Exploring the Dirty Side of Women's Health

Mavis Kirkham

• Publisher: Routledge
• Year: 2007
• ISBN:
  9781134176786
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

In this book, a team of international contributors examine bodies, leakage and boundaries, illuminating the contradictions and dilemmas in women's healthcare.

Using the concept of pollution, this book highlights how women and health issues are categorised, and health workers and women are confined to roles and places defined as socially appropriate. The book explores in-depth current and historical practices, such as:

• childbirth and midwifery practice
• policies and social practices around breastfeeding
• gynaecological nursing, female incontinence and sexually transmitted infections
• miscarriages and termination of pregnancy.

Addressing things out of place, from the idea of 'dirty work' to feeling 'dirty', from diagnoses that disrupt our self-image to beliefs and practices which undermine health service provision, this book uses the contradictions in our thinking around pollution and power to stimulate thinking around women's health.

Section 1
Mothers, midwives and dirt—past and present

1
Birth dirt

Helen Callaghan

Introduction

This chapter is a brief overview of the theory on birth dirt and is based on the work ‘Birth dirt: relations of power in childbirth’ (Callaghan 2002). The term ‘birth dirt’ was coined to describe the theory which explains the power and/or dirt relationships in childbirth. Birth dirt exists, but its nature will vary depending on the time, the place and the culture. Who and what is clean or dirty similarly varies and will depend on and similarly create the discourses surrounding birth in the particular time, place and culture.

The study from which this theory was developed was about women, both birthing women and midwives, and their experiences of birth in Australia. The aim of the research was to examine the discourses and related practices surrounding birth and how these discourses shaped the power relationships between the women, their families and their care-givers. The focus of the study was the interactions, particularly communication patterns, the use of language and the practices, that occurred between the woman, her support people and health professionals. Data collection consisted of videotaping women in labour in a tertiary level public hospital in a major regional Australian city. Twentytwo couples were videotaped; all except one couple were having their first baby. Discourse analysis was the method used to analyse the tapes.

Due to various disciplinary approaches, there are many ways of ‘doing’ discourse analysis and no agreed method or methodology. The common thread in all the approaches, however, is the privileged position of language and its structuring effect together with an interpretative and reflexive analysis (Burman and Parker 1993). As analysis of the data progressed, the importance of Foucault’s understanding of power (1972/1982, 1967/1997, 1980, 1994) and the clinical gaze (1975) became central to the thesis. Preliminary analysis of the videotapes led to an examination of my midwifery education through professional and consumer texts, casebooks and memory, with the concepts of ‘clean and dirty’ also being explored. As the study evolved, the focus sharpened and the study narrowed to the discourses surrounding who and what was considered clean or dirty and how this is constructed and played out in childbirth. Critical incidents were transcribed in detailed with a focus on the ‘clean and dirty’ aspects, then analysed using both texts and visual data. The incidents focused on various aspects of labour: one woman’s desire to protect her modesty and conceal her genitalia (‘the naughty bits’); a vaginal examination; the manner in which the midwives and the doctor dressed for birth; the hard physical work of the labouring woman; what is ‘yuck’ about birth and how both the midwives and the women and their families used very similar terms to describe this; breastfeeding and authoritative knowledge; and treatment of the dirty baby. The interpretations from each labour were synthesised into a unified sociopolitical analysis.

Pollution and dirt

Discussion on pollution inevitably leads to an examination of Mary Douglas’s seminal work, Purity and danger (1966/1992), in which she focused on the symbolic interpretation of the rituals associated with pollution. Both Douglas (1966/1992:35, 73) and Clark and Davis (1989:651) defined ‘ritual pollution’ (within a religious system) and ‘secular defilement’ (within a civil system) as a state of uncleanliness derived via contact with a ‘dirty’ or ‘polluting’ person, object or activity. However, the terms are used interchangeably, with ‘pollution’ the most commonly used term. For example, in discussions about the non-religious human, or the natural environment, the term used is usually ‘pollution’, or sometimes ‘contamination’, rather than ‘defilement’. In health systems the term used, in the sense of the item or person being dirty, is ‘contamination’.

‘Dirt’ is defined ‘as matter out of place’ (Douglas 1968/1999:109), or ‘disorder’, or ‘it exists in the eye of the beholder’ (Douglas 1966/1992:35, 2), or a ‘fantasy’ (Kubie 1937), or what ‘comes out of the skin or touches it and clings’ (Enzensberger 1972:9), or ‘the object jettisoned out of that boundary’ (Kristeva 1982:69). Douglas (1966/1992:120) considered the bodily orifices as vulnerable and whatever came from them symbolised both ‘danger and power’. She considered that contact with the refuse from the body orifices was also dangerous and carried a ‘symbolic load’ (Douglas 1966/1992:3).

Weaver (1994:77) has pointed out the difficulty of defining dirt: ‘“dirt” does not mean clean, good, clear, fresh, brightness of colour, hygienic, innocent, morally pure’. These various states are neither ‘natural’ nor ‘inherently stable’, while the person must fight to maintain these states through various methods: ‘cleaning, washing, confessing’, all of which indicate that there must be ‘ritualistic practices’ to maintain cleanliness (Weaver 1994:77–78). A clean/dirty hierarchical structure was noted by various authors (Clark and Davis 1989; Derrida 1981; Enzensberger 1972; Kubie 1937; Ross et al. 1968). Weaver (1994:78) noted ‘clean and dirty are not equal, dichotomous, mutually exclusive categories with independent and inherent meanings’. The role of dirt in society is explained:

all dirt relationships…[should be] reinterpreted as power relationships. Anyone carrying dirt is powerful, and anyone in power utilizes dirt for purposes of control. The one who can defile others, whether clean himself or not is the boss.

(Enzensberger 1972:47)

Pollution, for Enzensberger (1972:22–23), originates or is derived from four sources of dirt:

1. ‘Contact and excretion’
2. Intermingling
3. Decay and a reversal of order
4. ‘Mass’

Enzensberger (1972:32) included human social behaviour when discussing pollution and he wrote about dirt as being essential when there is ‘structure and order’. Dirt, for him, was the negation of the structure and order. He described the characteristics of dirt:

1. Dry objects
2. Spots and splashes
3. ‘The wet and fatty’
4. Anything sticky and that makes threads
5. Any form of coagulation or wobbling
6. Anything that ‘ferments, putrefies, sours…’
7. An increase ‘of mud clay slime slush ooze…’
8. ‘Everything that crawls creeps writhes wriggles…slithers or spurts…’

(Enzensberger 1972:16–17)

Although the list describes the physical characteristics of dirt, these characteristics are freely applied to people and their behaviours. For example, we speak of individuals as being ‘a worm’, or ‘a creep’, or they are ‘a fuck wit’. Many of these colourful, but derogatory, terms are ‘sex-elimination amalgam[s]’ (Clark and Davis 1989:657).

Kubie (1937:391) is explicit in that he considers the body a ‘mobile dirt factory, exuding filth at every aperture’. He suggested a hierarchy of dirt, that is, humans react to dirt as if it possesses different degrees of ‘dirtiness’ (Kubie 1937:394). He contended that there would also be a universal ranking of body products from the ‘cleanest’ to the ‘dirtiest’ (Kubie 1937). This assumption was confirmed (Dimond and Hirt 1974; Hirt et al. 1969; Kurtz et al. 1968; Ross et al. 1968). Milk was either the cleanest or the second cleanest item, while semen was one of the cleaner items. An important suggestion by Kurtz et al. (1968:13) is that the hierarchy of body products may be interpreted as products which are ‘natural’ and in harmony with the body—‘body-syntonic’ (tears, milk, and semen)—or those considered foreign, diseased, unnatural, or ‘waste’ products of the body—‘body-alien’ (faeces, phlegm, and pus). The latter group would include menstrual blood and the placenta.

Kubie (1937:395) admitted that the ‘most important single consequence of this hierarchy of fantasies is an unconscious but universal conviction that woman is dirtier than man’ (original emphasis). Although Kubie does not mention it, it is clear from his assumptions that the female genitalia are also considered dirtier than the male genitalia. Based on Kubie’s hierarchy, the female genitalia are dirty, not just because of their surroundings, but because of their physiology and their anatomical shape. He does discuss his belief in women’s obsessive conviction of having ‘one aperture too many and that a dirty one’ (Kubie 1937:398).

The functions of pollution

Douglas (1966/1992:3) believed pollution functions at two levels in society: an expressive level and an instrumental level. At the first or expressive level, the commonly held beliefs and social pressures are used to influence other people’s behaviour. For example, the dominant societal belief in the contagiousness of blood and body substances is continually being promoted by various health institutions and the media. There is an expectation from the community, institutions, and professional bodies that protective apparel will be used if there is any risk of contamination. The second or instrumental level at which pollution functions occurs when there is a violation of the law which threatens what is considered the ideal in society, with the violation itself being a danger both for the society and the transgressors (Douglas 1966/1992). Douglas considered this produced two effects: (1) the threat of danger forces the person to maintain the desired social order; and (2) the enforcer is also reminded of the necessity to maintain the social order.

Douglas (1966/1992) considered that because we want to avoid dirt, we become creative and organise our environment so that avoidance of dirt is easier, by creating environments that suit the desired function and minimise the need for purification rituals. Douglas (1978) commented that pollution and purification are linked by ritual, while the nature of the rituals will define the seriousness of the pollution. This concept can be applied to the health care system where dirt ‘specialists’ undertake the ritual purification or cleansing.

Dirt and work

Hughes (1971:312), a sociologist, believed that all occupations contained tasks which could be labelled as ‘dirty’, and provided a partial definition of ‘dirty work’—it was ‘drudgery…requires no skill. It has to be done, but is a low-prestige item.’ Work is ‘dirty’ in several ways: by being ‘physically disgusting’, or it may symbolise degradation, or it may be contrary to ‘our moral conceptions’ (Hughes 1971:343). According to White (1973:288), a ‘poor-man’s work’ means low pay levels, the worker is close to dirt and grime, is unable to determine when, where, and what he works at, often doing ‘hard, dirty, night-time jobs’. Various authors have labelled work as ‘dirty’, covering a variety of jobs in different occupations or groups, and varying levels of skill or knowledge. Some examples are: housework (Davidoff 1979); physically heavy, tough work (Reed and Kramis 1996); repetitive, unskilled manufacturing work, shift work (Probert 1989); sanitary work (Perry 1978; Prashad 1995); care of people considered on the margins of society—deviants, drunks, people who have overdosed, homeless persons, welfare and disability recipients (Brown 1989; Jeffery 1984); and body work. Body work includes nursing, midwifery, and hospice care (Hunt and Symonds 1995; Lawler 1991; Lawton 1998; Murcott 1993; Wood 2001). Littlewood (1991:178) has used the term ‘sick dirt’ to describe the demarcation of ‘dirt’ work in hospitals between nurses and domestic staff where the nurses remove one type of pollutant, excretions from the body, such as vomit, urine and faeces, while the domestics remove dust, tidy the spillage from flowers, and do other similar work.

Dirt and the health system

Clinical waste is defined as:

that which has the potential to cause injury, infection or offence, and includes sharps, human tissue waste, laboratory waste, animal waste resulting from medical, dental or veterinary research or treatment that has the potential to cause disease; or any other waste, arising from any source, as specified by the establishment.

(National Health and Medical Research Council 1999:7)

This definition is mirrored in other documents (NSW Health Department 1998, 1999a, 1999b) and they all use the phrase ‘potential to cause… offense’. These definitions support Douglas’s (1966/1992) claim that western concepts of dirt are actually what we have rejected from various symbolic systems and are related to matters of hygiene, or etiquette, or aesthetics. This is made explicit in the National guidelines for waste management in the healthcare industry (National Health and Medical Research Council 1999:9) when it is stated that the disposal of clinical waste is guided by ‘public expectations and aesthetic considerations’ (my emphasis). A similar comment is made in an infection control policy document (NSW Health Department 1992).

Birth dirt

‘Sick dirt’ (Littlewood 1991:178) is insufficient to explain the dirt of childbirth as in most instances the woman is not ill, and even if the process is abnormal it is rare for the dirt of abnormal childbirth to be the same as the dirt of a sick person. The childbirth process is limited by the physiological process and definite time constraints. The period of gestation, the labour and delivery period, and the postpartum period in which the woman adapts to her new body and role are also predetermined and known. The last is a minimum of six weeks, but is extended depending on the time the woman breastfeeds. The exact time frame may vary in different cultures and different times, but it is constructed around the physical reality of childbirth. The rare instances when ‘birth dirt’ would overlap with ‘sick dirt’ would occur when the woman experienced an illness related to the pregnancy—for example, hyperemesis,¹ endometritis,² breast abscess,³ abdominal abscess, wound infection.

Birth dirt exists, but its nature will vary depending on the time, the place and the culture. Who and what is clean or dirty similarly varies and will depend on, and similarly create, the discourses surrounding birth in the particular time, place and culture. Most importantly, the power relationships are reflected in who is ‘clean’ (powerful) and who is ‘dirty’ (powerless). In the 1970s, the dirt of birth was about ‘germs’, or bacteria. In addition to the care of the parturient woman, the midwifery focus of care, which was directed by the obstetricians, was on searching for infections, or potential infections, or preventing infection, with many ritualistic practices based around controlling the pregnant woman. Currently, body substances and fluids are considered ‘dirty’ or contaminating. The midwives’ work now incorporates controlling, containing and cleansing the new dirt of birth. Although the focus of the health professionals in each era examined in the study is different, ‘the relations of power’ remain the same—the control and surveillance of the childbirth process, and of the women, including the midwives.

The dirt of birth

Although during the labour and delivery process all body products are assumed to be contaminating, or dirty, there are particular body parts, or organs, or individuals which are treated as if they are particularly dirty. These are derived from or are unique to the woman’s body. In the videotapes the woman, her baby, and her family are seen as contaminating to varying degrees. Because of the continual potential severity of the contaminating ability of the woman, she is the person who needs to be most constrained. The baby, while dirty at birth, and a source of continual contamination, simply because of size and developmental age, is not a huge contamination problem. The baby can also be seen as a product of the hospital, as it was the management of the woman in labour and birth by the medical and/or midwifery staff which resulted in the birth of the baby. The baby formally becomes a patient at birth and begins a lifetime relationship with medicine.

Female genitalia and modesty

During labour the woman’s reproductive passages, but particularly the genitalia, are a primary focus of the health professionals’ attention or gaze. This is a cause of embarrassment for some women—one participant described and demonstrated how her breasts and genitalia were ‘naughty bits’ or ‘dirt...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Acknowledgements
• Introduction
• Section 1 Mothers, Midwives and Dirt—Past and Present
• Section 2 Breastfeeding as Pollution
• Section 3 The Dais
• Section 4 Leakage and Labelling