Knowing pregnancy and the unborn

In this section, I will discuss how women individually come to know their unborn and their pregnancies, and how they exercise (a degree of) agency in deciding which of these kinds of knowledges has more authority than the others at various points in their pregnancy journeys. I will also attend to new material from the accounts of pregnant women on the information sources used.

I am applying Donna Haraway’s (1991a) concept of situated knowledges to make sense of the process of knowledge production that is both located and embodied (and ultimately informs maternity healthcare). The process of coming to know is incomplete and material-semiotic, and as Carol Kingdon (2007, 112–153) found in her study on ‘knowing giving birth’, knowing pregnancy too is a fluid mixture of multiple interacting information sources, and comprises both what is felt inside (emotionally and physically) and outsider knowledge (‘facts’ and others’ experiences).

The process of knowing is thus adapted to the individual embodied life circumstances of the women and, as I will show, doing pregnancy, like doing birth (Kingdon 2007, 157–

162), is fundamental to knowing pregnancy. As I have already elaborated at length, doing pregnancy and the unborn is about sharing tasks, and for the most part cannot be equated with agency as grand social action and transformation. However, it is not passivity or merely subjecting oneself to cultural/institutional subject positions or to self-surveillance in accordance with desirable biographies imposed upon one.

Just as pregnancy is a socio-material process, so is knowing it. It is situated knowledge in the making (cf. Haraway 1997), not a static product but a continuous journey of transformation at various time-points in pregnancy. Furthermore, as women engage with pregnancy and attune to it they acquire new knowledges that manifest their new positions in the networks of social relations.

As I discussed earlier, making sense of pregnancy starts before there are any signs or sensations of pregnancy, or any notable changes in everyday life such as visiting the maternity healthcare clinic or rearranging home and daily routines. Sometimes the sense-making and corresponding activities start before women actually get pregnant, and it is definitely an ongoing process during the early stages of pregnancy when women experience feelings of ambivalence and unreality. Changing lifestyle and planning pregnancies to occur during ‘suitable’ life circumstances, for example, involves a lot of knowledge of healthcare and rules of social conduct in regard to the ‘ideal’ courses of life.

Furthermore, the fact that the unborn is given priority in life even though it rarely feels

‘real’ or ‘concrete’ for women at the beginning of pregnancy suggests that women are attuned to cultural competences of mothering. Such ideals and competences, according to which one is assumed to know how and when and for the sake of whom to get and to be pregnant, suggest traces of a life cycle model in which the life of a woman is equated with motherhood and her relationship to her children (see also Nätkin 1997, 193).

Encountering medical and nursing knowledge providers

It would seem that in the early stages of pregnancy, especially in the first pregnancy when women do not have any prior experience from which to draw knowledge, women rely more on outside knowledge of pregnancy and the unborn. They learn by doing, as

elaborated above, but also actively seek and gather information on pregnancy and the unborn. Here maternity healthcare as a platform for information and advice is crucial.

Almost exclusively, women told me that the top priority of the maternity healthcare service is and should be both to secure the health of the unborn and the pregnant woman and to give support in the form of discussion and information:

Q: What do you think is the most important function of maternity healthcare?

A: First of all, this health dimension in, as I have emphasised already here, that it is checked that all is fine, haemoglobin and so on and then the doctor’s appointments. Well yes, the health dimension shall be this quite brute first item before going to the mental dimension. The second thing, in my opinion, is peer support or in a way one can’t speak of peer support, because the clinic aunties [nurses] are not pregnant at the same time, so they can’t do that. But let’s talk about just support in that moment, because of course there are people that have not experienced pregnancy themselves and I don’t mean that they should, but they have the education and knowledge, so just as well they can advise and support.

(Pregnant woman 5, age 33, 14+2 weeks of gestation, first pregnancy)

The screening of physicalities, also emphasised in the above quotation, is itself linked to coming to know one’s pregnancy and the unborn. Finding out about foetal and maternal health is not just part of securing the health and well-being of oneself and the unborn, but is also integral to surviving pregnancy. Uncertainty and not knowing whether things are all right or what is wrong seems to be an unbearable situation for pregnant women. As discussed in previous sections, knowing pregnancy, especially medically, is controlling the uncontrollable.

However, what is new and interesting in this quotation is that professional experience and knowledge transferred to pregnant women is called ‘peer support’, and this is revealing of the way women attune to and express preferences over the forms of knowledge given at the clinics. Women do appreciate general health education and information on physical and psychological progression and the monitoring of pregnancies that is the same for everybody. This is so even in cases where women are already familiar with a lot of the general information and advice given to them before going to the clinic. They realise that a

universal service such as maternity healthcare must target its services to all women, regardless of their intellectual capital and resources. However, most of the women I talked to or interviewed expressed a preference for knowledge that was tailored to their needs as those needs emerge in the course of pregnancy, as in the following answer to my question about the most important function(s) of maternity healthcare:

A: So of course these general health things are looked at, that the baby grows and health it is always, but also this mental side or this that they [staff] support. The relationship between the mother and the public health nurse would be warm. It is a comprehensive thing. Of course these health things are important, but [… ] well they could […] I don’t know if there is anything in some brochure or handout [distributed at the clinics][…] but they could stress that one can talk if something is bothering one. Or somehow emphasise that side more.

(Pregnant woman 1, age 24, 39+ weeks of gestation, third pregnancy, second child)

It is not just medical knowledge, advice or other expert opinion, then, that is sought, but discussion per se, which obviously may result in pregnant women coming to know their pregnancies in medical, psychological or social terms, but which seems to have first and foremost a therapeutic goal. Being able to discuss any worries about pregnancy may ease anxieties and give reassurance and thus in itself contribute to the increasing awareness that specific things particular to individual pregnancies are, for instance, not something that needs to be worried about, and that one can learn to live with them.

Therapeutic and tailored support as one comes to know by doing often takes the form of hands-on guidance:

Q: Can you think of an example of something that has been especially nice [referring to previous answer, according to which the pregnant woman has had generally good experiences of maternity healthcare]

A: For example the visit to the [name of the clinic] where we’ve been for the ultrasounds. Well there the nurse [ultrasound technician] explained all the time what she was doing and what was showing [on the screen]. I thought that was really nice. [… ] Then I think that they [the public health nurses] have time to talk and listen and explain about stuff on these regular appointments.

Q: Can you think of any other special service that the clinics offer that you think is important and that you consider helpful in your pregnancy?

A: Well it was good that I was referred to a nutritional therapist. I mean that is not a mandatory visit but [it was offered] if I wanted [to go] and at one point I did want to go. That was a good thing. Then now that the heartbeat is listened to every time [at the appointments]. Well, it is always nicely calming to hear them and that they sound good and that everything is fine. Then of course these practical documents that have been sent, the applications for maternity benefits, to Kela [Social Insurance Institution of Finland]. I have got guidance for that [to fill them out]. I have read about them somewhere beforehand but then I have been all confused about how one is supposed to fill them out and how and where and what, but they helped me there [at the clinic] so much about what to do and when to send them. […] But quite good cooperation has been done for example in this nutrition planning in that in the beginning I had to add milk products [to my diet]. It was a thing that annoyed me a bit, but I do understand that I need to get calcium. I don’t normally use milk products that much. So I had to force myself to eat yoghurt and stuff to get any milk products down. Together we planned [with the therapist and nurse] what I could eat.

(Pregnant woman 3, age 28, 27 weeks of gestation, first pregnancy)

In the quotation, the pregnant woman comes to know her pregnancy by negotiating and trying out what kinds of milk product she might tolerate. She also comes to know her unborn, not just as some entity that needs calcium, but also as a physical and healthy human being, at for example the ultrasound scan when the technician tells her what is showing on the screen.

Women always remembered to emphasise to me that screenings such as the ultrasound and listening to the foetal heartbeat are important first and foremost because they are concerned with foetal health. However, as touched upon earlier in this chapter, women are also interested in determining the sex and seeing the foetal image, although this has to be subordinate to caring for health issues and is explained in terms of ‘the best interest of the child’. It is as if a ‘good mother’ who cares about her unborn is not allowed to be too interested in foetal gender or in ‘seeing the baby’. But she should not be totally uninterested either, because that would imply unwillingness or inability to get to know one’s baby, to start the mental and social transformation into a caring parent who already bonds with her baby prior to birth (see also Mitchell & Georges 1998, 111–112).

Furthermore, because discussions, advice, screenings and so on have a special therapeutic dimension, they can be understood as ritualistic. The ‘need’ to get screenings and advice in order to sooth the nerves and ‘to hear that this and this is just normal’ (Pregnant woman 3, age 28, 27 weeks of gestation, first child) suggests a symbolic value, especially when we take into account that there is no medical reason for the routine use of screenings. By attending the screenings women get assurance not just that the unborn is healthy but also that it is ‘real’, and they get a kick-start in the process of personalising and bonding with the unborn, as elaborated earlier. Thus the screenings and appointment discussions serve to satisfy emotional needs and strengthen social bonds, which are both common to ritual activities (on rituals see e.g. Douglas 1984/1966).

Screenings and discussions as therapeutic activities seem simultaneously to serve the purpose of moral and social education into parenthood. Women describe the personification and bonding process as a must, and put great emphasis on the knowledge about pregnancy and the unborn provided by healthcare actorsas therapeutic. It is a relief not just to find out what one is not supposed to eat, drink or do, but also to find out what one is allowed to feel and think about the ‘baby’, one’s partner or the uncertain future.

Women especially appreciated the nurses’ friendly and ‘equal’ approach, and their detailed and closely examined answers about and descriptions of, for example, foetal anatomy on the ultrasound screen or feelings of unfitness to meet the demands of motherhood.

However, according to the pregnant women, social and mental aspects of pregnancy were concerns that were the most neglected ones, and something that should be an explicit focus in maternity healthcare:

Q: In general, if you could change maternity healthcare in any way what would you change?

A: Well, maybe it would be linked more to this mental side. I think there has been rather little about it at any stage, that mental change when one becomes a parent. Because you really don’t understand fully during pregnancy how much it changes your life. There is some mention about it in all those millions of brochures [handed out in the clinics] but it is something that could be paid attention to as early as the beginning of pregnancy. And I don’t know, but maybe that way men could get more out of the appointments if we were approached as a family that way [… ] that there

is in those millions of brochures and papers […] there is about partnership and what happens when you become a family and so on. But I don’t think we have discussed a lot about it yet. Even now for example about how the first child will encounter the baby. We haven’t discussed a lot about that. It is more like I have searched for information on my own.

(Pregnant woman 6, age 33, 31+ weeks of gestation, second child)

What is suggested in this quotation is not that there is no room for the discussion of mental or social transitions to parenthood and family life, but that such issues should be raised in discussion and advice by the staff. In addition to hoping for more guidance, women sometimes critiqued the brochures handed out at the clinics, and the one family counselling class on parenthood provided by the clinics and available for all. In all three clinics where I had the opportunity to attend this class, it was often taught by a priest from the local parish. This provoked some confusion and upset. On occasion I heard deep sighs and mutterings when an instructor with a clerical collar stepped into the room. I never had the chance to discuss the feelings women associated with having a priest as an instructor for family counselling. However, the nurses filled me in by telling me that pregnant women and their partners do sometimes object to a religious professional giving advice on family matters. Similarly, the brochures and advice in general were criticised for having a too narrow a view of parenthood and family relations, as in the following snapshot from an interview:

Q: How about, you know, issues concerning parenthood and partnership, that are not really factual [… ] Have they corresponded with your perceptions?

A: What irritates me about that is that they are really generalised, those partnership issues everywhere. A man is like this and a woman is like this. That is true up to a certain point but when you think that people are individuals. I bet I have many masculine characteristics and my man has something feminine in him. […] Then there are these things that at least in our family we have always taken as self-evident, such as that communication must work. When we have from the beginning talked really openly. We are able to talk about things and feelings and everything. One must take care of one’s partnership, it is said always in these brochures. We have taken that for granted and because of that […] We didn’t get married right away, and we didn’t even think about having kids [...] we wanted to get to know each other first and live together and children will come later if they are to come and if we want. Of course not everybody can have children even if they

want to. They [brochures, classes] do defend the expectant mother [… ] that the man must understand that there is going to be hormonal mood swings and stuff. You shouldn’t leave all the housework for the woman. And then they show the man that, look, you should help and you should understand. But a modern man has read about that stuff a little [before hand].

(Pregnant woman 3, age 28, 27 weeks of gestation, first child)

In this quotation it is implied that the advice is too generalising, stereotypical and even outdated. It is something that both women and men already know. Here again specificities and individual guidance are wanted. Another thing that was described as good about certain counselling classes, and that was missing from most of the activities offered by maternity healthcare, was peer support. In one of the clinics, the nurses had arranged ‘a breastfeeding model’, a woman who had recently given birth, to attend a class on birth and breastfeeding to tell about and discuss her experiences. This was something the women liked a lot, and I never heard such excited and active conversations in any other classes.

Mostly, then, for peer support, as well as for more specific and additional information, pregnant women have to rely on other available resources.

Knowing by doing and sharing experiences with others

In the quite early stages of my fieldwork I observed how the frontline setting of maternity healthcare and the encounters taking place in it were organised by a wide range of translocal documents and ways of interpreting them. One of the most contradictory sources of information seemed to be the Internet. Pregnant women told me that they actively and widely searched for textual and visual material on pregnancy, especially on the Internet.

This did not always go down well with the maternity healthcare nurses or midwives.

According to them, there are a lot of competent and recommended (‘truthful’) websites, such as state research institutes and NGO sites. However, since they cannot control the search results, they are forced to spend time correcting false assumptions and calming down women who come to appointments terrified after viewing pictures of malformed foetuses, for example. Although the Internet is certainly more open than traditional media to genres of representation other than the medical (e.g. Moore & Clarke 2001), the pregnant women I talked to and interviewed seemed quite critical of Internet sources. They select the forums carefully:

Q: Where have you got and searched for information about pregnancy? You already talked about this diary you follow [a book on pregnancy progression step-by-step][…]

A: Quite old-fashioned literature. But some from the Internet. I have visited these discussion forums where there are expectant mothers. It has been a really good thing. You don’t necessarily get any knowledge but peer support. Never information, you can’t trust it because there aren’t any professionals to answer what is the cause of this and that. Those are the two main things. And of course something like ‘Vauva-lehti’ [a popular Finnish periodical on pregnancy and baby life] and others that my sister has given to me.

(Pregnant woman 5, age 33, 14+2 weeks of gestation, first pregnancy)

Q: Have there been any other sources of information [in addition to the public health nurse at the clinic], where you have [got] information on pregnancy from?

A: Well the library. The library and then of course all the magazines. Well, in principle all, because

A: Well the library. The library and then of course all the magazines. Well, in principle all, because