Maternity healthcare work in Finland as a field

2. Theory and methodology

2.2 Maternity healthcare work in Finland as a field

In this section I will give a brief (historical) description of the organisation of Finnish maternity healthcare from the viewpoint of historical ‘regulatory frames’ and give a contextual description on the fieldwork clinics. Regulatory frames are the ‘wide variety of conceptualizations, theories, policies, laws, plans, guide-lines etc. that operate at a general level to structure the institutional action and reality coordinating people’s work [both nurses and pregnant women] at local level’ (Smith 2005, 191). This section should be read to some extent as an ideological narrative (Smith 1990), and it approaches the institutional commitments and so on that are placed upon care work as organising social relations in everyday work, rather than as abstract entities. The chapter will end in a brief review of the recent prior research on maternity and child healthcare practices.

Maternity healthcare organisation: Protecting mothers and saving children

Finnish maternity and child healthcare (MCH) clinics are organised within public health centres, and are intended to ensure a good standard of health for the mother, the unborn child, the infant and the family as a whole (e.g. Screening and Collaboration in Maternity Healthcare 1999). Its services are provided free of charge, and as such the provision of care indicates that health services for pregnant women have become a state responsibility – a part of the Finnish welfare society.

On many levels throughout the history of Finnish maternity healthcare women have played an active role in its provision. First of all, the maternity and child healthcare clinics are run by public health nurses (and, to some extent, by midwives), most of whom are women, rather than by doctors. In general, the role of doctors and hospitals has never become as prevalent in maternity healthcare in Finland as it has elsewhere (for example, in the United

notions presume humanity and universal rights (Ramazanoglu 2002, 34-35; Singleton 1996). The only real working solution presented so far has been to do both kinds of research, e.g. by Nancy Fraser (1995b, 166-168) in a commentary on her debate with Judith Butler.

Kingdom). Indeed, in Finland maternity healthcare has remained in primary healthcare,²¹ centred on maternity healthcare clinics, where public health nurses and midwives provide the services (Benoit et al. 2005, 727–729). Hence, while feminist researchers and activists in other national contexts (e.g. the USA, UK) have identified ‘the medical turn’ in, or medicalisation of, maternity healthcare as a key feature of the history of care for pregnant women (e.g. Martin 1987; Oakley 1984), this pattern of medicalisation is not fully applicable to the Finnish context (Kuronen 1994a; 1999, 73; Kuosmanen 2007, 169).²² Other researchers have noted that Finnish maternity healthcare can best be characterised as a site of activity among women (Kuronen 1999; Mesiäislehto-Soukka 2005), a site for population politics/policy (Nätkin 1997), or an institution of public management (of women as citizens) (Wrede 2001; 2003).²³

The second key feature in the background to contemporary maternity healthcare provision in Finland is the influence of women’s movements. The women’s movements, involving both bourgeois and working-class women, greatly influenced the establishment and formation of the maternity welfare work that began in the early 20^th century, and later of the nationalisation and institutionalisation of maternity healthcare initiated in the 1930s.

The period after the Finnish civil war in 1918 was characterised by anxiety concerning population growth and the future of the nation. It may be said that during those times maternalism²⁴ as a political movement and discourse became combined with progressive

21 As opposed to special healthcare provided by hospitals.

22 The medical turn and the medicalisation of pregnancy, childbirth and maternity healthcare refer to a shift that took place along with the rise of modern medicine in many Western countries. Women as healers and midwives played a central role in care for pregnancies and births until the emergence of the male-dominated, technology-driven medical profession that slowly took control of care for pregnancies and childbirth (Wajcman 2000, 63–64). As the concern of the medical profession, then, childbirth and pregnancy have been enacted more as illnesseses than a natural (home) events (Wajcman 2000, 65–66). The concept of

medicalisation is, however, a problematic concept because it tends to simplify the authority of medical profession and its implications for societies (Wlliams 2003, 9-16; Conrad 2005).

23 Activity among women refers to the central role of women in maternity healthcare. Population

policy/politics refers to the fact that political anxieties and discourse about population growth and the future of the nation have been closely connected to the institutional history of maternity healthcare since the period after the Finnish civil war in 1918. Finally, the institution of public management refers to the insight that maternity healthcare functions as an institutionalised site for strategically managing women in a disciplinary way specific to a socially liberal line of thought.

24 Maternalism refers to, in the Finnish (and other European) context, a (welfare) political discourse and agency in which women’s issues are reduced to issues concerning mothers and children. It includes political movements where women (biological mothers or not) promote the well-being of mothers and children.

Maternalism has, however, been considered to be one of the driving forces of the welfare state and

(or pro-natalist) population policy. Reproductive politics that emerged from the women’s movement in the period from 1918 to the end of 1960s pursued not only population growth (or quality improvement) but also welfare for and protection of mothers and, through them, children. (e.g. Nätkin 1997, 16–17; 2006, 27–30; Vuori 2003, 42–43; Anttonen 1997, 181; Wrede 2003.)

The early maternity and child health welfare work referred to above emerged as a way to resolve emerging social problems. These problems included population policy anxieties and worries over infant mortality, but also moral concerns pertaining to, especially working-class, women’s lives. Since the first decades of maternity welfare work at the beginning of 20^th century, maternity healthcare in Finland (as in some other parts of the Western world) has become increasingly specialised, medically and to some extent psychologically, as part of a more general pattern of increasing professionalisation and institutionalisation. Consequently, the emphasis on social problems started to disappear (Kuronen 1999, 70; 1993; Benoit et al. 2005, 727–729; Wrede & Benoit & Sandall 2001, 36–40).²⁵

Traditionally, Finnish maternity healthcare provision has mainly operated as a preventive agency.²⁶ In practice this has meant that it has involved providing support in the form of advice and information for future parents, especially the mother-to-be and monitoring of the somatic changes experienced by the pregnant woman and the foetus. The 1944 legislation on municipal maternity and child healthcare (Laki kunnallisista äitiys – ja lastenneuvoloista 224/1944 and Laki kunnallisista terveyssisarista 223/1944) highlighted education, advice, guidance and health promotion. The services were to be oriented

modernisation in that it was used to hold people responsible for being ‘good citizens’ as required by the modern industrial world. The concept of maternalism in Anglo-American discussions and contexts is quite different in both content and style of argument. In Anglo-American discourse, motherhood did not include paid work outside the home, and the tone taken has tended towards the mystification of motherhood. (Nätkin 1997, 19; 2006, 28-29, 37; Anttonen 1997, 182.)

25 Only to be rediscovered during roughly the last three decades, at least rhetorically (e.g. Wrede & Benoit &

Sandall 2001).

26 Preventive agency refers to care work aimed at promoting healthy lifestyles and screening for problems before they become severe in medical and psychological terms. In general, the task of primary care work is not to provide treatment for illness. In cases where serious problems are detected a referral is made, for instance to a hospital or a psychologist.

towards all pregnant women and young children (not only to poor families). At the end of the 1940s, maternity benefit payments were made conditional, as women were required to visit a midwife or doctor before the 16^th week of pregnancy in order to be eligible. (Nätkin 2003, 23–24; Kuronen 1999, 63; Wrede & Benoit & Sandall 2001, 37.)

Up to the 1970s, maternity healthcare work could be characterised as an institution of protecting motherhood. Ritva Nätkin (2006) argues on the basis of her research on policy documents that reproductive politics from the first decades of the twentieth century protected the mother and her child (to-be) ‘in the inner chamber’ or ‘core’ of the family and nation. The protection of motherhood included both paternalistic and maternalistic control and glorification of motherhood, and implied a family type that is asymmetrical, as the mother of the family nurtures in the private of the home whereas the father protects and provides for the family. (ibid., 28–29.)

The Public Health Act of 1972 rearranged the whole primary healthcare system in Finland and revoked the 1944 MCH care legislation. This legislation offered only a brief instruction to each municipality ‘to organise education, including pregnancy counselling, and to arrange general health checks for its residents’ (Kansanterveyslaki 1972, 14§, transl. Kuronen 1999, 65). Nevertheless, maternity and child healthcare continued to be provided according to the model which had been crafted in the 1920s and consolidated in the 1944 legislation. (Kuronen 1999, 65–66; Wrede & Benoit & Sandall 2001, 38–39.)

Despite the organisational continuity in provision, the 1970s can be seen as a turning point for protection of motherhood. Welfare policy and reproductive politics started to lose pro-natalist elements that promoted increasing birth rates and obligations, and gained a more gender neutral and individual emphasis in regards to parenthood. In the new model of the family that has emerged, both the mother and the father participate in care and in working life and procreate by choice, not out of obligation to the nation. (Nätkin 2006, 30, 35;

Benoit et al. 2005, 728.) Despite the tone of gender neutrality and the symmetrical model of shared care and parenthood, in practice, as Jaana Vuori (2001) shows, care and tasks are not really shared ‘equally’. Mothers merely seem to gain the extra task of actively

incorporating the fathers as the new, caring and active fathers they are supposed to be according to protocol since 1970s and 1980s (see also Daniels 1999). Further, the break between the cultural figure of a distant breadwinner father of the past and the attentive father of the present has been questioned as a model that simplifies the historical multiplicity of fatherhood and policy on fatherhood (Aalto 2004).

National guidelines and recommendations and a universal patient casebook system regulated and coordinated maternity healthcare work fairly consistently from 1972 until the 1990s, when the operational environment of maternal care was changed (Viljamaa 2003, 36). In 1992 the national health administration (valtionosuusuudistus) was closed, and consequently municipalities were given far more responsibility to develop their own services. Abandoning the centralised model of maternity and child healthcare has also resulted in less centralised national regulation. As a result, municipalities have developed their own services which in diverse ways follow the recommendations, guidelines, health promotion policies and projects initiated nationally, municipally or by NGOs or other bodies. (Viljamaa 2003, 36; Julkunen 2010, 106.) In the city region in which I conducted my fieldwork, local guidelines for maternity healthcare were compiled in 2003–2004 and have been irregularly updated by maternity healthcare personnel both on the local intranet and in print. Understandably, all this inconsistency in the guidelines further complicates the textual coordination of everyday work done by nurses and pregnant women.

The most recent national guidelines for maternity healthcare, published in 1999 (and consistent with previous guidelines published in 1995), outlined the purpose of maternity healthcare as follows:

In a broad sense, maternity healthcare strives to promote the health and well-being of future parents, and to help them to take a positive view of family life and the role of the family in society.

The expectant mother, the father and the whole family should be able to perceive pregnancy, birth and care for the infant as a safe and enriching experience. Preparation for parenthood and child-rearing creates the basis for a lasting maturation process. In addition to medical and nursing care, the expectant parents want maternity healthcare to provide them with social, emotional and psychological support and assistance in their new life situation, especially when their first child is being planned, expected and born.

(Screening and collaboration in maternity healthcare 1999, 9, transl. Kuronen 1999, 68)

There is a strong emphasis on the psychological aspects of parenthood in this document, exemplified in the employment of terms such as ‘positive views’, ‘experiences’ and

‘emotions’ as noted also by Marjo Kuronen (1999, 68) in her ethnography on maternity and child healthcare in the 1990s. Medical care is only briefly mentioned. Advice, psychological support, social support (which is nowadays called psychosocial support in development discussions) and family-orientation are also mentioned in the quotation above. These aspects of health provision have been much discussed and criticised at least since the 1980s. (Yesilova 2009, 97–102.)

Psychological and social support appears to have been discussed and offered in terms of

‘psychosocial knowledge’. The term derives from traditions of psychological theory and is widely used in approaches to healthcare and social work nowadays. In a nutshell, it is family-psychological in nature. That is, psychosocial concerns refer first and foremost to concerns within family relations (Nätkin and Vuori 2007, 1), and the support offered often takes the form of therapeutic counselling (Yesilova 2008, 105).

At the same time over recent decades the focus has increasingly shifted to ‘early preventive/intervention’ (varhainen puuttuminen) agency in welfare politics and service reforms (Harrikari 2008, 123). Together these two tendencies have resulted in a situation where it seems to be politically acceptable to intervene in family life as early as possible in order to attend to every risk possible, those risks often being linked somehow to an ability to function in immediate family relations. What is emphasised and used as the guiding logic for argument in the debate and reform of services is concern for the children and ‘the (best) interest of the child’.

The concept of ‘the (best) interest of the child’ has been interpreted as a culturally

ambiguous and fluid concept (Nätkin 2003, 37–38; Kurki-suonio 1999, 1–2). Further, it is such a strong value object that arguing against it appears socially unacceptable in itself.

The only way to argue is within the concept, showing that the interest of the child lies

somewhere other than what has been assumed (see Hurtig 2003, 33; Kurki-Suonio 1999).

In the historical context of maternity health care today this slippery concept gains new content and subjectifies, in my opinion, a child even earlier than before – before birth.

Recent organisational changes

Since the beginning of the millennium, the overall field of the Finnish maternity and child healthcare (MCH) system has been undergoing a vast organisational change that stems from challenges to the prevailing policy guidelines. It has been recommended that instead of focusing on medical screening and children who have already been born, care work should direct attention to the social and psychological environment of the child(-to-be), in this case the social unit of ‘the family’, to prevent future problems (Rimpelä 2008, Viitala

& Kekkonen & Paavola 2008). Furthermore, the family should be participating as equals with healthcare professionals in the enhancement of child health, development and family welfare.²⁷ These developments in Finland can be associated with the idea of shared care, which is widely advocated in the health and social care systems of not just Finland but also many other Western countries. The concept is used to designate systems of health and social care in which laypeople are involved in taking responsibility and making decisions concerning their health and social circumstances, or where their health and social care is shared among various professionals (see e.g. Boyle et al. 2003; Winthereik 2008; Vuori 2001).²⁸

The emphasis on the MCH system and the argumentation for reform outlined above stem from two particular observations made by different national and municipal policy actors.

First of all, many commentators have noted that mental health, social and developmental problems are increasing among young children and accumulating in disadvantaged families (National Research and Development Centre for Welfare and Health 2006; 2007;

Rimpelä 2008). Second, early family relations are seen as crucial to child well-being, mental health and development (Kangaspunta et al. 2005; Goodman 2008; Swanson &

27 This participation of families is often discussed in terms of ‘family-centered work’ (see also Kangaspunta et al. 2005).

28 Here, then, shared care does not refer just to sharing care for children between mothers and fathers.

Wadhwa 2008).²⁹ This indicates that families need particular support at the critical stage of transition to parenthood. In Finland MCH clinics have played a major role in offering such support, as they reach almost 99 per cent of the population (Viitala et al. 2008).

Various interventions have been developed and implemented in an effort to bring about change in existing MCH work practices (Kangaspunta et al. 2005; Viitala et al. 2008). One such intervention is the so-called family-centered MCH clinic in the one large city in Finland where my field clinics are situated at.³⁰ In this model the changes to MCH system include: 1) the integration of hitherto separate clinics for maternity and child healthcare, and 2) the utilisation of the expertise of multi-professional teams in solving the problems of families. This involves pooling experts from the fields of early health and social care for children,³¹ and 3) new working methods to enable public health nurses and midwives to focus on psychosocial support,³² such as interviewing with and without forms (‘welfare assessment forms’)³³ and conducting home visits during late pregnancy.³⁴

29It is important to note that none of these worries or commitments are totally new; some of them date back to the 1960s (see e.g. Kuronen 1994a; 1999; Nätkin 2003, 19–20; Helén 1997, 11).

30 The intervention in question and its implementation were a result of two different projects. It was first piloted within the municipally funded project, which was part of a larger municipal mental health project in 2002–2004. The dissemination of this interventionist model was first carried out in a project which was a subproject of the nationally funded PERHE project (PERHE-hanke) in 2005–2007. The intervention model was to be applied to all child and maternity healthcare clinics by the end of 2011 as a municipal project.

31 In general nowadays, social and healthcare work is often described in terms of multi-professionalism. In a nutshell this refers to work which combines knowledge systems and expertise from more than one field. It aims for a more ‘holistic’ understanding of an individual family’s situation and to overcome administrative and organisational boundaries (Kangaspunta et al. 2005; Kangaspunta & Värri 2007; Aims and scope of the Family-centered MCH clinnic 2007; see also Nätkin & Vuori 2007, 7). In the case of the clinics where I did my fieldwork, the professionals included in the team were two public health nurses, two family workers (of which the other was preferably a social worker by profession), a social worker from child welfare services, a obstetrician or a pediatrician, and a maternity and child healthcare psychologist. Teamwork is carried out at the clinics in meetings that take place roughly every two weeks. The nurses bring cases to discuss to the meetings, and they also invite individual families in problematic situations to attend. At the meetings further action is negotiated.

32Psychosocial support just described in general terms is seen in professional documents as addressing issues such as anxiety (Castaneda & McCandless, & Palermo 1956), self-esteem (Rosenberg 1979), family relationships, and social support (Punamäki 1996, 3). When this concept is employed with reference to maternity healthcare, new (sub)categories emerge. Factors which are seen as crucial in indicating the need for support are identified in families’ social relationships, including problems in the woman’s relationship with her partner, anxiety levels, use of intoxicants, the family’s financial situation, and mental images of the child-to-be (e.g. Kangaspunta et al. 2004; 2005; fieldnotes from the health nurses’ training in spring 2007;