3. Pregnancy as an embodied experience
3.3 Maternity healthcare relations: a pregnant girl’s best friend?
A: Tests and other bodily interventions [reads from the list of services provided by maternity healthcare]. At least I don’t have any problem with them. Thinking that there are people that fear needles and don’t like it in general, but I don’t have any problems. I think that it is just positive in that sense that I like the fact that things are checked out. It gives this feeling of security and, like I said earlier, I like it that the doctor examines me, because it makes me feel that everything is fine.
72 On the fluidity, multiplicity and historically contingent character of the abstract term, see e.g. Nätkin 2003;
Kurki-Suonio 1999.
Then all should be fine. There is this scientific evidence that [… ] I suppose I always need that kind of proof.
(Pregnant woman 7, age 28, 13 weeks of gestation, first pregnancy)
As the above quotation shows, bodily intervention during pregnancy is justified in terms of foetal health and feelings of ‘security’ which are provided by ‘scientific’ clinical examination and knowledge. However, as I have discussed earlier, the ‘scientific’
examination and knowledge are never realised in some ‘pure’ and universal form, but are practical compromises managed in a social, cultural and political context. When one analyses the women’s accounts, multiple narratives and logics begin to appear. And when these logics and conceptualisations that they harbour are built into large-scale bureaucracies and institutions such as healthcare systems, then the power of those concepts and perceptions is strengthened (see also Bowker & Starr 1999). Before moving into the clinics to look at these multiple logics and then moving on to the relations between individual accounts of experience and institutional activities, I want to explicitly discuss women’s perceived positions in maternity care. Then I will finally feel that I have outlined the partial perspective, the entry-points and the standpoint, that organises my analysis into the social relations coordinating the activities at the clinics.
Women are mostly satisfied with the services provided by the clinics. They do wish for more tailored services and more time for the often therapeutic discussions with the nurse, but overall everybody I talked to realised that limited time and resources cannot provide everybody with their hearts’ desires. The doctors at the clinics, whom pregnant women without complications visit approximately three times, were perceived as quite distant, but their professional opinions, examinations or other bodily interventions were rarely questioned. Furthermore, health education and advice on parenting provided by the public health nurses were regarded as adequate, although sometimes stereotypical, quite general and too standardising. Consequently, for example, nurses’ remarks on weight gain and standardised advice to eat regularly to ease nausea were sometimes critiqued by the pregnant women. However, the public health nurses were assigned the most important and closest position in the maternity healthcare system in the women’s accounts.
The nurses appear as professionals and service providers with whom a ‘friendship-like’
relationship is formed over time. A cosy atmosphere was the common impression I gained at the clinics. Nurses already greet their client-pregnant women in the hallways, remember everybody’s name and family background, and create an environment that is informal.
This was greatly cherished by the pregnant women:
Q: Could you tell me about your experiences and feelings in general about maternity healthcare?
A: I think it is always exciting or I mean that when I was expecting my boy it was really exciting to go there. And it’s really nice to talk there. I have had really nice people as my clinic aunties [public health nurses] so it has been nice to talk about everything. Then it is really nice to get attention or that kind of attention one gets when one is pregnant. I have nothing negative to say. Sometimes [… ] [asks me to repeat the question which I then do] So positive, I like to go there. It is always nice to go to the clinic. What is developed is or not [… ] well, in a way kind of a not exactly a friendship but what is nice is when you develop this relationship with your auntie because she is the same one the whole pregnancy […] well it is somehow. And then it is nice when they [public health nurses]
remember then. They remember what we have discussed earlier, and that makes one feel that one gets attention and all that. I imagine it is possible that not everywhere where there are lots of clients they remember personal things.
(Pregnant woman 1, age 24, 39+ weeks of gestation, third pregnancy, second child)
Well, ‘not exactly a friendship’, as the woman put it, but something more personal than the kind of relationship one is used to having with healthcare or social services is being enacted. In fact, later in the same interview, the pregnant woman goes on talking about the conversational style of advice and concludes by saying: ‘[It is not like] you are this hatchery [and] you come to visit here and to check these things and then you leave. This is so that you develop a friendly relationship and you are able to talk.’
Furthermore, public health nurses and midwives, as in this quotation and quite commonly in Finland in general, are called ‘aunties’, and this associates clinic nurses with nursery nurses, who are often also called ‘aunties’. This does not suggest, in the Finnish context, any real resemblance to kin relations (sometimes all adult women are referred to as aunties when talking to a child), but it does suggest a cosy and friendly atmosphere where confiding relations are built. It is implied in the quotation that this confidential and
informal relationship is achieved through long-term acquaintance and the continuity of the relationship (see also Vaittinen 2011).
Along with the time-consuming process of getting acquainted, building a confidential relationship seems to require an aspiration to ‘equality’. ‘Equality’ is the key to opening up a conversation where there is space for negotiation:
Q: What kind of a role do you consider you have in the clinics?
A: The kind where I am appreciated as a client there and the interaction is equal so that they [nurses] are not above me and tell me how things are and what I should do. One can discuss things there.
(Pregnant woman 3, age 28, 27 weeks of gestation, first pregnancy)
There is a peculiar vocabulary for talking about one’s position in the activities at the clinics here, and in other accounts as well. In relation to the nurses, pregnant women are
‘clients’ and not, for example, friends or patients. What kind of ‘equality’, then, is manifest in women’s accounts? The term ‘client’ suggests a market reasoning where clients choose and professionals offer (care) ‘products’. However, given that care work is a process of transformation and coming to know, how is one able to ‘choose’ something that is produced in a shared manner and is open-ended? (On market logic in health care see Mol 2008a, 14–28.)
In the model of ‘equality’ in the women’s accounts the different roles of clients and professionals are recognised but no one has authority over knowledge or pregnant bodies.
They seem to be suggesting a relationship that ‘is moulded in the form of a [civic]
contract’ (Mol 2008a, 30). In a civic contract clients/patients are traditionally emancipated into citizens (ibid., 29).
In addition to and linked to these traces of market and civic standards, there remains something fuzzy about the positions and relations of nurses and pregnant women.
‘Equality’ in the relationship between pregnant women and public health nurses is not just
problematic in the market model, but also in the citizenship model. Citizens are free to choose through a bodily autonomy that is achieved through the taming of the body, and only when bodies are controlled can medical authority be done away with (Mol 2008a, 30–
37). In pregnancy, however, bodies cannot be fully tamed nor are they fully autonomous.
Bodily boundaries fluctuate, and the common characteristic is the uncertainty of the future.
Thus it would be wrong to state that the nurses do not tend to have medical or other authority over the pregnant women. This is also realised in the women’s accounts:
Q: When you think about the appointments as situations, what is your own role among everybody else there?
A: To be a mother. It feels like that when one is pregnant. Well, of course elsewhere as well [… ] everybody of course, when they realise that you are pregnant they start instantly to talk about the baby. And now of course [… ] because the premise of maternity healthcare is that everything is fine with the baby. Somehow I sometimes feel myself like, well, here I am, it [refers to the unborn] is there, that I am this hatchery there, when the baby is the focus of so much attention. But one is allowed to say for herself there how one feels. [Her nurse’s name] will listen.
Q: Do you have any example of how it shows that the baby is in the main role?`
A: First of all, when they start to ask how you are doing in the plural [in Finnish there are different singular and plural second person pronouns ‘you’]. And then, that ‘well the baby is feeling good today and here are the heartbeats’, ‘when you do this, the baby feels good.’ That the baby and how are you [plural] doing is in every sentence. It is like, well, I am no longer doing well.
(Pregnant woman 2, age 30, 20 weeks of gestation, first pregnancy)
The pregnant woman here recognises the open space for compromises and negotiation, but also that the object of care at the clinics is often the unborn and that her own activities are being prompted to work in cooperation ‘for the best interest of the child’. In this quotation the woman obviously does not fully appreciate the baby-centredness of the care, but this is not always the case:
Q: Can you think of some significant experiences and feelings linked to maternity healthcare?
A: I think it was nice that right from the beginning they talked about this baby as she/he. She/he is growing in your belly and she/he starts to move then. First it made me laugh terribly that they already said she/he. But then it did show great appreciation for new life to address already as a person, she/he.
(Pregnant woman 3, age 28, 27 weeks of gestation, first pregnancy)
Overall, then, doing babies and children, parents, and knowledge is something that is done in cooperation, especially with the nurse, and that may on occasion be smooth and on other occasion be full of friction. However, it is teamwork. Furthermore, it is an open-ended process of transformations. The situatedness of knowledge seems also to have implications for the notions of ‘choice’ and ‘autonomy’, which are the prevailing notions in contemporary debates on reproductive issues and rights (Kingdon 2007). For if there is no single point from which to know, can there be a single point from which to make an informed static choice to attend screenings, express preferences over birth method and so on? This is illustrated nicely in an account of ‘choosing’ to go to an ultrasound screening:
Q: I would love to hear more about them [screenings], about the thoughts they provoked and what did they feel like?
A: Of course we thought at first that of course we will go. When it is totally voluntary, one does not have to go to the Nuchal translucency screening [niskaturvotusseulonta in Finnish] at all. First it was clear as day that we would go there and we didn’t even think that we wouldn’t. And the main reason for that was that it would be nice to see what kind of a chap there is and that everything is all right. But then in a way […] when we explored the issue at length and thought it over and I had read this article where there was this mum that had given birth to a disabled boy and had taken this screening very hard and everything had been really terrible and hard for the rest of the pregnancy.
Then it just somehow came to mind that I have heard that one of my friends had it so that [in the ultrasound screening] it showed something, that there was something abnormal. The child turned out perfectly healthy eventually but what kind of feelings [friend’s name] must have had when obviously she was afraid that now something is wrong and stuff. And it is not really a hundred per cent [reliable] [ultrasound examination results] then it just came to mind that what if there is something [… ] I would have something vague that they wouldn’t know what it is and then I would be referred for further examinations [… ] when it could actually be just healthy. And also that I could never get an abortion anyhow unless it was clear that the child was so severely disabled that she/he wouldn’t survive. Yes, it went so that I soon had to think it over whether I should just cancel
it [the ultrasound appointment] when it is already on Tuesday next week. So, it is in a week now.
But we didn’t then. I think now that I will go there since we already went there to the ultrasound last week because of the sick leave [the pregnant woman has had severe nausea and been on sick leave and referred for an additional ultrasound because of that]. So there already, although it was quite early, the doctor checked out the organs and the anatomy in general and the nuchal translucency values and everything was fine at least then. Now it is easier and I don’t have to think about it because she/he [the doctor] already examined. Although I didn’t really feel anxious about it and I didn’t think about it. Good thing as such, but there are these issues.
(Pregnant woman 7, age 28, 13 weeks of gestation, first pregnancy)
In the quotation, the pregnant woman with her partner, through the process of reading and talking to friends about experiences linked to abnormal screening findings, has started to change her mind about attending the ultrasound screening. Then, because of an unexpected doctor’s appointment due to nausea, she was referred for an ultrasound at the hospital. In the end she decided to go to the maternity healthcare ultrasound too, because she already knew that it was really unlikely that there would be any abnormal findings. Thus finally going to the screening involved lot of coming to know, and during the process the reason for going was transformed from finding out about foetal health as the main reason for seeing the ‘chap’. ‘Choosing’ could be described as coming to know one’s choice.
Overall, although women also consider themselves as having the main role at the clinic, the tension between the ‘good’ for the unborn and the ‘good’ for the pregnant woman is often managed by choosing the unborn as the object of care. This choice is not neutral:
should the focus of concern be the assumed health implications of one’s lifestyle on foetal development, or the mental well-being of the pregnant woman, or perhaps the well-being of an older sibling who needs care and attention at the expense of the pregnant woman’s rest? And, since choices made often lead to action, what might they cost?
Maternity healthcare visits do provide pregnant women with feelings of ease and well-being in many ways, but also enact value-laden social relations and bonds between parents and the unborn through doings that are precarious and minimal and yet have major implications for the participants. Care work as managing uncertainty, therapeutic work and producing social ties can also be understood as a practice of biopower that constitutes
selfhood prior to birth. Next I will move on to see how all of this is articulated in everyday encounters at the clinics.