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Editorial
Kerreen Reiger
La Trobe University
Alphia Possamai-Inesedy
University of Western Sydney
Karen Lane
Deakin University
Article Text
This special issue of Health Sociology Review (ISBN 0-977524-25-6) is based on a workshop held in Sydney in June 2006 which was sponsored by the Academy of the Social Sciences of Australia, with further support from the Social Justice Social Change Research Centre of the University of Western Sydney. Entitled Risking Birth: Culture, Technology and Politics in 21st Century Maternity Care, the workshop brought together a multidisciplinary group of scholars and health professionals to discuss the salience of contemporary social theory to the politics of maternity care provision. Central to much of the debate was an exploration of the social and cultural factors which contribute to the current dilemmas facing maternity services within Australia - rising rates of costly technological intervention in the physiological processes of pregnancy and childbirth, staffing problems, and changes in professional roles and in models of service delivery. Despite the many governmental enquiries, subsequent recommendations and policy proposals, intervention rates have continued to climb to the point where some predict that, in a few years, a generation of healthy women will be having most of their babies by surgical means.
The workshop, and the resulting peer reviewed papers for this special issue of Health Sociology Review, extended existing social science analyses of the medicalisation of childbirth. Whilst previous research into the area has been clearly important in shedding a critical light upon childbirth practices (see Beckett 2005), recent social changes and resulting social theory debates pose new challenges. Accordingly, many of the articles in this issue contextualize current pregnancy and childbirth practices within what, following Ulrich Beck (1992), can be termed 'risk society'. Several of the authors in the issue draw extensively on the work of Beck, namely his concepts of risk society, reflexive modernization and individualization. They suggest that such concepts are essential to understanding the contemporary experiences of pregnancy and childbirth by women and their carers. Beck points to the ways in which environmental, economic and health dilemmas are becoming permanent backgrounds to our everyday life in advanced industrialization. Choice and flexibility, claimed to characterise risk culture, present new dilemmas for childbearing women and their partners as they now face a myriad of decisions concerning testing and the self-management of a pregnant and lactating body. Both caregivers and parents have to deal with new and highly contested forms of knowledge, and accordingly, new responsibilities and anxieties.
The workshop discussions concerning these issues were lively as sociologists, midwives, doctors and others grappled with teasing out the relationships between cultural and social change, provision of professional care, and the diversity of women's individual experiences. In particular, the ways in which in late modernity the fear of death in childbirth, common to traditional cultures and still salient in developing countries, has largely given way to fear of the dangers of life - concerns about the future well-being of the baby and mother. The use of genetic testing in pregnancy, increased surveillance by health professionals, new forms of access to informational technologies by women as health care consumers, media influences, and pressures on caregivers in an increasingly litigious society were discussed as central to shaping not only women's and their families' experiences but the politics of care provision.
The role of the state deserves close attention as neo-liberal economies like Australia, Canada, the UK, NZ and Britain move from a welfare state to a post-welfare state driven by the forces of globalisation, marketisation and managerialism. Many Australian state and federal government inquiries and subsequent recommendations have sought to decrease technological intervention in the physiological processes of pregnancy and childbirth (eg Commonwealth of Australia, 1999; New South Wales Health 2000; Victoria 2004), but 'medicalised birth' still dominates the mainstream health system. In a paper providing a critical overview of policy developments, Reiger traces the contradictory and contingent role played by the state as it both responds to competing interests yet advances a politically-driven health reform agenda. While new models of midwifery care and women-centred services are promoted, they are often undermined by workplace realities that reflect the pressures of health service rationalization and managerial control. Also addressing changes in models of care, Lane's paper focuses on changes in professional boundaries in the marketising environment of the 'audit society'. Exploring data from a study of inter-professional relationships, Lane asserts the importance of midwifery 'emotion work', not just as a strategy for pain relief, but as a highly-developed professional speciality in helping women to realise their own strengths in birthing without complication and without medical interventions. Both midwives and obstetricians need to acknowledge the routine role of midwives in normalising 'normal' and potentially pathological births and thus in making extensive savings in economic and social costs. Positing 'emotion work' as a new object of knowledge in the ongoing professionalizing project would allow midwifery to claim a new professional equivalence with obstetrics in this new state and market-driven era of collaborative care.
State policy developments and changing divisions of professional labour are also addressed by Zadoroznyj who discusses the problem of the elision of policies of support and surveillance with regard to the postnatal period. The South Australian government's limited Mothercarer Program targeted much-needed support in the home, providing help with other children, shopping and housework for a limited group of women who were discharged early from hospital. The mothers, who were self-selected, were those least socially, culturally and materially resourced, indicating that the program was well-placed to assist those in most need. By comparison, the government's universal Home Visiting Program acts more like a screening strategy that envelops every family with a view to detecting 'at-risk' families and providing early interventions. In the process, however, it privileges surveillance over support and, ignores the needs of women in favour of monitoring risk to the child as part of a wider social and psychological panopticon.
Reiger and Dempsey extend the risk society thesis to considering the 'performance' of birth. They propose that the cultural norms around fear of birth may become materialised in the body via social processes that augment or diminish women's agency. Routine medical tests, monitoring practices and devices to eliminate pain may reiterate (in Judith Butler's terms (1997)) a fearful risk-oriented culture producing an equivalent of the nineteenth century version of female passivity. On the basis of creative and performing artists' accounts of their 'crises of confidence', they argue that the challenge is to develop better support strategies to assist healthy women confronting normal, positive labour pain rather than succumbing to an obsessive preoccupation with self and risk-avoidance. Eckermann and Kildea's contributions also demonstrate how all birth is mediated by culture. The issue of how to conceptualise birth and, following this, where women should give birth is addressed by two papers which offer glimpses of other non-Western possibilities for women in developing countries and for Indigenous Australian women. Developmental strategies need to avoid the Western predilection for micro-surveillance, micro-management and obsessive self-discipline that Western women use as weapons against risk and uncertainty but which ironically undermine women's confidence in their abilities and their bodies. Traditional cultural beliefs as well as local economic imperatives need to be acknowledged, Eckermann and Kildea both argue, in designing maternity care regimes that reduce infant and maternal mortality rates but minimise social dislocation and lack of support. One positive solution to the challenge of servicing geographically-dispersed populations, discussed by Eckermann, has been the construction of Maternity Waiting Homes in Laos that provide access to skilled personnel, but seek to minimise the social and economic problems when mothers are moved from home to give birth. In order to lower the high Laotian maternal and infant mortality and morbidity rates, the Homes provide prenatal, birth and postnatal care. Most importantly, though they also support income-earning ventures that allow families to stay together and continue to support themselves economically while the women are waiting to give birth to their babies. The scheme is premised upon local community consultation whereby innovations are ratified by communal decision-making.
The pivotal role of community, and the proposition that 'risk' has a strong cultural dimension, are themes also central to Kildea's paper on Indigenous constructions of risk, ideas which stand in stark contrast to dominant white definitions. While high-technology, obstetric-dominated hospital settings are assumed by health providers to be the safest place to give birth, Aboriginal women tend to perceive the hospital as the crucible of risk. Hospital birth means they must leave their families and communities and especially the lands of their ancestors to which they are spiritually linked. Kildea's analysis of Australian Aboriginal women's birthing needs, and her comparison with responses to those of the Inuit in Canada, demonstrates that risk-avoidance is not merely the absence of 'objective' hazards but involves feeling safe within the bounds of tradition. As Aboriginal women state that they would rather birth in their own community with known caregivers 'even if it is not as safe', risk management for them is thus choosing among a hierarchy of risks rather than eliminating risk altogether. This argument was made especially clear at the workshop through a powerful visual presentation given by a young Indigenous mother, Fleur Magick, who described her experiences of seeking to birth 'on country'. Her account of struggles with professional caregivers who took only a medically-oriented risk-framework indicated its inadequacy to address Indigenous women's needs.
That questions of interpretation, information-provision and consent are central to women's experience is further demonstrated in Donovan's examination of prenatal screening and testing within the New Zealand context. Donovan argues that although screening increases women's 'options', it decreases their 'choices' in the sense of informed and freely-made decisions because the protocol for informed consent ensures that women must make a choice. Even a choice to desist carries with it an unacceptable burden for many women since the only 'remedy' for those with a positive test result indicating an abnormality is termination. Failure to comply brings further sanctions within a regime of increased surveillance and heightened anxiety that carry over into the rest of the childbearing experience. At the wider level of changes in Western culture, Alphia Possamai-Inesedy's article also demonstrates how a shift in responsibility, choice and control has impacted upon birthing women. The pregnant woman now faces an 'imperative of avoidance' (Beck 2000:17) whereby no-one escapes the impending threat of hidden and obvious hazards, including those of the body itself. Pregnancy and birth are now ostensibly ridden with risks, prompting women to take evasive actions which will vary according to individual identity and personal philosophy of the body and birth. One outcome, however, is an increasing cultural acceptance of an armoury of medical interventions. As Possamai-Inesedy and Donovan argue there is no such thing as a risk-free birth because the discourse of risk is undeniably pervasive and invasive.
It is clear that, as the papers brought together here and the initial workshop discussion indicated, women themselves now need to grapple with new dilemmas but also new opportunities. Genetic testing and screening technologies, such as ultrasound imaging, predict future disease states making visible 'risks' that would otherwise remain hidden within the body. However, there are negative backlashes. Surveillance increases and anxiety spirals, especially as this 'biomedicalisation' phenomenon is also driven by health industries exploiting commercial opportunities in treatment products and in funding research that discovers new 'risks'. Yet the papers in this volume also point to ways in which childbearing women, and those seeking to improve maternity care provision, are engaged in contesting the politics of risk construction in contemporary culture and challenge assumptions that risk society is, at least as yet, totally dominant.
References
Beck U (1992) Risk Society: Towards a New Modernity, London: Sage.
Beck U (2000) The cosmopolitan perspective: Sociology of the second age of modernity. The British Journal of Sociology 51(1): 79-105.
Beckett K (2005) Choosing Cesarean: Feminism and the politics of childbirth in the United States. Feminist Theory 6(3): 251-275.
Butler J (1993) Bodies That Matter: On the Discursive Limits of 'Sex', New York: Routledge.
Commonwealth of Australia (1999) Rocking the Cradle, Community Affairs References Committee Sydney Senate: 371-505.
Department of Health NSW (2000) NSW Framework for Maternity Services 2000-2005, Sydney NSW: Department of Health.
Department of Human Services (2004) Future Directions for Victoria's Maternity Services, Melbourne: Department of Human Services.
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