Vol. 7 No. 1 (2023)
Peer Reviewed Articles

Challenging Pronatalism Is Key to Advancing Reproductive Rights and a Sustainable Population

Nandita Bajaj
Population Balance, Antioch University
Kirsten Stade
Population Balance

Published 2022-12-08 — Updated on 2023-02-03


  • reproductive autonomy,
  • population,
  • environment,
  • fertility,
  • pronatalism

How to Cite

Bajaj, Nandita, and Kirsten Stade. 2023. “Challenging Pronatalism Is Key to Advancing Reproductive Rights and a Sustainable Population”. The Journal of Population and Sustainability 7 (1):39-70. https://doi.org/10.3197/JPS.63799953906861.


Social and environmental justice organisations have silenced discourse on human overpopulation due to fear of any association with reproductive coercion, but in doing so they have failed to acknowledge the oppressive role of pronatalism in undermining reproductive autonomy. Pronatalism, which comprises cultural and institutional forces that compel reproduction, is far more widespread, and as damaging to individual liberties as attempts to limit reproduction. The failure to recognise the enormity of pronatalism has led to the wholesale abandonment of voluntary, rights-based efforts toward a sustainable population despite widespread scientific agreement that population growth is a major driver of multiple cascading environmental crises. We examine the full range of patriarchal, cultural, familial, religious, economic and political pronatalist pressures, and argue that the reluctance to address population as a driver of the ecological crisis serves the very pronatalist forces that undermine reproductive autonomy. We posit that addressing overpopulation, and the pronatalism that drives it, must be central to international conservation and development efforts to elevate reproductive rights while also promoting planetary health.


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  1. Adair, L. and N. Lozano. 2022. ‘Adaptive choice: Psychological perspectives on abortion and reproductive freedom’. Women’s Reproductive Health 9 (1): 1–26. https://doi.org/10.1080/23293691.2021.1999624.
  2. Alexander, B.B., R.L. Rubinstein, M. Goodman and M. Luborsky. 1992. ‘A path not taken: A cultural analysis of regrets and childlessness in the lives of older women’. The Gerontologist, 32 (5): 618–626.https://doi.org/10.1093/geront/32.5.618.
  3. Amir, M. 2006. ‘Bio-temporality and social regulation: The emergence of the biological clock’. Polygraph: An International Journal of Culture and Politics 18: 47–72.
  4. Bajaj, N. 2022. ‘Dismissal of “population alarmism” is rooted in pronatalist ideology’. In-Depth News, 3 November. https://www.indepthnews.net/index.php/opinion/5709-dismissal-of-population-alarmism-is-rooted-in-pronatalist-ideology (accessed 5 November 2022).
  5. Bajaj, N. and A. Ware (Hosts). 2022. ‘Dr. Kimya Nuru Dennis: The unique challenges of being Black and childfree’. (No. 75) [Audio podcast episode] In The Overpopulation Podcast. Population Balance, 24 May. https://www.populationbalance.org/episode-75-the-unique-challenges-of-being-black-and-childfree (accessed 1 September 2022).
  6. Balmforth, T. 2015. ‘Russian patriarch calls for abortion curbs, touts conservative values’. Radio Free Europe Documents and Publications, 22 January. https://www.rferl.org/a/russia-religion-patriarch-abortion/26807767.html (accessed 1 September 2022).
  7. Bearak, J., A. Popinchalk, B. Ganatra, A.-B.Moller, Ö.Tunçalp, C. Beavin, L. Kwok and L. Alkema. 2020. ‘Unintended pregnancy and abortion by income, region, and the legal status of abortion: Estimates from a comprehensive model for 1990–2019’. The Lancet Global Health, 8 (9). https://doi.org/10.1016/s2214-109x(20)30315-6.
  8. Becker, G. and R.D. Nachtigall. 1992. ‘Eager for medicalisation: The social production of infertility as a disease’. Sociology of Health and Illness 14 (4): 456–471. https://doi.org/10.1111/1467-9566.ep10493093.
  9. Bell, A.V. 2019. ‘Trying to have your own first; it’s what you do: The relationship between adoption and medicalized infertility’. Qualitative Sociology 42 (3): 479–498. https://doi.org/10.1007/s11133-019-09421-3.
  10. Bhambhani, C. and A. Inbanathan. 2020. ‘Examining a non-conformist choice: The decision-making process toward being childfree couples’. International Journal of Sociology 50 (5): 339–368. https://doi.org/10.1080/00207659.2020.1797265.
  11. Blake, J. 1972. ‘Coercive pronatalism and American population policy’ in R. Parke Jr. and C. Westoff (eds), Aspects of Population Growth Policy pp. 85–108. Washington, DC: US Commission on Population Growth and the American Future, USGPO.
  12. Bongaarts, J., J. Cleland, J. Townsend, J. Bertrand and M. Gupta. 2012. ‘Executive summary – family planning programs for the 21st Century: Rationale and design’. https://doi.org/10.31899/rh11.1017.
  13. Bradshaw, C.J., P.R. Ehrlich, A. Beattie, G. Ceballos, E. Crist, J. Diamond, R. Dirzo, A.H. Ehrlich, J. Harte, M.E. Harte, G. Pyke, P.H. Raven, W.J. Ripple, F. Saltré, C. Turnbull, M. Wackernagel and D.T. Blumstein. 2021. ‘Underestimating the challenges of avoiding a ghastly future’. Frontiers in Conservation Science 1. https://doi.org/10.3389/fcosc.2020.615419.
  14. Bricker, D.J. and J. Ibbitson. 2019. Empty Planet: The Shock of Global Population Decline. First ed. New York: Crown.
  15. Briggs, L. 1998. ‘Discourses of “forced sterilization” in Puerto Rico: The problem with the speaking subaltern’. Differences 10 (2): 30–66. https://doi.org/10.1215/10407391-10-2-30.
  16. Brown, J.A. and M.M. Ferree. 2005. ‘Close your eyes and think of England’. Gender & Society 19 (1): 5–24. https://doi.org/10.1177/0891243204271222.
  17. Bruenig, E. 2021. ‘Invasion of the baby-haters’. The Atlantic, 11 August. https://www.theatlantic.com/ideas/archive/2021/08/jd-vance-childless-left-culture-wars/619705/ (accessed 1 September 2022).
  18. Campbell, M. and K. Bedford. 2009. ‘The theoretical and political framing of the population factor in development’. Philosophical Transactions of the Royal Society B: Biological Sciences 364 (1532): 3101–3113. https://doi.org/10.1098/rstb.2009.0174.
  19. Carroll, L. 2012. The Baby Matrix: Why Freeing Our Minds From Outmoded Thinking About Parenthood & Reproduction Will Create a Better World. United States: LiveTrue Books.
  20. Center for Reproductive Rights. 2022. The World’s Abortion Laws. https://reproductiverights.org/maps/worlds-abortion-laws/ (accessed 1 September 2022).
  21. Chaurasia, A. 2020. ‘Population effects of increase in world energy use and CO2 emissions: 1990–2019’. The Journal of Population and Sustainability 5 (1): 87–125. https://doi.org/10.3197/jps.2020.5.1.87.
  22. Coole, D. 2021. ‘The toxification of population discourse. A genealogical study’ The Journal of Development Studies 57 (9): 1454–1469. https://doi.org/10.1080/00220388.2021.1915479.
  23. Corfe, S. and A. Bhattacharya. 2021. ‘Baby bust and baby boom: Examining the liberal case for pronatalism’. Social Market Foundation. https://www.smf.co.uk/publications/baby-bust-and-baby-boom/ (accessed 1 September 2022).
  24. Crist, E., C. Mora and R. Engelman. 2017. ‘The interaction of human population, food production, and biodiversity protection’. Science 356 (6335): 260–264. https://doi.org/10.1126/science.aal2011.
  25. Crist, E., W.J. Ripple, P.R. Ehrlich, W.E. Rees and C. Wolf. 2022. ‘Scientists’ warning on population’. Science of The Total Environment 845: 157166. https://doi.org/10.1016/j.scitotenv.2022.157166.
  26. Dasgupta, A. and P. Dasgupta. 2017. ‘Socially embedded preferences, environmental externalities, and reproductive rights’. Population and Development Review 43 (3): 405–441. https://doi.org/10.1111/padr.12090.
  27. Dayi, A. and E. Karakaya. 2021. ‘Neoliberal health restructuring, rising conservatism and reproductive rights in Turkey: Continuities and changes in rights violations’, in A. Dayi, S. Topçu and B. Yarar (eds), The Politics of the Female Body in Contemporary Turkey: Reproduction, Maternity, Sexuality, pp. 17–42]. London: I.B. Tauris. https://doi.org/10.5040/9780755617432.ch-001.
  28. de la Croix, D. and C. Delavallade. 2018. ‘Religions, fertility, and growth in Southeast Asia’. International Economic Review 59 (2): 907–946. https://doi.org/10.1111/iere.12291.
  29. Dierickx, S., L. Rahbari, C. Longman, F. Jaiteh and G. Coene. 2018. ‘“I am always crying on the inside”: A qualitative study on the implications of infertility on women’s lives in urban Gambia’. Reproductive Health 15 (1). https://doi.org/10.1186/s12978-018-0596-2.
  30. Dildar, Y. 2022. ‘The effect of pronatalist rhetoric on women’s fertility preferences in Turkey’. Population and Development Review 48 (2): 579–612. https://doi.org/10.1111/padr.12466.
  31. Donath, O. 2015. ‘Regretting motherhood: A sociopolitical analysis’. Signs: Journal of Women in Culture and Society 40 (2): 343–67. https://doi.org/10.1086/678145.
  32. Donath, O., N. Berkovitch and D. Segal-Engelchin. 2022. ‘“I kind of want to want”: Women who are undecided about becoming mothers’. Frontiers in Psychology 13. https://doi.org/10.3389/fpsyg.2022.848384.
  33. Farvardin. 2020. ‘Reproductive politics in Iran: State, family, and women’s practices in postrevolutionary Iran’. Frontiers: A Journal of Women Studies 41 (2): 26. https://doi.org/10.5250/fronjwomestud.41.2.0026.
  34. Farivar, M. 2022. ‘What is the Great Replacement Theory?’ Voice of America, 18 May. https://www.voanews.com/a/what-is-the-great-replacement-theory-/6578349.html (accessed 1 September 2022).
  35. Fassbender, I. 2021. Active Pursuit of Pregnancy: Neoliberalism, Postfeminism and the Politics of Reproduction in Contemporary Japan. Leiden: Brill. https://doi.org/10.1163/9789004499553_007.
  36. Fodor, Éva. 2022. The Gender Regime of Anti-liberal Hungary. London: Palgrave Macmillan.
  37. Fu, B., N. Qin, L. Cheng, G. Tang, Y. Cao, C. Yan, X. Huang, P. Yan, S. Zhu and J. Lei. 2015. ‘Development and validation of an infertility stigma scale for Chinese women’. Journal of Psychosomatic Research 79 (1): 69–75. https://doi.org/10.1016/j.jpsychores.2014.11.014.
  38. GFN. 2022. ‘Measure what you treasure’. Global Footprint Network https://www.footprintnetwork.org/ (accessed 1 September 2022).
  39. Gimenez, M.E. 2019. Marx, Women, and Capitalist Social Reproduction: Marxist Feminist Essays. Chicago: Haymarket Books.
  40. Golley, J. 2017. ‘Population and the economy: The ups and downs of one and two’. China Story Yearbook 2016: Control. Canberra: The Australian National University, ANU Press. https://doi.org/10.22459/csy.06.2017.03.
  41. Gordon, N. 2022. ‘China’s population will start shrinking sooner than expected, threatening its economy years ahead of schedule’. Fortune, 25 July. https://fortune.com/2022/07/25/china-population-decline-collapse-crisis-2025-sooner (accessed 1 September 2022).
  42. Gotlib, A. 2016. ‘“But you would be the best mother”: Unwomen, counterstories, and the motherhood mandate’. Journal of Bioethical Inquiry 13 (2): 327–347. https://doi.org/10.1007/s11673-016-9699-z.
  43. Gwatkin, D. R. 1979. ‘Political will and family planning: The implications of India’s emergency experience’. Population and Development Review 5 (1): 29. https://doi.org/10.2307/1972317.
  44. Gökarıksel, B., C. Neubert and S. Smith. 2019. ‘Demographic fever dreams: Fragile masculinity and population politics in the rise of the global right’. Signs: Journal of Women in Culture and Society 44 (3): 561–87. https://doi.org/10.1086/701154.
  45. Götmark, F., P. Cafaro and J. O’Sullivan. 2018. ‘Aging human populations: Good for us, good for the Earth’. Trends in Ecology & Evolution 33 (11): 851–62. https://doi.org/10.1016/j.tree.2018.08.015.
  46. Gürtin, Z.B. 2016. ‘Patriarchal pronatalism: Islam, secularism and the conjugal confines of Turkey’s IVF boom’. Reproductive Biomedicine & Society Online, 2: 39–46. https://doi.org/10.1016/j.rbms.2016.04.005.
  47. Heck, C.J., S.A. Grilo, X. Song, T. Lutalo, N. Nakyanjo and J.S.Santelli. 2018. ‘It is my business: A mixed-methods analysis of covert contraceptive use among women in Rakai, Uganda’. Contraception 98 (1): 41–46. https://doi.org/10.1016/j.contraception.2018.02.017.
  48. Hodgson, D. 2013. ‘How problematic will liberal abortion policies be for pronatalist countries?’, in A. Kulczycki (ed.), Critical Issues in Reproductive Health, pp. 153–176. Heidelberg: Springer Dordrecht. https://doi.org/10.1007/978-94-007-6722-5_8.
  49. Hollingworth, L.S. 1916. ‘Social devices for impelling women to bear and rear children’. American Journal of Sociology 22 (1): 19–29. https://doi.org/10.1086/212572.
  50. Hussain, S. 2009. ‘Motherhood and female identity: Experiences of childless women of two religious communities in India’. Asian Journal of Women’s Studies 15 (3): 81–108. https://doi.org/10.1080/12259276.2009.11666074.
  51. IPCC, 2022: Climate Change 2022: Mitigation of Climate Change. Contribution of Working Group III to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change [P.R. Shukla, J. Skea, R. Slade, A. Al Khourdajie, R. van
  52. Kaklamanidou, B.-D. 2018. ‘The voluntarily childless heroine: A postfeminist television oddity’. Television & New Media 20 (3): 275–293. https://doi.org/10.1177/1527476417749743
  53. Karklin, D. 2022. ‘The women who wish they weren’t mothers: An unwanted pregnancy lasts a lifetime’. The Guardian, 16 July. https://www.theguardian.com/lifeandstyle/2022/jul/16/women-who-wish-they-werent-mothers-roe-v-wade-abortion (accessed 1 September 2022).
  54. Kerr, C.-G. 2016. How Pronatalism Became Black: The Path from Black Antinatalism to Black Pronatalism. Amherst: Amherst College.
  55. Kopnina, H. and H. Washington. 2016. ‘Discussing why population growth is still ignored or denied’. Chinese Journal of Population Resources and Environment 14 (2): 133–143. https://doi.org/10.1080/10042857.2016.1149296.
  56. Kuhlemann, K. 2019. ‘The elephant in the room’, in N. Almiron and J. Xifra (eds), Climate Change Denial and Public Relations: Strategic Communication and Interest Groups in Climate Inaction, pp. 74–99. London: Taylor & Francis. https://doi.org/10.4324/9781351121798-6.
  57. Lalonde, D. 2018. ‘Regret, shame, and denials of women’s voluntary sterilization’. Bioethics 32 (5): 281–88. https://doi.org/10.1111/bioe.12431.
  58. Latchford, F.J. 2019. Steeped In Blood: Adoption, Identity, and the Meaning of Family. Montreal: McGill-Queen’s University Press.
  59. Madge, V. 2011. ‘Infertility, women and assisted reproductive technologies’. Indian Journal of Gender Studies 18 (1): 1–26. https://doi.org/10.1177/097152151001800101.
  60. Mateo, D. 2022. ‘‘I had no choice’: The people who regret becoming parents’. Neptune Pine, 16 July. https://neptunepine.com/i-had-no-choice-the-people-who-regret-becoming-parents/ (accessed 1 September 2022).
  61. McQueen, P. 2019. ‘A defence of voluntary sterilisation’. Res Publica 26 (2): 23755. https://doi.org/10.1007/s11158-019-09439-y.
  62. Mor, T. and Y. Rezek. 2017. ‘Pro-natalism policy, demography and democracy – Nonlinear Dynamics Analysis’. Proceedings of the 2nd International Conference on Complexity, Future Information Systems and Risk. https://doi.org/10.5220/0006367301240129.
  63. Naab, F., Y. Lawali and E.S. Donkor. 2019. ‘“My mother in-law forced my husband to divorce me”: Experiences of women with infertility in Zamfara State of Nigeria’ PLOS ONE 14 (12). https://doi.org/10.1371/journal.pone.0225149.
  64. Nandy, A. 2017. Motherhood and Choice: Uncommon Mothers, Childfree Women. New Delhi: Zubaan.
  65. Neal, Z.P. and J.W. Neal. 2022. ‘More than 1 in 5 Us adults don’t want children’. The Conversation, 3 August. https://theconversation.com/more-than-1-in-5-us-adults-dont-want-children-187236 (accessed 1 September 2022).
  66. Njoki, L. 2022. ‘The brutally honest truth about having kids that no one tells you’. The Good Men Project, 19 July. https://goodmenproject.com/featured-content/the-brutally-honest-truth-about-having-kids-that-no-one-tells-you/ (accessed 1 September 2022).
  67. Ofosu-Budu, D. and V. Hanninen. 2020. ‘Living as an infertile woman: The case of southern and northern Ghana’. Reproductive Health 17 (1). https://doi.org/10.1186/s12978-020-00920-z.
  68. Patrizio, P., D.F. Albertini, N. Gleicher and A. Caplan. 2022. ‘The Changing World of IVF: The pros and cons of new business models offering assisted reproductive technologies’. Journal of Assisted Reproduction and Genetics 39 (2): 305–13. https://doi.org/10.1007/s10815-022-02399-y.
  69. Pavlova, U. and J. Guy. 2022. ‘Putin revives Stalin-era “Mother Heroine” award for women with 10 children’. CNN, 18 August. https://www.cnn.com/2022/08/18/europe/putin-mother-heroine-award-decree-intl/index.html (accessed 1 September 2022).
  70. Potts, M. 2014. ‘Getting family planning and population back on track’. Global Health: Science and Practice 2 (2): 145–51. https://doi.org/10.9745/ghsp-d-14-00012.
  71. Purdy, L. M. 2019. ‘Pronatalism is violence against women: The role of genetics’, in W. Teays (ed.), Analyzing Violence Against Women. pp. 113–29. Switzerland: Springer Nature. https://doi.org/10.1007/978-3-030-05989-7_9.
  72. Qamar, A.H. 2018. ‘The social value of the child and fear of childlessness among rural Punjabi women in Pakistan’. Asian Journal of Social Science 46 (6): 638–67. https://doi.org/10.1163/15685314-04606003.
  73. Quraishi, S.Y. 2021. The Population Myth: Islam, Family Planning and Politics in India. Uttar Pradesh, India: HarperCollins.
  74. Raucher, M. 2021. ‘Jewish pronatalism: Policy and praxis’. Religion Compass 15 (7). https://doi.org/10.1111/rec3.12398
  75. Rees, W.E. 2020. ‘Ecological economics for humanity’s plague phase’. Ecological Economics 169: 106519. https://doi.org/10.1016/j.ecolecon.2019.106519.
  76. Regus, P. 2007. ‘The Emerging Medicalization of Postpartum Depression: Tightening the Boundaries of Motherhood’. Thesis, Georgia State University. https://doi.org/10.57709/1062357.
  77. Rich, A. 1995. Of Woman Born: Motherhood as Experience and Institution. United Kingdom: W.W. Norton and Company.
  78. Ripple, W.J., K. Abernethy, M.G. Betts, G. Chapron, R. Dirzo, M. Galetti, T. Levi, P.A. Lindsey, D.W. Macdonald, B. Machovina, T.M. Newsome, C.A. Peres, A.D. Wallach, C. Wolf, and H. Young. 2016. ‘Bushmeat hunting and extinction risk to the world’s mammals’. Royal Society Open Science 3 (10): 160498. https://doi.org/10.1098/rsos.160498.
  79. Rivkin-Fish, M. 2010. ‘Pronatalism, gender politics, and the renewal of family support in Russia: Toward a feminist anthropology of maternity capital’. Slavic Review 69 (3): 701–24. https://doi.org/10.1017/s0037677900012201.
  80. Rottenberg, C. 2017. ‘Neoliberal feminism and the future of human capital’. Signs: Journal of Women in Culture and Society 42 (2): 329–48. https://doi.org/10.1086/688182.
  81. Samways, D. 2022. ‘Population and sustainability: Reviewing the relationship between population growth and environmental change’. The Journal of Population and Sustainability 6 (1): 15–41. https://doi.org/10.3197/JPS.63772239426891.
  82. Sargent, C. and M. Harris. 1992. ‘Gender ideology, childrearing, and child health in Jamaica’. American Ethnologist 19 (3): 523–37. https://doi.org/10.1525/ae.1992.19.3.02a00060.
  83. Sinding, S.W. 2008. ‘What has happened to family planning since Cairo and what are the prospects for the future?’ Contraception 78 (4). https://doi.org/10.1016/j.contraception.2008.03.019.
  84. Sinding, S.W. 2016. ‘Reflections on the changing nature of the population movement’. The Journal of Population and Sustainability 1 (1): 7–14. https://doi.org/10.3197/jps.2016.1.1.7.
  85. Stade, K. 2022. ‘I am not a slave to the biological clock’. Ms. Magazine, 11 July. https://msmagazine.com/2022/07/11/women-biological-clock-child-free-world-population-day/ (accessed 1 September 2022).
  86. Tatum, M. 2021. ‘China’s three-child policy’. The Lancet 397 (10291): 2238. https://doi.org/10.1016/s0140-6736(21)01295-2.
  87. Telli, P., T. Cesuro lu and F.T. Aksu. 2019. ‘How do pronatalist policies impact women’s access to safe abortion services in Turkey?’ International Journal of Health Services 49 (4): 799–816. https://doi.org/10.1177/0020731419855877
  88. Tremayne, S. and M.M. Akhondi. 2016. ‘Conceiving IVF in Iran’. Reproductive Biomedicine & Society Online 2: 62–70. https://doi.org/10.1016/j.rbms.2016.07.002.
  89. Tsigdinos, P.M. 2021. ‘An IVF survivor unravels “fertility” industry narratives’. Journal of Marketing Management 38 (5–6): 443–59. https://doi.org/10.1080/0267257x.2021.2003847
  90. Turnbull, B., M.L. Graham and A.R. Taket. 2016. ‘Pronatalism and social exclusion in Australian society: Experiences of women in their reproductive years with no children’. Gender Issues 34 (4): 333–54. https://doi.org/10.1007/s12147-016-9176-3.
  91. UN. 1994. Report of the International Conference on Population and Development. United Nations: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/icpd_en.pdf (accessed 1 September 2022).
  92. UNDESA. 2014. Abortion Policies and Reproductive Health Around the World. United Nations Department of Economic and Social Affairs: https://www.un.org/en/development/desa/population/publications/pdf/policy/AbortionPoliciesReproductiveHealth.pdf (accessed 1 September 2022).
  93. UNDESA. 2015. Government Response to Low Fertility in Japan. United Nations Department of Economic and Social Affairs: https://www.un.org/en/development/desa/population/events/pdf/expert/24/Policy_Briefs/PB_Japan.pdf (accessed 1 September 2022).
  94. UNDESA. 2021. World Population Policies 2021: Policies Related to Fertility. United Nations Department of Economic and Social Affairs: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/undesa_pd_2021_wpp-fertility_policies.pdf (accessed 1 September 2022).
  95. UNPFA. 2022. Nearly Half of All Pregnancies Are Unintended – a Global Crisis, Says New UNFPA Report. United Nations Population Fund: https://www.unfpa.org/press/nearly-half-all-pregnancies-are-unintended-global-crisis-says-new-unfpa-report# (accessed 1 September 2022).
  96. Wallace, T. 2022, ‘Europe faces ageing population nightmare in absolute collapse’. The Telegraph, 13 July. https://www.telegraph.co.uk/business/2022/07/13/europe-faces-ageing-population-nightmare-absolute-collapse/ (accessed 1 September 2022).
  97. Wells, H. and M. Heinsch. 2019. ‘Not yet a woman: The influence of socio-political constructions of motherhood on experiences of female infertility’. The British Journal of Social Work 50 (3): 890–907. https://doi.org/10.1093/bjsw/bcz077.