MARCIA A. ELLISON
Massachusetts General Hospital
Harvard Medical School
Authoritative Knowledge and Single Women's
Unintentional Pregnancies, Abortions, Adoption,
and Single Motherhood: Social Stigma and
This article explores the sources of authoritative knowledge that shaped
single, white, middle-class women's unintentional pregnancies and child-
bearing decisions throughout five reproductive eras. Women who termi-
nated a pregnancy were most influenced by their own personal needs and
circumstances, birth mothers' decisions were based on external sources
of knowledge, such as their mothers, social workers, and social pressures.
In contrast, single mothers based their decision on instincts and their re-
ligious or moral beliefs. Reproductive policies further constrained and
significantly shaped women's experiences. The social stigma associated
with these forms of stratified maternity suggests that categorizing preg-
nant women by their marital status, or births as out-of-wedlock, repro-
duces the structural violence implicit to normative models of female sexu-
ality and maternity. This mixed-method study included focus groups to
determine the kinds of knowledge women considered authoritative, a
mailed survey to quantify these identified sources, and one-on-one inter-
views to explore outcomes in depth, [authoritative knowledge, social
stigma, abortion, birth mothers, single mothers, unintentional pregnancies]
We need to anthropologize the West: show how exotic its constitution of reality has
been; emphasize those domains most taken for granted as universal... make them
seem as historically peculiar as possible; show how their claims to truth are linked to
social practices and have hence become effective forces in the social world.
childbearing nor to single women, indicates the cultural censorship of an experience
—Paul Rabinow 
t least 48 percent of women living in the United States will experience an
unintentional pregnancy by midlife.1 The lack of public awareness of the
high rate of unplanned pregnancies, which are neither limited to early
Medical Anthropology Quarterly 17(3):322-347. Copyright © 2003, American Anthropological Association.
SINGLE WOMEN'S UNINTENTIONAL PREGNANCIES 323
shared by many women and their partners. This censorship reflects the tensions of a
dominant pronatalist ideology within a culture that increasingly prizes self-deter-
mination (Blake 1974; Solinger 2001). Planned pregnancies are socially pre-
scribed, and women expect to be able to time their pregnancies to fit their life goals
and family needs at a socially accepted age and marital status. Married women
avoid social stigma regarding their unplanned fertility through their legal relation-
ship to a man, which allows them to "pass" (Goffman 1963). In contrast, single
women2 are particularly vulnerable to the social stigma surrounding unintentional
In the United States, when marriage is not an option, single women who unin-
tentionally conceive face three alternatives: to terminate their pregnancy, to adopt
away their child, or to become a single mother. This study suggests that each of
these alternatives permanently and profoundly alters a woman's life course and her
reproductive history or "procreative story" (Ginsburg 1987). The meaning of the
term history as a story or tale is derived from the Greek historia, for inquiry, and
from istor, knowing, what is learned.4 This study further suggests that women's
stories and the knowledge that single women glean from their pregnancy and child-
bearing outcomes have been culturally censored. Moreover, this censorship signals
the implicit structural violence5 (Kleinman 2000) that underlies normative models
of female sexuality and fertility and the rhetoric of what it means to be a "good"
and worthy woman, mother, and wife.6 Because reproductive policies in the United
States have been ethnically bifurcated (Collins 1995;Davis 1981; Litt 2000; Solin-
ger 1992), this study is limited to the sources of authoritative knowledge that shape
single, white, middle-class women's unintentional pregnancies and their sub-
sequent childbearing decisions.7
Pregnancy, Knowledge, and Power
The label "authoritative" is intended to draw attention to [the status of a body of
knowledge] within a particular social group and to the work it does in maintaining the
group's definition of morality and rationality. The power of authoritative knowledge
is not that it is correct but that it counts.
—Brigitte Jordan 
Since Jordan's groundbreaking work in the mid-1970s, studies of authorita-
tive knowledge (AK), have clarified how social differences in power, authority,
prestige, and access to resources shape birthing practices. These differences per-
petuate forms of stratified reproduction "that supports and rewards the maternity of
some women, while despising or outlawing the mother-work of others" (Rapp
2001:469). For example, the biomedical hierarchies of hospitals, medical clinics,
and epidemiology tend to reproduce and privilege a birthing ecology dominated by
technological interventions and professional and medical expertise, while occlud-
ing ethnomedical knowledge and women's embodied knowledge (Jordan 1997;
Kitzinger 1997). In contrast, birthing practices that minimize social hierarchies be-
tween birth attendants and parturient woman tend to incorporate pluralistic sources
of knowledge, such as maternal embodied knowledge, touch, instincts, ethnomedi-
cal knowledge, and cultural practices that privilege social affiliations (Davis-Floyd
and Davis 1997; Kitzinger 1997; Sosaet al. 1980).
324 MEDICAL ANTHROPOLOGY QUARTERLY
Studies of authoritative knowledge in childbirth have illuminated the muta-
ble, context-dependent quality of the birthing knowledge that counts in non-
biomedical settings. For example, among the San, primiparas are not expected to
have the requisite knowledge to meet the cultural ideal of a silent and unassisted
birth; their first birth is often assisted (Biesele 1997). Similarly, in rural Mayan
communities, a midwife may yield to the knowledge of a multipara in labor, but as-
sert her own authority over an inexperienced primipara (Jordan 1978; Sargent and
Bascope 1997). Thus, differences in power and authority are not simply indices of
hegemonic versus pluralistic knowledge systems, but may be determined by
women's reproductive histories.
Women may also resist, negotiate, and reproduce the hegemony of biomedi-
cal birthing. For instance, Betty-Anne Daviss (1997) describes how the secular
logic of an epidemiology-based program to reduce maternal-child mortality rates
inadvertently increased the personal trauma to laboring Inuit women. The practice
of airlifting parturient Inuit women to a distant hospital invalidated ethnomedical
models and severed women from birth "as a community, social and spiritual act"
(1997:441). Similarly, women of color and working-class women, who may face
the triple jeopardy of ethnicity, class, and hegemonic medical models, may be
more likely than white middle-class women to resist dominant biomedical models
and instead draw on parallel systems of knowledge (Litt 2000; Martin 1987). In
contrast, women may inadvertently reproduce the hegemony of medical models, as
they ambivalently accept medical advice regardless of its actual benefits, in an at-
tempt to hedge their bets as reflective consumers and responsible mothers
(Browner and Press 1997).
The dense interplay of agency and social forces revealed in these studies un-
derscores that women are, ineluctably, neither free agents nor passive victims. This
study explores one of the historically most contested forms of conception—single
women's unintentional pregnancies—and underscores the intractable tensions be-
tween individual agency and social forces, which are further shaped by shifting re-
Five reproductive eras have profoundly shaped women's fertility-regulating
options in the United States: the mid-19th century statutes that criminalized abor-
tion and the distribution of contraceptives; the cult of motherhood as a civic duty;
the subsequent cult of scientific motherhood;8 the post-World War II adoption
mandate; and the interplay of the FDA approval of birth control pills in 1960 and
the 1973 passage ofRoe v. Wade. Each of these eras reified shifting forms of medi-
cal and scientific knowledge. In this study, I explore the sources of knowledge that
count, and their moral and rational concomitants, for single women who discover
they have unintentionally conceived.
Criminalizing Abortion and Contraceptives
Until the mid-19th century, the quickening, when a woman first senses fetal
movement, confirmed pregnancy (Duden 1993). Abortion, which was viewed as a
means to remove "obstructed" menses, was not socially sanctioned; yet abortifa-
cients were widely available to both single and married women. With the estab-
lishment of the American Medical Association in 1848, physicians used the medi-
cal management of childbirth to separate themselves from competing models of
SINGLE WOMEN'S UNINTENTIONAL PREGNANCIES 325
medical knowledge (Mohr 1978). Their purported biomedical authority encom-
passed all aspects of maternity, including female sexuality, morality, and the scien-
tific determination of pregnancy and fetal personhood. By 1872, this consolidation
of medical authority, paralleled by social reform movements, culminated in the
Comstock Act, which prohibited the advertisement and mailed distribution of con-
traceptives and abortifacients. Although a lively black market for contraceptive de-
vices and abortifacients continued to thrive (Tone 2001), by the Turn of the Cen-
tury abortion had become illegal in the United States and women's fertility was
more firmly under legal and medical authority.
The Cult of Maternity as Civic Duty .
The social purity movements of the early 1900s, increased birth rates among
recent non-Protestant immigrants, paralleled by declining birth rates among white
Anglo-Saxon Protestants, resulted in fears of "race suicide" (Berebitsky 2001;
May 1995). President Theodore Roosevelt called on white middle-class and upper-
class Protestant women to fulfill their civic duty and procreate. His pronatalist
campaign reified maternity, typified by nurturance and self-sacrifice, as women's
highest calling and civic duty (Berebitsky 2001; May 1995; Solinger 1992). As ur-
banization and industrialization increased the gender stratification of labor, gender
ideals were further redefined (Apple 1987; Nathanson 1991). In contrast to the
18th-century colonial era, where the practice of bundling contributed to a 33 per-
cent rate of premarital conceptions and births (Lawson and Rhode 1993; Smith and
Hindus 1975),9 during the Progressive era feminine purity and premarital chastity
became the cornerstones of maternal moral superiority (Brodie 1994; Nathanson
1991). This reification of white, middle-class maternity as a civic need resulted in
the establishment of evangelical maternity homes and widows' pensions. Thus, it
was socially expected that single, pregnant, middle-class white women and wid-
ows would keep and raise their own children (Berebitsky 2000; Kunzel 1993).10
The Cult of Scientific Motherhood
By the 1920s, the advent of the first-wave feminist movement, the newly
formed Children's Bureau, and rising maternal-child mortality rates culminated in
the 1921 Sheppard-Townner Act. This legislation allocated federal funds to pro-
mote hospital births and increase women's access to obstetric specialists. Hospitals
offered the "twilight sleep," x-rays, transfusions, and sterilized equipment. Scien-
tific experts proffered advice to mothers on the management of household germs,
infant feeding, and childcare (Apple 1987; Wertz and Wertz 1977).
As the new science of eugenics garnered cultural authority, the etiology of
single women's unintentional pregnancies shifted from a redeemable moral fail-
ing, to feeblemindedness, a form of heritable intellectual inferiority. Thus, the
management of maternity homes shifted from evangelical charity workers, to so-
cial workers with the scientific training necessary to deal with heritable disorders
(Kunzel 1993; Solinger 1992). This new scientific approach dictated that a single
mother and her child remain together in the maternity home until the child, at six
months of age, could undergo an intelligence test Within this model, social workers
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Appendix A: Demographics of survey respondents.
Upper middle class
Working class or poor