The emergence of the unborn

‘Babies’, ‘babies-to-be’, ‘foetuses’ or ‘womblings’ as the unborn are sometimes called at the clinics or their best interests are not the same from site to site or time to time. Rather they are multiple, as are other concerns in pregnancy, and they travel in accordance with the progression of pregnancy and the logic of the sequence of appointments. The nurses have told me that in general evoking mental images of the baby-to-be’s personality, kin attributes and early interactions – talking about babies and children, in general – is something that they focus on later in pregnancy.

However, babies and children do appear even at the first appointments. First of all, the unborn are occasionally called babies and children even at the beginning of pregnancy.

This is not done consistently in the early stages, but of course it has consequences nonetheless. For instance, pregnant women have told me about their feelings of bewilderment when nurses talk about babies at a stage when they have hardly grasped that they are pregnant themselves.

It is not just a question of occasional naming of the unborn, however. Not only are the unborn objects of care or harm, they also do things, as in the following ethnographic description of a first appointment:

The nurse is interviewing the pregnant woman about her use of milk products. The pregnant woman has stated on her form that she drinks two or three glasses of milk a day. The nurse asks an additional question about whether the pregnant woman eats yoghurts and other such products.

Turns out that she has sour whole milk a few times a week. Altogether, then, the amount of calcium she gets a day is too small for the needs of a pregnant woman. The nurse comments on this and explains the extra need of about 200 milligrams by saying that ‘as a woman you need calcium. The baby will take all she/he needs but if you don’t take care of your calcium intake during pregnancy you will make your bones very brittle.’ Then she goes on to talk about the extra need for vitamin D during pregnancy and breastfeeding and other nutritional concerns in pregnancy.

(Videotape T7N, first pregnancy)

Thus not only do pregnant women do things to their unborn, but the opposite also occurs, even in the early stages of pregnancy and during the first visits to the clinics. The unborn

‘take’, ‘need’ and ‘require’, and it seems to be a maternal responsibility to attend to these needs and requirements. One can see that addressing nutritional issues in pregnancy by using a rhetoric of foetal demand and maternal supply has the potential to affect pregnant women’s sense of self and activities quite differently than, for example, reassuring them that the foetus will get all its nutrition from the maternal body.

Despite all these doings associated with the unborn, however, it is apparent that they are enacted more vaguely and are more like a developing human life, or potential for human life, in general. Social, ethical or moral issues to do with the unborn are by no means marginalised, but they are secondary objects of concern at the beginning.

The unborn also arise as a specific issue in discussions about screenings for foetal abnormalities, which are raised as early as the first appointment. This is because the first ultrasound, the nuchal translucency screening, is done during the 13th week of gestation, and thus before the nurse and pregnant woman meet for the second time. Surprisingly, the nurses are rather reticent about the screenings. They often refer to the material sent in advance, and sometimes just ask if the pregnant woman and her partner have decided to go. If they do give any further elaboration, they usually restrict themselves to ‘neutral’

information like this about screening, and emphasising informed choice in the decision about attending:

The nurse has been entering information about the pregnant woman’s last menstruation, and since the pregnant woman has already been to an additional ultrasound because of some bleeding she asks to see some documentation from the ultrasound to find out the estimated birth date. The discussion turns to the standard ultrasound when the nurse makes a reference to the brochure about screenings that was sent by post, and asks if the pregnant woman and her partner have thought about choosing to go to the screenings. The pregnant woman says yes, and the nurse books an appointment via the computerised booking system. Then she starts to explain what one can and cannot see at the ultrasound: ‘The so called 13th week ultrasound is this nuchal translucency screening, and it is the measurement of the back of the neck that is mainly looked at. It is possible

that all the structures don’t show yet, for example, often the structures of the heart, because of the foetus’s position and the place of the placenta [...] so they don’t show. They [technician, nurse] will automatically give you a new appointment for the 20th week [if they cannot get enough information from the picture]. But the measurement of the neck one can get, and to estimate how far along the pregnancy is and to check the placenta.’ Later the nurse assures the woman, who asks about further screenings, that she will be getting another ultrasound in the late stages of pregnancy, if there any are worries over the size or the position of the unborn.

(Videotape P40, second pregnancy, first child)

It is close to the end of a first appointment. All the information-gathering and standard advice-giving have been completed, and the pregnant woman and the nurse have gone to the laboratory room to test the pregnant woman’s urine for sugar and protein. The pregnant woman’s [male]

partner stays in the appointment room. When the nurse returns, he asks when one can know that the child is healthy. The nurse explains that no one can guarantee it with a hundred per cent certainty.

The man qualifies his question by asking: ‘as far as it is possible to know?’ The nurse responds by elaborating on the procedure: ‘Well, in the first ultrasound examination, structures are looked at.

So one is able to see that there are no severe structural defects. They [technician, nurse] measure and look at the length of the thighbone and the girth of the head, and then they relate these to normal measurements. And then it is possible already to see things about internal organs and the heart and things like that.’ After a little pause the nurse goes on to repeat that the examination leaves many uncertainties, and then asks the partner whether they have thought about what to do in the situation of an abnormal finding. The partner then bypasses the question by merely saying that they will just think things through as they come. The nurse pauses for a while as if waiting for further elaboration, and then starts talking about how the pregnant woman is still young and that disabilities and so on are more likely when the maternal age gets higher.

(Videotape T5NM, first pregnancy)

Nowhere in the sequences of explaining the screening procedure and examination – here or in the other videos – is there really reference to the unborn as more than a foetus in the purely technical terms of the ultrasound technology’s capabilities: ‘structures’,

‘measurements’, ‘lengths’ and ‘girths’ of necks, heads and bones. The technology appears as a realistic, transparent and a direct gaze into the womb at its occupant in a ‘natural’

bodily process and at the possible environmental factors, such as in cases of genetic abnormality or lifestyle-related syndromes (cf. Eräsaari 1997). Women may consequently appear as merely maternal bodies – and thus as the sum of their lifestyle (see also Markens

& Browner & Press 1997), age and genotype – and their relation to the unborn as that of quantifiable cause and effect and an indicator of possible defect.⁸⁰

Purely technical and medical foetuses and maternal bodies, however, only exist in theory, in systems such as medical classifications (the International Classification of Disease, for example). Furthermore, the technology’s lack of ability to see everything, and the remaining doubt and uncertainty of the examination results, are also realised in practices (see also Schwennesen & Koch 2012). It is not just that the early ultrasound at 13 weeks’

gestation is not sharp enough, but also that the screenings are never sharp enough. Even the brochures on screening sent to the parents-to-be take note of this and other related uncertainties, such as the risk of miscarriage associated with the most common further screenings (amniocentesis and chorionic villus sampling).

The leaflets reveal that the screenings disclose ’50 % of the major structural deformities, almost 100% of structural defects of the brain, but only 10–15 % of heart hamartia’ (Foetal screenings I). On the other hand, it is said that even ‘a normal finding does not guarantee a healthy child at birth,’ (Foetal screenings I; Foetal screenings II) and ‘only in one in four of the pregnancies that have tested positive in the nuchal translucency test and/or serum test show anomalous chromosomes in the amniocentesis or chorionic villus sampling tests’

(Foetal screenings II). Furthermore, the leaflets, as well as the nurses’ choice of approach, take patient autonomy as a self-evidently good by stressing (in bold) in five separate paragraphs within six pages of text that the choice to attend the screenings is and should be voluntary, and that the difficult decision about further ‘care’, which usually means terminating the pregnancy, is one that only the parents have ‘a right’ to make.

In all, both the leaflets and the nurses’ answers and explanations at the clinics are framed by a medical ethical repertoire in alliance with biomedical (population-based) knowledge of mechanisms for the genesis of abnormalities. Similar observations on distanced and (seemingly) neutral science-oriented approaches have been made in studies of genetic

80 The partner’s lifestyle and genotype are also addressed, but rarely in reference to ultrasound screenings,.

counselling, for example, in Finland and in the United States (Meskus 2009, 176–179;

Rapp 2000, 63–73).

This is also in line with the local and national instructions and recommendations. They are quite technically oriented instructions, and ethical considerations are scarce (e.g.

Handbook of maternity healthcare 2007; Screenings and collaboration in maternity healthcare 1999). Yet there is some discussion:

Screenings should be considered ethically as well, because screening decisions draw from both [medical] knowledge and values. [… ] The decision to attend the screenings and how to use the results of the test is the responsibility of the parents. The task of the community is to support the parents in finding the right decision for them and bearing the consequences. [… ] The power to decide does not mean that they are responsible for their child’s disability if they do not want to attend the screenings or have the pregnancy terminated. […] It is ethically wrong to make anyone confront this kind of question [to attend the screenings and decide what to do with the test results]

without preparation. [… ] Pregnant women are to have adequate information on the decisions that attending the screenings might require beforehand.

(Screenings and collaboration in maternity healthcare 1999, 48–49)

The medical ethical and/or biomedical reasoning linked to policy guidelines is not, however, the only way of referring to screenings. It seems that it governs reasoning only when decisions about attending are discussed. After the actual screenings, in cases where there are no serious findings, and even during the appointment when decisions about attending have to be made, the rationale changes. Take for example the appointment just quoted above. Later during the same appointment:

The pregnant woman and the nurse are finishing up the first appointment. Before going to the laboratory room to check the urine sample for protein, the nurse reminds the pregnant woman that her man is welcome to attend appointments in the future. They joke a little bit about the partner’s forthcoming summer vacation: ‘then he can’t use work as an excuse not to come to the clinic.’ The nurse gets serious and lists the appointments that might be of special interest for the partner. ‘When we start to talk about family counselling classes, it would be very nice if you both could attend them, and ultrasound appointments are good and make the pregnancy concrete […] this proof that many seem to need.’

(VideotapeP40N)

When comparing the earlier snapshot to this one, one can see that there is a shift in repertoire. Here the ultrasound still appears as a neutral medium and evidence-making machine, but not so much for the physical attributes of the foetus as for foetal and pregnant reality. What is being sought is the paternal response to pregnancy. Inviting partners to be participants in pregnancy in this way can be understood as invoking the start of a bonding process within which paternal (and maternal) selves are conceived, as are their foetuses, babies and children.

Furthermore, instinctual and bodily knowledge from within oneself about the unborn is evoked in association with ultrasound-mediated knowledge. Sometimes this instinctual gut experience of something clashes with the ultrasound information, and sometimes it coincides with it, as in the following description from an appointment:

The pregnant woman is lying on the examination couch and the nurse is measuring the size of her uterus. They chat casually about how it has started to get uncomfortable for the pregnant woman to sleep on her belly. Suddenly the nurse asks the pregnant woman whether she and her partner have asked about the gender of their unborn at the ultrasound appointments [they went to the 20 weeks’

gestation ultrasound]. The pregnant woman grins and says that it is a boy. The nurse asks if the pregnant woman had any ‘feelings’ prior to the ultrasound [about the gender]. The pregnant woman admits that she had started to think that it was a boy. ‘It is just this feeling that one has,’ the nurse agrees, and moves on to find the foetal heartbeat.

(Videotape TP17N, first pregnancy, 22 weeks of gestation)

Here it is implied that the ultrasound technology confirms the premonition-like bodily knowledge women may have of their unborn. It is as if there are feminine qualities that mystically enable us to know from within such things as the foetal sex, in this case, but also about foetal health. To provoke such qualities and affects is, in my view, to mystify (female) nature. However, it also erodes the omniscience of the ultrasound technology by giving precedence, on occasion at least, to maternal experience-based estimates over technological measurements. Technology in a way allows women to know something that they already knew in maternity health care practices.

Making foetuses, babies, children and persons in general and in specific family relations in care practices is not just an issue of different agendas and concerns. It is also a temporal issue. It could be said that when pregnant women and their partners are introduced to foetal screenings, biomedicine, technoscience – ‘the facts’ – and family values and virtues are just starting to get mixed together.

Shifting the repertoire from the value-laden unborn with social ties to ‘scientification’ and talking about the unborn in clinical and technical terms can be understood as orienting to the unpredictability of pregnancy and screenings. This is something that the nurses also are aware of: they try not to personify the unborn in any way, so as to ease the anxieties women (and men, and even the nurses themselves) might have concerning the foetal screenings. For some nurses there appears to be an acknowledged timeline according to which unpersonalised foetuses belong to the beginning of pregnancy and personalised babies to the later stages of pregnancy:

Q: I noted when you described your work in general that it includes discussion and on the other hand screening and guidance. When you said that it is about screening the health of the mother and the foetus. So how do you talk about the foetus here at the clinic, or do you? Does it vary according to the situation or something?

A: Often, when I think about it now, I say [… ] probably I use the word foetus more in the beginning of pregnancy. Then when the pregnancy progresses into the second half and further, then it does change into a baby, it is then a baby. The reason why there is this divide is that when you go over 20 weeks of gestation and beyond the child can survive [premature birth]. If it is born earlier

‘foetus’ is maybe a bit less of a personal expression, if one has a miscarriage or developmental disorders [that have been diagnosed in the screenings]. I am not sure whether we are protecting the clients or ourselves but one does tend to use that word [foetus] more often.

(Public health nurse 3, age group 20–30)

So the repertoire shifts not just because of the unpredictability of the screenings and for the sake of managing emotions concerning them, but also because of the unpredictability of (premature) birth and miscarriage. This coincides with pregnant women’s hesitation to personalise the unborn, to rearrange the material setting of the home and to share their

pregnancies with others before 12 weeks of gestation when the probability of a miscarriage reduces significantly and around which the first screening results come in (discussed in more detail in the previous chapter). The pregnant women and the nurses who often have more medical knowledge thus attune themselves to medical calculations of probability and estimations of the worthiness of human life.

There is, in fact, a shift in care work in relation to enacting the unborn and its relation to its mother and mothering later in pregnancy, as implied in the above quotation. However, as already discussed in relation to the first screening and giving information and advice, the unborn is more than ‘the foetus’ in medical-technical depersonalised terms in the early stages in pregnancy. This is especially so in the case of two routine examinations – listening to the foetal heartbeat and enquiring about foetal movements – and in the numerous leaflets and brochures sent and handed out to pregnant women.

The foetal heartbeat can be heard at around 12–14 weeks of gestation, sometimes even earlier. Depending on the length of gestation when the pregnant woman attends the clinic for the first time, the foetal heartbeat is heard for the first time during the first or second visit. The unborn, be they called foetuses or babies or whatever at this point, do a lot of different things after the foetal Doppler device’s sensor touches the pregnant woman’s belly. Let’s look at one of my ethnographic descriptions of one such event:

It is near the end of the appointment, and after weighing her the nurse leads the pregnant woman to the examination couch to get the foetal heart beat. The nurse explains she will now do some external examinations: measuring the length of the uterus from the pubic bone to the belly button area, and taking the foetal heartbeat [in fact, later she will also feel the position of the foetus].

While doing the measuring she asks whether the pregnant woman has had any pinching feelings in the belly [uterus growing pains], and makes a remark about men not being capable of growing a

While doing the measuring she asks whether the pregnant woman has had any pinching feelings in the belly [uterus growing pains], and makes a remark about men not being capable of growing a