Toward a Broader Conception of Equity in Artificial Womb Technology

De Bie et al. provide a novel framework for assessing ethical considerations in artificial womb technology (AWT) based on four phases of human prenatal development (DeBie 2023). As the authors note, AWT is far more likely to enter the realm of clinical practice in the context of improving care for premature and severely premature neonates, or “fetonates,” while the prospect of implementing AWT for the purpose of fully gestating a human fetus from conception through full term development remains more science fiction than imminent reality at the moment. The authors’ conceptual framework offers a foundation for considering the ethical nuances related to each phase of prenatal development; as such, the article makes a contribution to the AWT ethics discourse and has potential to inform policy guiding future research and eventual translation into clinical practice. Building on this conceptual groundwork, we believe there is an opportunity to more fully anticipate and address ethical concerns as described in the “Fairness of Access” domain by De Bie et al. (DeBie 2023). The authors indicated their aim was to describe ethical considerations raised by their review in broad terms, and we appreciate the limitations imposed by the scope of their manuscript. However, the domain of fair access focuses almost exclusively on cost and additional financial barriers, while other pressing concerns about equity in access to and use of AWT are downplayed. We suggest expanding fairness of access to fully incorporate equity considerations. Drawing from our previous scholarship on reproductive justice in AWT (Kimberly, Sutter, and Quinn 2020), we call for a broader conception of equity in AWT addressing issues of disparities in access and in health outcomes for gestating individuals and their neonates. As the possibility for use of AWT in various neonatal settings becomes increasingly likely, assuring equitable access to and outcomes of this lifeenhancing and potentially life-saving treatment option will necessitate careful attention to the intersectional impact of race/ethnicity, gender, sexual orientation, and family configuration. The United States has a distressingly poor track record in provision of high quality preand-post-natal care to gestating/birthing people of color and their neonates (Wheeler et al. 2022). Thankfully, growing recognition of the impact of racism in maternal-fetal medicine at the systemic, institutional, and individual levels is creating a push for tangible change, along with increased awareness of the ways in which other forms of discrimination on the basis of gender identity, sexual orientation, and family configuration adversely affect the experiences of people who are pregnant or who give birth prematurely and their neonates (Attanasio and Hardeman 2019). These can include poorer health status associated with social determinants of health, lack of access to preventive and prenatal care, interpersonal discrimination on the part of health care providers and/or discriminatory institutional policies and practices (Sigurdson et al. 2019). These disparities are present in the neonatal intensive care unit (NICU) setting, where poorer neonatal outcomes for infants of color have been associated with differences in quality of care within a NICU and differences in access to high-quality NICU care (in other words, differences in quality both within and across institutions) (Sigurdson et al. 2019). Pregnant individuals of color are more likely to experience preterm birth requiring NICU care (Sigurdson et al. 2019), while racial/ethnic disparities in NICU follow up care have also been noted (Bockli et al. 2014). These trends are consistent with the history of reproductive technology for family building, not only