Doing Pregnancy, the Unborn, and the Maternity Healthcare Institution

Abstract

Tutkimus käsittelee syntymätöntä ja tämän suhdetta raskaana olevaan naiseen suomalaisen äitiysneuvolan toimintakäytännöissä. Syntymätön-termi viittaa siihen, miten naisen kohdussa kasvavalla elämällä on monta olemusta asiayhteydestä riippuen. Se voi esimerkiksi olla epämääräinen tunne naisen vatsassa, teknisesti ja kliinisesti ymmärretty sikiö, poliittisesti arvokas ihmiselämä tai jo perheen oma erityinen syntymätön lapsi. Tutkimus tarkastelee tapoja, joilla nämä erilaiset olemukset muodostetaan, liitetään toisiinsa ja naiseen perheessään raskauden hoidossa ja vanhemmuudesta neuvottaessa.

Tutkimuksen tuloksena on, että neuvolatyö on tulevien vanhempien tunteisiin vetoavaa työtä, joka ei kuitenkaan ota vahvaa kantaa hyvästä vanhemmuudesta. Tutkija havaitsi, että neuvola tukee ja ohjaa hienovaraisesti prosessia, jossa syntymättömälle on vähitellen ennen syntymää rakennettu paikka omana persoonanaan perheen konkreettisessa kotitaloudessa, sukulaissuhteissa ja vanhempien mielikuvissa. Tulevien vanhempien, erityisesti raskaana olevan naisen, oletetaan sikiövaurioita ja psykososiaalisia riskejä käsittelevän tiedon valossa pohtivan valintojaan ja tuntemuksiaan syntymättömästä. Tyyliltään perheterapeuttisen pohdinnan ja siitä keskustelemisen, reflektion, ajatellaan johtavan yksilölliseen itseohjautuvuuteen vanhemmuudessa.

Tutkimus osoittaa myös sen, että vaikka institutionaalisesti siedettyjen vanhemmuussuhteiden variaatio on laajentunut, neuvolan ideaaliperheenä näyttäisi olevan sitoutunut, yhteiskunnasta riippumaton ja kahden heteroseksuaalisen vanhemman perhe, jossa vallitsee sukupuolistettu työnjako, tehtävät ja velvollisuudet. Näistä velvollisuuksista poikkeaminen arvioidaan neuvolassa periaatteessa mitattavissa olevien riskitekijöiden avulla. Tutkimuksen havainto on, että poikkeaminen normaaliuden mittakaavasta, johon myös reflektion arvioitu puute voidaan lukea, johtaa naisten vastuullistamiseen, moraaliseen tuomitsemiseen ja interventioihin. Tuloksena on se, että joidenkin naisten suhteet syntymättömiin määrittyvät huonosti hoidetuiksi. Näiden naisten riskitekijöiksi arvioidut elämäntilanteet muistuttavat vanhoista yhteiskuntaluokkaominaisuuksista, vaikka periaatetasolla neuvolajärjestelmän tulisi kohdella kaikkia tasavertaisesti samoin

Tutkimuksella osallistutaan muun muassa keskusteluun hyvinvointipalveluiden muutoksesta sekä neuvolan roolista turvattaessa syntymättömän terveyttä. Tutkimuksessa havaitaan, että neuvonnan ja hoidon tapa, jossa ei oteta vahvasti kantaa, elää rinnan valtiopaternalismin kanssa. Toisaalta naisia ja miehiä kehotetaan itse pohtimaan ja tuottamaan identiteettinsä ja ratkaisunsa vanhempina ammattilaisten, sukulaisten ja vertaisryhmien hienovaraisella tuella. Toisaalta neuvolassa käyminen, sen aktiviteetteihin ja neuvoihin sopeutuminen näyttäytyy kansalaisvelvollisuutena, naisten velvollisuuksina syntymätöntä kohtaan. Velvollisuudet ovat usein abstrakteja lähisuhteiden emotionaalisia ja kiintymyskäyttäytymiseen liittyviä valintoja, joiden tekemisessä kuullaan myös naisten kokemuksia ja ajatuksia. Tässä mielessä neuvola suojelee syntymätöntä naisen kautta eikä hänestä huolimatta, kuten pakkohoitoratkaisut tekisivät, ainakin kunnes nainen ja hänen perheensä tulevat luokitelluksi riskiryhmäperheeksi.

Tutkimuksessa terapeuttinen reflektion ja hienovaraisen tuen tulkitaan kumpuavan osin yhteiskunnallisesta vaatimuksesta lisätä yksityisyyttä, itsenäisyyttä ja valinnanvapautta palveluita käyttäville. Vaikka kauniit voimaannuttamisen ja vapaaehtoisuuden toimintaperiaatteet tuottavat hyvinvointia ja toimijuutta joillekin naisista, ne myös sallivat raskaana olevien naisten kontrolloimisen ainakin yhteisöissään ja perheissään. Vaatimus valinnanvapaudesta voidaan tulkita myös kulutuskapitalismin vaatimukseksi kohdella naisia kuluttajina, jotka vapaasti valitsevat hoivapalveluja kuin tuotteita. Naiset eivät lopulta ole vapaita valitsemaan mitä tahansa ja markkinalogiikka sopii yleensä huonosti hoitosuhteisiin.

Tutkimuksen aineisto perustuu etnografiseen kenttätyöhön neljässä äitiysneuvolassa noin kolmen kuukauden aikana vuosien 2006–2008 välillä. Se koostuu videonauhoituksista, havainnoista, haastatteluista ja dokumenttiaineistosta.

This study is concerned with the relationship between pregnant women and the unborn in the context of maternity healthcare institution in Finland. Maternity healthcare in Finland is mainly a nursing practice that includes social support on the side of medical screenings and a long-lasting client–professional relationship which may be seen as supportive of pregnant women’s agency and reproductive freedom, unlike the technology-driven medical professional practice that tends to undermine pregnant women’s experience-based knowledge and represent the unborn as an autonomous, separate and conscious being.

To account for these kinds of practices and for the particular lives, activities and perspectives of pregnant women involved in them I have adopted an institutional ethnographic framework as theorised by Dorothy E. Smith. In institutional ethnography the social organisation of institutional work practices is by definition explored through the people who participate in them and from their perspective. Smith’s concept of standpoint has offered a way to orient research to the local particularities of pregnant women’s lives, working in this way as a methodological organiser for larger power relations manifest in particular ways in activities within maternity health care practices. In line with this orientation my study, first, inquires into women’s experience-based knowledge and viewpoints of pregnancy and the unborn to establish an outline of the interchanges with the institutional orders of maternity healthcare. Then, informed by these associations, my study asks how, at the practical level of care work, the unborn and its relationship to the pregnant woman is enacted both temporally and topically. Finally, having thus established that my research commitment is anchored in the engagement of pregnant women within institutional orders and out-of-orders, I will further attend to the question of how the agency of pregnant women is realised in relation to the unborn in these practices.

The research material was collected through ethnographic fieldwork at four different maternity healthcare clinics over approximately three months in the course of 2006–2008. The material was assembled through multiple methods of data production, including video recording, observation, interviews and documentary material. My analysis owes much to feminist studies of technoscience in material-semiotic practices (especially Donna Haraway’s) and their acknowledgement of heterogeneity, instability and fluidity of subjects, objects, agency and logics of institutional power.

The analysis shows that in the pregnant women’s experiences the unborn are enacted in a bodily process from an ambivalent feeling into something more concrete: a human life, a baby and, finally, one’s own particular baby, to whom are attributed at least potential personal characteristics, gender, social identity and kin relations. By doing pregnancy in many ways women come to know their unborn as persons that need to be attended to by naming, by changing lifestyles, tolerating medical interventions, acquiring baby goods, and rearranging households, life cycles and social relations by engaging others, especially partners, to participate emotionally and practically. A lot of this preparation is done in the ‘best interest of the child’. The notion is used to display cultural maternal competence but as a vague and fluid concept it allows some variety of choice as to which kind of a maternal self one may become and what kind of a social world expressive of a particular kind of unborn–woman relationship one may (co)create in her individual family life.

The ‘best interest of the child’ is ultimately an institutional policy level term that is used in quite subtle ways in the everyday activities of the clinics. Characteristic of the work of public health nurses’ is the careful building of rapport and solidarity to manage affectively the anxieties of pregnant women and their partners about the unpredictabilities of pregnancy, and to encourage changes in lifestyle. The delicate negotiations involved in promoting transformations for parenthood include taking up a position as a mediator of scientific ‘facts’ about foetal damage and psychosocial risks, and not taking a strong stand on good parenting. Scientific ‘facts’ are geared to maternal response in order to change lifestyles and to encourage bonding with the unborn. In these ways multiple unborns are performed.

In these practices there is a temporal, yet somewhat incoherent, logic to enacting the unborn that accords with biological development as the technoscientifically known. The unborn are transformed from foetuses, human life and babies in general to particular babies and children in a more distant future. The care work does not, however, rely totally on the omniscience of technoscientific confirmation: it works to complement less visible models of bodily ‘female instinct’ having more distant origins. The two subjects of medical practice, the foetal patient and the maternal patient, never fully emerge in the practice.

Emotional, psychosocial and socio-material transformations in unborn–woman relations are on the formal agenda of care in around the third trimester of pregnancy, when family counselling starts. There are more and less standardised ways of supporting these transformations and screening for problems in them. Counselling interaction takes the form of (family) therapy. The parents-to-be are encouraged to reflect and talk about their mental journeys toward becoming their parental selves with the professional objective of attuning them to family values and bonding them with a baby that has subjective characteristics. The nurses guide at a distance and approach parenthood abstractly in terms of psychosocial knowledge. Psychosocial knowledge appeals to the ‘social’ for support in parenthood from family members, peer groups, a variety of professionals, and even ‘the whole village’. Compared to the early stages of pregnancy, with their limited range of medical and nursing advisors, late-term care lifts the unborn up for the scrutiny and performance of a multitude of actors.

Multiple support groups are perceived as necessary according to the current ideology of maternal competence that claims that women need to be educated scientifically to know their unborn’s needs, ‘choices’ and demands. Professionals should work as equal partners with citizens in the name of more choice and autonomy. As public servants nurses do not have the authority to act as custodians to the unborn, but manage risks and establish securities through prevention methods that do not wholly determine the ways and forms of well-being. The problem with this approach is that, paradoxically, it allows control to be exercised over pregnant women despite the beautiful operating principles of empowerment and voluntary partnership. It may place the determination of maternal competence and the child’s well-being in antagonistic hands. Advancing freedom of choice and diversity among women may be subsumed into a rising wave of neoconservative values that invite women ‘freely’ to choose conventional family lives in which they are reunited with the unborn at the expense of reproductive autonomy.

Under the ethos of not taking a stand the power to organise social relations is also redirected to work from below. Pregnant women are held accountable at clinics for the choices they make when these do not fit into a scale of normality in assessments of risk factors. As a result some women’s relationships with their unborn are enacted as poorly managed because they diverge from measurable scales that coincide with the characteristics of social class divisions. Mastering and attuning to the assessment encounter and its therapeutic code, however, seems to imply possibilities for establishing oneself as a respectable maternal self and a change to avoid unwanted intervention and moral judgment. These strategies of respectability, self-reflection and narration are required to follow the appointment interaction and to express preference for certain maternal competences, such as working relations with one’s partner and a willingness to try to change for the ‘better’. Although in principle today anyone who steps into a clinic is treated equally as ‘the same’, one can see how women in poor living circumstances may become objects of intervention and paternalism when they are more easily given the terms to talk about their hardship than more privileged women. The ideal, thus, remains a committed family with two heterosexual parents who are assigned gendered tasks and responsibility: women are assigned bodily nurture and a position as mediator between the unborn and the male partner who is the biological father and who takes care of the household and is an attentive father. State paternalism that makes attending and attuning to maternity healthcare activities a civil responsibility lives side by side with the emergent rationale of voluntary partnership, where self-reliance in parenthood is the operating principle.

In conclusion, I argue that maternity healthcare work is affective labour that critically reworks the medical-technical foetal person and insists on time, trusting professional relationships and the experiences of women. It provides for health and well-being and feeling of security and choice, and vague agency within the scope of institutionally tolerated parental relations that allow one to authorise oneself a space where it is also permitted to lose control and be creative. Further, offering women more choice and autonomy in the form of therapeutic reflection may work in desirable ways for some women. It may, however, also be interpreted as a demand of consumer capitalism and a managerialist response of the welfare service system to that demand. Women are not really free to choose whatever they desire, as I have shown, and market models fit poorly to care relations. Overall, while the everyday practices at the clinics are messy and no form of power has the ability to impose a totalising hold on them, particular unborn and maternal selves and social ties before birth are produced in a style that facilitates changes and processes that are expected, to a large extent, to take place by themselves. As such the ability and inability to turn a relationship of a pregnant woman and an unborn into a mother–child relationship can be understood as a practice of biopolitics and biopower.