Getting acquainted, assessed and slotted into the system

The first and the second trimester (8–30 weeks of gestation) appointments (including approximately three visits to the nurse, two visits to the doctor and one or two ultrasound

screenings) can be characterised as filled with activities within which pregnant women, their partners and the unborn are being assessed and then slotted into the systems of primary healthcare, hospital wards and the welfare (parental) benefits system. These activities make their cases actionable, and ensure that they are informed of formal recommendations and that their health and other concerns are kept track of.

Entering women into different systems of record-keeping according to which further action is taken is also entering them into a (systemic) process that to a certain degree predetermines their futures in pregnancy. It thus distributes pregnancy concerns, such as birth mode, postnatal livelihood and so on, over time and across sites of maternity care.

However, it is not just ‘the system’ that the women (and men) become acquainted with, but also the competences of mothering and fathering, their unborn, and their own positions as clients as realised in the institutional practice of maternity healthcare. This is further realised in the casualness and cosiness of the care work and its socio-material setting.

Filtering and advising on potentials

The first time I arrived at each field clinic I was always somewhat scared, confused and yet excited to be starting my fieldwork. It seems that, especially in first-time pregnancy, women and men are also scared, confused and yet excited – but obviously for quite different reasons. The first and lasting impression of the socio-material setting of the clinics however, was very relaxing and welcoming, at least for those fond of family-centered spaces. My impression, as well as that of the women I talked to and interviewed, was that the overall setting did not greatly resemble that which many of us are used to in other clinical healthcare contexts. As one steps through the doors into the waiting room, informal chatting, often about baby-related issues, is going on between people who do not even know each other. The nurses stop for a familiar chat with the pregnant women, their partners and children in the halls leading to appointment rooms, and there are colourful decorations, toys, magazines and information leaflets everywhere. It is like a gateway to a child-centred space, as well as a space for healthcare.

By the time pregnant women arrive at their first maternity healthcare appointment, they

have already been in phone contact with the nurse assigned to them and have received some brochures and forms to fill out for the appointment. Over the phone the nurse, after warmly congratulating the future parent(s), takes standard personal and medical information that might affect the medical plan for the care of the pregnancy, such as diabetes, the starting date of the last menstrual period, and the number of earlier pregnancies. The information package the pregnant women and their partners receive by post includes brochures on local maternity healthcare activities and actors, and on maternity, paternity and family benefits (Welcome to maternity healthcare 2007), and on screenings for foetal abnormalities (Foetal screenings I 2007; Foetal screenings II: nuchal translucency screening 2007). They are also sent standardised forms of personal information, intoxicant use (Audit – the Alcohol Use Disorder Identification Test), and nutrition and other lifestyle issues (seeAppendix II). All this is a kind of preparatory work for the first appointment, the first face-to-face encounter during which the information is discussed and entered into the computerised casebook system.⁷³

When pregnant women and their partners arrive with their completed forms for their first appointment, the nurses come and greet them in the waiting room and lead them into the appointment rooms, which look like hybrids of examination rooms, offices and nurseries.

There is usually time for some sympathetic discussion of general feelings about the beginning of the pregnancy,⁷⁴ but after that, in the case of the first appointment, it is strictly business according to the agenda set for the appointment.

Most appointments during pregnancy take about 30–40 minutes. The first appointment, however, takes about one or one-and-a-half hours, which is the recommended time in local

73The collection of information has been coordinated by a computerised casebook system since the early 2000s (Iivari & Korhonen 2007, 14). Public health nurses are required to enter the results of routine tests taken at every appointment (urine tests for sugar levels and protein, blood pressure, foetal heartbeat and weight) and any other information that comes up about physical and mental health, family and other social relationships, and financial matters of the women and their partners. They also use the system to retrieve information entered by physicians, hospital staff and ultrasound technicians or midwives. While the system is often used only briefly during the appointments, and information is mainly entered after the appointments themselves, during the first appointment information is filled in on the spot.

74 One of the issues discussed is whether the pregnancy was something hoped for, or at least accepted. The issue is obviously crucial in the sense that it has implications for the care plan: the relationship between an unwanted unborn, a pregnant woman and her partner becomes a particular object of care.

guidelines (Handbook of maternity healthcare 2007). Compared with other MCH services systems, such as the British system, this might seem like a relatively long time to interview pregnant women and (possibly) their partners. However, during this time slot the first formal assessment needs to be completed for the individual pregnant woman’s case to become actionable; the nurses are required by administrative standards to complete a scripted assessment. Furthermore, the nurses also need to give advice and information concerning future visits to the clinic and healthcare during pregnancy, including screenings, nutrition, consumption of intoxicants, exercise and other issues linked to lifestyle, as well as physiology, psychology and medical procedures in pregnancy (ibid.;

Screening and collaboration in maternity healthcare 1999). In the clinics where I did my fieldwork, the nurses also gave a tour of the clinic, and if the pregnant women asked for it, which they usually did, the nurses would sometimes try to get a heartbeat sound with a foetal Doppler device.

Given this institutional context, it is understandable that time is scarce. All the topics on the forms filled out by the pregnant women (and possibly their partners) need to be covered and entered into the system, and the standardised first appointment information and advice has to be given manner (Handbook of maternity healthcare 2007). However, there are no written guidelines as to how or in what order to give advice linked to the topics on the form. Thus some protocols are laid down, but others are not.

During the first appointment in particular, the forms, and thus the computerised casebook system, interfere to some extent with the raising and discussion of any pregnancy concerns not covered by the fixed topics on the form or the agenda for advice set for the first appointment (e.g. Handbook of maternity healthcare 2007). This in turn means that what can become most institutionally meaningful during this particular appointment are the categories used on the form and/or in giving advice and information related to them. One might say that the form has a standardising effect in that it works as afilter, and as such to some degree it may sanitise the detail that the pregnant women and their partners potentially bring to the work of assessment (Smith 2005, 170–180; see also Law 2009).

Further, the nurses at the clinics where I did my fieldwork had all been trained in interview

methods and were quite reflective about how they opened and conducted the conversation.

Hence the form’s and computerised system’s ‘interrogatory’ structure, and the closed questions that they impose on the conversations, seem to limit interview methods that are seen as more sensitive to pregnant women’s individual worries and experiences.

The nurses are quite critical of and apologetic about the filtering work of the forms and the casebook system during these appointments. I have heard them apologise to pregnant women and their partners for sitting by the computer and entering data while they talk.

One of the nurses once used the expression ‘let’s create your pregnancy on the computer here’ (VideotapeP40), which sums up the role of the casebook system at the first appointment. I have also had many discussions about the occasionally absurd order of items the system offers; for example, from last menstruation straight to family relations.

The nurses would also rather have more informal discussion with the pregnant women, in order to better start to establish a trusting professional relationship and to fulfil the task of scheduling and organisingall the individual appointments and sequences of appointments according to the individual women’s (and men’s) needs.

All in all, the first appointment agenda is both to assess and slot the pregnant woman, her partner and in a sense the unborn into the maternity healthcare system, and to start getting acquainted. Although the forms do ‘govern’ actions here, as they often do (Smith 1987;

2005; for slightly different kinds of approaches see also e.g. Martin 1987; Oakley 1984), they are not the sole actors in the transformation work done during the first appointment:

there are also particular women, men, nurses and the unborn, and these are not wholly predetermined by the classifications used in the forms and protocols.

In my material there are 10 first appointment videos, all of which seem to follow a similar pattern in how the relationship between the pregnant women and the unborn become enacted in the work of being slotted and getting acquainted. The interview with the forms and advice-giving is thus for the most part concerned with pregnancy as a physical and psychological process, and with what might be called its ‘environmental factors’, such as the incidence of disease or mental illness in the family, available social support, weight

problems, attendance at screenings, intoxicant use and so on. Looking at the forms or the casebook system entries (see Appendix II), or listening to the nurses listing various diseases when assessing any (prior) diseases that the future parents or their close family have, one might think that the logic of gathering information and giving advice and information is about addressing pregnancy issues in purely (medical) scientific and technical terms. However, the ways in which information and advice are given are often profoundly social in style, and full of expressions and metaphors that are by no means (scientifically) neutral.

This is mainly so in relation to health matters that have been labelled as something people should and could have control over: intoxicant use, nutrition, exercise and work-family balance:

It is a first appointment, and the pregnant woman and the nurse have just gone through the eating habits item in the interview. The nurse gives a little concluding speech about the importance of paying attention to one’s diet in pregnancy. She comments on the pregnant woman’s being slightly overweight by telling her that even though the normal weight gain in pregnancy is considered to be around 12 to 15 kilos, it is better for overweight women like her not to gain so much. She uses the expression ‘one does not have to eat for two,’ and goes on to educate the woman about how

‘pregnancy is a good place for many women to think through and change their habits for the sake of the baby and for themselves as well,’ and how sometimes habits ‘may change naturally and the weight might even go down’. At this point the nurse starts to explain how eating habits and being overweight have ‘concrete consequences for the baby’. She tells the pregnant woman that if her sugar levels are high, the baby’s sugar levels will be high as well, and the baby will be big and that might cause problems during birth. Furthermore, when the umbilical cord is cut, the baby’s sugar levels will drop and he/she will have to be admitted for observation. ‘Not to mention the long-term effects on breastfeeding.’ After listening to all these horrid consequences, the woman is reminded again by the nurse that ‘pregnancy is not, however, a disease, and one should not be too strict’;

‘one can feast as well, as long as the entirety is healthy.’

(Videotape P18N, first pregnancy)

The nurse, here as elsewhere, gives a medically and biologically correct explanation of the mechanisms by which the woman’s sugar levels affect the size and sugar levels of the foetus. However, the unborn and the pregnant woman are by no means totally

decontextualised or disconnected from their social/family contexts (see also Parry 2009;

Bäckstrand 2004), or from expectations concerning maternal competences. The scene of activities is not entirely framed by the biological object, the foetus or the biochemical process between it and its maternal body. Rather, by naming the unborn as ‘a baby’ and then relating food intake with individual choices to be made during pregnancy, nurses render the situation into a site of moral education and even guilt for women who have the potential to harm their babies (see also Rothman 1989b, 95) and who should learn maternal responsibility. Often in the videos this is also done in reference to the whole family: new choices and changes in eating habits, as well as in alcohol use and in scheduling family time, are suggested both to partners and to pregnant women in the name of the ‘baby’. In all of these cases, then, the scientific explanation, whether medical or, for example, developmental-psychological, is mobilised to legitimate the social virtues and (family) values raised by the nurses.

When asking and advising about prior and current diseases and pregnancy symptoms, women are not nannied or patronised in this fashion at all. This is most likely because (excessive) weight gain, intoxicant use, (lack of or excessive) exercise and work-family balance issues are considered and further enacted at the clinics as (potential) causes (of pregnancy-related disease and social problems), and not as generalsymptoms of pregnancy (Rothman 1989b, 93). With weight gain in particular there is a long history of medical emphasis that has had major social and psychological implications for women, in that they have learned not to trust their bodies or themselves in pregnancy (ibid., 93–95).

The same is true of breastfeeding, which for some is an unachievable goal, as is losing weight while pregnant. However, breastfeeding is not just recommended because of its health implications for the child, as in the ethnographic snapshot above, or for the fact that it is supposed to speed up the woman’s recovery. It is also recommended for its perceived psychosocial benefits for the child. It is framed as a crucial early interaction and a bonding practice. And what woman would not want to engage in a bonding practice with her child?

Breastfeeding is not, however, an issue that is usually discussed in detail during appointments in the early stages of pregnancy. If it is brought up it is just briefly touched

upon, as in the snapshot above. I will therefore return to it as we get to those later stages of pregnancy.

It seems that when it comes to causesof pregnancy-related diseases, such as diabetes and toxaemia, advice-giving at the first appointment, and later on as well, can be quite normative, and can imply that women are sources of potential harm to their babies and themselves. However, it would be unfair to claim that the nurses are invoking some unitary ideal of bodily control. ‘Pregnancy is not, however, a disease, and one should not be too strict,’ was how the nurse concluded the snapshot above. Women are even encouraged to take pleasure in this new freedom to consume (food).

Furthermore, especially in relation to beauty ideals and ideals of working life for women, the nurses do quite a bit of work to get women to go easy on themselves, albeit often on behalf of the best interest of the baby-to-be and in a style that implies a clear normative preference. There are numerous tiny dialogues about body image and weight issues that are repeated throughout the sequence of appointments; for example, after weighing them, nurses will compliment the pregnant women’s bellies and ‘check’ that their weight gain does not bother them: ‘This is not something that is preying on your mind, is it?’

(Videotape TP12N, 18 weeks of gestation).

The information and insights gathered and discussed during the first appointment do not only travel to different places via the casebook system, but also travel in time to the subsequent appointments. The nurses check the progression of things, be they physical, psychological or social in nature. The computerised casebook system plays a lesser role during the subsequent appointments, because after the first appointment it is only used briefly to retrieve information entered by doctors, ultrasound technicians, hospital staff or psychologists, and the results of routine tests and concerns raised in discussion are entered mainly after the appointments themselves are over. However, the case history, computerised or not, seems to reinforce the nurses’ concerns. Overall, it works as a distribution tool across different sites (contexts and places) and over time.

Addressing the futures in pregnancy

The beginning of the sequence of appointments is about getting slotted not just into the maternity healthcare system, but also into the system of maternity and paternity benefits.

Maternity healthcare and the benefits system are linked together so that payments are conditional, as women are required to visit a nurse, midwife or doctor before the 16th week of pregnancy in order to be eligible for these benefits. During the application process, the healthcare professional who is visited – often the public health nurse – will write out a certificate of pregnancy, which is then sent to Kela (the Social Insurance Institution of Finland) along with the application forms completed by the parents-to-be.

Furthermore, the nurses are required to inform the parents about parental benefits (i.e.

payments and leave) and child benefits at around 22 weeks of gestation. In practice the nurses give hands-on help with the tricky application procedure and filling out the forms.

In this way the parents-to-be, especially the pregnant women, can go on leave if they submit their applications at least two months before the estimated date of birth. Partners’

benefits do not need to be decided at this time: they can be applied for later, if and when the couple decide to share the parental leave. This seems to lead to a situation where women (are advised to) submit applications as the sole beneficiaries of parental benefits (disregarding the three-week paternal leave and the so called ‘daddy month’ granted to all). The taken-for-granted assumption seems to be that women will stay at home with the baby for at least the first half of the parental leave. This is manifest in the appointment videos, for example, in default comments such as that ‘if a mother thinks that the father

benefits do not need to be decided at this time: they can be applied for later, if and when the couple decide to share the parental leave. This seems to lead to a situation where women (are advised to) submit applications as the sole beneficiaries of parental benefits (disregarding the three-week paternal leave and the so called ‘daddy month’ granted to all). The taken-for-granted assumption seems to be that women will stay at home with the baby for at least the first half of the parental leave. This is manifest in the appointment videos, for example, in default comments such as that ‘if a mother thinks that the father