The current issue of Health, Risk & Society is a special issue, entitled “Risk, Pregnancy and Childbirth.” Along with an introduction by Barbara Katz Rothman, the issue contains seven articles organized around four thematic areas. The abstracts are listed below.
Pregnancy, birth and risk: An introduction
Barbara Katz Rothman
In this introduction, I use my nearly 40 years of work in the area to reflect on the total medicalisation of pregnancy and childbirth that informs even the critical sociology that purports to examine the issue. The risks that are faced in pregnancy and birth are not only the inherent dangers that midwives have worked with across time and space but also those particular risks introduced by medicalisation itself. Medicalisation blinds us to those risks on the one hand, while it blinds us to the skills and knowledge that midwives and birthing women themselves have on the other. The women and midwives researched in these articles show us that in pregnancy and birth, as in most of life, it is not just a matter of ‘real risk’ versus ‘perceived risk’ as risk theorists (too) often describe it. There is rather an intelligent balancing of risks, weighing of risks and contextualising of risks. What we see in this issue is a glimpse into the ways in which people intelligently, creatively and determinedly balance risks.
The Emergence of Risk Discourses in Pregnancy and Childbirth: Medicalisation, Feminism and Eugenics
‘Knowledge is power’: Risk and the moral responsibilities of the expectant mother at the turn of the twentieth century
Helga Kristin Hallgrimsdottir and Bryan Eric Benner
The notion that ‘older’ mothers experience elevated risks during pregnancy and childbirth has proliferated since the mid-twentieth century. In this article, we take the contemporary concern with age as a starting point from which to historicise and contextualise the concept of maternity risk. To this end, we examine maternal hygiene manuals (self-help guidebooks on motherhood and pregnancy) published between 1880 and 1920 in Canada, the United States and the United Kingdom. Our analysis of these manuals indicated that pregnancy during this period was presented as a potentially dangerous affair that required constant surveillance by the self (and others) to ensure favourable pregnancy outcomes. A dominant theme that emerged from the manuals was that the expectant mother was morally responsible for mitigating a range of risk factors, including adequate exercise, sleep, fresh air, as well as for choosing an appropriate father and ensuring his health. At the same time, the manuals indicated that the failure to seek out expert advice and take up responsible practices was linked to adverse consequences for the expectant mother’s health, and her newborn’s health and moral character later in life. We conclude this article by discussing how findings from our historical data can provide an important context for understanding risk discourses around pregnancy as historically specific and culturally contingent, especially with respect to risks associated with maternal advanced age.
Risky Pregnancy Behaviour: Policing Women
‘I don’t think it’s risky, but…’: Pregnant women’s risk perceptions of maternal drinking and smoking
Raphaël Hammer and Sophie Inglin
In Switzerland, official recommendations relating to alcohol and tobacco use during pregnancy are based on a zero-tolerance policy. However, epidemiological research indicates that some pregnant women do not adhere to the abstinence principle, and this raises the issue of how pregnant women identify and respond to health risks. This article draws on a sociocultural study of 50 mainly white, partnered and educated pregnant women carried out in Switzerland between May 2008 and June 2009. The study used semi-structured interviews that examined how and in what ways pregnancy had changed women’s consumption of alcohol and tobacco and their perceptions of their riskiness. In this article we draw on these data to examine participants’ perceptions of the risks of smoking and drinking during pregnancy. We examine three main issues: women’s understandings of official recommendations, their contextualisation of risk in daily life and the moral issues which they saw surrounding smoking and drinking during pregnancy. We found that the women in our study perceived drinking and smoking during pregnancy as different types of risks with different meanings. The participants contextualised official recommendations about drinking during pregnancy and had their own views about its riskiness. In contrast all participants saw smoking as harmful and risky irrespective of the level of consumption. The pregnant women in our study saw smoking during pregnancy as a risk-taking behaviour and a failure to act in the best interest of the foetus. In contrast, under certain conditions, they saw moderate drinking of alcohol during pregnancy as acceptable and responsible behaviour.
The risk of being ‘too honest’: Drug use, stigma and pregnancy
In this article, I examine the ways in which risk is constructed and managed by those involved in the pregnancy and childbirth of women who use drugs, including the women themselves. I discuss how constructions of risk influence maternal care outcomes and the understanding of choice, often in the form of stigmatisation. In this article, I draw on data from a qualitative research study that I conducted in 2011 in a western Canada city in which I interviewed 13 pregnant and parenting women who had used drugs during their pregnancy. In this article, I show how the everyday risk construction of pregnancy, labour and delivery is compounded significantly by drug use and the stigmatisation associated with this perceived risk-taking behaviour. The participants in the study often internalised this understanding of risk and this manifested itself in delays in accessing maternal health and social care services. The women in the study had different understandings of risk and these were structured by the women’s own understanding of general risk factors during their pregnancy, as well as their experiences of the constructions of risk and risk management by health and social care professionals. While structural life chances can constrain women’s feelings of self-efficacy, services that promote clients’ ability to make choices can facilitate reduced stigmatisation and facilitate the development of more compassionate and autonomous approaches to risk management.
Birth and Risk Management: Managing the Risks of the Birthplace
To what extent are women free to choose where to give birth? How discourses of risk, blame and responsibility influence birth place decisions
Kirstie Coxon, Jane Sandall, and Naomi J. Fulop
Over the past 50 years, two things have changed for women giving birth in high-income nations; birth has become much safer, and now takes place in hospital rather than at home. The extent to which these phenomena are related is a source of ongoing debate, but concern about high intervention rates in hospitals, and financial pressures on health care systems, have led governments, clinicians and groups representing women to support a return to birth in ‘alternative’ settings such as midwife-led birth centres or at home, particularly for well women with healthy pregnancies. Despite this, most women still plan to give birth in high-technology hospital labour wards. In this article, we draw on a longitudinal narrative study of pregnant women at three maternity services in England between October 2009 and November 2010. Our findings indicate that for many women, hospital birth with access to medical care remained the default option. When women planned hospital birth, they often conceptualised birth as medically risky, and did not raise concerns about overuse of birth interventions; instead, these were considered an essential form of rescue from the uncertainties of birth. Those who planned birth in alternative settings also emphasised their intention, and obligation, to seek medical care if necessary. Using sociocultural theories of risk to focus our analysis, we argue that planning place of birth is mediated by cultural and historical associations between birth and safety, and further influenced by prominent contemporary narratives of risk, blame and the responsibility. We conclude that even with high-level support for ‘alternative’ settings for birth, these discourses constrain women’s decisions, and effectively limit opportunities for planning birth in settings other than hospital labour wards. Our contention is that a combination of cultural and social factors helps explain the continued high uptake of hospital obstetric unit birth, and that for this to change, birth in alternative settings would need to be positioned as a culturally normative and acceptable practice.
Negotiating risky bodies: Childbirth and constructions of risk
Rachelle Joy Chadwick and Don Foster
Policy makers, practitioners and researchers have identified risk as a key concept in relation to maternity care and childbirth. There is however a lack of research exploring women’s discursive constructions of risk and childbirth in relation to sociological risk theories. In this article we explore pregnant women’s everyday negotiations of risk in relation to the self-chosen plan to birth either at home or via an elective Caesarean section. We use sociocultural risk theories to contextualise our findings. This article draws on data from a study conducted in 2005–2006 in which we interviewed 24 pregnant middle-class South African women who were planning a home birth or elective Caesarean section and used social constructionist discourse analysis to analyse the data. We found that women’s risk constructions were related to three different conceptions of birthing embodiment: technocratic bodies, vulnerable bodies and knowing bodies. Women who planned Caesarean sections were committed to biomedical constructions of risk and birth. Woman who planned home births shifted between endorsing and subverting biomedical models of risk. They also resisted definitions of birthing bodies as inherently abject (unclean, polluting, unruly) and constructed the process of giving birth as risky in medicalised settings. In such settings, the birthing body was constructed as vulnerable to objectification, loss of dignity and shaming. Women who planned to give birth at home constructed an alternative approach to birth which emphasised embodied ways of knowing, relational connection and empowerment over normative and medicalised risk constructions. In the process, biomedical risk definitions were destabilised.
Managing the Risks of Medicalisation
Time, risk and midwife practice: The vaginal examination
Mandie Scamell and Mary Stewart
In this article, we examine the impact on midwifery practice of clinical governance in the UK with its shift from individual autonomous practice based on personal experience and intuition (embodied knowledge) to the collective control of work based on guidelines and protocols (encoded knowledge) associated with the scientific–bureaucratic approach to care. We focus on the ways in which midwives use partograms and associated vaginal examinations to monitor and manage the progress of labour. The partogram represents (among other things) a timetable for dilation of the cervix during labour. Women who fail to keep up with this timetable are shifted from a low-to-high risk category and subjected to additional surveillance and intervention. In this article, we draw on empirical evidence taken from two independent ethnographic studies of midwifery talk and practice in England undertaken in 2005–2007 and 2008–2010, to describe the ways in which midwives practice of vaginal examinations during labour both complies with, while at the same time creatively subverts, the scientific–bureaucratic approach to maternity care. We argue that although divergent in nature, each way of practicing is mutually dependent upon the other: the space afforded by midwifery creativity not only co-exists with the scientific–bureaucratic approach to care, but also sustains it.
Pregnancy, risk perception and use of complementary and alternative medicine
Mary Mitchell and Stuart McClean
Pregnancy and childbirth are events of major significance in women’s lives. In western countries women are increasingly using complementary and alternative medicine during this time. However, there is little research exploring the factors that are influential in women’s motivations to use complementary and alternative medicine during pregnancy and childbirth. This article draws on data from a narrative-based study designed to explore women’s experiences of complementary and alternative medicine use during pregnancy and childbirth. The study involved 14 women living in the South-west of England, who had used complementary and alternative medicine during pregnancy and childbirth. We elicited narratives by interviewing women two to three times. The women in our study used complementary and alternative medicine both as a response to the uncertainty of pregnancy and childbirth and as a defence against manufactured risk, and in doing so indicated their desire to transform an unpredictable and unmanageable future into one which is more predictable and manageable. It was a means of dealing with the stress and anxiety associated with uncertainty which has to be dealt with. Their consciousness of the risks of biomedicine developed though the practice of complementary and alternative medicine, and their high educational status and relative affluence facilitated their choices. There was a tension evident in their narratives between a need to ‘be in control’ versus a desire for a natural childbirth without medical intervention. Women in the study showed their autonomy by actively pursuing complementary and alternative medicine while at the same time selectively using expert medical knowledge.
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It appears that you have published an entire issue on pregnancy and risk without the input of even a single obstetrician. Is that true? If so, it is a serious oversight since obstetricians are the experts on pregnancy and risk. How do you know that the midwives, nurses and social scientists included in the issue are accurate in their assessment of risk?
It is rich indeed to discuss “risk” and midwifery in the same sentence. Readers of this blog and the special issue it describes might be interested to learn of the case of Gavin Michael, a newborn baby in Las Vegas who died two weeks ago after suffocating on meconium in his mother’s belly, after his “midwife” negligently managed his mother’s pregnancy.
The “midwife” was a Certified Professional Midwife (CPM), a designation requiring barely a high school education and not recognized in any other developed country other than the US, where midwifery is almost entirely unregulated, where CPMs are not required to practice according to any standard nor to carry malpractice insurance, and where anti-medicine rhetoric encourages midwives’ reckless risk-taking in delivering breech, twins, and other high-risk pregnancies at home and while rejecting appropriate medical care. Midwives’ references to “risk” in pregnancy are rich indeed, considering the high prevalence of substandard medical practitioners among them, the wider discipline’s nepotist defense and protection of such practitioners, and the trail of dead babies such midwives leave in their wakes.
As for Gavin, his mother’s “midwife” allowed her patient to progress to 42.1 weeks and then, in a stunning display of incompetence, crowdsourced her Facebook friends for advice on how to manage her patient’s oligohydramnios (lack of amniotic fluid), which is widely recognized as an obstetrical emergency. Gavin Michael died as she drove the mother 30 minutes from one Las Vegas hospital to another, in an effort to get to a “midwife-friendly” centre of care to save her negligent butt. His grandfather posts here–I challenge any reader to read about this case without shedding a tear:
As for Katz Rothman, it is hard to take seriously her discussion of “the skills and knowledge that midwives and birthing women themselves have” in the context of cases like the one above, for which the parents have no legal recourse and in which there is unlikely to be any consequence for the midwife, who was previously convicted and fined in another state for causing a homebirth death. The moreso in light of attempts by Katz Rothman and the midwives of which she speaks so glowingly to spin recently published data indicating the horrifyingly high mortality and morbidity rates of homebirth midwives in the US. MANA, the professional organization representing US midwives and headed by Melissa Cheyney PhD, anthropologist at Oregon State, has suppressed these data for years and only recently published them under considerable pressure and with obfuscatory spin bordering on scholarly misconduct. “Risk,” indeed. One wonders how we can have any meaningful conversation about the concept without acknowledging how obstetrical risk is so wilfully misrepresented within the homebirth community (as pointed out by Dr. Tuteur above) and so uncritically dismissed by anthropologists and sociologists alike.
Anthropologists’ uncritical acceptance of NCB and midwifery rhetoric and our quiet acceptance of work like that of Cheyney and Rothman is an utter embarrassment to our discipline.
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