The Medicalization of Women’s Bodies: A Study of Changing Practices and Experiences of Childbirth

Introduction:

Since the nineteenth century we see a kind of medicalization of the human body in general and women’s reproductive capacities in particular. This article uses the cultural practices and experiences of birthing to investigate the medicalization of women's bodies. Childbirth has been one of the central concerns of human society. Its experiences and customs, however, change throughout time and space. In view of Ann Oakley's (1976) seminal claim that with the advent of modern medicine, the power which women held over the knowledge and practises of delivery seems to have moved into the hands of medical professionals, this article seeks to investigate childbirth from that perspective. This paper intends to record how women experience this shift and make sense of the changing practices of childbirth. This study examines how motherhood and modernity are experienced, understood, and portrayed via the lens of Cecilia Van Hollen's ethnography "Birth on the Threshold: Childbirth and Modernity in South India" (2003). The three generations of women from an Eastern Uttar Pradesh family now living in Jharkhand serve as a case study for this research. It relies mostly upon in-depth, unstructured interviews with this middle-class family, both in-person and over the phone. The focus of this research is on "real-life" issues such as what sort of maternity care these women should seek. It is an attempt to document the subjective ways in which these women mold such global processes of biomedicalization in local ways, and re-conceptualize and re-organize the world in which they live.

The process of giving birth has always been one of humanity's primary concerns. However, its customs evolve through time, and its experiences differ from one location to the next. This evolution in maternity care methods and perspectives provides an opportunity to consider the medicalization of women's bodies. We can observe this trend beginning in the eighteenth century, when the female reproductive system and the human body as a whole began to be treated more as a medical issue. The birthing process, formerly solely the domain of women, is gradually ceding power to medical experts as modern science advances (Oakley, 1976). There is little question that this change has precipitated a cascade of results for women. Our goal in this research is to collect and analyse data on how women talk about and think about these changes. In this research, we examine how increased medicalization of delivery has influenced the decisions that mothers and their families make. As we try to portray the nuances of this choice, we'll learn about the ways in which women negotiate against the imbalanced power of biomedicine.

Understanding the inner workings of contemporary biomedicine requires paying attention to the "choices" women and their families make on the type of treatment they get during delivery. These decisions are a reflection of how women shape medicalization processes on a global and local scale. Additionally, these "options" might be utilised to inquire into the lived, conceptualised, and represented connections between motherhood and the contemporary era (Hollen 2003). We may learn a great deal about women's efforts to rethink and restructure their worlds from the choices they really make in the midst of actual labour and delivery. The primary purpose of this study is to document the experiences of women on the evolution of maternity care in our societies.

Existing Scholarship

For this paper, we will be referring to some key feminist works on childbirth and modern reproductive techniques. The foremost among them is Ann Oakley’s (1976) “Wisewoman and Medicine Man: Changes in the Management of Childbirth”. Oakley’s fundamental assertion about the transfer of control over reproductive care from women to men forms the baseline of this paper. In addition, the framework provided by Cecilia Van Hollen (2003) in her ethnography- “Birth on the Threshold: Childbirth and Modernity in South India” acts as the constant point of reference. This paper closely follows her analysis of how the modernizing processes which impact childbirth have transformed the cultural constructions and social relations of reproduction in myriad ways. Apart from these sources, this study draws on Tulsi Patel’s (2012) work- “Global Standards in Childbirth Practices”- that investigates the ways in which the birthing body and its healing is understood and dealt with in different cultural contexts and within the same culture across time and social groups to see how different local medical worlds comprehend aspects of reality. Besides, Marcia Inhorn’s (2000) article- “Defining Women’s Health: Lessons from a Dozen Ethnographies”-contributes significantly to our understanding of women’s health concerns. In addition to this, articles like “The Biopolitics of Reproduction: Post-Fordist Biotechnology and Women’s Clinical Labour” (2008) by Catherine Waldby and Melinda Cooper shape our knowledge of modern reproductive technologies. Last but not the least, “Reinventing Reproduction, Re-conceiving Challenges: An Examination of Assisted Reproductive Technologies in India” (2011) is an excellent piece by Vrinda Marwah and Sarojini N. which pushes us to think critically about technological intervention in commonly assumed “natural” biological processes like conception and reproduction.

Changing Practices of Childbirth

There are several layers of complexity in the field of birthing. In the current international system, "modern birth" does not refer to a single entity (Hollen, 2003). However, there has been a recent upsurge in efforts to spread biological knowledge systems. When it comes to making important life choices, more and more people are turning to medical professionals for advice, as Cecilia Van Hollen describes in her work (Hollen, 2003). Thus, the "medicalization of childbirth" is "the process whereby the medical establishment, as an institution with standardised professional guidelines, incorporates birth in the category of disease and requires that a medical professional oversee the birth process and determines treatment," as she puts it (Hollen, 2003). We may examine "how women understand and act upon the changing management of labour in distinctive ways at the microphysical level to develop a particular, or vernacular, shape and experience of modern birth" (Hollen, 2003) by employing her methodology.

The Field Data

The following discussion on childbirth is based on a case study of three successive generations of women belonging to a middle-class family located in Bokaro Steel City, Jharkhand. This family has been residing in Bokaro for the past 48 years and traces its origin to a small village in Eastern Uttar Pradesh. It is an extended family, headed by a patriarch, whose wife Devi is part of the first generation of women (age group: 70s) being interviewed for this paper. Devi has five daughters and two sons; all of them are married and have children. Devi’s daughters and daughters-in-law form the second generation of participants (age group: 30s and 40s). The daughters of this second generation of women form the third-generation participants of this study (age group: 20s). Each generation of women has had distinct encounters with modernity and diverse experiences of maternity. (Note: All the names of individuals in this paper are pseudonyms.)

Generally, childbirth envelops three broad stages: (1) prenatal care; (2) delivery; (3) postnatal care. We will try to structure our study on these three stages and note down the respective experiences of each generation of women. In Cecilia Van Hollen’s words “there seems to be a shift from one institutional site, that is, the family and the midwife to another institutional site, that is, the public hospital as a site of both the state and biomedicine” (Hollen, 2003). According to her, this shift also symbolizes a shift in systems of knowledge about the women’s reproductive bodies (Hollen, 2003). Following this trail, we will record those aspects of change which appear to be of greatest concern to our participants and which exert the greatest impact on their decisions about where to go for prenatal, delivery, and postnatal care (Hollen 2003).

The first, as well as second-generation women, have plenty of tales to tell when it comes to childbirth. They usually converse in their mother tongue, that is, Bhojpuri, especially Devi who cannot speak in Hindi. However, it was not easy to persuade these women to talk about some intimate experiences of their life. In fact, it took a considerable amount of time to have that conversation with Devi. Since, most of these women were raised in their villages which lay on the same belt of Eastern U.P. they have imbibed a similar notion of shame (laaj-sharam).

A heavy baggage of honor (izzat) is attached to the women’s womb, which makes them quite hesitant to talk about its activities. Nevertheless, as soon as our participants got comfortable, the discussions used to stretch on. Keeping such factors in mind, interviews were conducted in an unstructured, face to face mode. They were complemented by telephonic interviews with those women of the family who resided elsewhere. Moreover, this study is still in its elementary stage, and is exploratory in nature. Rather than delving into formidable assertions, its aim is modest. At the very out set it is stated that the objective of this paper is to present the accounts of women, using their own cultural categories and metaphors.

Prenatal Care

Let us now turn towards the first instance where women get a chance to make a choice for themselves. A woman embarks upon a peculiar journey as soon as she acknowledges her conception. The clock of childbirth starts ticking when she misses her period after marriage, says Anjani, Devi’s elder Daughter-in-law. The first thing that comes to a woman’s mind after realizing her pregnancy is who to share the news with. Devi recalls that back in her time women were too shy to share the “good news” (naya samachar) even with other women of their household. Those women came to know of it only when they noticed the baby bump after a few months.

However, Devi’s two daughters-in-law, Anjani and Rekha, recount that Devi was the first one to know about their pregnancies, as she was the one who escorted them to the doctor to get it confirmed. The third-generation women, on the other hand, emphasize sharing the “good news” with their partners first, and only after that with their parents-in-law. Yet it appeared that women of all generations usually prefer to wait till the first trimester before revealing their pregnancy to family and friends. Devi and Anjani call it a general tendency among women to purposefully hide things like pregnancy and childbirth so as to prevent any mishap (nazar lagna), because these are times when women are most vulnerable to the evil eye.

Before moving to the next stage, let us have a look at the grave question of abortion, which comes in front of women at times. Almost everywhere, the patriarchal society in collaboration with religion and law has levied severe restrictions on abortion, so as to maintain their control over women’s reproductive capacities. Devi says that the concept of abortion was rather unknown in her time. She could not recollect any instance of voluntary abortion in her village. Instead, she mentions that miscarriages were more common during those days. The most frequently cited reasons for it included lifting heavy weight articles (bojha) while performing household chores, and sorcery (jaadu-tona).

Devi narrates an incident where she tried to control her reproductive capacity and decided to go for sterilization (nasbandi), after her second son (fifth child) was born. She was almost ready to leave the house with the nurse (memin) who came to fetch her to the block (tehsil) hospital, when the elder women of the house started panicking and informed the men sitting outside. As soon as the men got to know of her step, the male head of the household came to the threshold and shouted at her. He said that “children are a gift of God and one must continue to accept the gift as long as God gives it”. After getting scolded, Devi felt ashamed and dropped her plan.

The advancements in modern medicine have led to relatively more subtle and at the same time more overt mechanisms of controlling female procreative ability. The rising cases of sex selective abortions show us how new technologies, like ultrasound, meant to monitor the progress of the mother-fetus duo are being used to repackage patriarchal control over women’s bodies. Such use and abuse of medical technologies has, in fact, become common and acceptable to some extent in this region, as is evident from the opinions of our participants. The women in this region are doubly burdened with an urge to bear sons at one end and the pressure to regulate the family size at the other. In order to make these ends meet they take recourse to modern medical technologies and tweak them in suitable ways. For instance, it has become a normal, rather expected practice to go for prenatal sex determination if the couple already has a girl child.

Anjani and Rekha remark that even the doctors are aware of the patriarchal mindset of families and concede to the demands of society. Anjani recalls an incident where she had gone with Devi for her last ultrasound before the delivery of her second child. The male doctor was giving details of the baby, when her mother-in-law politely pressed him to spell out the sex of the baby. Devi said- “Doctor (sahib) you are telling us everything except the fact whether it is a boy or a girl”, to which the doctor replied with a smile- “Do not worry sister (behen ji) you will not have to pay any dowry”, hinting that it was a boy.

Rekha narrates another instance of negotiation, where one of her friends tried to conceal the sex of her baby so as to prevent her abortion. Her friend was sent to a (illegal) prenatal sex-determination clinic twice by her family to find out whether she was carrying a boy or a girl. But each time, upon reaching home, she made it up that the ultrasound machine was not functioning properly and hence failed to identify the sex of the baby. These incidents give us a glimpse of the small ways in which women try to exercise their agency and retain control over their bodies.

Delivery

Let’s turn to the central stage of childbirth now. Devi delivered all her babies at home, in her husband’s village, except her last child who was born in the city hospital. A special room in the house known as the “sauri ghar” was designated for childbirth. It was in this room that all women of the household used to deliver their babies. No man was allowed to enter this room, and childbirth was solely the responsibility of women. The midwife (chamain), always a so-called lower-caste woman, played a crucial role in childbirth. She was responsible for cutting the umbilical cord and cleaning the “sauri ghar” after childbirth. She even acted as an expert who would be called for help in complex deliveries.

Altogether it was the women who possessed the expertise and control over childbirth practices. The doctor was consulted only as a last resort and women would be rushed to the hospital only if the most experienced midwife gave up on her case. Here we can see why Oakley suggests that the midwife has been replaced by the nurse in the hospital setting and control over the knowledge of childbirth is seeping from the hands of women into those of medical professionals (Oakley, 1976). When she looks back, Devi compares the “conducive” environment of home, where the women and midwife rendered emotional support, with the “sinister” surroundings of the hospital where the unfamiliar doctor and medical staff sparked a fear that one must behave appropriately. Apart from that, the presence of men in the hospital further tensed the situation.

Anjani narrates her first pregnancy as if it was a matter of yesterday. She remembered all the details clearly and was more than excited to share how she became a mother. However, due to the space constraint we won’t be able to dive in to the details here. Anjani recollects that on the night before her delivery, she started having pain and informed her mother-in-law about it. Devi responded- “You should keep calm. There is no use going to the hospital right now because there also you will have to bear the pain on your own. And, it is better to suffer at home than in the monotonous hospital room”.

Going by the instructions, Anjani suffered silently the whole night without letting her husband know, who was sleeping next to her. It was only when dawn broke that she mustered the courage to ask her in-laws to take her to the hospital. Anjani’s husband restrained himself from participating in this affair and everything was handled by his family. This shows that childbirth has not yet become an exclusive responsibility of the husband-wife couple (Patel, 2012). It is very much a shared responsibility of household members and the kin group at large, especially in small towns and villages.

Anjani, when she reached the hospital next morning, was instantly admitted to the labor room, where two more “patients” were present. The use of the term “patient” itself indicates how parturition has come to be categorized as pathology in modern medical science. The gestating body is equivalent to any other pathological body, which must be treated and restored to its normal state. When the pain persisted and became unbearable, Anjani asked the doctor in charge to do something, to which the doctor replied coldly- “What do you expect? Should I give you a back massage?”. At that point, Anjani realized that be it a hospital or home, the pain has to borne by the woman herself. This instance also reminds us of Tulsi Patel’s argument that, indeed, such treatment and remarks by medical professionals are one of the reasons why middle-class and working-class women tend to stay away from hospitals (Patel, 2012).

Interestingly, Anjani’s second delivery presents another example of negotiation with medical structures. Anjani says that, when the third trimester ended and her due date passed, she sought an appointment with the doctor. After a week when she went to the hospital, the doctor asked her to get admitted right away. When she informed her in-laws about this, Devi immediately taught her to make an excuse and refuse the doctor. Anjani went to the doctor and somehow managed to convince her that she would be there by the next morning. When Anjani got back home, her family members, especially her father-in-law, advised, rather ordered her not to report to the hospital. The family believed that it was nothing but a trick of the doctors to get women operated and earn more money. So, Anjani waited for the “natural” labor pain to start, and only then showed up at the hospital. In contrast to the “God-like” image of doctors, we can see how common people are generally suspicious of the intentions of medical practitioners.

After talking to all our participants, one thing became quite clear- that normal delivery is labeled as the best method of giving birth. It is deemed to be natural and divine. The women believe that the pain is worth it, and only lucky women get an opportunity to experience it. But it appears that medicine has secularized and pathologized this pain. Besides, a normal delivery is also appreciated because of its capacity to somewhat loosen the grip of medical practitioners, as it minimizes their interference in the delivery process. Although it is extremely painful, women as well as doctors believe that the pain lasts only for a short time, and the body starts healing as soon as the baby is delivered. Women of this region, especially those of Devi’s generation look down upon caesarean sections. Those women who get operated during delivery are thought to be weak and fragile, because they submitted to the pain and got caught in the doctors’ trap. However, with the increase in caesarean deliveries around them, women of this region are coming to terms with the new reality.

There is a premium attached to motherhood in our society. Couples who are not able to bear children “naturally” seek alternative means. The invent of new reproductive technologies has enabled re-articulation of female reproduction in astonishing ways (Waldby & Cooper, 2008). In recent times, In Vitro Fertilization (IVF) has become the most popular Assisted Reproductive Technology (ART). Riti, a third-generation participant, opted for IVF a few years ago. However, it is important to note that the decision to go for IVF was not a quick one. It was adopted as the last resort, only after alternative systems of medicine like Ayurveda and Homeopathy had failed. Riti recalls her entire experience of IVF as a painful and draining one. It was full of ordeals and tested their patience from time to time.

Her family kept the whole process of IVF as a secret from their kith and kin, especially those living in their village. The reason cited by them was that their relatives residing in the village saw new reproductive technologies like IVF with awe, as something mystical. For them a test-tube baby was like an illegitimate child, as they believed that it was not the biological child of the couple. Besides, Riti’s family was very disappointed when she gave birth to a girl. They were of the opinion that if they had spent so much money, she should have begotten a son. Therefore, in their view, the whole IVF thing amounted to a failure, and they have decided they will never go for it again. Such instances point out that the authority of medical knowledge over people is still incomplete. In any case, the whole procedure of IVF is physically, emotionally and economically very taxing. Such a process, fraught with appointments, tests, and medicinal overdose, appears quite unimaginable for the women of Devi’s generation, who would see a doctor only in the direst of circumstances.

Postnatal Care

Childbirth is loaded with notions of purity and pollution. Once the baby is born, a series of rituals are performed. In the case of Devi, she had to remain confined in the sauri ghar with her child for twelve days after parturition. It was the responsibility of the midwife to clean the room every day, at dusk and dawn. The midwife was also liable to give a proper oil massage to the mother for at least a month. During her stay in the sauri ghar, a woman was relieved from the household chores. All this was done to ensure that the mother’s body starts rejuvenating. When it came to Anjani and Rekha’s postpartum care, Devi made sure that they got the oil massage on time. Even if no midwife was available in her semi-urban colony, Devi asked a so-called lower-caste woman who sold vegetables in that area, to perform this task. She also gave her daughters-in-law all kinds of healing drinks and warm food that she was given during her postnatal period, to strengthen their weakened bodies.

So, we can see that women of the second and third generations received a mixture of modern and traditional services during childbirth. If we consider the spectrum, on one end, we have the first generation which seems to be more inclined towards the traditional healthcare systems, whereas, on the other end, we find somewhat greater modern medical penetration among the other two generations. The second-generation women seem to experience a more intense interaction between tradition and modernity. The fact that Devi herself fetched her daughters- in-law to the hospital for safe deliveries and sought medical advice for them whenever necessary portrays an acceptance of the superiority of modern biomedicine. However, this acceptance is not absolute or complete, as these women have not yet surrendered their choices entirely to the biomedical system. They have devised their own ways of negotiating with the system, like emphasizing upon normal delivery.

Perhaps, when the question of “choice” between home-birth and hospital-birth was posed in front of all these women, they seemed to unanimously agree upon the risk-reducing capacity of hospital births. They said that the presence of trained professionals around them instilled some sort of hope that if any complication arises, it will be attended to. So, it feels that these women want to build a safety net around themselves, by picking and choosing favorable services from both traditional and modern childbirth practices. It seems that they accept and allow biomedical interference, but only to a certain degree.

Apart from this, while talking to our participants we get a sense that all of them prefer to consult a female gynecologist. In fact, we get to note an interesting tendency among the women of the third generation. Many of the unmarried third-generation women, especially those residing outside their hometown, depicted a preference for women gynecologists who did not judge them for their sexual activeness. They avoided going to gynecologists in their hometown, as there was a risk that these gynecologists, because of being situated in the small town, would judge their character for being sexually active, and the more threatening thing was that they could expose their sexual life to their family members who would escort them there.

In fact, the third-generation women tend to cut their dependence on medical institutions to an extent by referring to videos available on the internet where female gynecologists answer the “most-asked-questions” and health concerns of women. This hints how women try to reduce their reliance on medical professionals or rather avoid the aforementioned risks by going to these self-help sources available on social media platforms. We can clearly see that women are not passive bodies who merely accept what is imposed upon them; they very much exercise their agency and endeavor to weave a safety net around themselves.

Conclusion:

It is apparent that childbirth is no longer an exclusively women’s affair, yet the Indian case is somewhat different than its European counterpart. India’s experience of modernity is a kind of mixture of the traditional and the modern. In fact, we came across an array of peculiarities in our case study as there is multiplicity of practices in our country. In reality, we are likely to encounter certain discrepancies when we apply Ann Oakley’s model to Indian society. However, it is not to suggest that her frame of analysis can be dismissed altogether; the essential findings still resonate with her work. We are sure that many nuances are left untrodden and new facets will emerge when we expand our research base and talk to a larger group of women. That is why this paper avoids any kind of generalization at this stage. We know that we have just touched the tip of the iceberg. There is a range of depth to be explored. Yet we can note one thing for sure, that science and medicine are not above the socio-cultural context; they are firmly rooted in our social relations. Similarly, we cannot really talk about solely “personal” or “individual” decision-making when it comes to childbirth. A variety of factors play vital roles in everyday decision-making process of women, more so when it comes to decisions that pose questions regarding the control over their reproductive capacities.

References

Hollen, C. V. (2003). Birth on the threshold: Childbirth and modernity in South India.

Inhorn, M. (2000). Defining women’s health: Lessons from a dozen ethnographies.

Marwah, V., & Sarojini, N. (2011). Reinventing reproduction, re-conceiving challenges: An examination of assisted reproductive technologies in India.

Oakley, A. (1976). Wisewoman and medicine man: Changes in the management of childbirth.

Patel, T. (2012). Global standards in childbirth practices.

Waldby, C., & Cooper, M. (2008). The biopolitics of reproduction: Post-Fordist biotechnology and women’s clinical labour.

Rishu Aryan

Pursuing Masters in Sociology, JNU