Pregnancy, Risk and Biopolitics

On the Threshold of the Living Subject

Lorna Weir

• Publisher: Routledge
• Year: 2006
• ISBN:
  9781134163557
• Edition: 1
• Topic: Sozialwissenschaften
• Subtopic: Feminismus & feministische Theorie

Traditionally, Euroamerican cultures have considered that human status was conferred at the conclusion to childbirth. However, in contemporary Euroamerican biomedicine, law and politics, the living subject is often claimed to pre-exist birth. In this fascinating book Lorna Weir argues that the displacement of birth as the threshold of the living subject began in the 1950s with the novel concept of 'perinatal mortality' referring to death of either the foetus or the newborn just prior to, during or after birth.

Weir's book gives a new feminist approach to pregnancy in advanced modernity focusing on the governance of population. She traces the introduction of the perinatal threshold into child welfare and tort law through expert testimony on foetal risk, sketching the clash at law between the birth and perinatal thresholds of the living subject. Her book makes original empirical and theoretical contributions to the history of the present (Foucauldian research), feminism, and social studies of risk, and she conceptualizes a new historical focus for the history of the present: the threshold of the living subject.

Calling attention to the significance of population politics, especially the reduction of infant mortality, for the unsettling of the birth threshold, this book argues that risk techniques are heterogeneous, contested with expertise, and plural in their political effects. Interview research with midwives shows their critical relation to using risk assessment in clinical practice. An original and accessible study, this book will be of great interest to students and researchers across many disciplines.

1 On the threshold of the living subject

The threshold of the living subject constitutes the zone of transition into and out of human bodily substance. Unlike the threshold of exit, the threshold of entry occurs in and through another body. Women in pregnancy bear the between, the entrance across which the unborn must pass in order to be distinguished from those who carry them. Neither a pure moment in time nor a single point in space, the threshold of the living subject has duration and extent. When and where that between begins and ends, what status the bodily substance at that threshold might have, is an entirely social and cultural matter.

Thresholds mark the transition from inside to outside, the imperceptible to the perceptible, the non-reactive to the reactive. “The threshold (die Schwelle) bears the between” wrote Heidegger (1971: 201) in his essay, “Language”.¹ Being the “settlement of the between,” the threshold “sustains the middle in which the two, the outside and the inside, penetrate each other” (Heidegger 1971: 201).² The between, however, may be difficult to conceptualize for cultural reasons. As Irigaray (1985) argued in her commentary on Plato’s myth of the cave, Western philosophy – and other truth regimes – have been incurious about zones and techniques of transition due to their persistent habit of thinking in dualistic categories such as inside and outside, light and dark, truth and illusion. At the birth of Western philosophy, Plato ignored the entrance to the cave.

Without a threshold, a building could not be entered or left; there would be no passage between inside and outside. The most ancient meaning of “threshold” in English pertains to dwellings: “the piece of timber or stone which lies below the bottom of a door, and has to be crossed in entering a house” (Oxford English Dictionary, second edition 1989). The first entries for “sueil” and “Schwelle” in the French and German historical dictionaries, Littré and Duden, also refer to the wood or stone at the base of a doorway passed over on arrival. Over the past thousand years the meaning of threshold extended to figure the border separating regions or fields, the beginning of an action, and the lower limit of perceptivity or reactivity. A threshold makes possible a relation between heterogenous places, practices and perceptions.

Until the mid-twentieth century in Western Europe and the territories of the European diaspora, the threshold of the living subject had been stabilized in common culture and expertise as definitively crossed only at the end of the birth process. Although its arrival would often be expected during pregnancy, the living subject entered social recognition only at the end of labour, classified then as a child and kin member. However, knowing a woman to be pregnant was fraught with interpretive uncertainties and ambiguities, both from the perspective of the woman herself and from those having expertise in attending births. Women looked to the experience of a new kind of movement in their bodies to know and announce that they were “quick with child”. Yet childbirth could occur without the prior experience of quickening, and quickening-like feelings took place without leading to childbirth. Sometimes the sensation of internal movements might cease, leading to further uncertainty; until the mid-twentieth century, physicians considered definitive diagnosis that the unborn was no longer alive difficult to make. Despite the intrinsic ambiguities of the birth threshold with respect to its beginning, it did have a clear end: the birth of a baby, who, if alive, was culturally recognized as having human status, simultaneously a person and an individual.

During the first two decades of the twentieth century, the birth threshold of the living subject came unsettled under the impact of concerted attempts to lower infant mortality and morbidity in Western Europe and North America. The optimizing of health in the first year of life led to the medical invention of a novel perinatal threshold, at variance with the previous birth threshold: a problematization of the threshold of the living subject as a site of questions, difficulties, responses. The birth and perinatal thresholds entered into conflict, opening to differing regimes for the governance of the body during pregnancy and labour.

The beginnings of the perinatal threshold took place in European and North American medicine during the period 1920–1950. As infant mortality rates fell during the first two decades of the twentieth century, analysis showed that infant deaths remained high close to birth. Reasoning that deaths prior to, during and shortly after birth had similar causation, and that the bodies of the fetus late in pregnancy and the newborn were fundamentally alike, physicians proposed a new measure and target of intervention: fetal and neonatal mortality, or, as it came to be called during the 1950s, “perinatal” mortality, that is, mortality around birth. The perinatal threshold lightened the significance of birth, consolidating the time late in pregnancy, during labour and just after birth as one continuous interval based on commonalities of bodily substance. The time and space of the perinatal ran across birth.

A threshold stabilizes and sustains a relation of inside and outside: “What goes out and goes in, in the between, is joined by the between’s dependability ... The settling of the between needs something that can endure” (Heidegger 1971: 201). Any change in the threshold, the between, alters the relation of inside and out. In the unsettling of the birth threshold by the perinatal threshold, the relation between the inside and outside of pregnancy was put in question. The threshold of the living subject had come to lack dependability.

The perinatal threshold folded a new division of time and bodily substance into the maternal body during pregnancy and birth. The concept of the perinatal distinguished continuities of time and bodily substance for the living subject before, during, and after birth from the time and bodily substance of the pregnant woman. In so doing, it consolidated the existence of the living subject prior to and during birth, providing a rationale for its care: the conservation of fetal life so as to optimize infant health. Where previously the birth threshold only definitively concluded at the end of the birth process with the separation of mother and child, the perinatal threshold distinguished mother from the unborn during pregnancy and birth. When the birth threshold became unfixed, the relation between inside and outside at the threshold of the living subject was shaken, affecting the pregnant woman, the living subject, the relation between these two subjects, and the forms of expertise acting on them.

Both the birth threshold and the perinatal threshold have contained interpretive ambiguities. From the perspective of the birth threshold, the status of the unborn between a woman’s declaration of quickening and birth was clouded over with uncertainty, a subject about which midwives and physicians knew little, but one that crystallized into a living subject at birth. The concept of the perinatal occupied this ambiguous interval, constituting it as medically actionable: the time of a living subject in some senses distinct from the pregnant woman. The singularity of the perinatal threshold in turn rendered unclear the relation of a woman during pregnancy and the birth process to the living subject she carried. So too, the absent “perinatal subject”³ during pregnancy and birth had an uncertain relation to the social and legal categories of person and individual. The temporal and spatial distinctions associated with the medical concept of the perinatal, the unsettling of inside and outside at the threshold of the living subject, were thus permeated with gendered power effects.

Thresholds have techniques facilitating entry and exit, techniques which organize the relations between inside and outside, before and after.⁴ At the threshold of the living subject, risk techniques were attached to pregnancy and childbirth during the 1950s with the intent of reducing perinatal mortality and morbidity. Standardized, population-based, routine risk assessment in clinical practice came to saturate pregnancy in succeeding decades, promising an ever receding utopia of health. I will show how risk-based prenatal care was offered as a solution to decreasing the perinatal mortality rate by acting on the period of time prior to the birth of the living subject. Perinatal risk factors were folded into the previous method of prenatal care. The calculative, preventive orientation of risk had its basis in epidemiology rather than the actuarial calculations of insurance; risk techniques have been analytically heterogeneous, although uniformly about security whatever their siting. In clinical practice, risk-based prenatal care bound together categories of epidemiological risk with diagnostic information, test results and patient histories; the result was to make standardized prenatal risk assessment into a higgledy-piggledy concatenation of epidemiological and clinical reasoning as risk came to invade the space of patient management, treated as equivalent to any clinical intervention. What goes by the name of risk in prenatal care has thus not strictly speaking been confined to risk judgements. The schema “prenatal risk assessment”, in all its analytic heterogeneity, has acted as a transmitter of security for the unborn configured as fetus, standardizing and concerting care of fetal health in clinical practice.

The perinatal threshold was consolidated in health care through risk techniques, later attaching to the legal regime through expert medical evidence. In the last two decades of the twentieth century Canadian courts, paralleling other Euroamerican legal regimes, considered displacing the birth threshold of the legal person (other than corporations) with a perinatal threshold in damage claims for prenatal injuries and child welfare litigation. In these actions medical evidence of risks to the health of the unborn was necessary for proof of fact, which establishes whether an event has occurred or a particular entity exists. Damage claims for prenatal injuries were made on behalf of a child born alive with health problems caused by an accident during pregnancy. Recoveries for prenatal injuries crucially depended on medical evidence linking a cause before birth with injury to a child’s health after birth. Prior to the 1990s, litigation involved third parties, that is, people who had injured a woman during pregnancy, but in the late 1990s, claims were brought against women themselves for conduct during pregnancy that was possibly linked to fetal health risks. A series of actions launched by child welfare authorities during the 1980s and 1990s similarly used medical evidence of fetal health risks from maternal conduct in an attempt to extend their child protection mandate to the unborn. Child welfare authorities sought to have women ordered into treatment or if necessary detained for the sake of fetal and child health. At issue in these cases was the relation between the child and the unborn configured as a fetus across the perinatal threshold.

Perinatal mortality is empirically associated with poverty, and thus the perinatal mortality rate has fallen on fundamental social cleavages. The series of child welfare cases in the Canadian jurisdiction primarily involved Aboriginal women and coincided with the efforts of health governance during the 1980s and 1990s to reduce the higher comparative perinatal mortality and morbidity rates among Aboriginal peoples. Within health governance, perinatal risk reduction took the form of removing Aboriginal women late in pregnancy from Northern Canadian reserves in order to give birth in Southern hospitals. Perceived as a pool of perinatal risk in health governance, Aboriginal peoples have a specific and harsh historical experience with the perinatal threshold.

As the perinatal threshold spread through risk techniques in the health and legal regimes, it met with a critical reception on the part of expertise. Within the health regime, risk-based prenatal care was criticized for increasing intervention rates with no basis in evidence. Intervention in turn increased iatrogenic effects: the negative health consequences caused by diagnosis and treatment. Midwives and a minority of physicians defended pregnancy as a state of health, priorizing clinical judgement over risk judgement, trying to fashion an alternative basis for pregnancy care separate from risk-based prenatal care: health beyond risk. In litigation pertaining to child welfare and damage claims in prenatal injuries, courts at the appellate level denied the applications that would have made pregnant women accountable for fetal health risks. Judicial law reaffirmed the birth threshold, thereby externalizing the perinatal threshold to the health complex. Unfixing the threshold of the living subject did not result in a rout for the perinatal threshold.

My work here falls within the history of the present – analysis that is broadly foucauldian in inspiration – a school that is deeply curious about the biopolitics of modernity, specifically the forms of reasoning, techniques and power used to optimize the health of populations. The present work extends this inquiry in the direction of examining the new intensities of care coursing around the living subject in the twentieth century at the threshold of its entry into population. Problematizing the threshold of the living subject was an event in biopolitics that shook the grid of intelligibility of the living subject at the threshold of its entry into population, together with the legal address of pregnancy and the liberal governance of women. I undertake a genealogy of a new medical concept, the perinatal, and the formulation of a new kind of mortality, perinatal mortality, the reduction of which was taken as a goal by national, regional, and local health care systems. Techniques for the reduction of perinatal mortality included a risk-based system of prenatal care intended to promote the security of the fetus. This vast and detailed implanting of a perinatal threshold troubled the previous cultural threshold of the living subject: birth. From the perspective of the birth threshold, the perinatal threshold was a place of paradox: mortality statistics not requiring live birth, antenatal records, and women incarcerated to reduce health risks to those not born.

Risk techniques are analytically heterogeneous, socially contested, and politically variable in effects. My account underscores the heterogeneity of risk techniques and their effects, a writing strategy consonant with current scholarship by historians of the present that seeks to understand risk governance as more than singular and actuarial. I argue that expertise has not simply proliferated risk governance, it has also sought to contain and reject the spread of risk. Exactly how risk governance has been limited or rejected deserves treatment, partly as a corrective to the social scientific writings that have assumed risk roams unchecked over the plains of the present. Nor does risk have any intrinsic belonging to liberal/neoliberal governance; risk is a technology of security with a rich history of both liberal and authoritarian service. Chapter 5 of this book examines an instance of risk taking an authoritarian turn in a series of legal cases brought by child welfare authorities attempting to throw women into detention and coerced medical treatment in order to lower risks to fetal health.

The problematization of the threshold of the living subject mobilized four differing forms of power: the security (of population), discipline (of individuals), the sovereign power of law, and governance. These comprise what I will call the power field of biopolitics, an unstable conjunction of interacting powers. Biopolitics may operate within law or where law has been suspended; if within law, biopolitics may be liberal or authoritarian. When the perinatal threshold entered law, the disciplinary confinement and mandatory medical treatment of women for the sake of reducing fetal health risks from their conduct, that is, for the security of the unborn configured as a fetus, was considered and eventually rejected in the Canadian jurisdiction, on the grounds that it threatened the intelligibility of tort law. In the United States of America there has as yet been no determinative reading at the level of the US Supreme Court. The potentialities of the perinatal threshold were given in the power field of biopolitics and have many possible ways of being realized.

My inquiry into biopolitics at the threshold of the living subject arises in the context of longstanding feminist concerns with the “public fetus” (Duden 1993: 50–55) in contemporary gender politics, specifically narratives of maternal–fetal conflict that position women and the unborn as equal persons with competing interests. Contemporary feminism has been haunted by the figure of maternal–fetal conflict and the attempted invasions of women’s liberty rights with which that figure had been associated at law. I share these concerns, albeit in the recondite analytic conventions found in the history of the present, but have wondered how the fetus came to be invested with such significance. One might respond to this question with an account of social movements, Christian religious fundamentalism, and discourses of state, but such approaches presuppose a preexisting salience of the fetus within health regimes that these social forces receive and that provides the basis for their claims-making. The extent to which pregnancy has become implicated in risk governance has likewise received feminist commentary, but how this came to pass has had no sustained treatment.

The framing of the present project within the biopolitics of population provides an account of how the unborn configured as fetus came to be publicized and the conditions for maternal–fetal division established. The perinatal threshold marked an historical break from birth as the entry into human status, a break based on a conceptual innovation: the constitution of a temporal interval encompassing newborn child and intrauterine fetus in a common bodily substance. This historical break with the birth threshold was thus not primarily centred in visual imagery pertaining to the fetus, significant though this has been, but in an epistemological rupture that later came to serve a governmental end. When the analysis of infant mortality statistics and the findings of pathological anatomy constituted early infant deaths and stillbirths as preventable, the project of increasing popular health in the first days of life unsettled the birth threshold. By the mid-1950s a programme of optimizing population health over the perinatal interval had been sketched: systematic prenatal risk assessment for the reduction of perinatal mortality rates. At the point that the concept of the perinatal was joined to a technology of risk, the biopolitics of population transcended birth and came to include the unborn. Pregnancy became a time for routinely conser...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Figures
• Acknowledgements
• 1. On the Threshold of the Living Subject
• 2. A Genealogy of Perinatal Mortality
• 3. Health beyond Risk: A Midwifery Ethos In Prenatal Care
• Appendix
• 4. Legal Fiction and Reality Effects Evidence of Perinatal Risk
• 5. Child Welfare At the Perinatal Threshold: Making Orders Protecting Fetuses
• 6. Biopolitics At the Threshold of the Living Subject
• Notes
• Bibliography