Researching Pregnancy.
Harriet Goss.
ACKNOWLEDGEMENTS.
As always, the completion of a project, particularly one that requires time and relative solitude, is never exclusive to those engaged in the doing of the daily ch.o.r.es of writing and production. We would like to thank rst our families, husbands Martyn Cornick and Anthony Johnson, and our children Daisy, Jack and Matilda, for their continuing support, patience and good humour. We also want to acknowledge the longer-distance support of our extended families who took on trust our non-appearance at events as the inevitable result of having an academic in the family. Other people have been important, in particular our immediate colleagues at Loughborough, Birmingham and Aston and especially our fellow researchers, Pam Quick, Penny Bee (nee Clarke), Elaine McWilliams, Charlotte Cast and Jasmine Bhagrath, without whom the material would not have been forthcoming. In this respect, we must also thank all the women who so kindly agreed to partic.i.p.ate in the various studies and shared their experience with us and the professional colleagues who a.s.sisted us in our research. Thanks too to the Society of Reproductive and Infant Psychology for providing an initial and ongoing forum for discussion. Last, we must thank Jane Ussher and the publishers for their continuing interest and persistent support.
INTRODUCTION.
Pregnancy in context.
Pregnancy is a challenging topic for research: it is a normal and even essential part of everyday life. It is a natural biological event: a physical process underpinned by a complex physiology. It is a psychological event and a personal transition; its meaning is also socially and culturally determined. It is time-limited. Research may be concerned with any one or more of these co-existing and wide-ranging elements but in doing so it is inevitably drawn into contradictory and paradoxical conclusions. Our own starting point as pregnancy researchers was a personal observation of a major memory lapse that occurred at work during a pregnancy. This lapse was immediately attributed to the state of being pregnant. Why such an attribution should have been made was what led to our studies of cognition in pregnancy. In reecting upon the material we collected, it was obvious that we could not simply describe a set of cognitive outcomes without placing these in the context in which they were reported and that this context was not simply "being pregnant" but a sophisticated interaction of those elements described above. Hence, our interest and, ten years later, this book.
In the book we address the thesis that there are strong dominant sociocultural constructions of pregnancy in modern society which inuence what research is conducted into pregnancy, how such research is carried out and the way results are interpreted. Our intention is to explore perceptions and myths about pregnancy and the relationships between these and pregnancy research. We would argue that such beliefs affect the way pregnancy is experienced by women. Specically, pregnancy allows the reproductive body to be a focus of legitimate surveillance and regulation, and research largely biomedical in origin but psychological research is not exempt has been instrumental in this process. We make use of material arising from our own studies of cognition, work, diet and exercise to ill.u.s.trate how social constructions are inuential in, and affected by, research which can act both to reinforce and to refute the myths about pregnancy.
We are particularly interested to examine the different ways in which women in the pursuit of their daily lives may themselves encounter 1 pregnancy research and cultural positioning of pregnancy. In this rst chapter, we introduce briey some of the issues that will be revisited in the following chapters and, in order to provide background for these later chapters, summarise the typical process of pregnancy and antenatal care.
News of a pregnancy is usually greeted with congratulations; pregnancy is seen as a joyous life event, concerning the personal and private hopes and desires of those directly involved. It is also a rite of pa.s.sage, enacted in the public domain, carrying with it changes in perceived roles and responsibilities. Pregnancy is viewed as healthy and natural, both as a necessary component of the transition to parenthood and as a biological and physiological process. As with other natural (reproductive) transitions that occur in women"s lives, such as menstruation or the menopause, pregnancy brings women into contact with health professionals and medical procedures to ensure the wellbeing of mother and baby.
However, natural or normal processes once const.i.tuted as health events carry with them a range of expectations and interventions. It has become customary to be highly solicitous of the processes of human reproduction. It is not enough to let pregnancy run its course. Women must be instrumental in a successful, problem-free pregnancy. Although different women experience their pregnancies in different ways, they are all recipients of professional advice, instruction and health education; the message that women receive when they are pregnant is that they must be vigilant of themselves on behalf of their baby. Once pregnant, women may nd themselves treated differently by those around them. A pregnant woman is not only perceived as an individual who may require medical care and protection, but also as a person who must be guided or disciplined into the correct modes of behaviour, since something that is described as natural (arising from biology) also conveys a sense of being out of control. In this sense, therefore, women are expected to ensure that they are healthy and prepared for pregnancy and those who do not conform in this way are construed as being selsh and unconcerned about the health of their unborn child. Thus, during their pregnancies women become the subject of comment and, on occasion, their public presence has even been seen as unacceptable. Pregnancy could therefore be said to be highly visible; it certainly attracts attention, both positive and negative, and prompts women to behave in certain ways. It provides very public and visually salient evidence of femininity. Beliefs about pregnant women reect wider beliefs about women generally, for example their emotional lability and women as theweaker vessel", whereas other beliefs reect the uniqueness and strangeness of pregnancy. Moreover, pregnancy highlights the ambiguous and shifting positions of women in society and the complexity of the negotiations necessary for them to accomplish such a major life event in an acceptable fashion.
While pregnancy is represented as a natural and healthy state, the acceptance of biology also has the effect of pathologising normal female 2 functioning and emphasising the unnatural and inherent problematic position of women being at the mercy of their physiology or hormones (Kristeva, 1997). This derives largely from the predominance of the medico-scientic tradition in pregnancy research, which arose from good intentions but has shaped not just pregnancy research but the beliefs a.s.sociated with it.
By this means, for example, explanations of behaviour and affect during pregnancy are couched in terms of physiological, neurological or endo-crinological change rather than psychological factors. Only recently has this powerful hegemony with respect to pregnancy been subject to marginal erosion in a faint awareness of the role of psychology in fertility. Pregnancy research itself both reects and fuels the changing context of women"s position in society and the nature of the areas that are attended to.
It is easy to a.s.sume that the medical intervention in pregnancy and childbirth has been a relatively recent phenomenon, deriving from changes in medical practice in the middle of the twentieth century. However, historically, pregnancy has been a topic of medically oriented research for several hundred years, as is well doc.u.mented elsewhere (see, for example, Barker, 1998; Garcia et al., 1990; Hanson, 2004; Murphy Lawless, 1998; Oakley, 1984; Tew, 1990). One major purpose of the initial involvement of the medical profession was to reduce the high rates of maternal and infant mortality. The development of public health measures and the devolution of technologies of practice to medicine and doctors arose from these demands for better maternal and infant health. The understanding of the nature of puerperal fever, previously the single largest killer of women in childbirth, cut maternal deaths dramatically by the end of the nineteenth century, although this was only nally resolved by the advent of reliable and easily available antibiotics and good antisepsis in the middle of the last century.
Once this had been accomplished, women"s health in pregnancy and childbirth could be reasonably a.s.sured and, although it remained an ongoing concern, it became largely secondary to the achievement of a healthy outcome. Thus, the baby"s health became the focus of research attention and this has been the primary rationale for much research and especially research in the medical and biological tradition on pregnancy ever since. An effect of the transfer of attention was the relocation of pregnancy from the private and home-based domain, albeit with the intervention of usually male specialised a.s.sistance, to the public and health domain. This is where it has steadfastly remained, particularly with the advent of the new technologies of reproduction and monitoring, and despite the efforts of various groups concerned to place women at the centre of the process, such as the Radical Midwives, the a.s.sociation for the Improvement of Maternity Services and the National Childbirth Trust.
As well as identifying and developing ways of improving mortality rates, medical research has included the development of the whole panoply of devices and services now considered routine in the process of pregnancy and 3 childbirth, for example the identication of screening techniques and technologies of intervention, such as measurement of the foetal heartbeat, the invention of forceps and improved pain relief. In doing so, research has served to increase women"s own reliance on external agents and expertise.
More signicantly, the medical tradition of research has also determined the way that research has been carried out in other domains. The attention to the baby has produced a range of studies using the same rationale of ensuring a healthy outcome and building on similar a.s.sumptions about women. Thus, research investigating risk factors for pregnancy has focused almost entirely on the outcome. For example, Da Costa et al. (1999), investigating psychosocial health and pregnancy complications, were concerned with how these might affect pregnancy outcome rather than with how they affect the woman"s own experience of her pregnancy. Work within the medical tradition which does attend to the woman herself is clearly aligned with the pathologising of pregnancy, by representing psychiatric disturbances as inherent to pregnancy (Brockington, 1994).
A major impact of the medical tradition in researching pregnancy, which has formed the subject of discussions of pregnancy by feminist writers and researchers such as Julie Kristeva, Iris Marion Young, Susan Bordo and Jane Ussher, has been the instantiation of a metaphor of containment, whereby the woman is regarded as a vessel for the foetus, an essential but secondary role. This metaphor also places women as being at the mercy of elemental forces which may endanger the contents of the vessel (Smith, 1992). The metaphor can be seen in operation in research and publications on all areas of pregnancy and surfaces in medical advice and popular literature and in turn contributes to personal and social expectations of pregnancy. We return to this in subsequent chapters (particularly Chapters 4, 5 and 7). The medical focus on outcome is also utilising the same metaphor of containment, where the emphasis is on the effect of various individual factors or situational variables on the outcome of pregnancy (the baby), rather than on the nature of women"s experience or interpretation of their situation. For instance, work on the effects of stress on preterm delivery (Hickey et al., 1995), or activities such as standing and lifting at work and their link to rates of foetal growth or preterm delivery (Hatch et al., 1997), attend to what women need to be told about these behaviours rather than how they might arise or relate to women"s own experiences.
The biomedical model of health is maintained and refreshed by such research.
Psychologically, pregnancy as a state is particularly interesting because it is a time of change. This change comprises the experience of the dramatic physiological alterations in women"s bodies over a short period and the social and cultural construction of the change in role and ident.i.ty. Such change carries implications for women"s wellbeing during the pregnancy and beyond, and for the way they are viewed by others. Thus, a major 4 psychological discourse of pregnancy, especially within a psychodynamic tradition, is on transition. In keeping with a primarily biomedical approach, however, such a discourse highlights the possible negative impact of transition on a woman"s psychological wellbeing: pregnancy as a potential crisis state, involving shifts in ident.i.ty and the move from non-motherhood to motherhood, as well as possible confrontations with unresolved issues (Breen, 1975; Deutsch, 1947; Raphael-Leff, 1991). In this view, pregnancy may be a.s.sociated with feelings of loss as well as gain. Any realignment of ident.i.ties a.s.sociated with transition occurs in a personal and in a social context and a further signicant psychological aspect of pregnancy is its public visibility. The visibility of pregnancy as an embodiment of reproductive fertility and s.e.xuality can transgress boundaries between the personal or private and the public domains and affect both personal and public beliefs about pregnancy. Feminist psychological writing and research is concerned to elucidate the manifestation of these personal and public beliefs and examine further the paradoxes of the required pa.s.sivity and agency that such beliefs engender. Importantly, in this context, pregnancy can be as an enabling state, offering the opportunity for shifts in women"s presentation of self (Charles and Kerr, 1986; Oakley, 1980; Slade, 1977; Wiles, 1994). Much psychological research has operated within the prevalent biomedical discourses already discussed and has been focused on doc.u.menting the nature of changes during the period of pregnancy, for example in the alteration of affect or mood that might accompany the potential crisis state such as anxiety or depression, with particular concerns about the implications of such changes for women"s longer-term mental and physical health. It is open to question how or whether the increasing focus on outcome and the accompanying requirement for vigilance impacts on psychological transitions, especially at a point in historical time when pregnancy is relatively infrequent and thus each pregnancy highly salient.
Arguably, partly because of falling birthrates and partly because of the increasingly public roles of women, not to mention the ubiquity of the media, the state of being pregnant in the early twenty-rst century has become more visible rather than less. Since the twentieth century, women have been experiencing fewer pregnancies in their lifetime and there are fewer live births than ever before. Accordingly, more time and effort is devoted to ensuring that each one is healthy, leading to the highly desired positive outcome.
Certainly, in the eighteenth century, women might have expected to have as many as six or eight children from at least eight pregnancies. At that time, the predictability of outcome was low, maternal health was often poor, foetal viability was variable and conrmation of pregnancy was quite late often around the time of quickening, at about four months. Thus, pregnancy was probably more frequent, often shorter and signicantly riskier for all concerned, especially for the women, who frequently died in 5 childbirth. This did not mean that there was little psychological investment in pregnancy. Just because it was not measured in the ways it may be now, there is no evidence that women were less anxious or concerned about each pregnancy (Hanson, 2004). However, the time available to attend to each pregnancy was probably somewhat diminished compared to the position today, when both frequency and the timing of conrmed status of pregnancy are very different.
Despite concerns about population growth in some parts of the world, gures show that rates of childbearing in Europe, the US and elsewhere have fallen signicantly over the past fty years, in some cases to well below the level considered adequate for population replacement (2.1 children per woman of childbearing age). For example, Italy has the lowest birthrate in the European Union (EU) at 1.32 and the most recent gures show the UK birthrate at 1.80 (Eurostat, 2005) and the Australian birthrate at 1.81 (Australian Bureau of Statistics, 2005). There are many possible reasons for the drop in the birthrate, one of which must be increasing female employment, in turn leading to a later age of rst pregnancy. The mean age for rst pregnancy in the UK is currently 27.5 years (ONS, 2006) (though this gure includes a higher fertility rate among women aged 30 34 than those aged 2529). In Australia, the average age of rst birth is now over 30 (Australian Bureau of Statistics, 2004). Whatever the deriva-tion of the average age of rst birth, the older it is, the more noticeable it makes the occurrence of pregnancy in much younger women, something we return to in discussions in Chapter 7.
Pregnancy itself lasts for approximately nine months, or 40 weeks. The expected due date is calculated from the rst day of the woman"s last menstrual period. The actual date of delivery, and the length of any individual pregnancy, may vary by as much as two weeks, depending in part on the length of the woman"s usual menstrual cycle, but will typically be between 37 and 42 weeks. The sophistication of home pregnancy testing means that a pregnancy may now be conrmed before the rst missed period, and does not necessarily require conrmation by a doctor. If it is possible to conrm a pregnancy before a menstrual period is missed, a woman"s engagement with the physical status of pregnancy and the potential baby starts early on too. This apparent certainty about a physiological state raises a number of interesting considerations with regard to the woman"s engagement with her condition and to the psychological preparedness for failure or termination and we consider this issue further in Chapter 2 on the paradoxes of pregnancy. Typically, the popularly antic.i.p.ated symptoms of pregnancy such as nausea and extreme fatigue occur in the rst phase or trimester (period of 14 weeks). The other popular representation of pregnancy as "blooming" tends to be a.s.sociated with the middle phase before the signicant maternal and foetal weight gain, together with the often-described physical discomfort, of the nal phase.
6.Current UK obstetric guidelines following medical research recommend that labour be induced at or around 40 to 41 weeks (NICE, 2003) in order to ensure that the woman and the baby are at least risk. The provision of antenatal and obstetric care emphasises the need to monitor health in order to reduce problems and minimise risk. When a woman is in good physical condition during pregnancy for example, the probability of complications during labour and delivery may be lowered (e.g. Dewey and McCrory, 1994; Simpson, 1993). The justication for medical involvement in pregnancy is the need to reduce any such complications and to identify and treat serious conditions of pregnancy which can signicantly affect women"s health, as well as that of their baby. These conditions include those a.s.sociated with high blood pressure and hypertension, such as pre-eclampsia, which are some of the most important causes of maternal and foetal morbidity and mortality in Western countries since the demise of puerperal fever as a cause of maternal death. Other serious medical conditions include toxaemia, obstetric cholestasis and gestational diabetes as well as placenta previa, where the placenta may be positioned such that it is obstructed, preventing v.a.g.i.n.al delivery. Babies born from the 37th week of pregnancy are counted as full term. Babies born before this time are considered to be premature, and the shorter the period of gestation, the more at risk the baby may be, with those born before 28 weeks likely to need considerable neonatal intensive care.
In the UK, antenatal care is provided by midwives and general pract.i.tioners as well as by obstetricians and specialist consultant doctors based in hospitals. Developments in the use of technology for antenatal screening mean more hospital-based tests. Routine antenatal testing can include: ultrasound scanning for anomalies; blood tests for rhesus status, blood group and rubella immunity; as well as indicators for spina bida, which is also checked at later scans (approximately 2023 weeks). Specialist additional tests may be carried out if considered necessary or appropriate, including nuchal scanning (for the identication of risk of Down"s syndrome), chorionic villus sampling and amniocentesis. The provision of routine testing outside the UK varies, for example the Netherlands is reluctant to offer routine prenatal screening for conditions which cannot be effectively treated, such as Down"s syndrome, although screening may be provided on request.
Women are encouraged to attend regular checkups with their doctors or community midwives to monitor the progress of the pregnancy and ensure that any deviations from the normal are identied, though the range of what is considered normal in antenatal encounters with midwives is quite broad. Studies of the conversations taking place during antenatal appointments highlight an overriding discourse on normality, whereby even irregularities are represented as normal (Linell and Bredmar, 1996). In addition to actual attendance at clinic, women"s partic.i.p.ation in public 7 health activities may be monitored for compliance, for example through the use of patient-held records, which are updated on each visit. This resource has the dual function of making visible to the women the current status of their pregnancy and the baby"s development and of permitting external sharing of the women"s health status by medical professionals. On the basis of the information carried in this way, women can change or monitor their health or behaviour and advice can be given at appropriate times.
Despite recommendations that a greater emphasis should be placed on the social context of childbirth and the best intentions of those involved in women"s care during their pregnancies, the level of technological and medical interventions in pregnancy and childbirth has increased, albeit within a rhetoric of normality and naturalness. This is perhaps inevitable when women of childbearing age have less experience of childbirth than at any previous time in history and when pregnancy is so obviously located in a medical context. Fewer than half of the women giving birth in England and Wales and less than two-thirds in Scotland do so without any form of medical or technological intervention (this includes the use of forceps, ventouse and caesarean section as well as pain-relieving strategies such as epidural injection and safety checks such as foetal heart monitoring). The rate of caesarean deliveries has signicantly increased over the last 25 years, causing some concern among pract.i.tioners and healthcare providers. The most recent surveys of obstetric practice in hospitals put the UK, the US and Brazil in the top ve countries for rates of caesarean delivery. Figures published for the last few years indicate a rate of about a fth of all live births in England and Wales being by caesarean section (21.5 per cent, Thomas and Paranjothy, 2001) though the majority of these are emergency caesareans, rather than elective. World Health Organization guidelines indicate that 5 per cent is the minimum rate of caesarean delivery, and that anything over 15 per cent is considered excessive or inappropriate. Rates higher than 15 per cent suggest that the procedure is not being carried out on health grounds, since the benet in terms of maternal mortality (from life-threatening conditions prompting the need for a caesarean section) levels off at this point. Reasons for higher rates may in part result from a perceived demand from women for elective surgery. This then compounds the rate increase, since one of the most reliable predictors of caesarean section is having had a previous caesarean, whether or not the need was medical or otherwise, and further increases the likelihood of its use as a routine procedure. For example, gures indicate that private health providers in Brazil deliver as many as 70 per cent of babies by this method (Potter et al., 2001). Notwithstanding the high rate of caesarean section, many hospital delivery suites and midwives also support a morenatural" birth, providing facilities for a more homely and family-friendly environment.
Women stay in hospital for a short time following the birth; in many cases they go home the same day or within two days. After a caesarean section, 8 they may stay in hospital for longer to ensure post-operative recovery. Once at home, care of the woman and her baby is once again provided by the midwife and general pract.i.tioner in the community. Women who are employed at the start of their pregnancy may take maternity leave the timing and length of leave available will depend on their country of employment with national minima and some qualifying requirements. In the EU, the statutory minimum period of leave available to women in all member states is 14 weeks, as recommended by the International Labour Organisation (2000), during which time jobs are held open. The leave can be taken both before the birth and afterwards. Some countries (Sweden is a well-known example) offer paid parental leave of up to 16 months.
Elsewhere, leave is not necessarily so generous or automatically available. In the US, for example, while some states do have arrangements for short periods of paid leave, this is the exception rather than the rule and the pregnancy may have to be dened as a disability by a doctor before benets can be paid. Otherwise, only women working in larger companies are eligible for a 12-week period of job-protected leave. The paucity of parental leave in the US puts it on a par with countries such as Lesotho, Papua New Guinea and Swaziland. In Australia, while job-protected leave of up to a year is available, there is no statutory minimum period of leave. In the EU, employers may also provide more generous leave of up to a year or longer, either of their own volition or in response to local legislation, some of which may be paid. The responses to pregnancy in the workplace are addressed further in Chapter 4, while the issue of how leave is embedded into a culture is also discussed in Chapter 2.
To summarise at this point, despite the relative infrequency of its occurrence and the signicance of pregnancy as a life event, in looking at the research on pregnancy it could still be said to be a game of "cherchez la femme". This paradoxical invisibility is not entirely new, rather it has been an emerging feature of the way that pregnancy has been viewed historically. Cultural shifts in the tolerance of risk and the recent expansion of technologies of reproduction have impacted on the way that pregnancy is managed and is incorporated into biological and legal domains. Despite the major scientic interest in these issues and the political rhetoric of choice, these phenomena also vary considerably in the attention they focus on the person of the pregnant woman. Thus, the effect of the relative infrequency of individual pregnancy has been to foreground the outcome of pregnancy and the woman"s role in a.s.suring that outcome. Such attention has tended to obscure the woman and the psychological processes involved and with these the mother. This is so not only in the wider social and cultural context but also in research.
In exploring the concepts of sanction and surveillance surrounding pregnancy, and in seeking the elusive woman at the centre of the event, it is inevitable that we will be revisiting a number of themes that have been 9 addressed eloquently by others, most recently, for example, in Clare Hanson"s book The Cultural History of Pregnancy (2004) and Jane Ussher"s book Managing the Monstrous Feminine (2006). By using as a basis the research we are most familiar with, which has perhaps received less previous psychological attention, we hope to exemplify the complexities of normal experience for women when they become pregnant, especially for the rst time. We should also state what this book does not do since it is clear that we cannot possibly address the full range of issues we raised at the start when describing pregnancy research as challenging. This is not only because of s.p.a.ce constraints or the integrity of the case we would want to make, but also because there is already existing work that deals more than effectively with these issues and, since they do not form the substance of our own research areas, are better left to others. Furthermore, while we have spread our net as widely as possible in identifying research, we cannot provide cross-cultural comparisons. We are therefore drawing on the situations best known to us pertaining to the UK and Europe, most of which we consider have broader resonances in the treatment and experiences of all women when they are pregnant. More specically, however, in talking about psychological perspectives, we are not addressing pregnancy and mood or women"s mental health in pregnancy, or postnatal depression. We will touch on the issues of risk perception, the ethics of screening and the technologies of reproduction but there is no explicit discussion of infertility or even childlessness. These are all signicant areas that concern women and for research; work by Lorraine Sherr, Paula Nicolson, Anne Woollett as well as authors already mentioned may provide some relevant material (see for example, Nicolson, 1998; Sherr, 1995; Woollett, 1991). Neither is this exclusively a feminist critique of psychological research into pregnancy although we are concerned to locate pregnancy as a personal and experi-ential event. And, last, although much of what we will discuss is pertinent to women"s experience more generally, our focus is limited to the period of pregnancy itself, and excludes discussion of the serious issues concerning the period or process of labour and delivery and intrapartum care, and early motherhood.
The book that follows is the outcome of a series of research investigations by both authors, together and separately, on aspects of daily experience in pregnancy that intrigued us and that are the subject of women"s vigilance and the potential focus for change as a result of pregnancy. Following a discussion of the various paradoxes of pregnancy and the concept of sanctions in pregnancy (Chapter 2), Chapter 3 addresses directly the way that psychological and other research has contributed to these in investigating cognition in pregnancy. Chapter 4 takes up aspects of the deciency model of pregnancy and performance in the context of the workplace, and addresses the cultural beliefs and att.i.tudes that impact on pregnancy and employment. Chapters 5 and 6 consider fundamental and topical issues of 10 diet and eating and activity and exercise in relation to advice that emanates from research ndings and the social expectations of pregnancy. Finally, in Chapter 7, we consider again the visibility of pregnancy and women"s roles, by drawing a.n.a.logies with the concepts of celebrity, and the book concludes, in Chapter 8, with a consideration of whether pregnancy can be considered "special".
2.PARADOXES OF PREGNANCY.
The context in which pregnancy is experienced is laden with paradoxes; in the heart of our construction of pregnancy in the developed world at the beginning of the twenty-rst century lie a set of apparently conicting views. In this chapter we will explore these paradoxes and how they impact on the experience of women themselves and the way the research agenda has both determined and been shaped by these contradictions. In order to do this we draw on the theories and ndings of research outside psychology, notably that of sociologists.
Growing safety and growing risk In previous centuries, pregnancy and childbirth were fraught with danger.
Poor pregnancy outcomes, in the form of miscarriage, the birth of disabled babies or even maternal and infant mortality, were relatively common.
Importantly though, they were largely seen to be beyond the control of women themselves or even those with specialist knowledge: midwives and, increasingly, doctors. As discussed in Chapter 1, pregnancy was conrmed relatively late and mainly through the woman"s experience of symptoms: missed periods, nausea, changes in the way her body felt and, eventually, quickening.
Nowadays poor outcomes for the mother or baby are relatively rare and pregnancy is conrmed and monitored by objectively measurable signs.
The expectation is that most women will seek help and advice at an early stage and any problems with the pregnancy can be detected and acted on.
Scientic and medical research has led to greater understanding of the physiological processes of pregnancy and preventable threats. With that has come a much lower risk of women experiencing the traditional hazards, but this does not seem to have been accompanied by a commen-surate lessening of the expectations of risk. Josephine Green (1990) in her major study of the experiences of women undergoing antenatal screening in the UK, Calming or Harming?, points out that for the pregnant women some degree of worry about whether or not the baby will be alright is still 12 the norm, with only 10 per cent of the women questioned indicating that they are not at all worried about the outcome of their pregnancy. This worry is largely unrelated to the tests that a woman undergoes or to her knowledge of such tests (Green et al., 1993). One factor that seems to underlie these perceptions of risk is a change in the perception of the role of human agency in pregnancy. The old certainties that nature would take its course, or that what happens is G.o.d"s will, have been replaced by notions of individual and social responsibility for the hazards that we may experience.
Sociologists have drawn attention to the experience of societies in the developed world becoming increasingly aware of hazards that may affect them yet at the same time becoming increasingly distrustful of those experts who traditionally have been relied upon to protect society from such hazards. Indeed, much of contemporary society distrusts those groups of experts who have drawn attention to the risks of such hazards: scientists, and medical and environmental experts. Ulrich Beck (1992) has termed this concept therisk society": a term which is used interchangeably with that of another sociologist, Anthony Giddens, theclimate of risk"
(Giddens, 1991). In his book The Risk Society: Towards a New Modernity Beck delineates the central dilemma of "the risk society" thus: In contrast to all earlier epochs (including industrial society), the risk society is characterized essentially by a lack: the impossibility of an external attribution of hazards. In other words, risks depend on decisions, they are industrially produced and in this sense politically reexive.
(Beck, 1992: 183) The risk society brings together a suspicion of scientic innovation with the irresistibility of using such innovation to make choices at an individual and societal level. In obstetrics, the ability to quantify the risk level of individual women and their babies, mainly through the extrapolation of epidemiological data, has been used to justify the use of technological interventions (e.g. caesarean section) by both health professionals and women themselves (Lankshear et al., 2005).
Alongside the risk society, or maybe as a function of it, we see other currents which have an impact on the experience of pregnancy. Even in Europe, which traditionally has adopted a social-medicine model in the allocation of resources, government policy interventions to redene patients as consumers of a public service, and funding pressures for health services, have encouraged the emergence of a self-care culture. In this context, people are taking more responsibility for their own health and adopting more consumerist att.i.tudes to healthcare (Lupton, 1997). In the UK we can also perceive the process of "de-professionalisation" whereby organisational 13 and managerial change brings about a reduction in professional control, demystication of expert knowledge and indeed a disembedding of that knowledge (Elston, 1991). This is linked to suspicion of the competence and ethics of doctors.
In pregnancy care, technological innovation has undoubtedly brought greater safety and a higher likelihood of a safe delivery. Ultrasound scanning and various other forms of screening as well as diagnostic tests help to reveal conditions in the foetus (e.g. heart defects, Down"s syndrome) and the mother (e.g. gestational diabetes, pre-eclampsia). The value of this information is seldom questioned but the benet of screening for foetal health in illuminating risks for individual women has to be weighed against the risk of harm from seeking that information. Most women will have screening for foetal health for rea.s.surance that nothing is "wrong". Indeed, Marteau (2002) has pointed out that many women do not realise that ultrasound, for example, can detect foetal anomalies, or that many screening tests are not diagnostic and produce results which are not denitive but probabilistic. Some results of tests are difcult to interpret even for the professionals conducting the tests as they reveal anomalies which may be signs of serious conditions or which may resolve themselves during the pregnancy. There is high morbidity a.s.sociated with both false negative and false positive results and the raised awareness of risks itself raises anxiety.
At the level of behavioural advice, women are expected to act on information presented to them by midwives and general pract.i.tioners, but also respond to information which is often presented in a sensationalist manner by the media, including, increasingly, the internet. What is arisk behaviour" may be dened not by scientists who collect the data but by the media who present those data. As we explore in several of the following chapters, information about what is harmful or benecial to women and their babies may be presented as black and white with apparently little concern for the impact this has on women"s decision making during pregnancy, or their emotional wellbeing. What is more, the behavioural advice presented will often come too late for many women to act on it, relating as it does to preconception or early pregnancy. Thus, the concept of thegood mother" extends back to before the baby is actually born. In weighing up current scientic opinion with the views of social commentators presenting a position in opposition to conventional medicine, women are accepting that the locus of control is within themselves.
As psychologists we seek to understand these feelings of uncertainty and risk at a time of increasing certainty and safety by considering the individual processes which underlie such feelings. Two areas of research, in psychology and in the social sciences more generally, seem to be relevant here. The rst area is concerned with individual perception and a.s.sessment of risk, and the second with the social amplication of risk through the ma.s.s media.
14.We now understand a great deal about how people judge the likelihood of an event or their risk of experiencing a particular outcome. Early work on decision making in health a.s.sumed that people consider how pleasant or unpleasant outcomes of certain courses of action are and weight them by how likely each outcome is. So they will, consciously or unconsciously, choose the course of action with the highest weighted score. This is known as "subjective expected utility theory". The empirical evidence that people do not necessarily make decisions in this way, even when encouraged to do so by "decision support" systems, has led many professionals, particularly economists and doctors, to the conclusion that people are not good decision makers. However, we can show that the mechanisms that people use most of the time will lead them to decisions which are best for them, with the least cognitive effort. In understanding these mechanisms we can understand the way that women use the information presented to them, and act upon it. Of key importance to the experience of pregnancy is, rst, the perception of categorical safety or threat, so behaviour is perceived as either risky or not (Redelmeier et al., 1993). This inuences not just the way in which information is perceived but also the way it is presented.
Second, people have difculty in distinguishing between very small probabilities, and the value of following one course of action rather than another may appear obvious to an epidemiologist considering populations but not to a lay person considering only their individual risk status. Finally, outcomes that are easier to bring to mind are judged to be more likely; this has been termed the availability bias" (Tversky and Kahneman, 1981). The ease with which an outcome is brought to mind is inuenced by how frequently or recently a person has been aware of it and also by strong emotions being a.s.sociated with it. So, media coverage of a particular hazard or event makes it seem more likely. The literature in this area has been dominated by these cognitive mechanisms, however, more recently researchers have returned to considering the ways in which emotions such as antic.i.p.ated regret" inuence perceptions of risk and concomitant decisions. For example, Wroe et al. (2005) have shown that parents" decisions on vaccination are inuenced by emotion, and particularly that risk a.s.sociated with inaction is perceived as more acceptable than positive actions.
In recent years both researchers and political and social commentators have become increasingly interested in the way in which risk is propagated, particularly by the ma.s.s media. This "social amplication" of risk not only makes people aware of hazards they may face but also tends to encourage a distrust of experts and organisations involved in risk management. This leads to uncertainty and feelings of danger. Different types of media, even different types within media (e.g. tabloid and broadsheet newspapers), produce different narratives of risk (Murdock et al., 2003). So, women are confronted both by fcial" information produced and disseminated by 15 health professionals and information produced by a wide range of media, which command varying degrees of trust.
How then do individual women respond to the risks presented to them by different sources? Joffe (2003) has suggested that, when presented with the likelihood of hazards, individuals use the ways of reasoning and the values common to the groups with which they identify. Thus, the source of the threat and how that source is viewed, and the way the threat is linked in to group ident.i.ty, will determine how an individual will respond. If women are relying more on external representations of risk and less on their embodied experience then it is likely that their decisions and actions are better understood by examining the values of the group to which they belong rather than the scientic evidence presented. If we accept that individual actions are guided by cultural and subcultural values then screening technologies and information presented with a view to guiding women to one course of action (e.g. terminating pregnancies where the baby would be born with a life-limiting condition) may lead to unexpected effects on a large scale. These might include a growing opposition to the termination of pregnancy because of its use to prevent the birth of children with what to most groups would seem not to be a serious condition (e.g.
cleft palate), or, conversely, the distortion of population, e.g. through s.e.x-selective abortions, which has led to a shortage of girls in some states where boys are more highly valued.
This leads us to another paradox of pregnancy. Reproductive technologies and risk interventions while reducing uncertainty at one level appear to make individual pregnancies more uncertain.
Being a little bit pregnant The change between being not pregnant and being pregnant has long been used as an example of a quantum change in colloquial English. The sentenceyou can"t be a little bit pregnant" is used to challenge a position of uncertainty. However, the earlier detection of pregnancy itself or problems with the pregnancy and the possibility of preventing the birth of babies with serious health problems have led to what Barbara Katz Rothman (1986) has memorably termed thetentative pregnancy".
Pregnancy testing kits were rst actively marketed for home use in the 1970s, a development of near patient testing used by health professionals to test patients without recourse to laboratory facilities. Manufacturers and suppliers are driven by commercial concerns, albeit tempered by ethical and social considerations. The use of this technology was for some time treated with suspicion by doctors and pharmacists (Stim, 1976).
However, home pregnancy testing has been absorbed into routine antenatal care, and has improved in reliability and ease of use as demand for it has increased. Its use has been further sanctioned in the UK by the 16 evaluation of over-the-counter tests by the Medical Devices Agency. Self-testing may be seen as part of the development of aself-care culture", discussed above, with patients as "consumers" taking more responsibility for their own health, and having rights over information about their bodies (Lupton, 1997). NHS Direct, drop-in health centres on the high street and health sites on the internet are other manifestations of this movement. The use of these technologies in the home must be set against the wider social and cultural context in which a changing healthcare system impacts on patient behaviour and relationships between patients and healthcare professionals (Rose, 1990). Most importantly here, pregnancy testing allows women to conrm a pregnancy long before the signs and symptoms of pregnancy appear and without conrmation from health professionals who hold privileged knowledge. At once a pregnancy becomes a reality at a much early stage and also is less likely to result in the birth of a baby: a pregnancy which ends early can no longer be regarded as amissed period"
but has to be regarded as a failed pregnancy and the pregnancy test is just the rst of many tests which will lead to decisions about whether the pregnancy should continue or not. Lewando-Hundt and her colleagues (2004) discovered that 37 per cent of women who were receiving antenatal care in a UK centre which did not offer rst trimester screening for Down"s syndrome paid to have this screening done privately.
Barbara Katz Rothman in her book The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood (1993) suggested that the introduction of amniocentesis irrevocably changed the way that pregnancy was viewed both by pregnant women themselves and their partners, and by those others not directly involved. Rather than the birth of a baby with, for example, Down"s syndrome being regarded as a family misfortune, it is now regarded as a personally avoidable mistake. Thus, the ability to test the health of the foetus has led to the possibility of embark-ing on a pregnancy which will not necessarily have to be seen to term.
The case of amniocentesis was complicated by the danger inherent in the procedure itself, particularly in the early days. So the risk of terminating a wanted pregnancy through this invasive procedure had to be weighed against the possibility of giving birth to an unwanted" baby if the procedure was not undertaken. The a.s.sumption was made that if a woman chose to have an amniocentesis she must be willing to terminate the pregnancy if the result was positive. Nowadays, not only is amniocentesis much less likely to lead to an unintended termination, but also it has largely been superseded by other technologies which provide more or less denitive results on the health status of the foetus without any risk of termination, being based on blood samples or imaging techniques. However, the a.s.sumption still seems to be made that if a woman is willing to undergo testing she must be willing to act on the basis of the information provided to terminate a foetus that is not "perfect". This is particularly the 17 case when technologies provide this information very early in pregnancy, that is, when the woman is only a little bit" pregnant.
Jenny Hewison and her colleagues (2004) have posed the question of who sets the agenda for technological development in antenatal testing.
They have investigated the views of mothers living in the north of England from Pakistani and white European ethnic origins, on the range of antenatal diagnostic tests which could become available and the value of the information afforded by them. Using a set of scenarios which described, but did not name, various conditions, women were asked rst whether they would test for each condition and second whether they would terminate a foetus discovered to have this condition. There was considerable agreement on the conditions which women would most want tests for and for which they would seek termination of pregnancy: anencephaly, trisomy 13 or 18 (which lead to death within months of birth), quadriplegia and d.u.c.h.enne muscular dystrophy. However, fewer than 25 per cent of the women questioned would consider a termination for most conditions and there was great divergence in what conditions would be so severe that the woman would feel that termination was better than continuing with the pregnancy. These include conditions for which tests are currently widely available, such as Down"s syndrome. Furthermore, the percentage of women who wanted antenatal diagnosis for each condition was far higher than the percentage of women who would consider termination.
So the development of antenatal testing services seems to be being driven by the technology. However, this is not to say that the women studied by Hewison and her co-workers were not very much in favour of these developments, but that what they want from testing is information, not a way of ensuring a perfect baby. Giddens (1991) talks of "colonizing the future" by attempting to predict risk of hazards and preventing them; however, for women contemplating the health of their children the prediction seems to be far more important than the prevention, at least at any cost.
The secret made visible We have discussed above the impact of antenatal scanning and testing on the individual choices that women now have to make about their pregnancy. However, there is another important aspect of this technology and that is that testing is taking precedence over the private lived experience of the mother. As we have said, pregnancy was formerly conrmed and monitored through the embodied experience of the mother. Now that experience is made public through technological means. Foremost among these technologies is ultrasound scanning, which provides pictures of the foetus.
Ultrasound scanning is the most commonly used screening technology in antenatal care and is taken up by the overwhelming majority of pregnant 18 women in the developed world. It has long been used to check that the foetus is alive, has no major abnormalities and to check that the date of conception estimated from the mother"s account ts with the growth of the baby. As the technology has become more sophisticated it is possible to produce very high-denition pictures and to detect more signs of abnormality at an earlier stage, for example nuchal fold abnormalities seen in foetuses with Down"s syndrome.
Parents generally welcome the chance to see the foetus. Indeed, the visual record of a baby"s life is now likely to start with the rst ultrasound picture.
The visual representation is a very powerful mechanism which turns a foetus into a baby. Both parents, and indeed others, are able to experience the foetus and therefore bond with it, rather than just the mother. In 2004 Stuart Campbell released 3D and 4D pictures and "lms" of foetuses from 12 weeks, showing the development of behavioural routines such as "stepping". The pictures were incorporated in a book Watch Me Grow!
(Campbell, 2004), which has become a bestseller. However, the release of these pictures, particularly real-time depictions of the movement of foetuses, fuelled debate on termination of pregnancy and led to calls to restrict the ability of women to terminate pregnancy even in the rst trimester. High-denition ultrasound has made the foetus appear more like a person not only to the mother carrying that foetus, but to the public at large.
Through ultrasound scanning the foetus is literally put under surveillance, without any input from the mother other than her consent and presence. The mother in the ultrasound picture is a container, or rather a frame, for the subject. The primacy of her intimate and private experience of the growing foetus has been overtaken by the distanced and public scrutiny by health professionals and others. Rather like a wedding where more time is spent on capturing the event in photographs than on the ceremony, the visual record of the foetus is given more credence than the account of the person who is present at the event.
So far in this chapter we may have appeared to take a rather negative view of the consequences for pregnancy of the information age. So before going on, let us reiterate here that advances in technology and understanding of the processes of pregnancy and birth have undoubtedly improved the experience of pregnancy and childbirth for many women.
Although the onus of decision making has shifted to the individual, many women would welcome that empowerment. And although pregnant women are now bombarded with information and advice, many women welcome, desire and seek them out. From the pregnancy test which allows them to conrm their own pregnancy, through the web pages and magazines which allow them to learn about pregnancy for themselves, the rst ultrasound picture which takes its place in the family alb.u.m, to the prior warnings of difculties with the baby"s health or birth which allow 19 action to be taken and preparation, many women feel that the greater control and rea.s.surance offered now is a price worth paying for the rise in responsibility and anxiety which may accompany them.
Absence of women in research on the most feminine of states The research reviewed above in relation to women"s experience of, and response to, reproductive technology is largely atypical of research on pregnancy in that the views and motivations of women have been sought and studied; though even in this area, such views are seldom sought before the technology is introduced. In most of the research we will be reviewing in this book, the women themselves, as actors, seem curiously absent. Most research concentrates on the outcome of pregnancy related to the baby.
While the behaviour of women may be mapped and linked a.s.siduously to particular pregnancy outcomes, and women judged on the basis of their behaviour, the motivations and beliefs of individual women are seldom sought. Rather, their health, behaviour and even state of mind are regarded as characteristics of the container of the foetus. In the chapters that follow we will return to this theme and we hope that it will become clear that one of the motivations of our own research on pregnancy is to put the psychology of women back at the centre of this uniquely feminine experience.
Pregnancy as an exceptional normal state There are several senses in which pregnancy is simultaneously regarded as a normal and exceptional state. As we commented in Chapter 1, pregnancy is becoming an increasingly uncommon event for individuals, especially in Europe, where the birthrate has long been below replacement levels for the majority ethnic groups. Yet pregnancy is regarded as a commonplace experience. This is particularly the case in the workplace, where pregnancy may be a common event among the staff of a large employer. Any individual woman on that staff, however, is likely to only experience being pregnant at that workplace once. This may help to explain the level of prejudice that women experience when they announce that they are pregnant. As we have found in our own work, fellow workers and employers may regard pregnant workers as a group as incapable of carrying out their jobs and as unfairly ent.i.tled to special treatment and benets. At the same time they may have very positive views of individual pregnant women they have worked with (Pattison et al., 1997).
In this chapter we have concentrated on the construction of pregnancy and the implications of that construction in the developed world. One of the reasons for this is that although pregnancy is a universal experience, it is seldom studied or even considered from a cross-cultural perspective.
Simultaneously, two positions are held, sometimes by the same researchers.
20.The rst is that all women are basically alike in their reproductive processes and that pregnancy can be dened by the physiological changes women undergo. If this holds, then cross-cultural comparisons will add little to the studies of partic.i.p.ants readily available to researchers in their local environs. We will see this perspective dominating the research on cognition in pregnancy in Chapter 3. The second perspective is that resource availability and social conditions vary to such an extent across the world that information needs to be gathered on women who are alike in these regards. This is the perspective that dominates research on pregnancy and work covered in Chapter 4. However, where cross-cultural comparisons are made the results can be illuminating in understanding the interplay between the physiological and the psychological. For example, studies of dietary habits of women from different cultures could be interpreted as showing that the basic motivations of women are the same, which is that physiological changes and demands prompt behaviour to improve the health of the baby. However, depending on the cultural beliefs, these may be manifest in eating earth in one culture or vitamin pills in another (Henry and Kwong, 2003). See Chapter 5 for a further exposition of this point.
Another sense in which pregnancy is both normal and exceptional is as a natural process which is still highly medicalised for most women in the developed world. In recent decades organisations such as the National Childbirth Trust in the UK have supported pregnant women by providing information and education, and attempting to limit the amount of medical intervention that women experience. However, the National Childbirth Trust itself brings together unlikely allies. It was founded in 1957 to champion the position of doctors, notably Grant d.i.c.k-Read, who felt that middle-cla.s.s women were being put off childbearing through poor preparation for birth, leading to fear, particularly of the pain involved.
This eugenic motivation is far from the motivations of feminist champions of natural childbirth who see the medical model of pregnancy and childbirth as an example of the way that patriarchies control women. The natural childbirth movement has led to changes in the way women are treated and certainly to the way that many women now give birth. At the same time, though, the reproductive technologies described above, the fear of litigation if a baby is not born healthy and the trend for women to have fewer babies have led to the medicalisation of pregnancy on an unparalleled scale.
Is there never a good time to be pregnant?
Women in the developed world now have unprecedented control over the timing of childbearing. Advances in contraception, fertility monitoring devices and a.s.sisted reproductive technology have meant that most women can choose to have children and choose when to have them. However, 21 the timing of pregnancy is hedged around by conicting cultural mores.
Teenagers, older women, women without a job and women with careers are all publicly criticised for choosing to have children when they do.
Similarly, white European women are criticised for having single children; the natalist policies of many European countries, notably France, provide considerable welfare support for families with several children. A similar natalist approach to benets is taken in Australia by the current Conserva-tive administration. However, at the same time, and in the same countries, minority ethnic women are criticised for having several children and beneting from that welfare support. Central to this general disapproval seems to be the a.s.sumptions that women are exercising choice and that once again the avoidance of risk is a matter of personal decision making.
Furthermore, though, the belief is held that in exercising choice women are pursuing their own selsh ends. So older women are a.s.sumed to be putting their career rst, and younger women are portrayed as avoiding earning a living by having children at the times they do. Little credence is given to the view that when heteros.e.xual women choose to have children is inuenced largely by the presence and willingness of men to act as fathers. Indeed, the role of men in the creation of families is rarely considered in these discourses. The importance of the presence of a suitable and willing putative father in the choice to have children was highlighted in Fiona McAllister and Lynda Clarke"s (1998) study of childlessness in Britain. They found that those childless women they interviewed who were living alone held conventional views on partnerships and would not contemplate becoming a single parent. In general, decisions to remain childless, and, by extension, to delay childbearing, were not made in a vacuum but rather crucially depended on relationships with partners and the perceived suitability of women"s circ.u.mstances for parenthood.
At the extreme, the view of women caring for their own interests over the interests of their children leads to policies which curtail the rights of pregnant women over their own bodies. Sheena Meredith (2005) in her book Policing Pregnancy: The Law and Ethics of Obstetric Conict makes a powerful case that in recent case law in the US and the UK pregnant women are denied the rights of self-determination and bodily integrity which are enshrined in law for all others. Such cases arise when health professions do not agree with the women themselves on best courses of action or behaviour. Thus, the pregnant woman nds herself in legal con- ict with her foetus, or rather others who regard themselves as more suitable guardians of the foetus.
The debilitated nurturing In reviewing the research literature on pregnancy, one could be forgiven for questioning whether women are t to be mothers. We suggest that beliefs 22 about pregnant women reect wider beliefs about women generally, perhaps because pregnancy provides such clear evidence of femininity.
Traditional beliefs about women in Western society are characterised by beliefs about the weakness and vulnerability of women. So women are seen as theweaker vessel", p.r.o.ne to debilitation, in need of protection from men and governed by irrational and emotional thinking. As reproduction most clearly delineates s.e.x if not gender, these stereotypical views of women tend to be most clearly connected to women in aspects of reproduction: menstruation and the menopause, but above all pregnancy. We are left, then, with the view that women are at their most vulnerable when they are responsible for the wellbeing of unborn children. Researchers seldom discuss or engage with this anomalous position, yet it is a strong inuence on the kind of research which is carried out and how results are interpreted.
Sanctioned behaviour The word "sanction