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Finding a 'Safe' Place on the Risk Continuum: A case study of pregnancy and birthing in Lao PDR

Elizabeth Eckermann
Arts Faculty, Deakin University, VIC

Abstract

This paper addresses two questions. Firstly: are the risk regimes faced, and perceived, by pregnant women in rural Lao PDR substantially different from those experienced by pregnant women in western societies? Secondly, if the Lao experiences and perceptions are different, can improvements in maternal health in Lao PDR be achieved without Laotians inheriting the risk regimes of late modernity experienced by many women in western societies?

Secondary analysis is undertaken of data collected in 2005 for the evaluation of a pilot maternity waiting home in Bolikhan, Lao PDR. The results suggest significantly different risk perceptions and experiences between Lao and western communities, based on contrasting views of embodiment, identity construction and cosmologies.

In the Lao rural communities studied, there is little evidence yet of 'risk society' despite the introduction of western technologies and practices to improve maternal mortality and morbidity. It is argued that 'risk society' can be avoided.

Keywords

sociology, risk, birthing, maternal mortality, Lao PDR, development

Article Text

Paradoxes of risk society

Beck's (1992) concept of risk society provides an explanatory framework to elucidate some of the contradictory imperatives which contribute to identity construction and embodiment experiences for many pregnant women in late modern mainstream western societies (Lupton 1999, Lane 1995, Zadoroznyi 2001). Lifestyle risk discourses impact on pregnancy practices. Medical risk discourses influence both pregnancy and childbirth experiences. Many women in late modern western societies are still subject to the normalizing gaze (Foucault 1991) of medicalized births (Martin 1987) and heavily regulated pregnancies (Lupton 1999) at the micro level. They are also faced with the macro deregulation of a 'profusion of possibilities' and choices of providers and settings for birthing (Zadoroznyi 1999: 268), deregulated and uncertain insurance arrangements, and privatization of services, all of which involve inherent risk contingencies and undermine their subjective wellbeing (Pesavento, Marconncini & Drago 2005). How these conflicting risk imperatives of chaos and order (Turner 1997) are interpreted, and acted upon by pregnant and birthing women, are tempered by dimensions of difference such as ethnicity (Hsee & Weber 1999), age (Reichman and Pagnini 1997), geographical location, in particular rural living (Maternity Coalition 2005a, 2005b, Health West 2000) and social class, especially for the first birth (Zadoroznyi 1999).

Thus the extent to which women feel they have power and control over their pregnancy and birthing embodiment, and develop a confident capacity to negotiate the restrictive imperatives of surveillance of their bodies during pregnancy, as well as the multitude of birthing options, economic imperatives and insurance arrangements, varies with social, economic and demographic positioning. However, for mainstream western women, from all walks of life, pregnancy and birth remain domains of risk and disquiet despite relatively low mortality and morbidity ratios in the twenty first century (Lupton 1999, 2003b). The palpable risks of death, sickness and disability associated with pregnancy and childbirth have been largely replaced with the unintended 'risks' of both governmentality and unbridled choice which form part of a risk management cosmology. The 'risk meanings and strategies' which individuals reflexively develop 'are attempts to tame uncertainty, but often have the paradoxical effect of increasing anxiety about risk through the intensity of their focus and concerns' (Lupton, 2003b:13). These paradoxical effects include emotional alienation, obsessive concerns with avoiding risk, feelings of failure and inadequacy at not having the 'perfect' pregnancy or birth, the stress of too much choice, negotiating the vagaries of economic rationalism in service resourcing, over-medicalization and disempowerment (Lupton 1999).

Lupton (2003:13-15) argues that there are 'at least six major categories of 'risk' that currently appear to predominate in the concerns of individuals and institutions in western societies.. (including) 'lifestyle risks' (and) 'medical risks'. Rather than being globalized, these risks are highly specific and their prominence 'at this point in the history of western societies is indicative of the nature of the broader sociocultural, political and economic context in which they acquire meaning' (Lupton 2003b: 14). These risk have an 'important ontological status in our understandings of selfhood and the social and material worlds' and 'the heightened sensitivity to risk evident in the late modern era is developed through a highly reflexive approach to the world' (Lupton 2003b: 14-15).

Beck (1992) assumed that risk society is a globalizing trend which eventually will pervade communities worldwide. This paper puts forward the argument that improvements in health outcomes for pregnancy and birth in developing societies can be achieved without those societies becoming 'risk societies' as described by Beck (1992). With Lupton (2003b), it is argued that risk society reflects a series of cosmologies that are currently specific to late modern western societies. As such, it does not represent the inevitable trajectory for pregnant and birthing women in developing countries as they 'modernize'. However, all technological change carries political, economic, sociocultural and philosophical baggage (Nie 1999) which can be transported and 'installed' with the technology if traditional worldviews are significantly disrupted by the process of introducing change (Volti 1995). Preserving aspects of traditional cosmologies, while introducing measures to improve maternal mortality, morbidity and disability rates in developing countries, provides a buffer against the spectre of the 'natural' risks of pregnancy and childbirth being replaced by the 'manufactured' risks that characterize risk society (Giddens 1999). As such, pregnant women will not automatically be transformed from the 'contented sick' into the 'worried well', characteristic of late modern western societies. Obviously a cosmology that accepts pregnancy as 'having one foot in the grave' (Tan 2006) is not tenable in the twenty first century. However, with consultation, careful planning, and political will, pregnant women in developing societies can become the 'contented well'. Lao PDR is used as an example to illustrate this potential for maternal 'wellness without angst'.

Discussion

The medico-scientific perspective on risk in pregnancy and childbirth was often presented in the late twentieth century as a monolithic approach which ignored women's preferences and disempowered women by forcing their legs apart, strapping them into stirrups and subjecting them to a series of degrading practices in the name of safety for themselves and their babies (Martin 1987). While this still represents the experience of a minority of women giving birth in both western and non-western cultures, it is certainly no longer the norm in the twenty first century, even in hospital settings. The critiques of medicalization of major transitions in women's lives, which were generated by feminists such as Martin (1987), have had an impact on pregnancy and birthing practices throughout the world as witnessed in the debates about reproductive health at The International Conference on Population and Development (Cairo 1994) and United Nations Conference on Women (Beijing 1995). The rights approach to reproductive health agreed upon in 1994 and 1995 has had some limited influence on health policies and services in some countries (ARROW 2005) and the medico-scientific approach is no longer hegemonic and inflexible. However, women's identities during pregnancy and birthing are still circumscribed by the medical gaze. Surveillance and regulation of women's bodies during pregnancy and childbirth persists from a variety of sources, including from 'concerned strangers' in restaurants (Lupton 1999), and impacts on women's embodied identity. This is part of the 'culture of medicine'that constructs western risk perception (Lupton 2003) derived from an era of greater reliance on prescriptive biomedical imperatives and which forms the background for 'risk society' (Beck 1992).

Communities which have not experienced the same history of uncritical fascination with the rationality of bioscience, and effects of the panopticon in all spheres of life, do not need to inherit our history in their policies and practices of risk avoidance in pregnancy and childbirth. Even the popularly promoted measure of training traditional birth attendants in western medical practice has been questioned by the very organization that initiated it (WHO 2006: 24).

Factors outside of the realm of bioscience may be just as effective for countries to address in reducing maternal mortality, morbidity and disability. Political will appears to be a key factor in ensuring the success of risk reduction programmes in pregnancy and birthing. There is ample evidence from around the world that the best way to reduce mortality and morbidity rates is increased female literacy rates (Redwood 2005). The state of Kerala in India is the classic example where, despite having the lowest GDP and highest population density in India, it has the lowest mortality and morbidity which is largely attributable to high levels of female literacy and education (Thankappan & Valiathgan 1998). Economic development alone is not sufficient unless it is accompanied by political will to institute major social reforms such as education of women and girls. Greater involvement of men in childbirth in some countries, greater participation of men in contraceptive decision-making, and changing domestic roles in the family as women's employment participation rates increase have been shown to significantly affect reproductive practices and improve pregnancy outcomes (ARROW 2005). However, attending to social, economic and political factors is not enough. To avoid massive dislocation of populations, changes in health care environments also need to be negotiated (Fadiman 1998).

Pranee Liamputtong Rice (Rice et al 1994) documents an instance in Australia where she was able to negotiate a compromise with hospital administrators for a Hmong immigrant woman from Lao PDR. The woman wished to have her traditional embodiment (believing in the integrity of the three souls of the body) catered for within an Australian hospital setting (with a soul calling ceremony to re-instate one of the souls 'lost' during caesarian section). However, there was a need for intervention (caesarian section in a sterile environment) to save the woman's life. Relief of such 'morbidity' came from cultural rituals conducted by a Hmong priest in the theatre where the surgery took place rather than by psychiatric care or pharmaceutical and medical intervention. Significantly, these cultural rituals did conflict with the biomedical requirements of aseptic surgical intervention. The belief that health is only possible when the three souls of the body are present in the body, forms the backdrop against which many Hmong people whether located in their home country or as immigrants to western countries make their reproductive health choices and assess risk (Fadiman 1998). This belief also provides the context for their health experiences. Any threat to the integrity of the three souls of the body requires a soul-calling ceremony to return the soul to its rightful position within the body.

If practices such as this could be replicated in other settings, amongst immigrant groups in Australia, as well as in other countries (Fadiman 1998), the apparently inevitable risk replacement process could be avoided. The MWH in Bolikhan, and a recently opened one in Bokeo Province, along with those proposed as part of a 'Silk Homes' project of 17 MWHs in the southern provinces of LaoPDR (The Silk Homes Proposal 2006) provide an option for undertaking similar risk negotiation exercises among Hmong and Lao communities in rural Lao PDR. The finding that morbidity after a caesarean section related more to cultural fears and beliefs about one of the souls leaving the body after `cutting' than to post-natal depression or the physical aftermath of surgery (Rice et al. 1994) also has implications for examining how women see their embodiment in other minority cultures such as amongst indigenous communities. If western measures of 'successful' birthing ignore these beliefs and values, women who believe and trust in traditional methods are likely to suffer significant undiagnosable 'disquiets', possibly even mental and physical illness (Fadiman 1998), rather than wellbeing, during and after childbirth.

Conclusions

The 'obsessive self regulatory behaviour' (Lupton 1999: 5) of white urban women is not generally replicated in the experiences of pregnant Aboriginal women in remote settlements in the Northern Territory (Cass 2004) or among pregnant Hmong woman in rural Lao PDR (UNDP 2001). Fundamentally different risk regimes associated with pregnancy and childbirth, prevail across the economic and social development divide, including in indigenous communities within 'developed' nations (Blair et al 2005). Research conducted in 2005, in Bolikhamxay Province of the Lao Peoples' Democratic Republic (Lao PDR) was used to illustrate the impact of a different set of contradictory imperatives on concepts of risk in constructing identity and embodiment amongst pregnant Lao women. Included in the Lao PDR set of imperatives for risk avoidance were: emerging aspects of the instrumental rationalities of western medicine; principles of communism; and the multiple traditional practices of Lao and Hmong culture, Buddhism and animism. These often competing imperatives also impact on women's and men's perceptions of their options, their futures, and their capacity to control the birthing process. It is possible that, with truly consultative planning and management, and negotiation between traditional and rational imperatives for healthy embodiment, communities now faced with high infant and maternal mortality can avoid the paradoxical risks of 'risk society' that have developed in the west as well as free themselves from the tyranny of harmful traditional practices. The nexus between the 'comfort 'aspects of tradition and the technically useful aspects of scientific medicine can produce the conditions for good quality of life on both objective and subjective dimensions.

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