Abstract
Among women who give birth, roughly half describe their birth experiences as traumatic. Childbirth trauma is a topic of growing global interest for health and mental health professions. However, social work remains peripheral in this emerging area of scholarship and practice. This article presents a portion of findings from recent feminist narrative social work research exploring women’s narratives of their experiences of emotional distress in childbirth to illustrate the need for increased professional engagement with this important social issue. Analysis of participants’ narratives illustrates how Foucault’s discourse and power/knowledge can be useful in understanding the subtle social forces that shape birth experiences which may result in emotional distress. In this article, I argue the topic of childbirth distress falls within the reproductive rights framework and should be of importance to social workers. The findings presented below are discussed in the context of the International Federation of Social Workers’ ethical principles and its policy statement on women to support this position.
This article presents a portion of findings from recent feminist narrative social work research exploring women’s narratives of their experiences of emotional distress in childbirth to illustrate the need for increased professional engagement with this important social issue. The findings presented below are discussed in the context of the International Federation of Social Workers (IFSW)’s ethical principles and its policy statement on women to support this position.
Among women who give birth, between one third and one half describe their birth experiences as traumatic (Beck, Driscoll, & Watson, 2013). Internationally much has been studied and written about childbirth distress with scholarship arising from and concerning birth experiences in Australia (Beck, 2004), Belgium (Van Bussel, Spitz, & Demyttenaere, 2010), Benin (Fottrell et al., 2010), Canada (Reynolds, 1997), the Gambia (Sawyer et al., 2011), Iran (Taghizadeh, Arbabi, Kazemnejad, Irajpour, & Lopez, 2014), Kenya (Abuya et al., 2015), New Zealand (Berentson-Shaw, Scott, & Jose, 2009), Nigeria (Adewuya, Ologun, & Ibigbami, 2006), Norway (Garthus-Niegel et al., 2014), Romania (Anton & David, 2013), South Africa (Chadwick, 2009), Sweden (Forssén, 2012), the United Kingdom (Ayers & Pickering, 2001), and the United States (Anderson & Gill, 2014; Beck, 2004). 1
Many factors have been found to contribute to childbirth distress, including (but not limited to) fear of childbirth (Anderson & Gill, 2014); maternal orientation, coping style, and belief in ability to handle the birth experience (Berentson-Shaw et al., 2009); inadequate care for the mother from the partner and/or staff (Beck, 2004); complications during delivery (Adewuya et al., 2006); and fear for one’s own life or the baby’s life during delivery (Beck, 2004; Niner, Kokanovic, & Cuthbert, 2013). Additionally, certain life experiences and demographic characteristics have been found to be related to an increased risk of experience childbirth distress such as low socioeconomic status (Fottrell et al., 2010), a history of sexual trauma (Ayers, Harris, Sawyer, Parfitt, & Ford, 2009); prepartum mental health difficulties (Wijma, Söderquist, & Wijma, 1997); experiencing language barriers during birth (Niner et al., 2013); and experiencing racial discrimination during birth (Niner et al., 2013).
Understanding how these factors contribute to childbirth distress is important and has resulted in efforts to provide better care for those giving birth (e.g., see McKenzie-McHarg, Crockett, Olander, & Ayers, 2014). This research project used Foucault’s discourse and power/knowledge as a theoretical framework to explore how other, less obvious, social factors might also negatively impact birth experiences in often harmful ways. To be clear, this is not an article about physicians, or midwives, or women’s preparations for birth, or even hospital policies, which are all important to consider in childbirth distress. My argument is that focusing on individual bad actors and actions that result in poor outcomes will never paint the full picture of childbirth distress. Many social workers will work with people who have had negative birth experiences and are dealing with the sometimes difficult emotional aftereffects, and so I believe it is important for social workers to add our discipline-specific lens and analysis to the growing body of research in this area.
It is important to begin with a note about the language I am using to describe those who give birth. The literature on childbirth generally defines childbearing people as women, excluding those who do not identify as cis women (cis people are those whose experiences of their gender matches the gender they were assigned at birth), which makes invisible the experiences of those who have any gender other than cis woman in discussions about childbirth. Centering of cis women as normative for women occurs in the area of childbirth in the following ways: Trans women cannot yet biologically carry a pregnancy (as uterine transplant is still experimental) and yet are women (Jones et al., 2019), and not all people who can have pregnancies identify as women (e.g., some nonbinary and genderqueer people and trans men can be pregnant). Nonetheless, the people who participated in this study all self-identified as women (and not cis women specifically), and so for the purposes of this article I will refer to women in my discussion of childbirth experiences. I do not mean to erase the experiences of those who are not cisgender women and recognize this framing is problematic in that it may unintentionally continue to marginalize experiences other than those of cis women.
Because, like many feminist researchers, I am uncomfortable with the ways in which idealized ideas of objectivity have been wielded in ways that limit what is considered knowledge, I embrace an idea of knowledge production whereby what we can know is determined by our own positionality and life experiences. Informed by feminist philosophers such as Harding (1992), Haraway (1988), Collins (2000), and Smith (1987), I believe that perspective is always situated. As such I disclose my various and intersecting positions so that you, the reader, may make your own decisions about, and hold me accountable for, what I may or may not be able to see in this work. I have had three pregnancies, which resulted in three live children. One of my childbirth experiences involved significant difficulties and complications, which resulted in me experiencing physical pain, emotional distress, and ongoing medical and surgical interventions for a year after the birth. While I had this difficult experience, I have also had/have many experiences of unearned privilege.
I am a straight, cis white woman and as such I carry significant privilege. I was pregnant in my 20s, and as a young white woman I was not seen as an object of surveillance due to my race nor my age and indeed, each of my pregnancies were celebratory events in my community. Additionally, because English was the dominant language in all the communities where I gave birth, I was able to communicate with all staff free from any barriers to understanding on my part and without having difficulty being understood by others. Because I was/am in a heterosexual relationship, which is celebrated and considered normative, my partner was welcomed spontaneously into my birth experiences. I also had personal relationships with people who could access power in the health-care system, which provided me with a better outcome than I would have had without these personal connections. My childbirth experiences were also been shaped by my middle-class status, my experiences living with a chronic and (for the most part) invisible illness, my high level of medical literacy, and other factors of which I may or may not be aware.
Childbirth Distress and Social Work
Childbirth is often experienced as a major life event (Bachman & Lind, 1997; Thomson, 2011) and a growing body of evidence suggesting many women experience childbirth as a significantly distressing experience, with between one third and one half of women describing their birth experiences as traumatic (Alcorn, O’Donovan, Patrick, Creedy, & Devily, 2010; Beck et al., 2013). However, as with many topics related to sexual and reproductive health, social work research is underrepresented in the field of childbirth distress (Liddell, 2018). Given the preponderance of social workers who work as mental health professionals, and the high likelihood that most social workers will work with (at some point) women who have given birth, this lack of a social work–specific understanding of the phenomenon of childbirth-related emotional distress is startling. The topic of distress in childbirth is an important area for social work attention, specifically, as social workers are committed to upholding and advancing the rights of marginalized people, including those who are made variously vulnerable through their childbirth experiences.
Protecting the rights of women in childbirth and preventing human rights violations in childbirth are a growing area of social action (Burns-Pieper, 2016; Schiller, 2016b). Groups focused on advocating for human rights in childbirth pay close attention to the stories women tell about their birth experiences and the contexts in which these stories are told. In this way, human rights approaches center subjugated knowledges while fighting for social change (Schiller, 2015, 2016a). Likewise, social workers claim a commitment to producing knowledge that centers and highlights subjugated knowledges (Canadian Association of Social Workers, 2005a, 2005b). The stories women tell about their birth experiences can help identify the social processes that cause and contribute to emotional distress in childbirth, responding to gaps in service, and to improving the lives of those giving birth.
Discourse
In considering how some ideas about birthing women come to be seen as true while others remain in the shadows, it is helpful to consider Foucault’s concept of discourse. Foucault (1972) expanded the idea of discourse beyond simply denoting verbal performance, to include all that is produced by the verbal performance and social practices, and includes a consideration of the historical context of these verbal performances and social practices. Discourse establishes what is available to be thought of and talked about in any given time and place as well as determining who has the authority to talk about it (Foucault, 1972).
Foucault (1977e) explained that discourse can be used to maintain or expand dominant understandings and can also serve as a tool of resistance to dominance. While it may be that certain discourses become dominant, Foucault (1972) argued for a concerted effort to question and examine these “ready-made syntheses” (p. 24) and to understand the how discourse is related to power. This view of discourse as tied to both dominance and resistance has been useful for social workers seeking to disrupt the taken-for-granted, unquestioned assumptions associated with marginalization and oppression.
This view of discourse is helpful in understanding experiences of distress in childbirth. For example, it enables an understanding of how certain bodies have become identified as patients, mothers, parents, doctors, midwives, nurses, and so forth, each associated with specific claims to specific practices and expected behaviors. It highlights how certain ideas associated with childbirth became dominant, while others have (re)risen in resistance to these dominant practices. We can also understand how experiences such as emotions become defined through discourse as either pathological or acceptable and how these valuations of emotions are connected to pregnancy and childbearing bodies differently through history (O’Reilly, 2004; Ussher, 2010). The way in which some childbirth discourses become dominant while some are relegated as subordinate (opening up possibilities for resistance) leads to an examination of ideas regarding power and knowledge and how these are also linked to childbirth.
Power/Knowledge
Foucault’s (1977b, 1977g) concepts of regimes of truth, subjugated knowledges, and disciplinary power are relevant to this research, as they help explain how some knowledges determine what is available to be considered true about childbirth experiences, while other forms of knowledge are marginalized and discredited, and illuminate the processes whereby people monitor and change their behaviors in response to particular power relations.
Introducing the ideas of regime of truth and subjugated knowledges, Foucault (1977g, 1977h) explained how a society determines the types of discourse which it treats as truth, the rules for determining true from false, the rules for acquiring and developing what is considered true, and the status conferred upon those who are given the authority to say what is true. Specific kinds of power are attached to that which is deemed to be true and those forms of knowledge that are dismissed are subjugated knowledges.
Foucault’s (1977b) insights into disciplinary power also provide an important analytical tool for understanding childbirth experiences. Foucault explained that disciplinary power uses hierarchical observation—“the gaze” (Foucault, 1977f, p. 155), normalizing judgment, and the two in combination (in the form of examination) to regulate the behavior of great numbers of people with very little centralized effort. In this view, the examination serves as the evaluation, the punishment, and the reward simultaneously. For example, a pregnant woman who is examined by her obstetrician and is told that her baby is not growing as quickly as growth charts predict might be discursively constructed (if even only by herself) as a “bad mother,” which may result in her taking steps to change, monitor, and evaluate her own behavior so that she can fit within the “good mother” framing. This is not necessarily a negative social process but it is important to be aware that there is a social process here and that these sorts of processes operate differently on different bodies and social contexts with different results, and these processes and outcomes are attached to relations of power.
Foucault viewed power as more than an obstructive and repressive force, which serves only to deny access or withhold rewards; he argued that power is productive, always producing knowledge and discourse, and is present throughout the entire social body (Foucault, 1977a, 1977g). Foucault (1977c, 1982) also argued that power does not belong solely to the privileged, as resistance is a form of power that exists wherever dominant power is exercised, thus encouraging the rejection of dominator/dominated binary. The findings below reflect this view of power, where power is something that is exercised rather than possessed and is exercised variously depending on one’s position within social structures (Foucault, 1982).
Emotional Distress
Much of what we know about distress in childbirth comes from a psychological perspective, centering the construct of trauma and conflating the experiences of distress with the diagnosis of post-traumatic stress disorder (PTSD). The concept of trauma and its conflation with PTSD reflects and reinforces a focus on individual dysfunction and helps to maintain the dominance of medical discourse (Burstow, 2005; Lafrance & McKenzie-Mohr, 2013). This conflation also reinscribes the dominant white, male, patriarchal, Western, settler perspective on emotional distress. This results in masking the historical and ongoing trauma of Indigenous peoples, displaced people, and racialized people, and erases the important political, cultural, and social aspects of experiences and effects of trauma (Herman, 1997). While this study ended up being specifically about white women in Atlantic Canada, it is important to use anti-oppressive theoretical approaches that disrupt this dominance, even when studying variously privileged communities and people.
Understanding the analysis of our peers in other disciplines is important, and social workers should also exercise caution in simply adopting the theoretical framing and conceptual understandings of other professions. The dominant psychological understanding in the field of childbirth trauma, with its focus on individual pathology and individual responses, makes invisible the social structures that contribute to emotional distress in childbirth. Social workers must resist focusing solely on the individualized discourses of distress and bring the social into understandings of childbirth-related emotional distress. Given these concerns with the concept of trauma, this research instead centered the concept of emotional distress for this project.
I take up the term emotional distress, with a specific informed by the extensive feminist literature on women and madness (Cosgrove, 2000; Smith, 1975) and a questioning of the biological dominance and individualized pathology associated with emotional distress (Beresford, 2005). I understand emotional distress as an inherent part of life, an aspect of life that is worth considering without automatically pathologizing. I also believe that emotional distress acts as focusing force—a source of information which illuminates where things have gone wrong, where harm has been done, or something important has been lost or threatened (Cosgrove, 2000; Herman, 1997). That is, emotional distress can serve as a sign that one must undertake a “consideration of oppression and discrimination operating at individual and societal levels” (Beresford, 2005). Thus, this project asked the question “What are individual’s experience of distress in childbirth?” with a particular focus on exploring understandings and discursive constructions of distress in childbirth experiences.
Method
Research ethics board approval was sought and granted from both the university and health-care authority involved in the study. The study was carried out using feminist narrative inquiry and analysis (Fraser, 2004; Fraser & MacDougall, 2017).
Recruitment
Participants were recruited from various community organizations, community groups representing specific racial and ethnic communities, local informal parent and infant play groups, and through word of mouth referrals. Recruiting partners were given an “Invitation to Participate” letter regarding the project that included my contact information and a call for participants stating: I am recruiting participants for my study about distressing childbirth experiences. Distress, in this case, is defined as emotional suffering and upset, and may or may not be defined as traumatic by the person giving birth.…I am hoping to interview people who have experienced distress (however, they may define it) in childbirth within the last 12 months, who speak English, and who were at least 16 years old when they became pregnant.
Data Collection and Preparation
I met with each participant one time and recorded their interviews. Interviews were carried out using general, open-ended questions and prompts (e.g., “Please tell me about your childbirth experience”) and lasted between 45 and 90 min. Interview recordings were given to a hired transcriber who created documents of unedited, unformatted text. I refined the transcriptions by editing while listening to the original interviews.
The transcripts were formatted to reflect the flow of speech, where each phrase or clause was given its own line, so that the final transcript looked more like a poem rather than prose (Fraser, 2004; Riessman, 2013). At this stage, any identifying information was removed. All participants were offered the opportunity to review the transcripts and seven participants provided feedback requesting minor changes. I incorporated these changes so that the written narratives reflected the stories the participants desired to tell.
The long transcriptions were broken into specific stories or narrative segments to aid the analysis, and I assigned each segment a name based on the main message of the story (Fraser, 2004). I completed a summary analysis for each interview which I sent to any participant who had provided feedback on the initial transcript, with the invitation to provide further feedback on the analysis. Four participants provided feedback on the analyses which was incorporated into the final work. All feedback provided was minor, for example, requesting changes in wording or clarifying details and time lines.
Interpretation
I identified specific types of stories, themes, and contradictions, and I examined of the structure of the narratives by considering how each story was told. In analyzing the narrative segments, I deliberately searched for various domains of understanding which included: intrapersonal experience (self-talk, mind/bodily experiences), interpersonal experience (those segments that involve others, e.g., “I told her…”), across and within culture (ideas related to folklore, popular culture, and common sense), and structural/institutional domains (references to laws; social systems, such as health-care systems or legal systems; and issues of gender, class, and race; Fraser, 2004; Riessman, 2012). Some themes I identified in the data were difficult to categorize in any of these areas. Such thematic eruptions were considered for their uniqueness and for their commonalties (Fraser, 2004). I carried out a similar analysis across narratives in order to identify any commonalities and differences among participants (Fraser, 2004).
Participants
Fifteen women participated in this research and provided written informed consent. The participants were all white, nonphysically disabled women, ranging in age from 18 to 43 years, and came from a variety of regions across Atlantic Canada, including rural communities, small towns, suburban communities, and urban centers. All women gave birth in hospitals with physician-directed birth. This is typical for the region as midwifery has limited availability (“Midwifery-led births,” 2018). All participants were in coupled relationships; 14 in heterosexual relationships and 1 participant in a same-sex marriage. Participants described themselves as ranging from poor to middle class.
This article shares some of the narratives from six of the participants that represent the analysis across the 15 narratives. These specific narratives were chosen as representative narratives for their ability to illustrate the difficulties women experienced in trying to navigate discursive constructions of women and relations of power.
Findings and Discussion
I begin the findings and discussion below with examples that illustrate the linking of emotional distress in childbirth with gendered discourses that construct women who display certain emotions and behaviors during birth as overly dramatic, and as divas. I then apply an analysis of power to narrative excerpts and illustrate how this analysis can be helpful in understanding distressing birth experiences, first by exploring disciplinary power in childbirth, followed by a discussion of how participants experienced regimes of truth and subjugated knowledges. Throughout, I explore how oppressive ideas are held and acted upon internally by birthing women and externally by health-care professionals, in ways that also contribute distressing birth experiences.
Women as Overdramatic
Carrie had a complicated pregnancy due to her age (early 40s) and previous medical procedures. About 2 weeks before her scheduled C-section, Carrie noticed bleeding and began to have regular contractions. She went to the hospital where she was examined. At that time, the medical team did not share Carrie’s concerns about her pregnancy. Despite her concerns, Carrie understood that women who seek reassurance and advice from medical staff run the risk of being constructed as problematic within obstetrical care. Carrie was careful to seek reassurance only if she absolutely needed it so that she would not be branded as a neurotic, overly dramatic woman. I guess I felt like they didn’t want me to stay. That is why I decided to leave. I do remember thinking there was this other woman in the room across the hall from me but I just remember that they seemed to think, the way they responded to her, that she was being overly dramatic. They didn’t seem to think she needed to be there. So, I remember thinking maybe I don’t need to be here. Maybe I am being overly dramatic because they did check me, I had the ultrasound that Friday. The obstetrician that done the internal and they were giving me the option to leave so I felt like maybe they wanted me to leave. Yes, sorta like you are inconveniencing. I think that is part of the way I am anyway. I don’t like to bother anybody.
This is reminiscent of Martin’s (2003) work regarding internalized technologies of gender. Martin finds “the tyranny of nice and kind” in her analysis of how technologies of gender operate in experiences of giving birth, exploring how specifically white, middle-class women, perform work to present themselves and behave in ways that perpetuate gendered expectations of niceness and kindness even during the difficult and intensive work of giving birth.
Woman as Diva
Related to the idea of being overly dramatic is the gendered notion of being a “diva.” A diva is by definition a female operatic singer (Oxford English Dictionary, 2000). As opera is a dramatic performance, the connection between being too dramatic and being a diva is clear. The term diva, in the stories the women tell, functions as a discursive weapon to regulate women’s behavior.
Charlie shared the story of her first delivery where she felt ignored and not taken seriously. After about 36 hr of laboring along with frequent contractions and two trips to the hospital where staff checked her and sent her home (in stormy weather, on bad roads, in the middle of the night), Charlie finally returned to the hospital for the last time. She was told again that because she was only 1-cm dilated she was not in labor. However, in an effort to speed things along, the staff broke Charlie’s water. Suddenly everything changed when there was meconium in the amniotic fluid. Where before Charlie had been ignored, she was now under the watchful eye of her labor and delivery nurse. Now that she was being noticed, she was noticed only to be mocked and made fun of. Despite the now pressured and tense situation, Charlie was accused of being a diva by the nurse caring for her, while she was being induced to deliver her baby who was in distress. And then, I was lying there, just going through the contractions and she was like, she said, “I knew it,” I was like, “Knew what?” She said, “You did put makeup on this morning, didn’t you!” I said, “No?” She said, “You’re lying, you did, you are one of those diva mothers.” And I was like, “I have eyelash extensions, I don’t know what you are talking about or why you are even saying this to me.”
Morgan had a difficult childbirth after a difficult pregnancy. She had sudden complications with her pregnancy when her son’s heart rate went dangerously low. She was rushed into the delivery room and was informed that her son’s life was in immediate peril. Morgan, fearing for her own life as well as her son’s, asked if she would survive the emergency C-section that was about to be performed. The nurse caring for her responded with “I don’t know.” Happily, both Morgan and her son survived the harrowing birth experience. Her son’s heartbeat suddenly stabilized and she did not require the C-section.
Once the crisis had passed and it was obvious her son was no longer in danger, she began to wonder if maybe some of her other wishes and needs for her childbirth experience could be honored but she was afraid to ask for fear of being seen as a diva. I did have some wishes and it was funny because we were laughing because when everything was okay, I am like, “Is it too late to say what my wishes are?” They were kind of joking because it sounded so superficial after just what had happened and I even said that. I said, “I kind of feel like I am being a little shallow here or whatever but I have certain wishes. Is it okay to ask for those?” There were certain things that I wanted, I wanted him on my chest this time because nobody gave me the option last time. I didn’t even know that was an option, just cord milking and just some of those little things that I really wanted to do. Thank goodness I said something though but I was a little nervous to say something because I didn’t want to seem like, I don’t know, I don’t know what the word is. I didn’t want to seem silly, I guess, after everything that just, you know. I felt like a diva a little bit, you know what I mean? A little bit like a diva. Wow, God forbid you have some wishes after you almost just kicked the bucket, or thought you were going to kick the bucket. (laughter)
Disciplinary Power
In this research, disciplinary power refers to the medical gaze (i.e., the process whereby the medical experts are the subjects of the gaze examining the woman/patient who is the object of the gaze) combined with normalizing judgments, which together become the examination (Foucault, 1977b, 1977f). In this study, these disciplinary powers are not simply metaphorical; physicians literally examine women and evaluate them. In Foucault’s (1977b) disciplinary power, the examination serves to regulate a great number of people in a highly efficient manner. Pregnant women, women in the throes of childbirth, and new mothers experience this regulation in a very real way.
Like many women in this study, when she recounted her experiences of distress in childbirth, Garcia moved beyond what might be typically considered childbirth to include her experience of finding support as a new mother in online support groups. Many participants experienced childbirth beyond a discrete event, often weaving in stories of the time before and after birth (sometimes including narratives of previous births), highlighting the importance of viewing birth as a significant life experience and not simply as a discrete life event (MacDougall, 2018). In Garcia’s story, she, and the other women she connected with, struggled with wanting their emotional pain to be seen, and to be seen as valid, and yet she was desperately afraid of being judged by herself and others (especially social workers) as a bad mother, as a mentally ill mother. In this struggle for validity, Garcia and her friends found their own help outside of the medical system, a space of support outside the gaze of professional eyes—Facebook. It is nice to meet other moms, to have those resources. If I am having a really bad night and it is 3 in the morning, Facebook is a wonderful thing that has a chat program. We have a private group on Facebook of just these moms and we can go post and no one can see anything. I have the resource [center] so I feel that is helpful to know there is somebody there when I need somebody there. And the coordinators of that group are really helpful because they have other resources. I have gone to a group and just had a really bad day and I didn’t talk very much and I will leave and I will come to a Facebook message from them saying, “I noticed you were quiet today, is everything okay, is there anything I can do?” I have gone out to coffee with them just to get out because they can truly see that I just needed a friend I guess. So it is really nice to have that. I don’t know where I would be without that group. It is a huge fear. I know I am doing nothing wrong that they would take her but the fear is still there. I can’t get rid of it. I don’t think it is going to go away.
Regimes of Truth/Subjugated Knowledges
Sally’s case below exemplifies the power regimes of truth have in regulating what can been seen as true or valid, even when two authorities provide different versions of truth.
Sally was pregnant with twins and the obstetrician originally responsible for her medical care had planned with Sally and her wife to deliver the twins via a C-section, a plan Sally and her wife fully agreed with. However, one day at an appointment, Sally found out her obstetrician was leaving the practice and her care would now be taken over by another obstetrician. This new physician explained to Sally that she would not provide a C-section and that Sally would deliver the twins vaginally. The confusion between the two approaches, both being presented as evidenced-based and the best approach, overwhelmed and confused Sally. Towards the end though she went on leave for a little while and we ended up having Dr. B follow us. That was a big change because they have very different personalities but that was fine. But the biggest thing that changed was Dr. A had us put down for a scheduled C-section. As soon as Dr. B took over, that option was changed. I was never asked what I would like to have done but was basically told that, “Well it doesn’t matter, I’m your doctor, I’m going to be delivering. You don’t need to have a C-section.” In the end, it turns out I was much happier with that but I did feel that decision was just taken away from me without being discussed why really, she felt so strongly the way she did. When preparing up to that, I prepared myself mentally for a C-section, so that was a big change but we dealt with that.
Foucault’s (1977d) regime of truth also illustrates the process whereby subjugated knowledges in childbirth (e.g., Sally’s knowledge) became legitimized by attaching the subjugated knowledge to medical expertise. As demonstrated below, the ideas Sally expressed about what she did or did not want in childbirth (not breaking the waters due to the risk of cords being around the babies’ necks) were dismissed as invalid and unimportant. However, once the person with authority (the doctor of the day) examined the babies and the cords, and agreed the cords were unusually long (as had been Sally’s fear), then both the physician and Sally felt the fear was justified. To me, in my mind, having your water broken was a really bad idea and it can cause a lot of problems. But there was just, “Nope, that is what we do, that is what we are doing.” And then sometimes I get very passive, so I am just like, “Whatever, I don’t care, you are the doctor, you know best so just do what you need to do” kind of thing. Because I want two healthy babies. But definitely in the back of my mind throughout the entire process was, “What is going to happen if that happens?” One of my biggest fears going in was, I don’t know why, but all along I had nightmares about cords, cords being wrapped around babies, that is a big fear of mine. Having two increases the risk and so that was my nightmare that I have two babies but they are not both going to be born okay. It was just kind of like, “Well that’s ridiculous, you’ll be fine, don’t worry about it.” That’s a fear, you know, of mine and it stayed right along. And the funny thing is, is afterwards, of course they are pulling everything out, the placenta and everything and I just felt like she was pulling forever. So I said to her, I said, “What do the umbilical cords look like?” She said, “Well there is a lot of cord, this is the most cord I have ever seen and there is two, there is a lot of cord.” I wonder if part of my body was like, there is extra cord and we don’t know why, and I don’t know if that contributed to my fear or why, but it was. That told me my fear was real, I really did have a right and reason to be fearful of that cord.
Sally, even while struggling to be seen as a valid authority on her own body and her own embodied experience, struggled with feelings of uncertainty until her doctor agreed with her assessment of risk. This demonstrates how regimes of truth operate through invisible mechanisms of power, where women are taught to doubt their own knowledge and defer to professional and external authority as part of their role as women, patients, and mothers. This supplanting of personal experience with deference to medical authority, specifically in regard to birth, is insidious. The ostensibly objective outside view of birth is seen as more credible than the subjective lived experience of birth, and one way women align themselves with gendered norms is through their own alignment with this understanding of authority. Chadwick (2009) and Martin (2003) had similar findings in their childbirth research, detailing how women replaced their subjective bodily experiences with objective external measures when recalling birth experiences.
Julie resisted regimes of medical dominance, by demanding that her knowledge of her own body was important. Julie’s resistance to the dominance of medical discourse interacted with her desire to be (and to be seen as) a good patient and a good woman. She continued to fight for her knowledge of her own body and of her baby’s needs to be considered. Julie shared the story of her complicated delivery and postpartum time. This delivery was complex, as a previous birth had resulted in a uterine rupture and the death of that baby, along with serious medical and surgical complications for Julie. For this birth experience, Julie was committed to breastfeeding her baby in the neonatal intensive care unit (NICU) and did not back down on this even in the face of pressure from nursing staff to bottle-feed. Well, it did feel, it did feel like there was a competition. There was a competition of who is right and who is wrong. But there wasn’t a right or wrong, there was just a different way of doing things. Then they were like, “We really don’t know how much he is drinking out of your breast, so maybe you shouldn’t breastfeed him.” And I am looking at them, “What do you mean? I want him to get used to this because this is what I am going to have when I go home.” “Well, we don’t know how much milk is coming out.” “Well, I could tell you. In 20 minutes, I can pump 16 ounces out of one breast.” And they were like, “No you can’t.” I would go to my room, put the pump on, pump 20 minutes and come back with a full bottle of 8 ounces and almost a second bottle full just from breast and they were like, “That is not possible, you must have pumped both.” I was like, “I am not going to argue with you, this came from one breast.” Like really. And the gynecologist was there and she looked at the nurse and she goes, “Well you are talking about Julie here. Nothing is normal about Julie. Her lungs are not at the right place and her kidneys are not at the right place and her uterus just miraculously fixed itself. So if she says she pumped two bottles in 20 minutes then she pumped two bottles in 20 minutes. It is what it is.” And then she walked out And then nurse looked at me like “huh.”
Martin (2003) links the social requirements and expectations gender (e.g., keeping conversation going, acts of selflessness) with Foucault’s (1977b) technologies of the self as “internalized technologies of gender” that present in the birth experiences of white, middle-class women, stating “Understanding gender as an internalized technology is useful in describing why women are nice and kind during childbirth where other conceptualizations of gender fall short” (p. 58). Clearly, some of these internalized technologies of gender are at play in these narratives; however, even when the white, middle-class women in this study performed their feminine role according to these expectations, they were not protected from negative consequences, and when women resisted these technologies (by asking directly for what they wanted) or navigated the technologies (by making gentle suggestions that their needs to be met), the external technologies of gender (expectations of and corrections by the medical team) prevented women from having their needs met. It is a typical paradox—if women perform their gender as expected, they are at fault for not being more assertive; if women are more assertive and betray gendered expectations, social forces quickly reestablish their subordinate position through discursive moves (such as being called a diva) and the negative outcomes are also seen as their responsibility for not being feminine enough.
This study’s findings suggest it is important to understand emotional distress in childbirth beyond the idea of individual bad actors, who do something to someone, with negative individual outcomes, and extend understanding to consider the ways in which the constructions of women and the ways in which power/knowledge operate in health care contribute to emotionally painful birth experiences. In this study, we can see how discursive constructions of women reside in those giving birth as well as those attending births, and how disciplinary power dances with these discursive constructions in ways that diminish and shame women (using terms like diva and overdramatic), generally undermine the role of women in birth (among medical professionals as well as birthing women themselves) and work to remove agency and women’s ability to make informed decisions about their births which are respected and appropriately deferred to by medical staff.
Implications for Social Work
We can see how internal technologies of gender influence women’s behavior in childbirth resulting in appeasing and perhaps passive approaches to childbirth (i.e., “nice, kind, relational and selfless,” Martin, 2003, p. 61), and much has been written about how external social forces, such as the medicalization of birth, result in particular kinds of control (Cahill, 2001; Davis-Floyd, 1987). Social work is a field concerned with both internal experiences and structural factors, and as such I believe it is well positioned to highlight how these internal and external social forces work to shape childbirth experience, and how they work to maintain power relations.
The women in this study had various experiences of emotional distress in childbirth due to the ways in which they were discursively constructed and by the manner in which power operated in their birth experiences. And it is important to note, these were all white women, most of whom carried other privileges as well. There is significant evidence suggesting racialized minority women, poor women, single women, and young women experience greater risk of mistreatment in childbirth (Abuya et al., 2015; Center for Reproductive Rights, 2014; Fottrell et al., 2010; Niner et al., 2013). Because the participants in this study were all white women, I use a rights framework instead of a reproductive justice framework. Reproductive justice comes from the work of black women in the United States (Ross & Solinger, 2017) and in a manner similar to how intersectionality has been taken up by white women, there is a risk of white researchers (such as myself) co-opting this framework to explain gender-based oppression while removing the specific analysis of racialized oppression (Bilge, 2013). Whether using a rights framework or a justice framework, calls have been made for social workers to be more involved in the movement for improved reproductive health (Alzate, 2009; Liddell, 2018), and as part of this movement, it is crucial for social workers to begin to recognize and address the harm being done to women (and likely those with other gender identities) in childbirth.
Pregnant and laboring women break apart the very idea of the individual, where we must see the woman and baby in a unique way from other stages of personhood, and where the well-being of both is dependent on and affected by each other (Lindemann, 2012; Schiller, 2016b). In this model, childbirth rights advocates argue that women must be centered and trusted to make decisions for their own bodies, pregnancies, and their own babies. This means women must be respected as fully human and worthy of respect and dignity, relations of power must be illuminated so that oppressive practices can be challenged, and those giving birth must be centered in systems associated with pregnancy, labor, delivery, and postpartum care.
Social work is based on respect for the inherent worth and dignity of all people and the rights that follow from this. Social workers should uphold and defend each person’s physical, psychological, emotional, and spiritual integrity and well-being (IFSW, 2012). We have seen how sexist, derogatory constructions of women undermine women’s self-determination in childbirth, as women discipline themselves in order to comply with the narrowly constrained definition of acceptable womanhood. In demanding this of women, women are moved to the periphery of birth when they should be centered. We have seen how women’s self-determination in childbirth is undermined. While the discourse of risk (to the fetus) is employed to support the removal of self-determination, the removal of women’s right to make their own decisions about their care and interventions can also occur when there is no risk (Schiller, 2016b). Take for example, Sally who had no input into whether she would have a C-section or vaginal birth and who asked not to have her waters broken though they were broken anyway. There was no emergency nor even urgency in her birth situation. There was time to consult about decisions (surgical vs. vaginal birth), and there was certainly time to honor decisions that had been discussed (breaking the water).
The constructions of women and their disciplining and self-disciplining create understandable emotional pain in birth. If social workers are to “uphold and defend each person’s physical, psychological, emotional and spiritual integrity and well-being” (IFSW, 2012), we must, as a profession, pay attention to the effects that negative birth experiences have on women’s well-being. The IFSW (2016), in its policy statement on women, begins with a rationale for why the rights of women are deserving of special and unique consideration by social workers, recognizing that childbirth is a central concern: Because women bear the world’s children and do the majority of child- and family-care related work in all societies, self-determination in child-bearing and access to the full range of reproductive health care services are essential [emphasis added], but international aid for these services is currently declining or restricted in use. (sect. 1.1) IFSW will work to improve the health status of women of all ages. Social workers are commonly involved in the delivery of women’s health care, including maternal and child health, mental and behavioral health care services, and sexual and reproductive health care, including the care and prevention of HIV/AIDS and other sexually transmitted diseases. Improving the health and well-being of women requires attention to physical, mental, emotional, and social well-being and the provision of gender-sensitive prevention, intervention, and long-term care services. (sect. 5.6) IFSW endorses women’s self-determination in all health care decisions as a core professional value, including all decisions regarding sexual activity and reproduction. Social workers understand that women have the right to receive competent and safe reproductive and sexual health care services free from government, institutional, professional, familial, or other interpersonal limitation or coercion. (IFSW, 2016, sect. 5.7)
Proactively, social workers can model anti-oppressive understandings of distress through their work on interdisciplinary teams. Social workers working in health care can provide peer education regarding childbirth distress beyond individual level understandings, respond actively to victim blaming discourses in health-care settings, use and create opportunities to speak with maternity patients/clients about their wishes and expectations for birth, and advocate for these expectations to be considered valid so that women in their most vulnerable time have some of the burden of navigating expected gender-based behavior mitigated.
Reactively, social workers in their roles as mental health professionals, or in roles working with parents and children, should check in with those who have recently given birth to ask about the experience, and work with those who have had distressing birth experiences to increase understanding about how these experiences might have come to be, rather than reinforcing self-blame and pathologizing explanations of distress. Social workers can advocate for better treatment of all birthing people in health care and society more generally by supporting such campaigns such as Human Rights in Childbirth (“Human Rights in Childbirth,” n.d.).
Further social work–specific research into childbirth distress is an important component of increasing our involvement in reproductive health research and practice as we have been called to do by Alzate (2009), Liddell (2018), and others. Research centering experience that keeps a critical lens will allow a deeper and broader perspective and knowledge base on this topic. For example, it would be interesting to explore how reproductive health-care policies specifically impact (positively or negatively) distressing childbirth experiences. Some work has been done in this area (see McKenzie-McHarg et al., 2014) but there is opportunity to expand this. While social workers may not be involved in childbirth as it is happening, our research has the opportunity to support those who do such work (such as midwives) in order to create and advocate for policies and practices that are in line with reproductive rights and reproductive justice frameworks and that work to create equitable and excellent health care (“Close the Health Gap,” n.d.).
Pregnant and laboring women are often seen as vessels holding a more precious being, and many women who have become mothers find themselves as entities whose purpose is to sacrifice their own needs and rights for those of their child (Schiller, 2015, 2016b). This is seen in the oft-repeated statement women utter when trying to come to terms with their childbirth experiences, “all that matters is a healthy baby” (Shabot, 2016; Lindemann, 2012; Schiller, 2015, 2016b). This study shows that a healthy baby is not all that matters.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Nova Scotia Health Authority Research Fund (892753).
