In her book The Logic of Care: Healthcare and the Problem of Patient Choice, Annemarie Mol relates a story that partially prompted her philosophical investigation into choice and care in the Dutch healthcare system:
It is still the early 1990s. I am pregnant and 36. A national committee of experts in the Netherlands where I live has looked at the statistics and suggested that pregnant women over 35 should have an amniocentesis and thus the option of abortion should their foetus have Down’s Syndrome. Given where I am (I have a healthy child and work that fascinates me and it is difficult enough as it is to juggle between them) I follow the advice. I take a day off and go to the hospital where I also happen to be doing the field work for the book that I am working on at the time. It is slightly strange to shift from the role of observer to that of patient. But I lie down on the examination table and feel the ultrasound probe moving over my belly. Still in my field-work habits, or just to break the silence, I say to the nurse who is preparing the long needle that will be inserted into my womb: ‘I hope it all goes okay.’ We both know that a small percentage of women have a spontaneous abortion as a result of the procedure. The nurse snaps back: ‘Well, it is your own choice.’ Back home I dutifully sit down on the couch, legs up, to reduce the chance of the threatened spontaneous abortion. But I also start to make notes for what turns out to be field work after all, albeit for some future book. I wonder what the nurse might have said that would have fitted a logic of care. ‘Let’s indeed hope it goes well’; or ‘Most of the time there’s no problem’; or ‘Are you worried about it?’ She might have touched me in a kind way. And she might even have used the moment to encourage me to behave and say: ‘You may want to have a quiet afternoon, then.’ But instead she illustrates beautifully how mobilising the logic of choice can lead to poor care. It can shift the weight of everything that goes wrong onto the shoulders of the patient-chooser.
(Mol, 2008: xi)
Mol contrasts this with a story about a psychiatric patient who won’t get out of bed — should he be allowed to ‘make this choice’? One respondent says that if resources were not limited, the solution is to send a nurse to sit and talk to the patient about why he does not want to get out of bed. The decision must rest on the specific facts of his situation, not on some general principle. In her book-long investigation into this other ethic, this ethic or logic of care, Mol asks us to consider how lots of choice is not the pinnacle of good care — and to consider what other things might be. Her context is diabetes care in the Netherlands, but her thoughtful work has got me thinking about my own work and that of Katharine Mckinnon’s looking at birth and spaces of birthing and labouring.
In her piece on the ‘Geopolitics of Birth’ (Mckinnon 2014), Mckinnon points out that while feminist analysis has done much to bring attention to the experiences of the labouring and birthing women, it only ‘partially addresses the shortcoming of the existing literature on birth’. She explains her approach further:
While it [feminist geopolitics] provides an impetus for linking analysis of the ‘macro’ to the ‘micro’, the institutional to the intimate, it does not address a strong tendency in the birth literature to enact a binary of medical vs natural, hospital vs home, obstetrician vs midwife. In this research I am exploring new materialities approaches, in particular Actor Network Theory (ANT) as a way to sidestep such binaries, adapting an ANT method of cataloguing all the human, nonhuman and subhuman actants without assuming they are already positioned in relation to a two-sided debate (Mckinnon, 2014: 3).
One of the issues for Mckinnon is the role of hormones and other ‘subhuman’ actors here: while in labour, our hormones bring us into a different, liminal, space of being, where our ‘rational’ and ‘calculative’ brain is ‘switched off’ in favour of an instinctual and embodied ‘in the moment’ experience, where time seems to stand still and speaking or calculating seems like too much effort. We know that this is a normal part of giving birth, and often marks the transition to the second stage of labour where the birth actually occurs. Mckinnon’s point, in her 2014 article, seems to be that these ‘subhuman’ actors are present in various combinations in a diversity of births, and it is unhelpful to enact binaries where one must choose a side in a pre-determined arrangement of options (medical-hospital-high-intervention or natural-home-low-intervention). Instead, Mckinnon explores the use of theory that allows a cataloguing approach to the birth space, mapping, as it were, a diversity of actors and thus possibilities.
Mckinnon’s work fits in with Mol’s concepts of the logics of choice and care here: in labour, the rational choice part of our brain actually needs to be ‘shut down’ in a way, so that we might allow ourselves to fully immerse in the instinctual and embodied practice of labouring. Yet, in most healthcare systems such as New Zealand’s (and Australia, where Mckinnon works, and the Netherlands where Mol works) we valorise choice in our healthcare — and in fact, in our Western notions of personhood. This means that in the logic of choice, birthing women are asked to keep their rational mind ticking over in order to continue to make choices (the endless questions from your maternity carer!). Yet in order for birth to progress smoothly, it is best that we enable an environment where rationality can be momentarily put aside. But many people — even those present in the rooms of birthing women — find it uncomfortable when birthing women become irrational or unable to articulate choices. It is almost as if the woman has become ‘subhuman’, because of our (Masculinst?) attachment to rationality as a function of humanity. New materialism and strands of feminist thought attempt to propose other ways of being human: being human in community for example. Drawing on these understandings of humans-in-common, we might propose that ‘choice’ is not the measure of good care, and look for other ways that good care might already be offered.
How, then, do we care for women and babies being born, in an enabling way, that meets them where they are at and enfolds them in community? Katharine Mckinnon and I have interviewed women in Australia and New Zealand, and asked them to map the spaces in which they have given birth, commenting on the objects, the people, and the other institutional presences in the room. What we are trying to do is to map a birthing ‘assemblage’, where socialities, spatialities, materialities and more come together (differently) to enable (different) particular outcomes. We are not looking for broadbrushed answers to ‘which space is better’, but to examine the assemblage and consider how assemblages might be ‘tweaked’ to enable better care (rather than just more choices).
Linda, a New Zealand mother in a small city, had planned to homebirth both her sons, but both had ended up in C-Sections. Linda was reconciled to these births — she felt she and her midwives had given homebirth a good shot both times. Linda says about her births:
It just worked that she [midwife] gave me enough time to make my own decisions without me floundering about not making a decision so that she had to push one. Because I’m sure some people wouldn’t make a decision and then they’d have to be forced to make one. Then the person would feel like they hadn’t made the decision. So they’re kind of in a no win situation. I feel that I was able to process the information, make a decision that I was happy with. So it was possibly just personality on both sides.
It is clear from this quote, and others in Linda’s interview, that her strong rational decision-making character was evident even while labouring. She was happy with her C-Sections because she felt that the decisions were made by herself. She was given the opportunity to explore the possibility of giving birth, despite never dilating more than 1cm in more than three days. Linda’s acceptance of her difficult births is framed in terms of decisions: 1) the fact that the baby got to ‘decide’ the day of the birth and experience some labour and 2) the fact that Linda was able to logically work through a progression over several days in order to explore every other alternative to C-Sections.Linda makes a reference to other people who ‘wouldn’t make a decision’ and then ‘forced to make one’ and then ‘feeling like they hadn’t’. What is likely in Linda’s case is that because her labour wasn’t progressing, she is unlikely to have got to a stage of transition and ‘turning inward’, unlikely to have the hormone actors working to shut down her rational side — she never mentions feeling like this even when I probed this area in the interview. In fact, she tells me of an incident where she gets ‘stroppy’: she changes her mind about having an epidural and her mother and husband try to hold her to her original birth plan and the amount of time she had decided to trial labour. She felt that she was rational and able to make that decision herself, but her support crew inappropriately assumed she was irrational.
I said “You are not listening to me!” Then I had a contraction, and then the contraction finished and I said “I have a right to change my mind”.
Linda, by virtue of the fact that she never reached the ‘irrationality’ of the transition stage of labour, was able to embody the rational decision-making consumer that our healthcare system seem to prefer. In her second birth, she made a choice to take an epidural three hours earlier than she planned in light of new information: unlike her first child where she had dilated 1cm after several days, with her second her cervix had not dilated at all. Linda realised that her pattern of labour was unlikely to change, and given her previous experience and her feelings of exhaustion, decided to use an epidural for pain management.
Although we can read Linda’s story as a ‘logic of choice’ story, since she was rational all the way through and able to make clear choices as a ‘healthcare consumer’ and communicate them to her human supporters, we can also begin to read in a logic of care and pay attention to the specific place and its objects assembled for the labour and birth. The specificities of Linda’s situation called for an adjustment to her plan — the hormones and contractions were not progressing the birth, her walking and swiss ball and hunger and pain and previous experience and more all assembled in such a way that the target time for trialling natural labour in her second birth became to seem unreasonable to her. Her midwife was attentive to these factors, and cared for Linda within the specificities of the situation (whereas the support crew were perhaps applying a more general antenatal class advice of how to manage ‘women in labour’?). Linda also draws my attention to other specifics of care unrelated to decision-making that made her C-Section experience less terrifying, firstly, the fact that her midwife joined her in the operating room (OR) and secondly:
They had this big wide TV screen [in the OR] and they were playing some beautiful images of a beach and some lovely music. It was really cool…I just lay there and like chilled out for a bit because instead of like going look at all those instruments and stuff, it was somewhere to focus on.
Given that only five minutes of her time in OR was dedicated to getting her baby out, with 50 long minutes directly afterwards while they stitched her up, this caring intervention/object certainly made a difference to Linda’s experience.
Unlike Linda, Martinne has had homebirths for all her three children. In all of her births, the most important aspect was having whanau* around. Her greatest fear was having to have a C-Section without her husband or kids present. At each birth, she also had a younger relative present in order to give them an experience of birth. When I interviewed her about these experiences, we discussed the objects and people present in the small room in the flat in which she gave birth to her eldest daughter. Martinne says of her first midwife:
[she was] talking to me through everything and was emotional support and she was getting me cold cloths and doing all those things that I really appreciated. So to be honest …She was good but just – yeah, really fussy, she was – I remember getting quite annoyed with her, asking me silly things like how am I feeling. Wanting to swear at her.
Despite generally good experiences around giving birth, Martinne could also identify moments and objects and particular ways of doing things that were unwelcome. In the quote above, she mentions how annoying it was to have the midwife ask her ‘silly’ questions — that is, bring her rational mind into play and wasting energy on making decisions or talking. Martinne appreciated the hands on approach of her partner, who physically comforted her, and the aroha support of having whanau nearby or in the room in a show of presence and support. In Martinne’s case the presence and/or absence of whanau members was what made her feel cared for and supported, even though she preferred them to be quiet and not interrupt. The ability to carry out certain rituals related to her and her partner’s Maori heritage was also an important aspect of experiencing care or aroha, for example, retaining the placenta/whenua for burial in a pot (later to be taken ‘back home’).
In Martinne’s case, one could argue that the ‘choice’ to give birth at home enabled her to have the birth she ‘chose’, and a healthcare system should provide lots of choices so people can be happy with their own choices. But as we can see in the quote I pulled out from Martinne’s transcript, there is a sense that just having the ‘consumer’s right’ to choose the place or style of birth is not the only thing involved in good care. Martinne wanted her midwife to be skilled in reading her nonverbal body language and respecting her state of mind (Martinne described it ‘in a zone’ and ‘not really conscious’), and in one of her births this wasn’t the case.
Situated care, then, works with the mother and whanau to create a birth plan while in the rational state, but also allows for other types of communication and other types of interactions that do not sit easily with the ‘rational decision-making healthcare consumer’ subjectivity. The research that I have been doing with Katharine Mckinnon, some of which I have drawn on in an initial analysis here, opens up different theoretical possibilities for articulating what this situated care might look like. While the discourse of rational decision-making healthcare consumer appears to empower women in making birth choices that should be respected, the discourse does not always highlight the situated complexity of care in the moment — especially where nonverbal, nonrational, nonhuman and subhuman interactions are present as they often are in birthing. We are interested in exploring different ways of talking about good care within our health system.
*Wordpress seems unable to let me do macrons, so excuse any Maori words without their correct macrons!