The Rhetoric of Pregnancy

Marika Seigel

• Publisher: University of Chicago Press
• Year: 2013
• ISBN:
  9780226072074
• Topic: Scienze sociali
• Subtopic: Sociologia

It is a truth widely acknowledged that if you're pregnant and can afford one, you're going to pick up a pregnancy manual. From What to Expect When You're Expecting to Pregnancy for Dummies, these guides act as portable mentors for women who want advice on how to navigate each stage of pregnancy. Yet few women consider the effect of these manuals—how they propel their readers into a particular system of care or whether the manual they choose reflects or contradicts current medical thinking.
Using a sophisticated rhetorical analysis, Marika Seigel works to deconstruct pregnancy manuals while also identifying ways to improve communication about pregnancy and healthcare. She traces the manuals' evolution from early twentieth-century tomes that instructed readers to unquestioningly turn their pregnancy management over to doctors, to those of the women's health movement that encouraged readers to engage more critically with their care, to modern online sources that sometimes serve commercial interests as much as the mother's.The first book-length study of its kind, The Rhetoric of Pregnancy is a must-read for both users and designers of our prenatal systems—doctors and doulas, scholars and activists, and anyone interested in encouraging active, effective engagement.

1

Operating Instructions for Pregnancy

Instructions inform readers how to make, create, or otherwise manipulate something.

DAN JONES AND KAREN LANE (2002)

My pregnant body didn’t come on slowly, a result of the accumulated evidence of missed periods, cravings, quickening. It came on suddenly, in the minutes between peeing on a stick and seeing a pink cross materialize. (I have to admit, though, that I had had to see two more of those crosses before I really believed.) One of the first things that I did after receiving this positive result was to call the University Health Clinic, tell the receptionist that I was “pretty sure” I was pregnant, and to make an appointment with a doctor. Barely a week later, I paid a visit to that doctor, who further confirmed my pregnancy with a blood test and ultrasound. He pointed out the yolk sack, a black bean sprouting on a blurry field.

After my pregnancy was confirmed, after I felt that it was official, one of my first stops was a mega-chain bookstore with a well-stocked maternity section. I grabbed the book that was most prominently displayed in the bookstore, the title I’d seen frequently on other women’s coffee tables (not to mention on pregnant women’s bedside tables on TV and in the movies): What to Expect When You’re Expecting (Murkoff, Eisenberg, and Hathaway 2002). As I eagerly leafed through the book, I was confronted with lists (one for each month of pregnancy) titled “What You [meaning I, meaning the pregnant woman] May Be Concerned About”: from cesareans and STDs and genetic problems to alcohol and drug use, microwave exposure, occupational hazards, weight gain, and air pollution. Needless to say, I found things “to be concerned about” with which I hadn’t been concerned five minutes ago: the lunchmeat in the sub sandwich I’d had for lunch, for example, and the exhaust spewed by congested downtown traffic.

The book was full of techniques for minimizing the risks posed by these concerns. For instance, I was advised not only to abstain from alcohol and drugs, to follow a “best odds” diet, and to exercise (within limits), but also to be “wary of the superwoman syndrome” (i.e., trying to “do it all,” trying to have a career and a family—guess which one fell by the wayside first?). The manual also emphasized the countless ways that my incompetent, nauseated, bloated, constipated, bleeding body could malfunction. This manual, in effect, told me to see my pregnant body as a risky body and to undertake a program of self-discipline—under the supervision of a qualified medical professional—that would keep those risks in check. I felt disempowered and angry, although at the time I couldn’t articulate what was “wrong” with the manual.

Risk management also defined my birth experience following this first pregnancy. I went into labor five and a half weeks early, and so gave birth at the large regional hospital with attendants whom I did not know rather than at the small regional hospital with one of the certified nurse midwives whom I had been seeing throughout pregnancy. If I had given birth at only five weeks early, I could have stayed at the small regional hospital; but five and a half weeks put me into a high-risk category. I was scared, unprepared, and not in a position to question any procedure pre-, mid-, or postchildbirth.

For example, I was given Pitocin to induce labor, which brought on continuous, unbearable contractions that threatened to cut off the baby’s oxygen supply. I was forced to labor on my left side without moving or changing position so that the baby could be monitored. During this time, an internal fetal and uterine monitor was inserted, a procedure that was excruciatingly painful. Finally, I requested, and was given, an epidural—this was a great relief. Throughout my labor and delivery, medical staff evaded or refused to answer my and my husband’s questions and concerns. After my daughter, Annika, was born, she was immediately brought up to the neonatal intensive care unit. Aside from one short visit, I was told I couldn’t see her again until after the doctors performed their grand rounds the next morning (at about 11:00 am, as I recall). I was told that I couldn’t stay in the neonatal intensive care unit with Annika; instead, I stayed in my hospital room for one night and then was forced to check out of the hospital and to check into a hotel across the street for the remaining time that Annika was in intensive care. Over the course of these days and nights, I walked from the hotel to the hospital every three hours to see Annika and to attempt to breastfeed her (often she was deeply asleep at the times I was allowed to visit, and I could not rouse her to eat). Moreover, Annika was given formula even though I requested—in person and in writing—that she be fed only the breast milk that I was pumping.

Some of these things may seem unrelated to the pregnancy manuals and issues of access to the technological system of prenatal care that I will be discussing, particularly the things that happened after Annika’s birth. I see these events, however, as a continuation of having what Adam Banks calls “functional” rather than “critical access” to the medical-technological system of prenatal care (which overlaps, after all, with the system of childbirth). In Race, Rhetoric, and Technology: Searching for a Higher Ground, Banks argues that “meaningful access to technology” (he’s talking about digital technologies, but what he says applies to all kinds of technological systems) isn’t “just about its availability or proximity to us” (Banks 2006, 138). Rather, in order to be able to “meet the real material, social, cultural, and political needs in their lives and their communities,” people must have all different types of access to technologies and technological systems. First, they must have material access to the technologies. Second, they must have functional access, “the knowledge and skills necessary to use these tools.” Third, they must have experiential access, or the opportunity to use the technologies frequently and to integrate them into their lives. Finally, they must have critical access, to “understand the benefits and problems of these technologies well enough to be able to critique them when necessary and use them when necessary” (and, I would add, to not use them when necessary; Banks 2006, 138).

As a user of this medical-technological system of prenatal care, I had material access to the system (an access that, it is important to note, many women don’t have) and enough knowledge to engage functionally, and effectively, with the system. I was compliant. I followed the rules, had the tests, gained the recommended amount of weight, and so on. In spite of this functional engagement, I still went into labor early (as thousands of women do for unexplained reasons). When I was in the midst of preterm labor and in a high-risk position, I did not know how and when I could question the system, only how to comply with the system. I did not know what my rights were or which procedures I could and could not refuse or about which I could ask for more information before making a decision. Learning how to question the experts, how and when to disengage from the system, and what one’s rights are should be routine prenatal care instruction for both pregnant women and their partners. Although there are certainly procedures that I would, in retrospect, have agreed to again, there are others I could have, and probably should have, questioned or refused and still others I should have demanded that were not offered. I had not, in other words, learned critical access.

The fact that mainstream documentation on the topic of pregnancy and childbirth facilitates functional, rather than critical, access to the technological system of prenatal care would not be such an issue if the system worked well for all its users; if the system was user centered; and if it achieved what it is supposed to achieve. What is the work of pregnancy within this system (whether carried out by doctors, nurses, midwives, partners, or the pregnant woman herself) intended to produce? What is the telos (the purpose or goal)? For many women, and certainly in most pregnancy manuals, the answer would be a “normal” baby, or the healthiest baby possible. Other things that might be produced by the work processes of pregnancy (work processes such as attending prenatal visits; monitoring one’s diet, exercise and weight; reading pregnancy manuals; following medical recommendations) include an “easier” labor, or a labor in which the pregnant woman has more control and autonomy, or a birth process that results in a healthy mother (a normal mother?). If we accept, though, that the goal of working at pregnancy is, and should be, to produce a certain kind of baby (certainly to produce a healthy baby), then the technological system of prenatal care isn’t working, or isn’t working equally for all of its users. Take, for example, the US Department of Health and Human Services’ data on births for 2006–10 (at the time of this writing, 2009 was the latest year for which final data was available; only preliminary data was available for 2010), which shows that the cesarean delivery rate rose 2 percent from 2008 to 2009 to 32.9 percent of all births, a record high. Although preliminary data for 2010 indicate a very slight drop in the C-section rate (to 32.8 percent), the rate has “risen more than 50 percent” since 1996 (Martin et al. 2011, 2).

Although the preterm birth rate (percentage of infants delivered at less than 37 completed weeks of gestation) has declined slightly from 12.33 percent in 2008 to 12.18 percent in 2009 and to 11.99 percent in 2010, the rate “rose more than 20 percent from 1990 through 2006” (Martin et al. 2011, 10). As the authors of the report of preliminary data for 2010 note, “despite recent declines, the preterm rate remains higher than for any year from 1981 through 2001” (Hamilton, Martin, and Ventura 2011, 5). The authors further observe that the decline in 2010 was mostly due to a decline in “late preterm (less than 37 completed weeks of gestation)” births. “The rate for early preterm (less than 34 weeks) births,” the report states, “was essentially stable at 3.50 percent” (Hamilton et al. 2011, 5).

The percentage of babies born at low birth weight also rose steadily through 2006, to 8.3 percent of all births, “the highest level in four decades” (Martin et al. 2009, 2). The percentage of low-birth-weight babies has declined slightly since 2006 (to 8.15 percent in 2010), but the last couple of years have not shown significant declines (Hamilton et al. 2011, 5). The number of women suffering from pregnancy-related hypertension, which can lead to serious complications in pregnancy (including to maternal and infant death) “has risen more than 50 percent since 1990” to 4 percent of all women who gave birth in 2009 (Martin et al. 2011, 2).

Furthermore, according to an October 2008 data brief from the National Center for Health Statistics, “the U.S. infant mortality rate did not decline from 2000 to 2005,” and the U.S., in comparison with other developed countries, ranks a staggering “29^th in the world in infant mortality, tied with Poland and Slovakia” (MacDorman 2008, 2). All of this is in spite of the fact that the rate of prenatal care use, and of early initiation of prenatal care (across races and ethnic groups), has, for the most part, risen over the same time period that preterm birth rates, low-birth-weight rates, and cesarean delivery rates have also been on the upswing—from1990 to 2003, for example, “the proportion of women beginning care in the first trimester of pregnancy has increased 11 percent” (Martin et al. 2005, 2).¹ All of this is also true in spite of the fact that US women have more prenatal care visits, on average, than women in most other European countries (Hamilton, Martin, and Ventura 2007, 14; Martin et al. 2007, 14; Strong 2000, 7), where preterm birth rates and infant mortality rates are significantly lower. There are also significant racial and ethnic disparities in birth outcomes. For example, the infant mortality rate for black women in the United States is more than twice as high as it is for white women (infant mortality rates for Puerto Rican and Native American women are also significantly higher than those for white women). As the National Center for Health Statistics notes, “many of the racial and ethnic differences in infant mortality remain unexplained” or are not adequately explained by differences in “socioeconomic status” and “access to medical care” (MacDorman 2008, 3). There are similar disparities in rates of preterm births and of low-birth-weight babies (Martin et al. 2010, table 24).

All of this is not to say, of course, that prenatal care is the cause of these problems, and it is certainly not to say that women should forgo prenatal care during pregnancy. It is to say, however, that the technological system of prenatal care is in need of change both to facilitate access and to ensure that it is centered on the needs of all of its users. As Thomas Strong has put it, “The conventional wisdom that prenatal care [at least in its current form] is crucial to the well-being of mothers and babies is incongruent with the findings of published medical research and our nation’s experience over the last half-century” (2000, 29). The medical-technological system of prenatal care is a system with which a majority of US women will engage during the course of their lives and is a system that is increasingly positioning them in terms of managing their “risky” bodies and practices in order to perfect the fetus, even extending into what is beginning to be known as “preconception care” (Moos 2008). How we define the work of pregnancy has material consequences on women’s bodies and ways of living and, increasingly, has consequences not only for women who are pregnant but for those who are potentially pregnant as well. For example, in April of 2012 the Women’s Health and Safety Act was signed into law in Arizona—among other provisions, the law defines pregnancy as taking place on the date of a woman’s last menstrual period, which is usually about two weeks before conception actually takes place. As Erin Frost observed in a recent presentation to the Council for Programs in Scientific and Technical Communication, although obstetricians have long calculated gestational age from the first day of the pregnant women’s cycle, legally codifying this medical practice “overrides the role of the medical professional and presumes acontextual similarities for all pregnancies.” Although the law’s intent is mainly to limit the time window during which women can legally have abortions in Arizona, it also means that “any menstruating person in Arizona now exists in a state of perpetual pregnancy, legally speaking” (Frost 2012).

Rhetoric, Feminism, and Technical Communication

In this book, I tell the story of prenatal care through its documentation and look at how it developed alongside of, out of, and sometimes in opposition to the technological system of prenatal care. I seek to understand how instructions for pregnancy came to be articulated in a certain way and how they might be articulated differently. Because pregnancy manuals seek to persuade their users to undertake certain practices while pregnant, to break old habits and form new ones, to be pregnant in certain specific ways, ways that are usually—but not always—articulated to a biomedical context, this book is situated most broadly in conversations about the rhetoric of health and healthcare. As Judy Segal puts it, “The relations of rhetoric and medicine are various and webbed,” from the banter through which a doctor might attempt to identify with her patient during an office visit to the obvious persuasive intent of the ads for sleep aids and antidepressants that pervade daytime television to the citations that contribute to the credibility of an article in a medical journal (Segal 2005, 2). As Barbara Heifferon and Stuart Brown put it in the introduction to their collection of essays titled The Rhetoric of Healthcare, scholarship in this area “initiates inquiry into the role of rhetoric in various health care and medical discourses and examines what rhetoric—as a discipline in its own right—can contribute to this complex and essential field” (Heifferon and Brown 2008, 2). Likewise, I employ methods of rhetorical analysis both to better understand pregnancy manuals and to suggest ways that such methods could be employed to improve communication about pregnancy. (I describe my specific method of rhetorical-cultural analysis in more detail in the next chapter.)

This book also draws from and contributes to feminist scholarship about pregnancy, childbirth, and technologies of reproduction that has been conducted in a number of fields, including history, anthropology, sociology, philosophy, rhetoric, and science studies. In some ways, as Alice Adams argues, pregnancy seems “to reassert in some primitive way [a woman’s] functional service to the species” (1994, 80). Many feminist scholars have described how medical, scientific, cultural, philosophical, and technological discourses and developments work to highlight that functionality and to downplay women’s humanity. Scholars such as Janelle Taylor and Barbara Duden have chronicled how technologies of visualization have made the fetus a public figure, disconnected from the maternal environment (Taylor 2008; Duden 1993). Dorothy Roberts has argued that technologies of “temporary sterilization” such as Norplant and Depo-Provera are disproportionately deployed on low-income African American women (as incentive or punishment), whose reproduction is deemed to be a threat to society (1997, 106). Elizabeth Ettorre and Rayna Rapp have similarly observed how technologies like genetic prenatal testing as well as the reproductive technologies such as in vitro fertilization are partially influenced by neoeugenic discourse that dictates who has the right to be born and who has the right to reproduce (Ettorre 2000, 2001; Rapp 1999). Scholars such as Ann Oakley and Emily Martin have described how pregnancy became an object to be dissected by the medical gaze and how the pregnant body became governed by metaphors of machinery, consumption, and production (Oakley 1984; Martin 1992). Within feminist circles, there has also been much critiquing of the medical, technological, and intervention-heavy approach to childbirth, an approach that, critics argue, frequently alienates women, makes them feel out of control of the birthing process, and facilitates unnecessary, painful, and sometimes traumatic procedures (Block 2008; Davis-Floyd [1992] 2003; Kitzinger 2006; Leavitt 1986; Martin 1992; Wertz and Wertz 1989).

As I will argue in the next chapter, pregnancy manuals are a kind of technical communication—they are concerned with procedure and instruction. Research in technical communication and usability has long been concerned with describing what makes instructions effective and ineffective and, thus, is also essential to understanding these particular instructional documents. Specifically, however, this project is a contribution to feminist research in technical communication, which seeks to expand the scope of what counts as technical writing both to reclaim women’s contributions to the field and to “challenge the dualistic thinking that severs public and private, household and industry, and masculine and feminine labor” (Durack 1997, 257). Some of the work in technical communication that I would characterize as feminist and that has been influential to my own work includes Elizabeth Tebeaux’s work on Renaissance-era household management manuals (Tebeaux and Lay 1992), Kathryn Neeley’s work on women’s “mediated” writing about science and technology in the eighteenth and nineteenth centuries (1992), Durack’s work on sewing machine documentation (1998), Amy Koerber’s work on breastfeeding documentation and discourses (2005), M...

Table of contents

• Cover
• Copyright
• Title Page
• Dedication
• Epigraph
• Contents
• Foreword
• Acknowledgments
• 1. Operating Instructions for Pregnancy
• 2. Usable Pregnancy
• 3. The Father of Prenantal Care: J. W. Ballantyne and System-Constitutive Documentation
• 4. The Mothers of Prenatal Care: Elizabeth Putnam, the IDNA, and User-Centered Care
• 5. Getting in the Way: Pregnancy Manuals during the Women’s Health Movement
• 6. What to Expect from Risk Management
• 7. System Error: Troubleshooting the Pregnant Body
• 8. Virtually Pregnant: Consuming Prenatal Care
• Conclusion: Instructions for Systemic Change
• Notes
• References
• Index