Interpreting Compliance and Resistance to Medical Dominance in Women's Accounts of Their Pregnancies
by Rachel Westfall and Cecilia Benoit
Yukon Bureau of Statistics; University of Victoria
Sociological Research Online 13(3)4
Received: 19 Feb 2008 Accepted: 8 May 2008 Published: 31 May 2008
The dominant discourse of 'risk' underlies the medical surveillance of pregnant women. This article draws upon interview data from a purposeful sample of twenty-seven childbearing women, focusing on the tensions and negotiations that take place for these women between the informal, everyday experiences of childbearing and the formal boundaries of organised medical/midwifery care. Through such techniques as narrative reconstruction, rationalisation, and resistance and compromise, our respondents were active agents in interpreting and shaping their reproductive experiences. Yet, their experiences were invariably framed within the dominant discourse of medicine, pointing to its relevance even for women choosing alternative models of maternity care.
Keywords: Pregnancy, Maternity Care, Medical Dominance, Resistance, Medicalisation, Midwifery, Narrative
Introduction1.1 The social science literature on the organisation of maternity services illustrates a variety of competing approaches to care for childbearing women, with the sociological literature focusing mainly on tensions between disparate philosophies and care styles. A spectrum of care styles exists, including self-care, lay support, midwifery, family physician and obstetric care. The recent literature on the sociology of health professions has largely focused on professional boundaries and relationships between different styles of care provider, policy makers and health care institutions. We describe this literature below.
1.2 While health professionals and others have taken positions from time to time as to which of these models of care is the best for women, few researchers have attempted to ask women from across a spectrum of care options about what they want in the design of their maternity care. At the same time, the patient/maternity care provider relationship has lately become a subject of some considerable interest (Sandall et al, in press ).
1.3 We set out to examine the patient/care provider relationship by asking women to tell us why they chose their particular health providers, and about their decision-making regarding medications, use of obstetrical technologies and home or hospital birth. Such an examination allowed us to gain a deeper comprehension of women's experiences of pregnancy and how those experiences are shaped by broader societal processes. As our research unfolded, we discovered that what women want, and why, are complex issues that are not necessarily congruent with what physicians or indeed other health professionals, including midwives, say women want (DeVries et al. 2001). This discovery led us to revisit the transcripts and listen more carefully to the voices of the women themselves and explore the ways in which they reframe and/or attempt to resist professional control of their childbearing experiences.
1.4 The main aim of this paper is to describe these tensions and negotiations that take place for women between the informal, everyday experiences of childbearing and the formal boundaries of organised medical/midwifery care. Before presenting our analysis, we briefly describe the background literature which has informed our reading of the women's narratives.
Review of the Literature2.1 Medicalisation is the process whereby key life events or processes (such as birth, death, sexuality, disability, or menopause) are brought under the control of medicine (Zola, 1972; Conrad, 1992). Critical writings present medicalisation as a process that places limits on personal choice and agency and encourages dependency on the health care system (Lupton, 1997). Feminist scholars have noted that medicalisation affects the lives of women more profoundly than those of men, as a result of women's more visible reproductive cycles, more frequent contact with physicians, and subordinate role in the hierarchical system of health care (Riessman, 1983).
2.2 Other scholars have argued that medicalisation is a self-serving process whereby the scope of medicine has expanded in the interests of physicians, ultimately increasing their social status and incomes but at the expense of collegial relations with allied health professionals and quality patient care (Arney, 1982; Freidson, 1988). Pertinent to this paper, this view is supported by historical data regarding the suppression of midwifery and the rise of obstetrics in the United States (Wertz & Wertz, 1989) and Canada (Bourgeault, Benoit & Davis-Floyd, 2004). Some researchers argue that the expansion of medicine into ever-farther reaching areas of people's lives is limited only by its financial feasibility and, under a corporate model, the likelihood that a particular diagnosis or procedure will allow health insurance companies to turn a profit (Clarke et al., 2003; Conrad, 2005). Indeed, many parts of the process of medicalisation, especially in the United States, are shifting "from professional to market domains" (Conrad &, Leiter, 2004:158). A number of players are now involved in defining the boundaries of medicine, including "buyers…; providers…; payers…; and consumers" (Conrad & Leiter, 2004:160).
2.3 Other scholarship, however, has pointed out that it is the state, rather than the market per se, that has taken on an increasingly active role to control the influence of medicine. This has been the case in countries such as Canada and northern European countries where the state has acted to promote the interests of competing professional groups such as nurses and midwives (Allen, 2000; Evetts, 2003; Benoit et al., 2005), "alternative" health providers (Saks, 1995), as well as the needs and concerns of patients/clients. The promotion of innovative primary care models and shared patient care arrangements made up of interdisciplinary teams of physicians and other health providers and the focus on 'patient-centred care' underway in some countries is believed to result in more egalitarian relationships between physicians and other health professionals as well as between physicians and patients (Bury, 2004; Nancarrow and Borthwick, 2005; Wrede et al., 2006). Jones and Green (2006), writing on recent changes in primary care in Britain, have gone so far as to argue that a new notion of professionalism is now in vogue among physicians, in which medicine is seen as a job like any other, one that should be balanced with family and leisure, and involve democratic relationships with other professional staff and patients.
2.4 On a similar note, scholars have argued that patients, or consumers, have become formidable players in the negotiation of their health care. This literature describes health care patients as active rather than passive agents (Bury, 1998, 2004). Maternity care recipients are apparently anything but passive recipients, and indeed, they have been described as 'reflexive consumers,' (Zadoroznyj, 2001), some even developing an activist role based on past childbearing experiences.
2.5 In summary, the research literature on medicalisation suggests that while at the conceptual level the concept still has analytical worth (van Teijlingen, 2005), its societal dominance may have given way to a system in which authoritative knowledge is increasingly held by a variety of players, including professionals, semi-professionals and 'lay experts,' the latter relying largely on experiential learning (Bury, 1998, Bury 2004). This system legitimates current trends towards individual choice in style of care, as it acknowledges not only alternative care providers but also childbearing women themselves as authoritative sources of health information.
2.6 Below we explore women's experiences with pregnancy in an urban West Coast Canadian environment. We focus on the tensions and negotiations that take place between the informal, everyday experiences of childbearing and the formal boundaries of organised medical/midwifery care. Our study took place in the province of British Columbia, shortly after certified midwifery was integrated into the public health care system. In terms of publicly-funded care, the women in our study had the choice of either a maternity physician or certified midwife as their primary birth attendant. In BC, certified midwives come from either nurse-midwifery or direct entry midwifery training programs, and no distinctions are made between the two as far as professional practice is concerned. It appears that few pregnant women are even aware of midwives' different training backgrounds providers. The new BC model of midwifery care, wherein pregnant women are called clients rather than patients (CMBC 2003), aspires to have a more balanced power relationship between women and their care providers, in comparison with the traditional patriarchal model of physician care. And yet, publicly-funded midwifery care did not go far enough for some women, who opted out of the public health care system, hired lay midwives or opted for unassisted birth with no formal care provider present. Yet, as we show below, even these women do not reject all aspects of medicalisation.
Research Design3.1 The broader aim of this qualitative study was to gather information on women's experiences with self-care and health care in pregnancy, childbirth and lactation. We recruited our participants by means of a flyer that asked for volunteers interested in talking about their "self-care and health care in pregnancy." The flyer was posted in several high-traffic locations in the province's two large metropolitan areas (Vancouver and Victoria), circulated in the offices of certified midwives, the Home Birth Association of BC, and the "Best Babies" program for low-income pregnant women in the capital city. This recruitment technique, known as purposeful sampling, attracted the attention of potential participants who were interested in sharing their views and experiences on prenatal self-care (Lincoln & Guba, 1985; Patton, 1990). Because this was a self-selected sample, our participants leaned towards alternative health care strategies and were not representative of the population as a whole. The sample was particularly interesting because it included women who utilised lay midwives as well as those who chose to give birth unassisted; these women comprise a small minority of all birthing women and would have been hard to find through randomized sampling techniques. The Human Research Ethics Board at the University of Victoria reviewed and approved this research, and all the participants reviewed and signed consent forms prior to their interviews.
3.2 The researchers who wrote this article are both mothers, and both are academics who have conducted other research into maternity care styles in local and cross-cultural contexts employing a critical health sociology framework. As is usually the nature with qualitative studies, it is likely that researchers working in other paradigms, and in particular those who are also maternity care providers, would draw additional, and perhaps different, conclusions from the same dataset. We hope that these findings will generate discussion and will stimulate other research in the area of women's maternity care experiences.
3.3 Over a thirteen month period in 2002-3, the first author interviewed twenty-seven women who were purposefully sampled to represent a demographically diverse sample. The women were also chosen to represent a spread of maternity care provider types: physicians, certified midwives, lay midwives, or no provider at all (i.e., unassisted birth). We chose to stratify the sample in this manner so that we would be able to make comparisons between the perspectives and experiences of women from these various styles of maternity care.
3.4 Two sets of semi-structured interviews (Boyatzis, 1998) were conducted. The primary interviews took place in the third trimester of the women's pregnancies, and follow-up interviews took place between one and four months post-partum. Twenty-three of the participants were available for the follow-up interview, for a total of fifty interviews. The four women who did not take part in the second interview had either moved and could not be reached or did not respond to multiple requests for a second interview. All of the women whose narratives are analyzed in this article were interviewed twice; none were lost to follow-up.
3.5 The interviews covered the following subjects: the women's socio-demographic backgrounds, personal experiences of childbearing, views on medical intervention during labour and birth, self-care practices, and general impressions of the care they received across their childbearing period. Most of the questions were open-ended in nature, and they generated narratives of various lengths describing the subjective experiences of the women as they went through pregnancy, birth, and the adjustment to parenting a new child.
3.6 The interviews, ranging from forty-five to ninety minutes in length, were tape-recorded and transcribed. The first author conducted all the transcriptions and subsequent coding, allowing multiple opportunities for reviewing the data and identifying thematic content (Boyatzis, 1998). Both authors contributed to the development and exploration of themes which were emergent from the data. The women had an opportunity to review and revise the transcripts from the first interview at the time of the second interview (Creswell, 2003). Whenever possible, we sent them the transcripts from the second interview by mail or email, so that they might check for transcribing errors. In this manner, we corrected some minor errors in the transcriptions, but the women did not request any fundamental changes.
3.7 Thematic analysis, the analytical method used here, is frequently employed to process qualitative data gathered thorough semi-structured interviews such as ours (Boyatzis, 1998; Denzin & Lincoln, 1994; Kitzinger & Willmott, 2002; Miller & Crabtree, 1992; Phipps, 2001; Webb, 1999; Weiner et al., 2001). For this study, we began the process of thematic analysis by identifying themes that were inherent in the interview questions, such as the women's choice of care provider, place of birth, and use of alternative and conventional medicine. Once such themes were identified throughout the text, we catalogued and compared them for consistency and patterns, such as the relationships between women's perspectives on primary care provider and place of birth and their age, parity, and medication use.
3.8 However, the interview transcripts comprised a rich textual data set that provided far more than a catalogue of maternity care services used and self-care strategies. On a more fundamental level, the study allowed for a window on women's expectations, formed within a specific set of the possibilities and constraints, and their congruency with the women's actual experiences of pregnancy, birth, lactation and overall maternity care. Accordingly, we sought to analyze themes that were not built into the interview questions, but rather emerged from the women's narratives.
3.9 For the purposes of this paper, our analytical framework includes several emergent themes: (1) naturalistic concepts of childbearing, (2) negotiating and interpreting medical monitoring and intervention, and (3) modes of resistance. The conceptualisation of childbearing refers to the perspective or viewpoint of the respondents of childbearing as a natural life process. Medicalised interpretations of pregnancy and birth appeared as a counter-narrative which served to shape and frame the women's childbearing experiences in terms of medical technology, observation and intervention. Modes of resistance describe the women's responses to this 'clash of cultures', and relates to outright non-compliance with certain elements of medicalisation, such as screening and treatment protocols, but also to what we refer to as reluctant compliance, wherein women are hesitant to fully 'take on' medical diagnoses or high-risk roles, yet they feel a need to make compromises to meet the demands of both the naturalistic and the medical discourse on childbearing.
Results and Discussion
Socio-Demographic Data4.1 The participants ranged between nineteen and forty-three years in age. For some, this was their first pregnancy, while others had as many as three children already. The majority of the women (twenty-two) were Canadian born; others were born in the United States, Germany or Asia. Most (twenty) were Caucasian, though a few were Asian, Métis (of Aboriginal and French Canadian mixed heritage), or had some other mixed background. All of the women we interviewed had completed high school, and the majority (twenty-two) had some post-secondary education; ten women held undergraduate and/or postgraduate degrees. The women came from a variety of occupational backgrounds; some were unemployed, some were students, and some had professional occupations. There was no clear association between educational level and income; most of those with higher education either were students or were at home caring for young children. While three of the women said they were single, most said they had male partners.
4.2 At the time of the initial interview, fourteen of the twenty-seven women were planning home births. This was unusual for women in BC, where the overall rate of homebirth was approximately 1.5 percent in 2002 (BC Vital Statistics Agency, 2003), and reflects the uniqueness of our purposeful sample, as discussed above. The women were also interesting sociologically because of the various styles of maternity care they had chosen. Seven women were receiving their primary maternity care from physicians (family doctors or obstetricians), and eleven had chosen to be attended by certified midwives. Women choosing to have the care of a certified midwife were over-represented in the sample compared to the general population, as 15 – 20% of pregnant women in the local region typically receive midwifery care (BC Vital Statistics Agency, 2003). Five other participants had hired lay midwives, and had no formal certified maternity caregiver. The latter group of women paid the fees of these lay midwives out-of-pocket at a cost of $1500-2500 CDN (750-1250 British Pounds) per course of care. It is not known what proportion of women seek out-of-system maternity care in the region, but the number is likely very small.
4.3 Although lay midwives work outside the formal health care and legal systems of the province, the women we interviewed did not report many differences between this model of care and that offered by certified midwives. According to the women, both lay and certified midwives emphasised shared decision-making with clients, and both typically offered longer prenatal appointments than did physicians. The women who ultimately chose lay midwives said they did so because they had been unable to find suitable (in terms of personality or philosophy of childbearing) certified midwives, or they had a pre-existing mistrust of all health providers—physicians, nurses and midwives--who belonged to the formal health care system. This mistrust was usually founded on past negative experience, or on the assumption that anyone who was part of the 'system' would necessarily emphasise the medical management of pregnancy and birth.
4.4 Finally, four of the women in our study requested no assistance from any type of maternity provider whatsoever, choosing instead to give birth with just their families (two), family and friends (one), or with a doula (one) in attendance. Only one of these women received any formal prenatal care. A fifth woman also attempted to give birth without a care provider, after learning that the lay midwife she had hired would not be able to attend her. Of the five, she was the only one who chose to transfer to hospital during a prolonged labour, not due to a medical emergency, but because she wanted the help of anaesthetics so she could get some much-needed rest. The other four women successfully gave birth at home without medical or midwifery support.
4.5 Below, we explore the narratives of seven women who participated in each of these styles of maternity care. The narratives of these particular women were chosen to represent our respondents in the broadest sense, as it was our original intention to compare and contrast the range of perspectives and experiences that were included within the four styles of maternity care that were available to them. Accordingly, these seven women experienced the full range of styles of maternity care found among the other participants, and they had a variety of previous childbearing experiences. In selecting these particular narratives for our analysis, we hope to accurately portray the diversity of our participants' experiences, while illustrating those aspects of the childbearing experience which the women had in common.
4.6 Despite the predominantly medicalised nature of formal care during pregnancy and childbirth in the study region, our research participants appeared to embrace a naturalistic view of childbearing. Universally, they described pregnancy as an embodied experience and an integral part of everyday life, albeit a transitional and sometimes physically uncomfortable process. This was true regardless of the style of maternity care the women chose, suggesting that it is likely a viewpoint shared with many other women who go through pregnancy under similar circumstances. This possibility merits further study with a broader sample.
4.7 Della, pregnant with her fourth child and planning an unassisted birth, saw childbearing as an experience for the whole family:
Pregnancy and birth should be just a normal, natural thing. It should be a happy and exciting time, a time that husbands and wives and families are drawn closer together. And children as well. You know, a time for kids to learn about reproduction, so that it just becomes normal, a normal, natural part of life, as opposed to this great kind of mystery.Others chose to frame the experience in terms of medicalisation. "No, I don't consider pregnancy to be a medical condition," said Mimick (a pseudonym, as are all the participants' names which follow), having noticed a question about it on the researcher's interview question sheet. At age twenty-nine, this was Mimick's second child. She had hired a lay midwife as her primary attendant for this pregnancy, and she was planning a home birth. During her first interview, Mimick described her view of pregnancy: "what I see is the medical society seeing pregnancy as a parasite that has to be surgically removed… I don't see it [pregnancy] as a medical condition. I see it as a fact of life." Yet Mimick would ultimately give birth to this child in hospital vaginally with an obstetrician in attendance, by her own choice, giving evidence of the complexity of the issues at play here: what women say they want is, at times, incongruent with what they choose (DeVries et al., 2001).
4.8 A not dissimilar view of pregnancy came from another second-time mother, Andrea, a thirty-year-old woman who had chosen the care of an obstetrician. In our first interview, she explained that she viewed pregnancy as a self-care issue: "If you know your own health, and you sort of take relatively good care of yourself, or know your own body, you kind of know when things are right and when they're not right." At eight months pregnant, Andrea said that she felt she had done a reasonable job of taking care of herself so far, particularly since she now carried out her paid job at home. She related that while pregnant with her first baby, she had commuted daily to a downtown office, a factor which she felt had negatively influenced her health and well-being. In addition, she felt better informed this time around:
I think the first time for me anyways, I was sort of naïve. I read, I would read the books, and think, okay, that's fine. And I just wouldn't even know of questions. I wouldn't even think of questions to ask. And its once you've been through it once, have the labour and delivery, and end up with a child at the end of it, the next time you're a lot more aware of, well hang on, I just don't take things at face value. My doctor said, "oh, just take this." "Okay!" And this time round, it's like, oh well I've heard a few other things now about how to deal with morning sickness, or how to deal with back pain, or you know, whatever. Weight gain, or nutrition, or exercise, things like that.
4.9 Andrea's experience as a second-time mother, as well as her improved access to information (she felt the internet had become a more accessible and reliable source of information since she had her first child), put her in a position where she felt comfortable making some of her own decisions around pregnancy care. A combination of experience and expertise enabled her to become a more active agent in conceptualizing her pregnancy. All of the other multiparous respondents reflected this view. While they acknowledged that each pregnancy was unique, they were able to draw upon their past experience and interpret the new pregnancy in relation to their previous ones. Regardless of style of care, these women's stories of past and present pregnancies suggested that in second and subsequent pregnancies, there was much less need for the maternity care provider to help conceptualise and validate the pregnant woman's experiences—'mothering the mother,' so to speak. Rather, the care provider tended to shift for the women into the role of their expert consultant.
Diagnostic Testing: Negotiation and Interpretation
4.10 Though Mimick and Andrea both chose to give birth with an obstetrician's help—the most medically-oriented option available to them—their naturalistic views on pregnancy were shared by the other participants. They all viewed pregnancy as a natural process, yet also as a time when they felt a particular need to pay attention to their personal health and wellness in a holistic sense. The fact that the women viewed childbearing as a natural process was not inconsequential. It helped them develop a more critical perspective on the diagnostic tests and procedures that accompanied their prenatal care.
4.11 Despite their naturalistic philosophical views on childbearing, all but three women had their pregnancies monitored through a standard professional course of prenatal care provided by a family physician, certified midwife, or, in a few cases such as Mimick's, a lay midwife. In each case, this care included a number of routine diagnostic procedures such as urine sampling, blood testing for blood haemoglobin levels, antibodies and infectious diseases, blood pressure testing, fundal height measurement (an indicator of fetal growth), and documentation of the fetal heart rate.
4.12 Some women also consented to prenatal ultrasound imaging. These diagnostic tests sometimes discovered potential health problems. For instance, Andrea, quoted above, described a 'bubble' on her placenta, found through ultrasound and later deemed by a specialist to be of little importance. This incident was a source of worry for Andrea and became one of the defining milestones of her pregnancy.
4.13 Andrea had unquestioningly gone for the ultrasound test, as she said: "at 20 weeks, just the routine one, the standard one that everyone seems to go for" (emphasis added). Her choice of obstetrician had made her ultrasound examination mandatory; that particular care provider had not given her the choice to opt out of having an ultrasound, as some physicians and most midwives would have done. Andrea's choice of words, describing the ultrasound as routine and standard, reflected her unquestioning acceptance of the procedure. And yet, with hindsight, she could see that the procedure had led to an unfortunate period of anxiety. In this case, rather than contributing to Andrea's anxiety, her obstetrician normalised the event, and in doing so helped to relieve her client's concerns:
So, of course the clinic that I had gone to said "It's an angioma, it's a clot of blood vessels," and what not. This is considered high risk. Refer to BC Women's, refer to BC Women's [Hospital]. So my doctor said, "I've never heard of anyone having something like this, I've never seen this before. I guess we'll send you to BC Women's for an ultrasound just to see what they say." So that was very reassuring, that she sort of downplayed it. And my doctor looked at the report and said, "I don't know why they're using words like high risk, or words like," you know, a couple of the other phrases in the report. She said, "I've never ever seen or heard of this and it's probably not what they think it is, it may be, but chances are it's not." So I had a second ultrasound, and I saw a perinatologist just after that ultrasound, and she said, "No, it's something that happens, it's one of those things, it just doesn't get fully incorporated into the cord or the placenta." … But it was four weeks between the two ultrasounds, you know, chewing on your fingernails and everything.
4.14 Later in the interview, Andrea referred again to the worry that accompanied diagnostic testing. Regarding a blood test for some genetic problems that her baby might have been at risk for, she related the following:
I remember the first time [my first pregnancy] I had the test done, I thought blithely, oh yeah, sure, yeah, let's do it, why not. And then my doctor sat me down and said, "Okay I have some results for you," and she started reading through the ream of blood tests and whatnot, and she said, "Oh yes, and your alpha-feto-protein," AFP or whatever it's called. And all of a sudden my heart started pounding. Do I really want to know these results? And she says, "Oh it's fine, everything's fine." Oh thank God. Yeah, I just had a moment of, wow, what if this test is not a good result? You know, or there's a really high risk? Obviously the test doesn't predict with certainty, but it can tell you if you have an elevated risk. I thought, uuh, stop!
4.15 Yet, Andrea did not stop the process of the medical observation and management of her pregnancy. She viewed her experience with a critical eye, but unlike some of our respondents who chose alternative maternity care styles, she did not seem to view it as any indicator of a systemic problem. This lends support to sociological research pointing to the extensive medical control of women's reproductive life events such as pregnancy in North America, when risk is assumed, and things are considered normal only in retrospect (Conrad, 1992; DeVries, 2005; Lorber, 1975; Riessman, 1983; Rothman, 2001). Additionally, it illustrates how pregnant women often express a preference for the type of maternity care that is readily available to them, without envisioning other feasible alternatives (DeVries et al., 2001). In the mainstream, the 'best possible care' includes the judicious use of modern biomedical technology (Clarke et al., 2003). And in Andrea's case, paradoxically but perhaps not atypically, the escalation of 'risk' was moderated by her obstetrician, who worked to reassure her by normalising the results of her diagnostic tests.
4.16 Even our participants receiving primary care from certified midwives were not necessarily opposed to diagnostic testing or the risk labels that followed, though they tended to question these procedures more openly. One woman in certified midwifery care, Kerri, had been diagnosed with gestational diabetes in her first pregnancy. At the time of the study she was pregnant with her second child, and she had gone through a 'standard' testing procedure to see whether she had developed diabetes again. She was herself a trained nurse, and at the time of the first interview was working for an agency that provided support services to pregnant women. Kerri described how her nursing education and clinic work gave her access to a wide range of health information and services, much of which, she said, the lay person would probably not know existed. She explained how she used her scientific and practical nursing knowledge to try and resist the medicalisation of her pregnancy following a diagnosis of gestational diabetes, though in the end she experienced extensive monitoring and medical control:
I was fighting it in the beginning, because you read the research and it says intervention doesn't necessarily change outcome. So why are we diagnosing people, stressing them out, putting them on diets, making them go for all this testing, and putting them on insulin? And I guess, in the end, you know, I was talking to the endocrinologist, and he's like, 'well basically, treatment doesn't really hurt, either.' [But] once you get into that track of believing you're high risk, I think it does hurt people. [Y]ou know, because pregnancy can be difficult enough, and then you, you know, I'm on like I take four shots of insulin a day, and then I'm still testing four times a day. So that's like eight, eight pokes a day.
4.17 For Kerri, prenatal diagnosis and treatment, as she put it, "ruins your pregnancy." Dutch midwives have expressed similar opinions in focus groups on ultrasound screening. As one midwife put it: "You can ruin a pregnancy with it, or an entire part of it…. You take away an unconcerned pregnancy, that's what you remove" (Rothman, 2001:193). But Kerri's pregnancy narrative is complex because she had made a conscious, well-informed choice to undergo treatment, yet she appeared to be well aware of the peace of mind that she had lost. Acting as an agent in her own care, she rationalised her choice to undergo testing and treatment, but her narrative reflects the fact that she had not made her choice easily.
I guess with a lot of things in pregnancy, you never really know if what you do makes a difference. Whether it's taking folic acid, or you know, abstaining from this or doing that, there's no guarantee that it's really going to make a difference. So I guess it's like a lot of things, but luckily I'm not the type of person who's squeamish about needles, so it's not a huge imposition to me.
4.18 Perhaps it was Kerri's medical education and lived experience of caring for childbearing women that shaped her pregnancy, where she 'gave in' to medical monitoring while expressing a longing for a pregnancy that was not 'ruined' by continuous surveillance. She was able to take a step back and look at how her situation would be experienced by other women: "I can imagine that for somebody who was really against taking medications and that sort of thing, it would be difficult." Frank (2000) also found that people who are vulnerable due to illness may become ensnared in the formal medical technocracy and yet perform, at the informal level, individual acts that significantly change the meanings they apply to this 'medical takeover.' It is clear from Kerri's narrative that she was ambivalent about further monitoring, yet in the end she gave in, probably because her lived experience and the social context of her life pushed her in the direction of becoming a 'high risk' candidate. Other researchers have also found that human agency sometimes fades into the background when facing "routinised structural and cultural constraints and patterns" (Snow, 2001: 374). There were many other examples of rationalisation in the narratives of women from all styles of care. A few such examples are discussed below as they emerged in relation to other themes. In particular, as we shall see, rationalisation appeared as a fundamental part of making compromises between what the women desired in their care, and what they actually got.
4.19 The women's agency did not always retreat following medical diagnosis of prenatal health problems. Take Shannon, who was informed through ultrasound diagnosis that one of her baby's kidneys might be malformed. Like Kerri, Shannon was in certified midwifery care for her first pregnancy. She had carefully researched birth attendance options and had interviewed several certified midwives before choosing one. She had also had arranged for her own sister, a trained doula, to be present for the birth and for a week or two afterwards. Shannon was committed to natural childbirth and had planned a home birth. Her decision to have an ultrasound scan was not an easy one, as the procedure, she related, is quite controversial in the alternative birth community which she identified with.
4.20 Shannon did not view the ultrasound procedure as 'routine' and 'standard'; she saw it as one of a variety of diagnostic options that were available to her as a part of her course of care with a certified midwife. Despite her reservations about the procedure, Shannon went ahead with it, saying she had found 'middle ground' with her husband who had a liking for technology. However, when she received the dire news from the ultrasound technologist that their unborn child might possibly have a malformed kidney, she chose to push the medical information aside, rather than reinterpreting her pregnancy as 'high risk' and in need of enhanced monitoring:
They were recommending another ultrasound at thirty weeks and we [my partner and I] said 'no.' We had trouble enough deciding to have one [ultrasound], and we're not comfortable with any more than that…I mean the baby's body will tell us if there's something wrong with the kidney. And we'll handle it then. But there's no need for my body and the baby to be exposed to more ultrasounds. Otherwise we're just going to trust that there was a glitch on the, on the ultrasound. It is all speculation, anyways. You know, two years ago they didn't even have the technology to see the kidneys [emphasis added].Here, Shannon voiced the naturalistic view that we heard often from the women who sought alternative styles of care: she would know if something was wrong with her baby. It is this trust in one's intuitive knowledge that most strongly divided the women choosing physician care from those choosing alternative styles of care. It also marked her apart from Kerri, who made her prenatal care decisions on the basis of scientific knowledge, rather than relying on her intuitive knowledge.
4.21 The clients in physician care also felt reassured by the kinds of knowledge that were passed down from generation to generation. Andrea talked about her parents' reaction to her scare with the bubble on her placenta:
Of course, my family said "Don't worry about it, don't worry about it. Thirty years ago, people never knew about these things, and look how many babies turned out okay. These things happen. If you didn't know about it, it wouldn't be bothering you. You wouldn't be lying awake at night."
4.22 The midwifery model of care helped to create an environment in which Shannon was able to choose to downplay the results of her ultrasound in favour of her intuitive knowledge, and Kerri was able to make the choice to manage her gestational diabetes using the conventional medical protocols. As noted above, the midwifery model of care emphasises individual choice regarding diagnostic testing and procedures, and as such, it encourages the individual to determine the extent to which her perception of reality is shaped by test results. Though she consented to the first test, Shannon was under no obvious pressure from her certified midwife to enter into a full series of tests. Shannon said her midwife supported her decision not to undergo any further testing. In Shannon's words: "she just said 'okay,' and she hasn't bothered us about it."
4.23 The women in physician care had somewhat different experiences, with less emphasis on patient empowerment, yet a reluctance to label pregnancies as 'high risk' at any opportunity. While Shannon's midwife seemed to her to be comfortable with her choice not to have a second ultrasound, Andrea was automatically referred for one by her obstetrician "just to make sure" there wasn't a problem with her placenta. And both Andrea and Shannon sought some relief from their anxiety by applying the rationale that technology had only recently evolved to the level of being able to detect the unique features of their placenta and unborn child.
4.24 Though Shannon chose to reject further testing, her hesitant manner of speech, restless hands, and the fact that she mentioned this incident in the interview at all, suggested that the first test had affected her sense of well-being. Her story is not one of complete loss of personal autonomy and submission to the bureaucratic machinery of medicine, however. Rather, Shannon played an active role in constructing her experience of pregnancy, giving it biographical coherence, while responding to her personal circumstances: a techno-happy husband, a seemingly-neutral midwife, a dominant discourse of pregnancy risk and the need for surveillance, and her participation in a counter-culture which rejects this dominant discourse.
4.25 Like many women who are reluctant to take on a 'high risk' label or assume a 'sick role,' Shannon rejected a medical diagnosis, instead normalizing her experience by choosing to avoid frequent diagnostic tests which would interrupt the flow of her everyday life. This finding differs from Frank's (1995:6) description of the "obligation of seeking medical care as a narrative surrender." Through this process, he argues, people reconstruct their personal narratives around medical narratives, which positions medical narratives at the centre of any interpretation of life events. In Shannon's case, however, narrative reconstruction involved the conditional rejection of medical narratives, and was thus a form of individual resistance. Some writers have argued that women's narratives represent their experience, but also serve to shape that experience (Miller, 2000). While built in part out of a locally available stock of narrative resources and embedded in societal institutions (Holstein & Gubrium, 2000), these narratives nonetheless present an avenue for self-construction and personal agency. Shannon reinforced her personal narrative, guarding against a potential medical 'narrative takeover' by describing her mistrust of ultrasound technology and reiterating her faith in her own intuition to inform her about her child's health.
Avoidance of Formal Prenatal Care
4.26 As Shannon's narrative in particular alluded to, prenatal diagnostic testing is currently the site of heated debate, as certified midwives in BC are required by their licensing body to gather certain types of diagnostic data and to inform their clients about the tests available. This situation appeared to have shaped our midwifery participants' experiences of pregnancy, such that they described their pregnancy experiences as organised largely around choosing which tests and measures to undertake. However, not only midwifery was affected by prenatal surveillance. We found that even the three women who had 'unassisted pregnancies' made reference to standard pregnancy diagnostic measures. Two of these women mentioned self-monitoring as a possibility, but none of them reported regularly 'measuring' their health or the progress of the pregnancy.
4.27 Take, for instance, Anne, whose two young children were both born at home, as her third child would be. At our first interview, she described how she approached this third pregnancy: "I feel confident in providing my own care. I don't check my blood pressure; no urinalysis, no weight checks. I don't think any of those things are necessary." Like Anne, the two other women who went without formal prenatal care revealed an acute awareness of what they were doing without when they framed their pregnancy stories.
4.28 In short, it seemed apparent (even among the women who actively sought out non-medicalised pregnancies) that standard prenatal diagnostic procedures are part of the dominant discourse surrounding pregnancy. Similar to what Monto (1997) found in a qualitative study of birthing women from one region in the United States, our more 'radical' or 'fringe' participants felt moved to mention the medical monitoring they had chosen to avoid. Studies of the women's health movement also note this tendency among followers keen to articulate an alternative vision by critiquing medicine, and yet using medicine's benchmarks when measuring success (Kleinman, 1996; Ruzek, 1978).
4.29 Other women maintained autonomy over their current pregnancies by first reflecting on how medicine and even midwifery had led them down an undesirable path during previous pregnancies. This time, these women took steps to ensure that they would have greater control over the events surrounding their pregnancies and births. Della was a case in point. At the time of our first interview, she was forty-two years old and pregnant with her fourth child. After having been diagnosed with toxemia (edema, protein in her urine, and high blood pressure; this condition is also known as pre-ecclampsia) in her three previous pregnancies, and then enduring an emergency Caesarean section in each case, Della had chosen to go through this fourth pregnancy unassisted. She held a postgraduate degree in public health and had a number of years of experience working in a local health office. As such, she said she felt very well qualified to interpret the scientific literature and self-monitor her fourth pregnancy:
I just kind of watch to see if my legs or my feet swell. I'm drinking a lot more water this pregnancy than I have with the other ones. I started doing that right from the beginning, thinking that that would make a difference as well, with the swelling in my legs. That tends to be what happens to me at the end.Della was certainly aware of how physicians and midwives might interpret her medical record; with her history of toxemia and three surgical deliveries, she would be a 'high risk' patient. Yet in this pregnancy, she had chosen to reject the authority of the medical community that recommended regular monitoring and testing.
4.30 Perhaps the existence of the 'unassisted birth movement,' in which Della mentioned she participated via email exchanges, gave her enough information to satisfy her desire for knowledge about her pregnancy and courage to live with her unconventional choice. Through this movement, Della said, women shared lay strategies for preventing and managing toxemia, such as the consumption of large amounts of protein (which she rejected, having tried it in a previous pregnancy) and drinking large amounts of water (which she accepted). Yet Della had made unconventional choices in her previous pregnancies as well by utilizing lay midwives as well as physicians, for these three pregnancies predated the certification of midwives in the province. The undesirable outcome of these pregnancies (illness, followed by surgical deliveries) perhaps provided the impetus for Della to rely entirely on self-care this time around. Particularly in the case of her third pregnancy, when she was in lay midwifery care, Della felt that her maternity care provider had failed to meet her expectations:
I stayed home [in labour] until I was basically almost fully dilated. And then, my blood pressure went up a little bit, and I had a nervous midwife who said, 'I should call the doctor right away.'… So my last baby ended up being an unnecessary Cesarean. Not in any sense of the word did I have informed consent. So, I was pretty pissed off at the midwife and majorly pissed off at the physician. Unfortunately, the midwife was going through registration [to be a certified midwife] at that point in time. And so, she was, I mean she was very nervous. She didn't want to do anything to jeopardise her registration. I really lost faith in midwives. So I decided to do my next [pregnancy] differently [emphasis added].
4.31 What marked Della's discontent with her previous maternity care most strongly was her sense of having her lay embodied knowledge overrided by the more formal knowledge of her care providers. For example, she related how in her second pregnancy, she had recognised the symptoms of toxemia and checked herself into hospital, though her family physician and lay midwife both told her she did not have toxemia. As it turned out, she was indeed diagnosed with toxemia after arriving at the hospital. And in both her first and third pregnancies, she described how she did not feel adequately informed to make important decisions around her care. Her care providers had kept her 'in the dark,' in her view, until it was too late for her to participate in decision-making. This disempowerment, or lack of agency, created a discord described by Beck (2006) in the narratives of women experiencing posttraumatic stress disorder after childbirth. Della, wanting to avoid a fourth traumatic birth, and wanting to rekindle her faith in her body's ability to give birth naturally, felt that the her best choice was to opt out of formal maternity care entirely.
4.32 By providing her own maternity care, Della, was unusual, different, even defiant, and her route was marked even by herself as 'alternative.' Without her privileged socio-economic situation and advanced educational credentials, and without the biographical context of three previous pregnancies, the pregnant self that Della narrated would likely have been different and the birth strategies chosen more conventional. Unlike many of the other women in our study who were first-time mothers, Della had access to a rich body of memories about her earlier pregnancies and negotiations with physicians and different types of midwives. Her 'knowledgeable narratives' thus displayed an acute awareness of the real possibilities open to her (Williams & Popay, 1994; Williams, 2003). The successful home water birth of her fourth child appeared, for Della, to come as a reward for her extensive research and independent decision-making throughout the pregnancy and labor process:
The birthing part, it was wonderful. You can't beat that. You can't beat the pushing out part. I mean, you know, the fact that the baby kind of drops and you kind of grab the baby and you're the first one to hold him, you know? And it's so different [from a Caesarean birth] because you're holding him, and you're the one who gets to say what the sex is, and nobody takes your baby away from you. There was a bed right there on the floor, and so I just laid down on the floor with him and held him and just nursed right away, and he cuddled beside me. You know, you can't beat that.
4.33 Like Della, other participants, particularly those who were not first time mothers, relied on their own knowledge bases, philosophies of care and childbearing experiences to choose styles of care that felt most appropriate to them. For example, some (such as Andrea, quoted above) sought care from a care provider who was familiar to them: typically their own family physician, or a physician or certified midwife who had attended their previous births. Several others (including Shannon, also quoted above) carefully screened potential care providers, choosing the one who seemed to be the most suitable. Most of the participants changed care providers if they felt a particular practitioner did not agree with them on certain key issues. For example, Jamie, a thirty-two-year-old certified midwifery client, was pregnant with her second child. Her first child had been medically-induced under a physician's supervision; she expressed strong dissatisfaction with how this pregnancy and birth had gone.
It's not that I didn't have information the last time, I had lots of access to books, but I just found my doctor was not very communicative with me. I would ask questions, and she either wouldn't know, or she'd say, I'll get back to you, and she never would. Then, my doctor had to go away when I was like 8 months pregnant because her parents died. And I got passed off to somebody else in the clinic, and this guy was kind of a jerk…. He put me in the hospital [because of high blood pressure], and then didn't come to see me. He just dumped me there…. So then when my doctor came back, I was quite angry about everything that had happened, and it just seemed like they were like, 'well, let's just get this woman done with,' kind of thing. It seemed like they just didn't want to deal with me any more, because I had problems with this guy. I really feel like that was part of the decision why they induced me at that time. And with the Pitocin [synthetic Oxytocin, which induces uterine contraction], it's like you're sitting there watching the nurse press a button, and that's how your labour is progressing. I mean, it's just, 'lie on your back and do what we tell you', basically. I don't know. I think it's really, really hard, even as an informed person, to fight against it. So I'll just stay away from the whole thing…. I don't really want to think about what happens if I go over term [this pregnancy]. I guess I just don't want to go through that. I'd probably jump up and down on my head if I had to, to prevent that.
4.34 In her efforts to avoid another medicalised birth, Jamie had chosen to have this second child at home, and she had employed the most "laid back" certified midwife she could find, after leaving the care of an "uptight" certified midwife. She described her experience with the two midwives like this:
So I found a midwife, and it's not that she's incompetent or anything, it was just personality difference. She's just very high strung. I found that I would leave her office, and I would be stressed out. Because she would be like, you can't eat more than two pieces of fruit a day, and I was having morning sickness, and all I could eat was fruit, and I'm like okay, you want me to starve myself? She just, it wasn't threatening, just very panic oriented. So I found another midwife who's sort of new in town. And she's just very calm, and she has a good sense of humor, and when you go to her office, it isn't like a hospital bed; it's like a day bed with cushions. And you sit on the couch, and it's in a house, and when you go to the bathroom it looks like a real bathroom. The whole atmosphere is very relaxed, and she's very relaxed. I need someone who's calming to be around me, and she's definitely like that.For Jamie, the second midwife's office appeared to convey a sense of normalcy, which was important to her perhaps because she was planning a home birth and did not wish so be reminded of her previous hospital experience. The office space and the midwife's calm manner fit well with Jamie's envisioned birth scenario, whereas the more 'high strung' midwife with a clinical office space did not fit well at all. Jamie thus set the stage for her own birth experience by anticipating how her midwife would affect how Jamie experienced her labour. She had engaged in the kind of "anticipatory strategic action" (Snow, 2001: 370) which allowed her to define her birth environment, and while avoiding medical monitoring, she had access to the minimal technical support that she felt she might need.
4.35 Jamie's choice appeared to be a compromise—she had opted for a certified midwife (professional support) who provided the least clinical-feeling care she could conceive of. And though she was able to have her baby at home, she still seemed to need to figure out how some of the midwife's actions fit with her desire for an intervention-free birth:
There as only one time that I didn't feel in control. And that was when we were in the tub, and … [the midwife] wanted to check to see how far along I was. I guess I didn't appear to her to be ready [to start pushing], you know? She was wanting me to get out of the tub so she could check my dilation, and then my water broke in that contraction. And she just said, "well I'm going to check you right here." And I didn't want her to touch me. Because I mean, I remember that from my last labour too, it's like when you're in labour, somebody puts their hand in there. … She ended up checking me during a contraction, because she wanted to see where the baby's head was or something. I, she, there was a really valid reason for it at the time and she explained to me, and I can't remember now because it's all a haze. But she actually checked me during a contraction while I was in the tub. And I was like, "no, don't do this." And she was just like, "I have to. I have to see where you are. I have to see what's going on." So, so she did that. And that was like the only time when I really, really didn't want her to be doing that, but she sort of did it anyway.
4.36 Though this event at first appeared to have been a source of conflict between Jamie and her midwife, she was able to rationalise what had happened later in the interview, and thereby draw the event more securely into her narrative:
To be honest, even though, even though I didn't want her to be checking me at that particular moment, I was happy to know what was going on. I was actually glad to know, so that was fine. But, yeah, in the moment, you're just like, "No, don't do it."
4.37 In making compromises between her needs for a professionally supervised birth and an intervention-free one, Jamie closely resembled the other multiparous midwifery clients. Like Jamie, the others accepted things like cervical exams and amniotomies, even in cases where they had explicitly stated that they had found such things to be traumatic during their previous births. This suggests that when it comes to interventions, it perhaps matters less what is done, and more how, where and by whom. For Jamie, an act performed by a trusted midwife in her own home was something she could rationalise. In contrast, she had made it clear in her first interview that the same act performed by an unfamiliar nurse or unfriendly doctor was unacceptable and potentially traumatic for her:
I'm really afraid of going to the hospital. I'm just really afraid that I'll get this horrible nurse, and some stupid doc, the kind of doctor that walks in and like, sticks his hand in you without even saying "Hi," you know?
Conclusions5.1 This article draws from the experiences of a small, non-random sample of women who uniquely represent a range of maternity care styles available to them in British Columbia, Canada, where certified midwifery has recently been integrated into the public health care system. Our qualitative findings suggest that participants are not docile recipients of medical care but more akin to Zadoroznyj's 'reflective consumers' (2001) who display agency to the degree that they seek information from a variety of channels to support their decision-making, and they expect their care providers to acknowledge them as legitimate sources of health information. This was the case with participants regardless of the style of care they chose or ended up with in the end. The choices they made were sometimes complex, but those who felt empowered by their care all expressed satisfaction with their choices, with their care providers and with their deliveries. Practitioners who enabled the women to make choices around their care, while avoiding risk-labelling, were greatly appreciated by the women. Those who the women felt they knew personally, either through a prior caring relationship or the establishment of good rapport, were also well valued.
5.2 While the limitations of the study's design prevent us from making broad conclusions, the narratives we have presented above provide us with an opportunity to deepen our understanding of medicalisation as a multi-layered and contextualised concept (Wrede et al., 2001; Benoit et al., 2005; Wrede et al., 2006; van Teijlingen, 2005). While the medicalisation of pregnancy enters into women's decision-making and their interactions with health care providers, lay people, and academic researchers, these women simultaneously draw upon their personal histories and everyday resources to reshape, validate or question the extent of medicine's arm in shaping their experiences.
5.3 Our preliminary findings lend support to the Canadian trend towards offering women greater choices in their style of maternity care within the public health care system, including the provision of midwifery services and access to collaborative teams. Further research with a larger representative sample of women, would confirm or refute these policy directions.
AcknowledgementsThis research was undertaken as a part of Rachel Westfall's doctoral degree requirements at the University of Victoria. It was funded in part by a University of Victoria Graduate Fellowship and a Research Grant from the Sara Spencer Foundation. The women who took part in this research are gratefully acknowledged for having shared this intimate time with us.
Notes1Canadian medical care is publicly-funded and administered, and all Canadians have access to physician and hospital services free at the point of delivery (known as Medicare). Under the Canadian system, health care is thus viewed as a right, rather than a commodity (Kluge, 1999). The Canada Health Act, proclaimed in 1985, requires all provincial health plans to be publicly administered and not-for-profit (Kluge, 1999). The Canadian health care system has been described as paternalistic (Okma, 2002) because medical professionals and governments make decisions about service provision, whereas consumers have little say in health and social policy-making. Nonetheless, Canadians have lobbied for the right to choose between several styles of maternity care, including obstetric, family physician, and midwifery care. As a result, midwifery care has recently become publicly-funded and regulated in some provinces (Bourgeault, Benoit & Davis-Floyd, 2004). In our study region of British Columbia (BC), for example, certified midwifery became available to women in some localities in 1998. Previously, midwifery care had been an underground service for which birthing families paid out-of-pocket (Burtch, 1994).
2The term 'midwife' is now reserved for use by registered midwives under the BC Health Professions Act. In an attempt to avoid prosecution for practicing midwifery without a license, some unregistered midwives had opted for the term 'traditional birth attendant.' However, as this term has a specific meaning in the international literature which does not accurately reflect the work performed by BC's unregistered midwives, we have opted to use the term 'lay midwife' for the purpose of this paper. We use 'lay midwife' to distinguish unregistered midwives from 'certified midwives', those who are publicly funded and legally permitted to practice in the province.
3 Had we chosen to focus on the women's birth stories rather than their perceptions of prenatal care, we would have selected our sub-sample differently, for these seven women all went on to have vaginal births, and all of their infants were healthy.
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