

Yet despite her active decision to become pregnant, she too is acutely aware of the profound contingency of successful reproduction, expressed here in an idiom of gratitude:

So I just, I thank God for both of my kids, you know, because I could have had an abortion within the time of my pregnancy or, you know, something could have happened. I could have fell in the street and lost my baby or, you know, a car accident or anything like that. So I just, my babies are very, very, very meaningful for me. I mean they, they really changed my life.

Diana, likewise, accepts responsibility for the decision to have a child and to seek shelter at Naomi’s House rather than stay at home, childless, and tolerate her partner’s abusive behavior.

We just, just decided to have a baby. Now I think about it, I’m like, I should have waited but, but I mean, I love my baby and I don’t regret it – but, I’m thinking, but, because, I’m really here because of him. You know, because I, myself, if it was just me, I wouldn’t mind going to my sister’s house, back and forth, you know, like that. But, because of him I’m here [at the shelter].

Diana was one of five of the women we interviewed who did not use the language of blessing to describe their pregnancies, but she also acknowledged that attributions of agency can be tricky because even decisions made with less than full intentionality or understanding of repercussions (‘we just decided to have a baby’) can turn out to have significant (and in her view positive) consequences later on. In this way, much like the women who did use the language of blessing, Diana viewed her pregnancy and subsequent visit to Naomi’s House as a turning point in her life for the better.

Lisa described the day she arrived at Naomi’s House as ‘one of the worst days of my life … but, you know, you got to take the bitter with the sweet’. She added that if she had to do it all over again she ‘probably would’ because otherwise ‘I wouldn’t be … able to tell my testimony and help others’. Lisa reframes her hardship as a kind of Christian testimony, a story of redemption that might offer hope to others who suffer. Janine spoke about the experience of being a homeless mother this way:

I believe that children are a blessing. I believe He [God] blessed me, you know, with three babies, you know. It’s an honor to be a mom, you know, a mother, it is. And it’s an honor to be a father. It’s an honor to procreate, period, and I feel like I was selected as a chosen – you know, there’s people right now that can’t even have babies. You know, my, one of my best friends, you know, she had some intestinal issues, so I think for her to become pregnant will be hard, hard for her.

Blessing and the experience of being chosen bespeak a vernacular religiosity that may not easily assimilate to the binary opposition between ‘religious’ (in other words, denominational) and ‘secular’ discourse that is sometimes presumed in social science research (see Huss 2014). It is important to note, for example, that none of our informants raised these issues with respect to the doctrinal permissibility of contraception debated in American political and religious discourse (though a few did, as noted above, express qualms about abortion or tubal ligation), but rather to convey a more diffuse and generalized ethos of pregnancy as a gift or blessing that cannot or should not be too closely controlled by human agency.

The language of blessing was also frequently used by women to depict reproduction under conditions of scarcity. Demetria, aged twenty-seven, had one abortion when she was thirteen and another several years later when her first child was sixteen months old. She did eventually have a second child through an unintended pregnancy, but spoke in interviews about her strong desire for additional ‘blessings’ of children through both pregnancy and foster motherhood before she turns thirty-five: ‘People are like, “You already [had] a boy and a girl, why do you want more”, but I’m like, “Maybe it’s because I’m blessed enough to have them”. Some people can’t have kids – I’m like, “A child is a blessing to all, so I want that blessing over and over again, as many as I can have”’.

One of the reasons for Demetria’s eagerness, we learned, was a sense that having children and caring for them would allow her to set right what had been ruined through her own mistreatment by a foster parent when she was a child. Religious and spiritual themes relating to pregnancy or motherhood were most powerful when they were related to specific events in the mother’s own life, against which they achieved resonance and meaning. In fact, we would argue that, while blessing is a multivalent expression with deep religious and cultural roots that deserve analysis in their own right (see Seeman 1998), one of the reasons that it resonated so powerfully for so many Naomi’s House women is that, like Christian grace, it was conceived as an unplanned ‘gift’ holding power to change things for the better.

Intentionality and contraception

It is important to emphasize that the women we spoke with described the limitations of reproductive planning in a variety of ways, not all of which shared the positive valence of ‘blessing’. While many of the difficulties described by our informants have also been noted by other scholars, their ubiquity in the narratives we collected calls for at least brief consideration, not least because it shows how consistently women’s matter-of-fact acknowledgement of hardship and celebration of blessing went hand in hand. Indeed, it is likely because of such hardship and their inability to control central features of their reproductive experience that this register resonates as powerfully as it does with Naomi’s House women. ‘The widespread sense that disadvantage and unpredictability permeate not only the economy but also social and personal relationships’, notes Johnson-Hanks (2005, 366) of her fieldwork in Cameroon, ‘reduces the social pressure in favor of transparent and predictable action’. Not only does the contingency of ‘caprice and circumstance’ (Cornwall 2007, 229) figure large in the determination of reproductive outcomes, but so do the strategic and sometimes impulsive choices made by other people, such as kin, medical professionals, and reproductive partners.

Only one of the women we interviewed at Naomi’s House was living with her partner; most emphasized that they were raising children on their own. They almost uniformly reported an inability to influence their partners to use contraceptives or contribute to child rearing, and frequently also described a lack of control over their own reproductive cycles and contraceptive use. Anthropologists have argued that public health policies that focus on contraceptive education for women may obscure the extent to which women’s agency is effectively constrained by male economic and social dominance (Farmer, Conners, and Simmons 1996). The women we spoke with echoed other American women interviewed by Esacove (2008), however, who tended to emphasize personal failures or emotional dynamics rather than structural constraints when recalling why they or their partners did not use contraception. When Demetria was asked why, given what she knew about the risks of sexually transmitted diseases and unwanted pregnancies, she had sex without a condom, she replied that she was ‘the type of person that – I couldn’t stick to my guns. If I felt like we should use a condom and he didn’t want to, and I couldn’t stick up for myself and say, “Look, you better use a condom or nothing”’.

When we asked women if their partners used condoms during sex, many said that their partners did not like condoms or were allergic to them. Janine admitted her partner’s inconsistency in his reported willingness to use a condom with other women when he cheated on her, and his refusal to use one with her, to which she grudgingly acquiesced. Tiffany said that only half of her partners wore a condom, and that she was sometimes unsure whether they were wearing one at all or using it correctly. Implantable hormones such as Norplant and other contraceptives were offered free of charge at local clinics, yet women expressed considerable reservations regarding possible or experienced side effects (see Huber et al. 2006; James and Rashid 2013; Lessard et al. 2012).

Regina’s account, which was not atypical, helps to illustrate the relationship between poverty, fear of side effects, and the vagaries of local access to particular forms of birth control in making effective reproductive planning difficult:

After I had Jamar [in 2002] I had got the Norplant. So, I had to get that removed. I was gaining a lot of weight, I just didn’t like it, so I had that for like a year. So I got that removed, then I did the pill for like another year. And what happened was, I was getting, [at] that same free clinic, I was getting the pills from there, and what they were giving me, they stopped carrying it. So I had to use something else and it was making me feel sick so I just stopped taking them and then I got pregnant.

‘I was going to get the shot’, said one woman in our focus group, ‘but, you know, everybody have their own side effects depending on how their body is; I don’t want to gain weight or have my hair fall out’. Another focus group participant said she remembered that IUDs were metal rods associated with cancer. The perception among these women that they lacked good options for contraception was reinforced by the fact that one-third of those interviewed claimed to be using some form of birth control at the time they became pregnant.

Several of the women we interviewed, and nearly half of the women in our focus group, reported negative encounters or fears of negative encounters with medical professionals. One woman expressed fear that doctors might ‘touch me the wrong way, because it has happened before’, while another reported that a doctor once told her ‘to her face’ that he did not want to treat her because her breasts were too large. One participant mentioned that the disrespect and condescension she was shown by medical professionals because of her youth ‘kept me from wanting to get involved in my reproductive health’. Experiences like these invoke a whole history of structural violence towards African American women within the American medical system (Mitchem 2004; Roberts 1998) that may help to engender not just mistrust of individual doctors but also a generalized mistrust of the medicalization of reproductive life and its concomitant ethos of reproductive planning.

Religion, spirituality, and reproductive contingency

Several of the women we came to know were active participants in local churches and religious groups, and members of our team attended church with two of the participants as part of our fieldwork. Yet analyzing the role of religion in this context is complicated by the fact that many women denied, when asked, that they were ‘religious’. Lisa insisted that she was not religious but rather ‘spiritual’, while Angela told us frankly that ‘religion’ is about ‘throwing stones’, in opposition to expressions of ‘faith’ and ‘love’. Bridgette drew a distinction between a ‘relationship with God’, which was about respect and reverence, and formal religion, which was about ritual practice and disdain for sinners. But this discursive opposition (between religion and spirituality), which has proven useful as an alternative to studies focused on church denominational membership (see Thompson 2006; Jesse and Reed 2004) also has deep Christian roots of its own (see Huss 2014), suggesting that it should be treated analytically with care (see Bender 2010; Herman 2014). The heavily negative valence of ‘religion’ was frequently voiced by women who were themselves quite active in local religious institutional networks and who regularly attended church. ‘Spirituality’, moreover, was preached from the pulpit during some of the local church services we attended with women from Naomi’s House. The pastor of Bridgette’s apostolic Pentecostal church, for example, gave a sermon in which she identified ‘religion’ with what she called ‘Hollywood Christianity’, by which she meant ‘putting the word of a pastor before the word of God’, and separating people by denomination, race, class, or gender rather than uniting them in faith. The same pastor said in another Sunday sermon that she wanted to ‘do things outside of the box’ by ‘following the spirit of the Lord and never going back to what I left [mere institutional religion]’.

These findings resonate with Marla Frederick’s (2003, 14–15) ethnography of African American women in North Carolina, who tended to identify spirituality with ‘maturation over time’, and with the ‘genuine concern about God’ that make prayer, church attendance, and reading of scripture into more than just empty practice. But if spirituality is understood in these African American religious settings to be intrinsically related to institutionalized religious life (and indeed, to be one of its desired outcomes), then the categorical opposition between religion and spirituality that has sometimes been posited by social science and public health researchers becomes rather difficult to sustain. Despite nearly universal self-description as ‘spiritual but not religious’, six of the fifteen women with whom we conducted life history interviews worshiped with a Christian community (usually a nondenominational or evangelical church) on a regular basis. Four of the women did not attend a church, but expressed a desire to do so, indicating that they wanted to be a part of a caring community that would support them and their children through homelessness. Five remained ambivalent about religious institutions, but said that they prayed on their own since going to church was not requisite for doing so. ‘You don’t have to go to church, you know’, Ashley told us, ‘to praise God’.

We respect informants’ terminological choices and definitions, but hesitate to adopt them as analytic categories without a better accounting of how they may relate to tools already in use by ethnographers and scholars of religion. Courtney Bender (2003, 68–70) provocatively argues, for example, that the emphasis on spirituality over religion is more likely to be voiced in interviews (rather than participant observation contexts) because interviews encourage informants to privilege accounts of freedom and personal agency over interpersonal connections and institutional ties. We are going further, and suggesting that Naomi’s House women invoke ‘spirituality’ not as an alternative to religion as classically understood but as part of an internal Christian discourse that includes a critique of some institutional Christian practice.

Kramer, Hogue, and Gaydos (2007, 332) have determined that ‘religious affiliation’ with a particular church or denomination plays ‘little to no role’ in determining whether American women who are sexually active will or will not use contraception. This does not mean, however, that religious experience, practice, or communal membership are unimportant in shaping women’s experience of conception, pregnancy, and motherhood. Several of the women at Naomi’s House described moving between churches over time in search of greater connection to others or acceptance of their pregnancy and parenthood. Others, like Lisa, felt surprised and validated by the support they received from communities in which they had been more tangentially involved before they became pregnant. Lisa’s decision to go ahead with her unintended pregnancy was reinforced not by any specific church doctrine but by a show of communal support for her decision to accept what she perceived as God’s blessing rather than ‘shamefully’ rejecting it. Public health research that focuses on narrow doctrinal or denominational considerations may well tend to miss the broader phenomenological implications of religious life.

Two-thirds of the women who participated in life history interviews at Naomi’s House interpreted their pregnancies – though unintended by them – as intended by an agency that trumps human planning. These women framed what some might treat as accidental, capricious, or even catastrophic events as evidence of a caring and transcendent cosmic order. On a descriptive phenomenological level, the contingency of ‘blessing’ corresponds to the radical uncertainty and frustration that characterized many aspects of Naomi’s House women’s lives. And it stands starkly at odds with the discourse of rational family planning that is widely and diligently promoted within public health, and indeed at the shelter itself (Centers for Disease Control and Prevention 1999; James and Rashid 2013). Even the five women who said that they actively chose to become pregnant – despite their youth, socioeconomic hardship, and overall lack of stability – challenge the common use of planning discourse by defining pregnancy in those challenging circumstances as an empowering realignment of the social world.

Though vernacular religious ideas about pregnancy as a blessing were important to most of the women we spoke with at Naomi’s House, we nevertheless want to emphasize that it would be a mistake to assume that religious conceptions always mediate against planning discourse. Indeed, Christian ethicist Amy Laura Hall (2008, 10) has documented the role played by mainline Protestant denominations in promoting ‘meticulously planned procreation’ among nineteenth and early to mid-twentieth-century American women, leading to what she called a ‘delineated, racially encoded domesticity’ identified with eugenics. Rather than assuming we know what religion means in reproductive settings, we urge scholars to attend to the local moral worlds that women actually inhabit – worlds that are often religiously inflected – and to follow their lead in tracing the complex relationship between shifting perceptions of agency and contingency in reproductive life. Before we can begin to really parse homeless women’s relationship to planning discourse for example, we need to understand what a good outcome looks like to women struggling under these circumstances, and become more attentive to the contexts in which choices that appear less than rational to some observers may nevertheless seem like reasonable options or even blessings to the actors themselves.

Conclusion: Rethinking unintended pregnancy

The identification of pregnancy and birth with divine blessing is neither recent nor trivial in Christianity and related religious traditions. The womb, writes biblical scholar Thierry Maertens, ‘is the organ that … shall be the privileged locus of divine benedictions’ (cited in LaCocque and Ricoeur 1998, 24). Contemporary anthropologists working in Jewish, Christian, and Muslim settings in different parts of the world have all documented the continuing and widespread salience of blessing (Ginsberg 1989; Kahn 2000; Bledsoe 2002; Johnson-Hanks 2006; Teman, Ivry, and Goren forthcoming) as an expression of divine agency in human reproduction, though only a few have devoted significant attention to culturally situated phenomenological analyses of this construct (see Bledsoe 2002, 253–55). Minimally, the contingency of blessing in these contexts means that reproductive agency is not entirely in human hands. This does not, however, have to imply fatalism, nor does it preclude determined reproductive activism (see Seeman 1998, 2010). On the contrary, it is precisely the balance between culturally situated notions of human agency and their contingent limits in some particular local moral world that vernacular theologies of blessing are called upon to mediate.

A better comparative phenomenology would trace the contours of effort and blessing not just in different religious contexts but also in different social settings and at different moments in the life course. The logic of divine blessing represents just one term in a broader semantic field that also includes other ways of thinking about contingency, like ‘grace’, ‘fortune’, or ‘moral luck’ (see da Col and Humphrey 2012; Malaby 2012; Seeman 2015). We are not positing any direct correlation between particular theologies of blessing and the reproductive experiences of contemporary women in our study. But we do seek to call attention to a range of cultural and religious scripts that effectively qualify the presumption of unencumbered agency that is embedded in rational choice models. ‘Blessing’ is just one potential formulation, in phenomenological terms, of the need to reckon in some way with the contingency of bodily outcomes, social efficacy, and the ability of women or men to flourish in culturally appropriate ways – including the ability to bear and raise children – even under conditions of scarcity and structural violence. Blessing is therefore comparable (though it is by no means identical) to tropes of ‘luck’ and ‘destiny’ that are central to women’s narratives about reproductive agency in other settings (Esacove 2008, 380).

We have followed in the footsteps of researchers (see Gammeltoft 2006; Esacove 2008, O’Dougherty 2008) who have analyzed women’s narratives to describe the complex interplay of agency and constraint (for a good theoretical discussion of this binary, see Archer 2000) that helps to define the contours of reproductive experience. Though our ethnography focuses, like others in the field, on conditions of extreme scarcity in poor women’s lives, we are also sympathetic to the argument by some ethnographers that strong measures of contingency – implying ‘randomness, uncertainty … [and] a sense of vulnerability’, as well as ‘the possibility of taking action to prevent or mitigate misfortune’ – may pertain in different ways to women’s reproductive experience more broadly (Bledsoe 2002, 23–25). As Johnson-Hanks (2008, 307) concludes, ‘reproduction remains partly outside the calculus of conscious choice even in post-transition societies. The conceptual problems are echoed by empirical fact: at the individual level, reproductive intentions predict outcomes quite poorly’ (see also Cornwall 2007).

Some scholars have begun to call for more nuanced measures of intention in public health research (Santelli et al. 2003) while others have challenged the very saliency of intention as an assumed category of women’s reproductive experience (Esacove 2008; see also Moos et al. 1997). Edin and Kafalis (2005, 142) note that for the poor women with whom they worked, ‘the very uncertainty and adversity involved transform[ed] the choice to bring a less-than-perfectly planned pregnancy to term into an act of valor’. Another study (Gerber, Pennylegion, and Spice, 2002) suggests that some women associate the term ‘intended pregnancy’ itself with negative terms like ‘plotting’, ‘trapping’, or ‘being malicious’. While our research does not speak directly to this issue, it does bear out the observation that resistance to planning discourse stems from more than just simple ignorance or lack of access to contraceptives, but is also bound up with independent forms of vernacular moral and religious discourses of reproductive intentionality.

Our study is admittedly limited by its focus on retrospective accounts of pregnancy and motherhood that might well differ from women’s accounts of sexual or reproductive choices made in real time (Dixon-Mueller 1993; Sobo 1995). Yet to the extent that even retrospectiveidioms and judgments help to shape a distinctive ethos of reproduction and motherhood (Somers 1994; O’Dougherty 2008; Esacove 2008; Edlin and Kefalas 2007), we believe that these stories do offer a crucial window onto women’s ways-of-reproductive-being in the world. As many studies show, women make decisions about mothering and reproduction amid a complex layering of structures, beliefs, and values, which must also take into account factors like interpersonal relationships (Frederick 2003; Cornwall 2007; van der Sijpt 2014), accessibility of medical expertise (Raine et al. 2005; Apple 2006), poverty (Finer and Zolna 2011; Edlin and Kefalas 2007), and structural violence (Roberts 1998). Our engagement with women at Naomi’s House allows us to see that between the dichotomy of agency and constraint there lie other possibilities that have only rarely been described in public health literature. Following the lead of Naomi’s House women would mean showing greater attentiveness to the ways in which ‘agentive capacities’ (Coole 2005; see Sahlins 2013, 52–53) often seem to reside outside the self in powerful social and professional institutions (like public health or medical agencies), in significant others (including male reproductive partners), and in divine agency that transcends human will and planning (see Seeman 2015). In a world where some women perceive such capacities as being spread thinly across social space – not gathered too effectively anywhere, and certainly not in their own hands – ‘blessing’ provides one possible language for describing the experience of unforeseen consequences. In this way, our ethnography resonates with Frederick’s account (2003, 217) of women who confront immense personal and structural trials by focusing on ‘God’s vision of their life’ for sexual health and flourishing.

One benefit of this phenomenological approach is that it opens the concept of intentionality to broad analytic comparison across lines of class, culture, and racial or religious background. Planning research focuses disproportionately on poor women of color (see James and Rashid 2013; Roberts 1998). Yet the fact that nearly half (49 percent) of pregnancies in the United States today are described as unplanned (Ellison 2003; US Department of Health and Human Services 2010) indicates that something of broader cultural import must be involved. Ambivalence with respect to the progressive and ongoing medicalization of pregnancy and reproduction is widespread in American society (see Apple 2006). Abortion (Ginsburg 1989; Kelley, Evans, and Headey 1993; Driedger and Halli 1997) and invasive genetic screening (Reist 2006; Ivry 2006; Hall 2008; Teman, Ivry, and Goren forthcoming) are just two areas in which discourses of intervention, prevention, and rational choice have met with strong resistance. In her ethnography of the abortion controversy conducted largely among white, middle-class American women during the 1980s, Faye Ginsburg (1989) shows that women who opposed abortion were also likely to invoke stories of personal blessing in the context of their decision to bring difficult, dangerous, or unplanned pregnancies to term despite perceived pressure from acquaintances or medical professionals to terminate. This appears to be an enduring feature of the American reproductive landscape, not at all limited to poor African American women.

While authorized public debate in the United States today tends to focus on relatively abstract questions like when precisely in fetal development life begins, or how to balance the putative legal rights of women and fetuses (Driedger and Halli 1997), vernacular resistance to languages of control and planning has not been widely investigated. Social scientists and public health researchers ought to more actively engage their informants in thinking these issues through. This means that the place of religion in reproductive health research needs to be fundamentally reconsidered. Rather than focusing narrowly on correlations between public health outcomes and religious institutional affiliations or health beliefs, we need to unpack the experiential implications of specific forms of community and exclusion as well as the distinctive forms of intentionality that religious life may foster (see Seeman 2015). The question, to put it simply, is not just whether ‘religion’ complicates efforts to promote family planning, but whether family planning efforts have adequately considered the diverse and multiply contested terrain of moral experience (Kleinman and Seeman 1998; Jackson 2013) through which individuals and communities navigate.

Described as free and spontaneously given, the blessing of unintended children allowed some women at Naomi’s House to reframe their experiences of homelessness, violence, and loneliness in powerfully redeeming ways. Even women who did not use the language of blessing in our study often spoke about motherhood, planned or unplanned, as an avenue to better social support or decisions to escape debilitating personal relationships. None of this can erase the documented health and economic risks associated with unplanned pregnancy for poor mothers and children. But it does suggest that better engagement with different registers and contexts of intentionality—including those associated with vernacular religious life and the contingency of ‘blessing’ – might contribute to more adequate accounts of women’s agency in reproduction. 

Acknowledgements

Many individuals provided helpful feedback on this paper. In addition to our anonymous reviewers, we would especially like to thank D. Iesha Renee Curie, Georgette Ilunga Nkulu Ledgister, and Dianne Stewart. Research was funded by a grant from the Emory Religion and Public Health Collaborative.

About the authors

Don Seeman is Associate Professor in the Department of Religion at Emory University. He is the co-editor of the Contemporary Anthropology of Religion book series at Palgrave-Macmillan and holds a PhD in medical anthropology from Harvard, where he also held an NIMH postdoctoral fellowship in Clinically Relevant Medical Anthropology. He recently completed a Social Science Research Council grant from the ‘New Directions in the Study of Prayer’ initiative, and is the author of One People, One Blood: Ethiopian-Israelis and the Return to Judaism (Rutgers, 2009). He convenes the Forum for the Ethnographic Study of Religion at Emory.

Iman Roushdy-Hammady received her doctorate in medical anthropology from Harvard and her nursing degree from Georgia State. Her ethnographic research has focused on genetic factors in susceptibility to environmental exposure to asbestos-like carcinogens, as well as reproductive health in ethnic minorities, and the social and behavioral determinants of health disparities in minority groups. She is also interested in the behavioral factors in the prevention of cancer, sexually transmitted diseases, and other chronic and infectious diseases. She served as PI and lead ethnographer of the study on which this is article was based while working as a postdoctoral research fellow for the Religion and Public Health Collaborative at Emory.

Annie Hardison-Moody is Research Assistant Professor in the Department of Youth, Family, and Community Sciences at North Carolina State University. She received her doctorate in religion at Emory University in 2012, where she focused on the intersections of religion and public health. She is co-editor of Parenting Practices as a Source for Theology: Mothering Matters (Palgrave Macmillan, forthcoming), co-PI for a USDA-funded sociological study of the family food environment, and director of a faith-based health promotion intervention. She is currently working on a project that explores food, culture, and religious practices among immigrant and refugee families. 

Winifred W. Thompson is Research Assistant Professor in the Department of Behavioral Sciences and Health Education of the Rollins School of Public Health at Emory University. Her research interests include investigating the social determinants of health in conjunction with how psychosocial and spiritual factors contribute to a woman’s health and wellness. Dr. Thompson is also Principal Investigator of three projects: The Avon Foundation Community Education and Outreach Initiative, The Health Needs Assessment of Metastatic Breast Cancer Patients and Healthcare Providers, and Addressing Triple Negative Breast Cancer in the African American and Caribbean Communities through Education, Navigation, and Screening, all located at Grady Health System in Atlanta, GA.  Specific areas of her research include holistic health, maternal child health, lay patient navigation, and breast and gynecologic cancers.  

Laura M. Gaydos is Associate Professor in the Department of Health Policy and Management of the Rollins School of Public Health, Emory University. She is also the associate chair for academic affairs for the Executive Masters of Public Health program at Emory. Dr. Gaydos’s work focuses on women’s health, reproductive health, maternal and child health, and the intersections of religion and public health. She explores the role of social and political context in healthcare decision making through mixed-methods research that employs both quantitative and qualitative modes of inquiry.

Carol J. Rowland Hogue is Professor of Epidemiology and Terry Professor of Maternal and Child Health at Emory University. She co-directed the Religion and Public Health Initiative for Emory, and has co-authored several studies of the impact of religious institutions and practices on reproductive health, including ‘An Emerging Field in Religion and Reproductive Health’ in the Journal of Religion and Health (2010), ‘Circumstances of Pregnancy: Low Income Women in Georgia Describe the Difference between Planned and Unplanned Pregnancies’ in the Journal of Maternal and Child Health (2007), and ‘Noncontracepting Behavior in Women at Risk for Unintended Pregnancy: What’s Religion Got to Do with It?” in the Annals of Epidemiology (2007).

References

Albanese, Catherine L. 2007. A Republic of Mind and Spirit: A Cultural History of American Metaphysical Religion. New Haven, CT: Yale University Press.
Apple, Rima D. 2006. Perfect Motherhood: Science and Childrearing in America. New Brunswick, NJ: Rutgers University Press.
Archer, Margaret Scotford. 2000. Being Human: The Problem of Agency. Cambridge: Cambridge University Press.
Bender, Courtney. 2003. Heaven’s Kitchen: Living Religion at God’s Love We Deliver. Chicago: University of Chicago Press.
Bender, Courtney. 2010. The New Metaphysicals: Spirituality and the American Religious Imagination. Chicago: University of Chicago Press.
Bledsoe, Caroline H. 2002. Contingent Lives: Fertility, Time and Aging in West Africa. Chicago: University of Chicago Press.
Brückner, Hannah, Anne Martin, and Peter S. Bearman. 2004. ‘Ambivalence and Pregnancy: Adolescents’ Attitudes, Contraceptive Use and Pregnancy’. Perspectives on Sexual and Reproductive Health 36, no. 6: 248–57. http://dx.doi.org10.1363/psrh.36.248.04.
Centers for Disease Control. 1999. ‘Achievements in Public Health, 1900-1999: Family Planning’. MMWR 48 (47): 1073–80. http://dx.doi.org/10.1001/jama.283.3.326.
Coleman, Monica A. 2008. Making a Way out of No Way: A Womanist Theology. Minneapolis, MN: Fortress Press.
Collier, Sarah A., and Carol J. R. Hogue. 2006. ‘Modifiable Risk Factors for Low Birth Weight and Their Effect on Cerebral Palsy and Mental Retardation’. Maternal and Child Health Journal 11, no. 1: 65–71. http://dx.doi.org/10.1007/s10995-006-0085-z.
Coole, Diana. 2005. ‘Rethinking Agency: A Phenomenological Approach to Embodiment and Agentic Capacities’. Political Studies 53, no. 1: 124–42. http://dx.doi.org/10.1111/j.1467-9248.2005.00520.x. 
Cornwall, Andrea. 2007. ‘Taking Chances, Making Choices: the Tactical Dimension of ‘Reproductive Strategies’ in Southwestern Nigeria’. Medical Anthropology 26, no. 3: 229–54.  http://dx.doi.org/10.1080/01459740701457058. 
Crosby, Richard A., Ralph J. Diclemente, Gina M. Wingood, Susan L. Davies, and Kathy Harrington. 2002. ‘Adolescents’ Ambivalence about Becoming Pregnant Predicts Infrequent Contraceptive Use: A Prospective Analysis of Nonpregnant African American Females’. American Journal of Obstetrics and Gynecology 186, no 2: 251–52. http://dx.doi.org/10.1067/mob.2002.120081. 
de Bessa, Gina Hunter. 2006. ‘Medicalization, Reproductive Agency, and the Desire for Surgical Sterilization among Low-Income Women in Urban Brazil’. Medical Anthropology 25, no. 3: 221–63. http://dx.doi.org/10.1080/01459740600840263. 
da Col, Giovanni, and Caroline Humphrey, eds. 2012. ‘Future and Fortune: Contingency, Morality and the Anticipation of Everyday Life,’ Social Analysis Special Issue 56.
Dixon-Mueller, Ruth. 1993. ‘The Sexuality Connection in Reproductive Health’. Studies in Family Planning 24, no. 5: 269–82. http://dx.doi.org/10.2307/2939221. 
Driedger, Leo, and Shiva S. Halli. 1997. ‘Pro Life or Pro Choice: Politics of Career and Homemaking’. Population Studies 51, no. 2: 129–37. http://dx.doi.org/10.1080/0032472031000149866. 
Edin, Kathryn and Maria Kefalas. 2005. Promises I Can Keep: Why Poor Women Put Motherhood Before Marriage. Berkeley: University of California Press.
Ellison, Marcia A. 2003. ‘Authoritative Knowledge and Single Women’s Unintentional Pregnancies, Abortions, Adoption, and Single Motherhood: Social Stigma and Structural Violence’. Medical Anthropology Quarterly, New Series, 17, no. 3: 322–47. http://dx.doi.org/10.1525/maq.2003.17.3.322.
Esacove, Anne. 2008. ‘Making Sense of Sex: Rethinking Intentionality’. Culture, Health & Sexuality 10, no. 4: 377–90. http://dx.doi.org/10.1080/13691050801898869. 
Farmer, Paul, Margaret Conners, and Jannie Simmons. 1996. Women, Poverty and AIDS: Sex, Drugs and Structural Violence. Monroe, ME: Common Courage Press.
Finer, Lawrence B., and Stanley K. Henshaw. 2006. ‘Disparities in Rates of Unintended Pregnancy in the United States, 1994 and 2001’. Perspectives on Sexual and Reproductive Health 38, no. 2: 90–96. http://dx.doi.org/10.1363/3809006. 
Finer, Lawrence B., and Mia R. Zolna. 2011. ‘Unintended Pregnancy in the United States: Incidence and Disparities, 2006’. Contraception 84, no. 5: 478–85. http://dx.doi.org/10.1016/j.contraception.2011.07.013.
Flueckiger, Joyce Burkhalter. 2006. In Amma’s Healing Room: Gender and Vernacular Islam in South India. Bloomington: Indiana University Press.
Frederick, Marla.2003. Between Sundays: Black Women and Everyday Struggles of Faith. Berkeley: University of California Press.
Gammeltoft, Tine. 2006. ‘“Beyond Being”: Emergent Narratives of Suffering in Vietnam’. The Journal of the Royal Anthropological Institute 12, no. 3: 589–605.
Gaydos, Laura M., Alexandria Smith, Carol J. R. Hogue, John Blevins. 2010. ‘An Emerging Field in Religion and Reproductive Health’. Journal of Religion and Health. 49, no. 4: 473–84. http://dx.doi.org/10.1007/s10943-010-9323-1. 
Ginsburg, Faye. 1989. Contested Lives: The Abortion Debate within an American Community. Berkeley: University of California Press.
Good, Byron J. 1994. Medicine, Rationality and Experience: An Anthropological Perspective. Cambridge: Cambridge University Press.
Hall, Amy Laura. 2008. Conceiving Parenthood: American Protestantism and the Spirit of Reproduction. Grand Rapids, MI: W. B. Eerdmans Pub. Co. 
Herman, Jonathan R. 2014. ‘The Spiritual Illusion: Constructive Steps toward Rectification and Redescription’. Method and Theory in the Study of Religion 26, no. 2: 159–82. http://dx.doi.org/10.1163/15700682-12341264. 
Herrman, Judith W. 2006. ‘The Voices of Teen Mothers: The Experience of Repeat Pregnancy’. MCN. The American Journal of Maternal Child Nursing 31, no. 4: 243–49. http://dx.doi.org/10.1097/00005721-200607000-00009. 
Huber, Larissa R. Brunner, Carol J. Hogue, Aryeh D. Stein, Carolyn Drews, Miriam Zieman, Joyce King, and Susan Schayes. 2006. ‘Contraceptive Use and Discontinuation: Findings from the Contraceptive History, Initiation, and Choice Study’. American Journal of Obstetrics and Gynecology 194, no. 5: 1290–95. http://dx.doi.org/10.1016/j.ajog.2005.11.039. 
Huss, Boaz. 2014. ‘Spirituality: The Emergence of a New Cultural Category and Its Challenge to the Religious and the Secular’. Journal of Contemporary Religion 29, no. 1: 47–60. http://dx.doi.org/10.1080/13537903.2014.864803. 
Ivry, Tsipy. 2006. ‘At the Back Stage of Prenatal Care: Japanese Ob-Gyns Negotiating Prenatal Diagnosis’. Medical Anthropology Quarterly, New Series, 20, no. 4: 441–68. http://dx.doi.org/10.1525/maq.2006.20.4.441. 
Jackson, Michael. 2013. The Wherewithal of Life: Ethics, Migration and the Question of Wellbeing. Berkeley: University of California Press. http://dx.doi.org/10.1525/california/9780520276703.001.0001.
James, E. Angel, and Moira Rashid. 2013. ‘‘Welfare Queens’ and ‘Teen Moms’: How the Social Construction of Fertile Women Impacts Unintended Pregnancy Prevention Policy in the United States’. Policy, Politics & Nursing Practice 14, no. 3-4: 125–32. http://dx.doi.org/10.1177/1527154413510408.
Johnson-Hanks, Jennifer. 2005. ‘When the Future Decides: Uncertainty and Intentional Action in Contemporary Cameroon’. Current Anthropology 46, no. 3: 363–76. http://dx.doi.org/10.1086/428799.
Johnson-Hanks, Jennifer. 2006. ‘On the Politics and Practice of Muslim Fertility: Comparative Evidence from West Africa’. Medical Anthropology Quarterly 20, no. 1: 12–30. http://dx.doi.org/10.1525/maq.2006.20.1.12.
Johnson-Hanks, Jennifer. 2008. ‘Demographic Transitions and Modernity’. Annual Review of Anthropology 37: 301–15. http://dx.doi.org/10.1146/annurev.anthro.37.081407.085138.
Jesse, D. Elizabeth, and Pamela G. Reed. 2004. ‘Effects of Spirituality and Psychosocial Well-Being on Health Risk Behaviors in Appalachian Pregnant Women’. Journal of Obstetric, Gynecologic, and Neonatal Nursing 33, no. 6: 739–47.
Kahn, Susan Martha. 2000. Reproducing Jews: A Cultural Account of Assisted Conception in Israel. Durham, NC: Duke University Press. http://dx.doi.org/10.1215/9780822378204.
Kelley, Jonathan, M. D. R. Evans, and Bruce Headey. 1993. ‘Moral Reasoning and Political Conflict: The Abortion Controversy’. British Journal of Sociology 44, no. 4: 589–612. http://dx.doi.org/10.2307/591412.
Kleinman, Arthur, and Don Seeman. 1998. ‘The Politics of Moral Practice in Psychotherapy and Religious Healing’. Contributions to Indian Sociology 32, no. 2: 237–52. http://dx.doi.org/10.1177/006996679803200205.
Kost, Kathryn, Susheela Singh, Barbara Vaughan, James Trussell, and Akinrinola Bankole. 2008. ‘Estimates of Contraceptive Failure from the 2002 National Survey of Family Growth’. Contraception 77, no. 1: 10–21. http://dx.doi.org/10.1016/j.contraception.2007.09.013.
Kramer, Michael R., Carol J. Rowland Hogue, and Laura M. D. Gaydos. 2007. ‘Noncontracepting Behavior in Women at Risk for Unintended Pregnancy: What’s Religion Got to Do with It?’ Annals of Epidemiology 17, no. 5: 327–34. http://dx.doi.org/10.1016/j.annepidem.2006.10.016.
LaCocque, Andre, and Paul Ricoeur. 1998. Thinking Biblically: Exegetical and Hermeneutical Strategies. Chicago: University of Chicago Press.
Lessard, Lauren N., Deborah Karasek, Sandi Ma, Philip Darney, Julianna Deardorff, Maureen Lahiff, Dan Grossman, and Diana Greene Foster. 2012. ‘Contraceptive Features Preferred by Women at High Risk of Unintended Pregnancy’. Perspectives on Sexual and Reproductive Health 44, no. 3: 194–200. http://dx.doi.org/10.1363/4419412.
Lifflander, Anne, Laura M. D. Gaydos, and Carol J. Rowland Hogue. 2007. ‘Circumstances of Pregnancy: Low Income Women in Georgia Describe the Difference between Planned and Unplanned Pregnancies’. Maternal and Child Health Journal 11, no. 1: 81–89. http://dx.doi.org/10.1007.s10995-006-0138-3.
Malaby, Thomas. 2012. ‘Our Present Misfortune: Games and the Post-bureaucratic Colonization of Contingency’. Social Analysis Special Issue 56: 103–16. http://dx.doi.org/10.3167/sa.2012.560208.
Mitchem, Stephanie. 2004. ‘Jesus Is My Doctor: Healing and Religion in African American Women’s Lives,’ in Religion and Healing in America, edited by Linda L. Barnes and Susan S. Sered, 281–90. New York: Oxford University Press.
Moos, M. K., R. Petersen, K. Meadows, C. L. Melvin, and A. M. Spitz. 1997. ‘Pregnant Women’s Perspectives on Intendedness of Pregnancy’. Women’s Health Issues: Official Publication of the Jacobs Institute of Women’s Health 7, no. 6: 385–92. http://dx.doi.org/10.1016/s1049-3867(97)00081-9. 
Mosher, William D., Jo Jones, and Joyce C. Abma. 2012. ‘Intended and Unintended Births in the United States: 1982-2010,’ National Health Statistics Reports 55. http://www.cdc.gov/nchs/data/nhsr/nhsr055.pdf.
O’Dougherty, Maureen. 2008. ‘Lia Won’t: Agency in the Retrospective Pregnancy Narratives of Low-Income Brazilian Women’. The Journal of Latin American and Caribbean Anthropology 13, no.2: 414–46. http://dx.doi.org/10.1111/j.1935-4940.2008.00044.x.
Primiano, Leonard Norman. 1995. ‘Vernacular Religion and the Search for Method in Religious Folklife,’ Western Folklore 54, no. 1: 37–56. http://dx.doi.org/10.2307/1499910.
Raine, Tina R., Cynthia C. Harper, Corinne H. Rocca, Richard Fischer, Nancy Padian, Jeffrey D. Klausner, and Philip D. Darney. 2005. ‘Direct Access to Emergency Contraception through Pharmacies and Effect on Unintended Pregnancy and STIs: A Randomized Controlled Trial’. JAMA 293, no.1: 54–62. http://dx.doi.org/10.1001/jama.293.1.54.
Reist, Melinda Tankard. 2006. Defiant Birth: Women Who Resist Medical Eugenics. North Melbourne, Victoria: Spinifex Press.
Roberts, Dorothy E. 1998. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. New York: Vintage.
Sable, M. R., and D. S. Wilkinson. 2000. ‘Impact of Perceived Stress, Major Life Events and Pregnancy Attitudes on Low Birth Weight’. Family Planning Perspectives 32, no. 6: 288–94. http://dx.doi.org/10.2307/2648197.
Santelli, John, Roger Rochat, Kendra Hatfield-Timajchy, Brenda Colley Gilbert, Kathryn Curtis, Rebecca Cabral, Jennifer S. Hirsch, Laura Schieve, and Unintended Pregnancy Working Group. 2003. ‘The Measurement and Meaning of Unintended Pregnancy’. Perspectives on Sexual and Reproductive Health 35, no. 2: 94–101. http://dx.doi.org/10.1111/j.1931-2393.2003.tb00111.x.
Schwarz, Eleanor Bimla, Patricia A. Lohr, Melanie A. Gold, and Barbara Gerbert. 2007. ‘Prevalence and Correlates of Ambivalence towards Pregnancy among Nonpregnant Women’. Contraception 75, no. 4: 305–10. http://dx.doi.org/10.1016/j.contraception.2006.12.002.
Seeman, Don. 1998. ‘“Where Is Sarah Your Wife?” Cultural Poetics of Gender and Nationhood in the Hebrew Bible’. Harvard Theological Review 91, no. 2: 103–25. http://dx.doi.org/10.1017/S0017816000032028 
Seeman, Don. 2010. ‘Ethnography, Exegesis and Ethical Reflection: The New Reproductive Technologies in Israel’. In Kin, Gene, Community: The New Reproductive Technologies among Jewish Israelis, edited by Daphna Birenbaum-Carmelli and Yoram S. Carmelli, 340-60. Berghahn Books: New York.
Seeman, Don. 2015. ‘Coffee and the Moral Order: Ethiopian Jews and Pentecostals against Culture’. American Ethnologist 42, no. 4: 734-48. http://dx.doi.org/10.1111/amet.12167.
Sobo, Elisa Janine. 1995. Choosing Unsafe Sex: AIDS-Risk Denial among Disadvantaged Women. Philadelphia: University of Pennsylvania Press. http://dx.doi.org/10.9783/9780812200379.
Somers, Margaret R. 1994. ‘The Narrative Constitution of Identity: A Relational and Network Approach’. Theory and Society 23, no. 5: 605–49. http://dx.doi.org/10.1007/bf00992905.
Spain, Janine E., Jeffrey F. Peipert, Tessa Madden, Jenifer E. Allsworth, and Gina M. Secura. 2010. ‘The Contraceptive CHOICE Project: Recruiting Women at Highest Risk for Unintended Pregnancy and Sexually Transmitted Infection’. Journal of Women’s Health 19, no. 12: 2233–38. http://dx.doi.org/10.1089/jwh.2010.2146.
Stanford, J. B., R. Hobbs, P. Jameson, M. J. DeWitt, and R. C. Fischer. 2000. ‘Defining Dimensions of Pregnancy Intendedness’. Maternal and Child Health Journal 4, no. 3: 183–89. http://dx.doi.org/10.1023/a:1009575514205.
Teman, Elly, Tsipy Ivry, and Heela Goren. Forthcoming. ‘Obligatory Effort [Hishtadlut] as an Explanatory Model: A Critique of Reproductive Choice and Control’. Culture, Medicine, and Psychiatry.
Thompson, Winifred. 2006. ‘Factors Affecting Pregnancy and Birth Outcomes: A Holistic Approach’. PhD diss., University of South Carolina.
US Department of Health and Human Services. 2010. Healthy People 2020. Accessed 10 December 2014. Available from https://www.healthypeople.gov/2020/topics-objectives/topic/family-planning.
van der Sijpt, Erica. 2014. ‘Complexities and Contingencies: Towards a Model of Reproductive Navigation’. Sociology of Health and Illness 36, no. 2: 278–90. http://dx.doi.org/10.1111/1467-9566.12064.
Wu, Justine, Sean Meldrum, Ann Dozier, Nancy Stanwood, and Kevin Fiscella. 2008. ‘Contraceptive Nonuse among US Women at Risk for Unplanned Pregnancy’. Contraception 78, no. 4: 284–89. http://dx.doi.org/10.1016/j.contraception.2008.04.124.