Part one
Sexuality and the Body
Chapter 1
The Mother and the Hospital
An unfortunate fit between the womanâs internal world and some hospital practices
Dana Breen
ACKNOWLEDGMENTS
With thanks to Dr Jenny Lewis, Ian Birksted, Stuart Marks and Dr Abe Brafman for their constructive criticism.
Pregnancy, and in particular a first pregnancy, is a bio-psychosocial event involving the womanâs sexuality, which requires coming to terms with past relationships, mourning the âold-selfâ, working through fears and fantasies about the birth and the new baby, making room for a new person, coming to terms with a new life style, coming to grips with a realistic notion of the âgood enough motherâ.(1)
This paper is an attempt to describe how external structures (in this case certain hospital practices) can articulate with these internal psychological conflicts, thereby increasing the chances of pathological reactions around the time of childbirth.
I will start by describing the psychological processes of change and the conflicts which take place in women at the time of having a baby, contrasting women who cope well with those who do not cope so well.
I will then go on, in the second section, to look at the way in which some characteristics of the institutional setting come to slot in with certain anxieties and with less adaptive ways of dealing with the feelings aroused at the time of having a baby.
I CONFLICT AND GROWTH
Pregnancy has often been described implicitly or explicitly as a hurdle which must be overcome in order for the woman to get back to her normal pre-pregnancy state, or an illness from which she must and in most cases does recover. As one pamphlet for expectant fathers puts it! âyou will find that the middle months of pregnancy are a more stable period and ânormalityâ returns some weeks after the babyâs birthâ (my emphasis). (2) This abnormality which colours the pregnant period is ascribed to bodily processes. In the words of another pamphlet! âthe probable reason lies in the complex series of chemical changes that are taking place throughout the body and in particular in the placenta (or after-birth),â (3) The woman is told not to worry because these strange emotions are not a part of her but are an artifact of the physiological changes and will disappear when she regains her former figure. Husbands are told to be patient and to remember that their wife is not really the way she is at the moment, that she is temporarily âpossessedâ. Psychological studies are also frequently based on this notion of a temporary disorder and women are tested for evidence of increased âneuroticismâ during pregnancy with an expectation that their scores will return to pre-pregnancy measures postnatally.(4)
Such notions of pregnancy as temporary possession by psychochemical forces, as temporary derangement which must be brushed aside, as illness from which the woman must and will recover, are not only patronisingly dismissive of what could be a most valued and specifically female experience, but also deny the importance and meaningfulness of the turbulent emotions which accompany all important life events. Pregnancy stimulates in the woman ideas of life and death, mortality and immortality, purposefulness and futility, ideas connected with her own infancy, mothering and fathering, about her own ability to nurture and be relied upon, about dependency, about her own capacity to be intimately and bodily involved with a newborn baby and later a child while at the same time able to retain a sense of individuality. These questions may not necessarily be so clearly formulated, but they cannot but be experienced in some form by a woman preparing to give birth to a child, and the turbulent and sometimes incomprehensible emotions relate in one way or another to these sorts of questions. In fact one can talk about a âcapacity to worryâ in the face of such a major life event. To worry is also to prepare oneself for the change which will take place and it is the woman who has no anxieties at all during pregnancy who is likely to experience psychological difficulties after the birth of the baby. To talk about temporary derangement or âincreased neuroticismâ is not only to misunderstand this healthy side of being able to worry and come to grips with mixed feelings and perhaps irrational feelings in the face of a dramatic event, but is also to deny the personal enrichment a person can find in coming into touch with the powerful emotions stimulated by this event, and the meaningfulness of these emotions. I find it more appropriate to think of pregnancy as one part of a total process, pregnancy in a psychological sense of growth and preparation, as a phase of development which can be coped with well or not so well, depending on various psycho-social aspects and circumstances. In this sense it is not possible to talk about one particular cut-off point, such as the birth, for instance. Major changes and experiences also take place after the birth of the baby, when reality comes to articulate with fantasy. I prefer to talk loosely about âchanges with the birth of a childâ â where particular feelings or the resolution of certain conflicts can take place at different points and at a different pace for each particular woman.
Instead of getting stuck on specific symptoms (nausea, tiredness, etc.) accompanying the psychophysiological process of pregnancy and which are akin to those of certain illnesses (and can feel with no doubt most debilitating), it is more fruitful to look at the meaning of the total process for a woman. The birth of a child and in particular a first child is a meaningful experience which cannot leave a woman unaffected. If she is able to integrate this experience and change, one can talk of âgrowthâ and âdevelopmentâ. In the words of Abigail Lewis, for whom it is a question of femininity versus masculinity :
the defiant tomboy that was me will be finally and irrevocably lost, but âsomeone else will be bornâ, though not so apparently as the baby is born. Or at least I hope so⌠âone must learn to change with changing circumstances or it is death indeedâ .(5) (Emphasis mine.)
A woman during pregnancy often comes closer to her childhood feelings, to reconsidering her past. She questions her position and her role.
Living far from home, in a separate life, I have come to feel at times in charge of my destiny, free of my blood. But certain doubts leak through. I have been a daughter, I shall be a mother. But what is there between? Am I anchored to this line forever? (Hermine Demoriane)(6)
That she has had a mother and that she will be a mother are inescapable facts. But what does this mean exactly to each woman, what does it mean in terms of what she feels about her mother, about motherhood and about her ability to mother? What does it mean in terms of the constraints she feels it places on her person? And beyond this what does it mean in terms of being a woman able to bear children? For Hermine Demoriane being thrown in this way back into her past seems to mean a certain loss of freedom, and her feelings concerning her own dependency are acutely aroused.
I found (7) that it is possible to describe processes of change in women with the birth of a first child. The focus in my study was on the changes in how women see themselves and their perception of the maternal role. I compared a group of women who coped well with having a baby (from both a psychological and a somatic point of view) with a group of women who did not cope well. Indeed opposite processes of change took place in these two groups of women. For the women who coped well (in the sense of psychological and physiological well-being) the processes included an identification with a good mother image, a reconsideration of the mother role which they could feel in tune with, a resolution when necessary of the split between âgoddessâ and âwitchâ. This split in the image of the mother is one which psychoanalysts locate in the earliest experience of the infant who does not yet connect the experience of contentment of one moment with the rage of another, and creates separate images of destruction and goodness. How these images are later integrated and the balance between them, will depend on the particular child and the womanâs life circumstances. Specific events reawaken the fear of this destructive force inside or outside the person, or the hope for a source of total satisfaction. At the time of having a baby these images of the perfect mother and the totally bad mother are reactivated through the woman becoming a mother herself, and becoming the mother to a newborn baby coming from herself and like she once was. The mother who copes, I found, is the one who is able to come to terms with her own past, find in herself a positive mother image, neither idealised nor denigrated, which she can call upon and identify with in relation to the new baby. I found that one of the things which makes this possible is that her standards are not pitched too high; to be a good mother, she comes to realise, is in large part a question of hard work and she is able to meet this demand to a reasonable extent. What happens to the noncoping mother is quite different. After the birth of the baby, even more than before, she sets unrealistically high standards for herself. The good mother she sees as one who is perfect and totally self-sacrificing. This is the mother she feels she never had and also the one she feels she cannot possibly be. She feels inadequate and bad. Against this background the babyâs cries and demands are felt as accusations and proofs of her inadequacy. She feels angry or guilty and thinks her badness is confirmed. For this woman, the internal split between the ideal mother and the terrible one, far from being resolved is increased, the childhood split between goddess and witch predominates. How a woman sees the maternal role in terms of the rest of her life is also important. I found in my study that the coping women were either satisfied by and identified with a very traditionally defined role after the birth of the baby, or on the contrary were able to recreate the mother role in such a way that they could positively identify with it without finding it too restricting. The non-coping women tended to perceive the mother role in a more traditionally idealised way after the birth of the baby, and this involved for them a greater conflict with outside interests and a greater dichotomy between what they wanted to do and what they felt they ought to do.
There are many reasons why one woman can reconsider the maternal role and be satisfied with herself as a mother while another woman suffers at not being the selfless mother she feels she ought to be. The role played by the institutional setting will be considered in the second section of this paper. Psychological factors stemming from her own early life will colour her aspirations and perception of herself as a mother in the way I described earlier. The behaviour of the particular baby will also be important in either helping a woman feel at peace with herself or on the contrary confirming her feeling of inadequacy. One woman describes this in relation to her two children:
John cried and cried and cried and he used to wake all the other babies up (in hospital), as soon as heâd open his eyes he cried, at night all the babies would wake up and be fed and heâd scream, every night I had to go to the nursery and every night they had to give me a sleeping tablet because I got in such a stateâŚ. I felt very rejected because he cried all the time and in the end very resentful, rejected by him, I never seemed to be able to do anything rightâŚ. Jane is so placid. John would open his eyes and scream, Jane would think about it before she let rip and even when she did it wasnât this terrible pitch, John used to have this terrible pitch which used to really jar, hers is rather apologetic, and sheâs been fabulousâŚ. Sheâs so loving. Everything I do is rightâŚ. I still feel guilty at how angry John can make me. I donât know how much was the fact that he was a difficult baby or how much that I was a difficult mother, I really donât know, or how much I resented him, maybe I just resented how having him made me feel.
While for this woman it is the placid baby who makes her feel a good mother, for another woman it would be such a placid baby who would arouse the fantasy that he or she could die any minute, or be lacking in healthy vitality.
Psycho-social factors related to a womanâs present socio-economic and work situation are also important and determine the extent of the change in circumstances brought about by the pregnancy and the new baby. How much a woman gives up economically, professionally or in terms of independence will vary and colour her feelings about being a mother. And also it may well be easier to feel a loving mother when all the time and energy are not taken up with coping with other children and a house single-handed, and there is no possibility of escaping for a few hours from the constant demands. This is where the actual amount of practical help given by the father of the baby also comes in. For as well as his perception of her as a mother (if he is supportive rather than denigrating of her mothering capacity) he can practically help to make her life less stressful.
One small study of women who had a psychotic breakdown after the birth of the baby suggested that the husbands of these women tended to compete with their wives in the female role, thus contributing further to the wivesâ feelings of inadequacy. The authors talk about these men as being the counterpart to what has been described as âcastrating womenâ, (8) The manâs own early images of the idealised and the denigrated mother, and his definition of the mother role will have an effect on the marital relationship and the womanâs feelings about herself as a mother.
Besides the ability to reconsider the maternal role so as to be in tune with a not too idealised image of it, the women who in my study coped well were able to feel themselves to be active and creative during pregnancy. After the birth of the baby the sense of activity of the coping women and the sense of passivity of the non-coping women were in even greater contrast. This is strikingly different from the traditional equation of femininity with passivity, since it is here possible to show that a good adjustment to this uniquely female experience goes with a feeling of initiation and activity. The evident activity necessary in childbirth itself has been referred to as masculine. One author talks of the âmasculine achievement of giving birthâ. (9) I think this is absurd. The qualities necessary for coping with childbearing are by definition feminine, and if such essential qualities are activity and a sense of creativity, then these qualities are an integral part of femininity (in the sense of femaleness).
II IN HOSPITAL
The birth itself
Childbirth is symbolic of the passage from non-mother to mother. It is the moment from which the primiparous woman (i.e. a woman pregnant for the first time) will be called a mother although she has already nurtured this child for nine months. For the woman who has already borne a child it symbolises the beginning of a new cycle. Anthropologists have described how other cultures deal with this momentous event by surrounding it with various practices and elaborate ârites de passageâ. The psychoanalyst Peter Lomas suggests that similar practices can be described in our own culture, in particular the seclusion of the parturient woman away from the rest of the family and from her usual habitat, and the powerful role which is given to the doctor in relation to the pregnant and parturient woman. (10)
Like other ceremonies, these practices can be symbolically helpful in regulating the transition, framing it into rigid rules of behaviour and offering a transition time without pressures. The weekâs rest in hospital is supposed to allow the new mother to take charge of her baby in her own time, under the supervision of the more experienced âmothersâ. Mistakes are tolerated and she is told to follow strict procedures and timetables. The whole seclusion in hospital is one which emphasises and condones the special nature of the event, its major implications, and allows a period of readjustment away from the strains of everyday life. It also helps a woman to feel protected against the strong emotions evoked by childbirth; she feels in a safe place, well protected by the doctor. The womanâs fears are partly due to her fantasy of the har...