Reproductive Disruptions

Gender, Technology, and Biopolitics in the New Millennium

Marcia C. Inhorn

• Publisher: Berghahn Books
• Year: 2007
• Print ISBN: 9781845455958
• eBook ISBN: 9780857455635
• Edition: 1
• Topic: Social Sciences
• Subtopic: Gynecology, Obstetrics & Midwifery
• Index: Social Sciences

Nominated for the 2007 Book Prize by the Council on Anthropology and Reproduction (AAA)

Reproductive disruptions, such as infertility, pregnancy loss, adoption, and childhood disability, are among the most distressing experiences in people's lives. Based on research by leading medical anthropologists from around the world, this book examines such issues as local practices detrimental to safe pregnancy and birth; conflicting reproductive goals between women and men; miscommunications between pregnant women and their genetic counselors; cultural anxieties over gamete donation and adoption; the contested meanings of abortion; cultural critiques of hormone replacement therapy; and the globalization of new pharmaceutical and assisted reproductive technologies. This breadth - with its explicit move from the "local" to the "global," from the realm of everyday reproductive practice to international programs and policies - illuminates most effectively the workings of power, the tensions between women's and men's reproductive agency, and various cultural and structural inequalities in reproductive health.

Part I

REPRODUCTION AND DISRUPTION: REDEFINING THE CONTOURS OF NORMALCY

Chapter 1

THE DIALECTICS OF DISRUPTION: PARADOXES OF NATURE AND PROFESSIONALISM IN CONTEMPORARY AMERICAN CHILDBEARING

Caroline H. Bledsoe and Rachel F. Scherrer

Introduction

Despite the development of so many advancements in obstetrics and related fields that have minimized the mortality risks of childbirth in the US, obstetrics remains the adversary of many contemporary American women. No other medical specialty is described in web sites, internet chatrooms, and magazine articles as being so disruptive, a fact that seems paradoxical given the joy that the event of childbirth is supposed to represent. Obstetricians attend over 90 percent of US births, and the great majority of obstetrician-attended births produce healthy mothers and children. Indeed, aside from the preventive medicines, obstetrics is the only specialty in which the expected outcome is normality. These facts would seem to merit more positive mention for obstetrics than it draws. Lawsuits, though indicators of many things, are telling. Obstetrics has one of the highest rates of litigation among the medical fields, whether measured by proportion of lawsuits per total number of cases or total payouts (see Richards and Rathbun 1999: 391).

A prominent charge from critics in recent decades has been that the field is not woman-centered. Recent figures on completing residencies in US medical schools, however, show that in 1999, well over half (58 percent) of those completing obstetrics/gynecology residencies were women. Just four years later, the proportion of women finishing obstetrics/gynecology residencies had risen to 71 percent, a gender shift that Brotherton et al. (2004) describe as the most dramatic in all the medical specialties over this time period.¹ Anecdotal evidence from the medicine-rich Chicago area (Scott Moses, personal communication) suggests that the men who enter the field today are largely specialists in the areas of surgery or high-risk medicine: those having few direct dealings with mainstream clinical patients. Still, the field of obstetrics is viewed with mistrust: a disruption in what should be the most natural of processes.

The character of the natural is arguably the guiding disciplinary question of anthropology, if not that of the social and health sciences in general. In the harder sciences, nature refers to elemental forces of physics, chemistry, and biology that would operate, in dynamic interrelation, in the absence of human intervention. Most anthropologists, however, following Kant (Prolegomena), refer to nature as that which society takes for granted. Thus, nature does not inhere in objects or processes as things-in-themselves, but in how the mind assembles its perceptions of them. Hence, what we see as natural or commonsensical depends on our vantage point in social class or history.² The problem for anthropologists, of course, is that because natives take for granted what they regard as natural, they seldom choose to talk about it.

If views of what is natural are historically and situationally specific, so too are views of disruption, since they represent the antithesis of whatever is considered natural. As views of the natural shift, views of what is disruptive shift accordingly, taking up their positions of opposition.³ Since the violation of what people hold as deeply felt cultural principles evokes intense sentiment, one way to get a fix on cultural conceptions of nature is to observe what action society’s members take in reaction to factors they describe as disruptive. Another way is to study how society institutionalizes its domains: structuring efficient relations to conduct specialized tasks and routinize behaviors, giving them rule-like status (Giddens 1979). Institutionalization also involves professionalization: training specialists and assigning them licensed authority to practice by demonstrating competence in the principles and standards of their specialties.⁴ With childbearing now representing, in American cultural ideology, the most quintessentially natural of human activities, efforts to institutionalize and professionalize it rise sharply to the surface of debate.

Framing our discussion in the worries that can surround reproductive events—the highly contingent, even dangerous character of reproductive naturalisms (e.g., Bledsoe 2002a)—we explore the mix of worries about disruption and the practices that appear to generate it in US middle-class ideologies today. In the US, infertility and miscarriage are described as highly disruptive events in reproductive life (see Becker 1997 and Layne 2003). Equally salient in voiced concerns about reproductive disruption is the use of highly technical instruments, drugs, and medical procedures, particularly by professional obstetricians (Davis-Floyd 1996). We show that contemporary American women do not have the same worries that women in the US previously had or that many women in the developing world continue to have, since few fear death or lasting damage from childbirth. With such strong pressures not only for perfect motherhood (Douglas and Michaels 2004) and a perfect baby (Rapp and Ginsburg, Chapter 3) but also, we believe, a perfect birth, women now fear actions by licensed practitioners that may interrupt what they see as a natural reproductive event. Building on the interactionist insights of Georg Simmel, we suggest that it is not what obstetricians do that is disruptive—the intrinsic nature of their actions—but rather the implications about control that the presence of a professional obstetrician in the delivery room represents.

In the popular American vision, “natural” often implies the absence of human intervention, and nature has been transformed into an entity threatened by control, requiring active preservation (for a similar discussion, see Haraway 1984/1985). While the pursuit of a natural birth appears to follow a similar logic, we believe that the term natural has come to be more strongly equated with a woman’s ability to retain control over her own birth event. To this end, American women have used opportunities presented by popular sources such as the internet to reach levels of near-professional obstetric competence. They become what we might term “professionalized patients”: highly versed in medical technicalities surrounding the specifics of their own case. The fact that a licensed practitioner has legal authority to act in the best interests of a patient who often has a remarkable degree of technical knowledge about the process she is experiencing—and who also has a strong desire to make her own decisions in a domain she considers so natural—makes the potential for discord very intense. Struggles between women and doctors in what has become a thoroughly professionalized reproductive environment produce a dynamic of perpetual and inevitable unease.

Data

The present chapter grows out of a longtime attempt to draw on the US for systematic juxtapositions against a series of striking empirical findings from West Africa.⁵ It builds on research that is characteristically ethnographic: participant observation, interviews, and tours of medical facilities in Chicago. We also conducted several lengthy interviews with physicians and midwives, and had a number of informal conversations with women, men, and nurses. The data we utilize here, however, will come primarily from published materials in popular media. These materials were produced by professional writers who direct their content at mothers or would-be mothers, and by women themselves, who write largely from their experience and problems. Such materials proliferate in doctors’ offices, hospitals, and drug stores, as well as on television and in internet articles, ads, and chatrooms. In this chapter, we draw on materials close at hand: magazines and web sites offering advice on how to negotiate the birthing landscape of facilities, products, and practitioners. We draw on two especially popular magazines: Fit Pregnancy and Mothering. Fit Pregnancy, published by Shape Magazine, targets a wide spectrum of middle-class women, with articles on everything from the latest stroller designs and recipes that allow pregnant women an extra 300 cautious pregnancy calories each day, to makeup tips on hiding that 2 AM-feeding-shift look and exercises for regaining postpartum muscle tone. Mothering, with its embrace of organic foods, cloth diapers, and midwives, as well as its militant animosity toward hospitals, labor anesthesia, and childhood vaccines, aims directly for consumers who seek naturalistic styles of life. We also examine an issue of Awake!, a pamphlet published by the proselytizing religious Watchtower organization (Jehovah’s Witnesses); the New York Times; and a textbook on medical malpractice law.

Although these sources may seem arbitrary if not odd, the examples they yield are not at all out of line with the thousands of texts and images we have examined, and are fully consonant with the ethnographic work. The personal stories, scientific facts, statistical findings, pictures, and advertisements in these sources articulate strong cultural convictions from middle-class America (and elsewhere in the world) about reproduction, and they reflect an abundance of philosophies that today’s women are urged to follow. They also describe alternatives, hint at ways of phrasing requests to physicians, and give names of professionals to contact for second opinions. Taken together, these materials lay bare a consuming, paradoxical world of worry, accusation, and strategy. Using “admonition language,” many of these sources urge women to conduct births in ways that are defined as natural and they cast implicit blame on those who fail to achieve them.

Needless to say, relying on sources that so transparently emphasize ideals is risky for generalizations regarding behavior. Only 1 percent of births in the US occur in the home, and only 5 percent occur in birthing suites or birthing centers. Robbie Davis-Floyd (pers. comm.) speculates that hospitals may use their birth centers, which comprise relatively small portions of their obstetrics facilities, for marketing purposes. If so, this fact is itself testimony to the strength of the sentiment that impels the quest for naturalism. Using such sources also raises questions about who is not represented. Almost entirely missing from US popular media on birth are references to women in countries where pregnancy and childbirth can set into motion utterly different visions of risk. That we found almost nothing in the popular literature on pregnancy and birth that was directed at lower-class women in the US is striking. It is very likely that our casts were not broad enough, though this relative absence is itself worthy of study. Yet attempting to achieve for balance and perspective among such a motley array of uneven sources is in one sense no different than using any data, in that one must always read “sideways” and between the lines, and triangulate even among “missing” data points.

The Tolls of Reproduction

From the frame of intervention–free birth goals, we are on much firmer ground concerning missing data when we turn to the specter of reproductive risks from earlier eras in the US that continue to plague women and children in other places today. In places like rural sub-Saharan Africa, most women frame the experience of reproduction very differently (Bledsoe 2002a). Cases of death or serious injury at birth that can pose devastating disruptions are, comparatively speaking, rare events in the US; but problems associated with reproduction take an enormous toll in developing countries.⁶ Africa has by far the highest rates of death in the world due to maternal causes: the death of a woman while pregnant or within forty-two days of the termination of pregnancy from causes related to the pregnancy or its management. According to estimates of maternal mortality in 2000 by WHO, UNICEF, and UNFPA <http://www.reliefweb.int/library/documents/2003/who-saf-22oct.pdf>, 529,000 women worldwide died of maternity-related causes. Sub-Saharan Africa, although it constitutes only 12 percent of the world’s population, accounted for nearly half of all maternal-related deaths (47 percent: 251,000), and African women were 175 times more likely to die from maternal causes than women in developed countries.⁷ And for every woman who died, twenty more suffered injuries to pelvic muscles, organs, or the spinal cord. In sub-Saharan Africa, individual women face the risks associated with childbirth from 4 to 8 times during their lives, with a cumulative lifetime risk of maternal death of 1 in 16, compared with one chance in 2,800 in developed countries: the largest difference between poor and rich countries of any health indicator. While women in Angola, Malawi, Niger, and Sierra Leone ran a lifetime risk of 1 in 6 or 7 of dying from maternal-related causes, women in Sweden stood a 1 in 29,800 chance and zero chance in Iceland. The principal factors cited for high maternal death rates in Africa include infection, multiple closely-spaced births, hemorrhage, obstructed labor, hypertension, and the complications of abortion, especially among adolescents. Besides these complications are a host of other potential ones: placenta previa (the positioning of the placenta between the baby and the birth canal, creating risk of hemorrhage), placenta abruptio (the disengagement of the placenta from the uterine wall before birth, cutting off oxygen and nutrients to the baby), umbilical cord entanglements, toxemia, Rh factor incompatibility, anemia, maternal diabetes, and infectious disease. Many obstetric emergencies cannot be averted in pregnancy, though their effects can be mitigated with sufficient resources. In the developing world, a lack of access to the kinds of medical interventions that Western women hold in invisible reserve to ensure normal outcomes are among the most important factors contributing to high rates of maternal mortality at the point of childbirth. Among the most noted resource problems are a lack of access to adequate pre- and postnatal care and a paucity of emergency obstetrical care for complications, basic supplies and equipment, transportation to referral points, and staff; many African countries, for example, have been hit in recent years by an overseas exodus of medical personnel.

Maternal deaths leave families without sisters, wives, and mothers, while young children whose mothers die run much higher risks of death than do children with living mothers. As for the risks that children themselves face, rates of infant and child mortality have come down dramatically in many parts of the world in the last three decades, including in a number of African countries, but a child in Africa still has a one in six chance of dying before age five, with impoverished children even more likely to die, and only half of all children in sub-Saharan Africa are immunized during their first year of life. Worldwide, around 60 percent of all infant deaths (deaths during the first month of life) are linked to infectious and parasitic diseases...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Preface
• Introduction: Defining Women’s Health: A Dozen Messages from More than 150 Ethnographies
• Appendix
• PART I Reproduction and Disruption: Redefining the Contours of Normalcy
• PART II Reproduction, Gender, and Biopolitics: Local-Global Intersections and Contestations
• List of Abbreviations
• List of Contributors
• Index