Part 1 (2/2)

In pregnancy care, technological innovation has undoubtedly brought greater safety and a higher likelihood of a safe delivery. Ultrasound scanning and various other forms of screening as well as diagnostic tests help to reveal conditions in the foetus (e.g. heart defects, Down's syndrome) and the mother (e.g. gestational diabetes, pre-eclampsia). The value of this information is seldom questioned but the benet of screening for foetal health in illuminating risks for individual women has to be weighed against the risk of harm from seeking that information. Most women will have screening for foetal health for rea.s.surance that nothing is 'wrong'. Indeed, Marteau (2002) has pointed out that many women do not realise that ultrasound, for example, can detect foetal anomalies, or that many screening tests are not diagnostic and produce results which are not denitive but probabilistic. Some results of tests are difcult to interpret even for the professionals conducting the tests as they reveal anomalies which may be signs of serious conditions or which may resolve themselves during the pregnancy. There is high morbidity a.s.sociated with both false negative and false positive results and the raised awareness of risks itself raises anxiety.

At the level of behavioural advice, women are expected to act on information presented to them by midwives and general pract.i.tioners, but also respond to information which is often presented in a sensationalist manner by the media, including, increasingly, the internet. What is arisk behaviour' may be dened not by scientists who collect the data but by the media who present those data. As we explore in several of the following chapters, information about what is harmful or benecial to women and their babies may be presented as black and white with apparently little concern for the impact this has on women's decision making during pregnancy, or their emotional wellbeing. What is more, the behavioural advice presented will often come too late for many women to act on it, relating as it does to preconception or early pregnancy. Thus, the concept of thegood mother' extends back to before the baby is actually born. In weighing up current scientic opinion with the views of social commentators presenting a position in opposition to conventional medicine, women are accepting that the locus of control is within themselves.

As psychologists we seek to understand these feelings of uncertainty and risk at a time of increasing certainty and safety by considering the individual processes which underlie such feelings. Two areas of research, in psychology and in the social sciences more generally, seem to be relevant here. The rst area is concerned with individual perception and a.s.sessment of risk, and the second with the social amplication of risk through the ma.s.s media.

14.We now understand a great deal about how people judge the likelihood of an event or their risk of experiencing a particular outcome. Early work on decision making in health a.s.sumed that people consider how pleasant or unpleasant outcomes of certain courses of action are and weight them by how likely each outcome is. So they will, consciously or unconsciously, choose the course of action with the highest weighted score. This is known as 'subjective expected utility theory'. The empirical evidence that people do not necessarily make decisions in this way, even when encouraged to do so by 'decision support' systems, has led many professionals, particularly economists and doctors, to the conclusion that people are not good decision makers. However, we can show that the mechanisms that people use most of the time will lead them to decisions which are best for them, with the least cognitive effort. In understanding these mechanisms we can understand the way that women use the information presented to them, and act upon it. Of key importance to the experience of pregnancy is, rst, the perception of categorical safety or threat, so behaviour is perceived as either risky or not (Redelmeier et al., 1993). This inuences not just the way in which information is perceived but also the way it is presented.

Second, people have difculty in distinguis.h.i.+ng between very small probabilities, and the value of following one course of action rather than another may appear obvious to an epidemiologist considering populations but not to a lay person considering only their individual risk status. Finally, outcomes that are easier to bring to mind are judged to be more likely; this has been termed the availability bias' (Tversky and Kahneman, 1981). The ease with which an outcome is brought to mind is inuenced by how frequently or recently a person has been aware of it and also by strong emotions being a.s.sociated with it. So, media coverage of a particular hazard or event makes it seem more likely. The literature in this area has been dominated by these cognitive mechanisms, however, more recently researchers have returned to considering the ways in which emotions such as antic.i.p.ated regret' inuence perceptions of risk and concomitant decisions. For example, Wroe et al. (2005) have shown that parents' decisions on vaccination are inuenced by emotion, and particularly that risk a.s.sociated with inaction is perceived as more acceptable than positive actions.

In recent years both researchers and political and social commentators have become increasingly interested in the way in which risk is propagated, particularly by the ma.s.s media. This 'social amplication' of risk not only makes people aware of hazards they may face but also tends to encourage a distrust of experts and organisations involved in risk management. This leads to uncertainty and feelings of danger. Different types of media, even different types within media (e.g. tabloid and broadsheet newspapers), produce different narratives of risk (Murdock et al., 2003). So, women are confronted both by fcial' information produced and disseminated by 15 health professionals and information produced by a wide range of media, which command varying degrees of trust.

How then do individual women respond to the risks presented to them by different sources? Joffe (2003) has suggested that, when presented with the likelihood of hazards, individuals use the ways of reasoning and the values common to the groups with which they identify. Thus, the source of the threat and how that source is viewed, and the way the threat is linked in to group ident.i.ty, will determine how an individual will respond. If women are relying more on external representations of risk and less on their embodied experience then it is likely that their decisions and actions are better understood by examining the values of the group to which they belong rather than the scientic evidence presented. If we accept that individual actions are guided by cultural and subcultural values then screening technologies and information presented with a view to guiding women to one course of action (e.g. terminating pregnancies where the baby would be born with a life-limiting condition) may lead to unexpected effects on a large scale. These might include a growing opposition to the termination of pregnancy because of its use to prevent the birth of children with what to most groups would seem not to be a serious condition (e.g.

cleft palate), or, conversely, the distortion of population, e.g. through s.e.x-selective abortions, which has led to a shortage of girls in some states where boys are more highly valued.

This leads us to another paradox of pregnancy. Reproductive technologies and risk interventions while reducing uncertainty at one level appear to make individual pregnancies more uncertain.

Being a little bit pregnant The change between being not pregnant and being pregnant has long been used as an example of a quantum change in colloquial English. The sentenceyou can't be a little bit pregnant' is used to challenge a position of uncertainty. However, the earlier detection of pregnancy itself or problems with the pregnancy and the possibility of preventing the birth of babies with serious health problems have led to what Barbara Katz Rothman (1986) has memorably termed thetentative pregnancy'.

Pregnancy testing kits were rst actively marketed for home use in the 1970s, a development of near patient testing used by health professionals to test patients without recourse to laboratory facilities. Manufacturers and suppliers are driven by commercial concerns, albeit tempered by ethical and social considerations. The use of this technology was for some time treated with suspicion by doctors and pharmacists (Stim, 1976).

However, home pregnancy testing has been absorbed into routine antenatal care, and has improved in reliability and ease of use as demand for it has increased. Its use has been further sanctioned in the UK by the 16 evaluation of over-the-counter tests by the Medical Devices Agency. Self-testing may be seen as part of the development of aself-care culture', discussed above, with patients as 'consumers' taking more responsibility for their own health, and having rights over information about their bodies (Lupton, 1997). NHS Direct, drop-in health centres on the high street and health sites on the internet are other manifestations of this movement. The use of these technologies in the home must be set against the wider social and cultural context in which a changing healthcare system impacts on patient behaviour and relations.h.i.+ps between patients and healthcare professionals (Rose, 1990). Most importantly here, pregnancy testing allows women to conrm a pregnancy long before the signs and symptoms of pregnancy appear and without conrmation from health professionals who hold privileged knowledge. At once a pregnancy becomes a reality at a much early stage and also is less likely to result in the birth of a baby: a pregnancy which ends early can no longer be regarded as amissed period'

but has to be regarded as a failed pregnancy and the pregnancy test is just the rst of many tests which will lead to decisions about whether the pregnancy should continue or not. Lewando-Hundt and her colleagues (2004) discovered that 37 per cent of women who were receiving antenatal care in a UK centre which did not offer rst trimester screening for Down's syndrome paid to have this screening done privately.

Barbara Katz Rothman in her book The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood (1993) suggested that the introduction of amniocentesis irrevocably changed the way that pregnancy was viewed both by pregnant women themselves and their partners, and by those others not directly involved. Rather than the birth of a baby with, for example, Down's syndrome being regarded as a family misfortune, it is now regarded as a personally avoidable mistake. Thus, the ability to test the health of the foetus has led to the possibility of embark-ing on a pregnancy which will not necessarily have to be seen to term.

The case of amniocentesis was complicated by the danger inherent in the procedure itself, particularly in the early days. So the risk of terminating a wanted pregnancy through this invasive procedure had to be weighed against the possibility of giving birth to an unwanted' baby if the procedure was not undertaken. The a.s.sumption was made that if a woman chose to have an amniocentesis she must be willing to terminate the pregnancy if the result was positive. Nowadays, not only is amniocentesis much less likely to lead to an unintended termination, but also it has largely been superseded by other technologies which provide more or less denitive results on the health status of the foetus without any risk of termination, being based on blood samples or imaging techniques. However, the a.s.sumption still seems to be made that if a woman is willing to undergo testing she must be willing to act on the basis of the information provided to terminate a foetus that is not 'perfect'. This is particularly the 17 case when technologies provide this information very early in pregnancy, that is, when the woman is only a little bit' pregnant.

Jenny Hewison and her colleagues (2004) have posed the question of who sets the agenda for technological development in antenatal testing.

They have investigated the views of mothers living in the north of England from Pakistani and white European ethnic origins, on the range of antenatal diagnostic tests which could become available and the value of the information afforded by them. Using a set of scenarios which described, but did not name, various conditions, women were asked rst whether they would test for each condition and second whether they would terminate a foetus discovered to have this condition. There was considerable agreement on the conditions which women would most want tests for and for which they would seek termination of pregnancy: anencephaly, trisomy 13 or 18 (which lead to death within months of birth), quadriplegia and d.u.c.h.enne muscular dystrophy. However, fewer than 25 per cent of the women questioned would consider a termination for most conditions and there was great divergence in what conditions would be so severe that the woman would feel that termination was better than continuing with the pregnancy. These include conditions for which tests are currently widely available, such as Down's syndrome. Furthermore, the percentage of women who wanted antenatal diagnosis for each condition was far higher than the percentage of women who would consider termination.

So the development of antenatal testing services seems to be being driven by the technology. However, this is not to say that the women studied by Hewison and her co-workers were not very much in favour of these developments, but that what they want from testing is information, not a way of ensuring a perfect baby. Giddens (1991) talks of 'colonizing the future' by attempting to predict risk of hazards and preventing them; however, for women contemplating the health of their children the prediction seems to be far more important than the prevention, at least at any cost.

The secret made visible We have discussed above the impact of antenatal scanning and testing on the individual choices that women now have to make about their pregnancy. However, there is another important aspect of this technology and that is that testing is taking precedence over the private lived experience of the mother. As we have said, pregnancy was formerly conrmed and monitored through the embodied experience of the mother. Now that experience is made public through technological means. Foremost among these technologies is ultrasound scanning, which provides pictures of the foetus.

Ultrasound scanning is the most commonly used screening technology in antenatal care and is taken up by the overwhelming majority of pregnant 18 women in the developed world. It has long been used to check that the foetus is alive, has no major abnormalities and to check that the date of conception estimated from the mother's account ts with the growth of the baby. As the technology has become more sophisticated it is possible to produce very high-denition pictures and to detect more signs of abnormality at an earlier stage, for example nuchal fold abnormalities seen in foetuses with Down's syndrome.

Parents generally welcome the chance to see the foetus. Indeed, the visual record of a baby's life is now likely to start with the rst ultrasound picture.

The visual representation is a very powerful mechanism which turns a foetus into a baby. Both parents, and indeed others, are able to experience the foetus and therefore bond with it, rather than just the mother. In 2004 Stuart Campbell released 3D and 4D pictures and 'lms' of foetuses from 12 weeks, showing the development of behavioural routines such as 'stepping'. The pictures were incorporated in a book Watch Me Grow!

(Campbell, 2004), which has become a bestseller. However, the release of these pictures, particularly real-time depictions of the movement of foetuses, fuelled debate on termination of pregnancy and led to calls to restrict the ability of women to terminate pregnancy even in the rst trimester. High-denition ultrasound has made the foetus appear more like a person not only to the mother carrying that foetus, but to the public at large.

Through ultrasound scanning the foetus is literally put under surveillance, without any input from the mother other than her consent and presence. The mother in the ultrasound picture is a container, or rather a frame, for the subject. The primacy of her intimate and private experience of the growing foetus has been overtaken by the distanced and public scrutiny by health professionals and others. Rather like a wedding where more time is spent on capturing the event in photographs than on the ceremony, the visual record of the foetus is given more credence than the account of the person who is present at the event.

So far in this chapter we may have appeared to take a rather negative view of the consequences for pregnancy of the information age. So before going on, let us reiterate here that advances in technology and understanding of the processes of pregnancy and birth have undoubtedly improved the experience of pregnancy and childbirth for many women.

Although the onus of decision making has s.h.i.+fted to the individual, many women would welcome that empowerment. And although pregnant women are now bombarded with information and advice, many women welcome, desire and seek them out. From the pregnancy test which allows them to conrm their own pregnancy, through the web pages and magazines which allow them to learn about pregnancy for themselves, the rst ultrasound picture which takes its place in the family alb.u.m, to the prior warnings of difculties with the baby's health or birth which allow 19 action to be taken and preparation, many women feel that the greater control and rea.s.surance offered now is a price worth paying for the rise in responsibility and anxiety which may accompany them.

Absence of women in research on the most feminine of states The research reviewed above in relation to women's experience of, and response to, reproductive technology is largely atypical of research on pregnancy in that the views and motivations of women have been sought and studied; though even in this area, such views are seldom sought before the technology is introduced. In most of the research we will be reviewing in this book, the women themselves, as actors, seem curiously absent. Most research concentrates on the outcome of pregnancy related to the baby.

While the behaviour of women may be mapped and linked a.s.siduously to particular pregnancy outcomes, and women judged on the basis of their behaviour, the motivations and beliefs of individual women are seldom sought. Rather, their health, behaviour and even state of mind are regarded as characteristics of the container of the foetus. In the chapters that follow we will return to this theme and we hope that it will become clear that one of the motivations of our own research on pregnancy is to put the psychology of women back at the centre of this uniquely feminine experience.

Pregnancy as an exceptional normal state There are several senses in which pregnancy is simultaneously regarded as a normal and exceptional state. As we commented in Chapter 1, pregnancy is becoming an increasingly uncommon event for individuals, especially in Europe, where the birthrate has long been below replacement levels for the majority ethnic groups. Yet pregnancy is regarded as a commonplace experience. This is particularly the case in the workplace, where pregnancy may be a common event among the staff of a large employer. Any individual woman on that staff, however, is likely to only experience being pregnant at that workplace once. This may help to explain the level of prejudice that women experience when they announce that they are pregnant. As we have found in our own work, fellow workers and employers may regard pregnant workers as a group as incapable of carrying out their jobs and as unfairly ent.i.tled to special treatment and benets. At the same time they may have very positive views of individual pregnant women they have worked with (Pattison et al., 1997).

In this chapter we have concentrated on the construction of pregnancy and the implications of that construction in the developed world. One of the reasons for this is that although pregnancy is a universal experience, it is seldom studied or even considered from a cross-cultural perspective.

Simultaneously, two positions are held, sometimes by the same researchers.

20.The rst is that all women are basically alike in their reproductive processes and that pregnancy can be dened by the physiological changes women undergo. If this holds, then cross-cultural comparisons will add little to the studies of partic.i.p.ants readily available to researchers in their local environs. We will see this perspective dominating the research on cognition in pregnancy in Chapter 3. The second perspective is that resource availability and social conditions vary to such an extent across the world that information needs to be gathered on women who are alike in these regards. This is the perspective that dominates research on pregnancy and work covered in Chapter 4. However, where cross-cultural comparisons are made the results can be illuminating in understanding the interplay between the physiological and the psychological. For example, studies of dietary habits of women from different cultures could be interpreted as showing that the basic motivations of women are the same, which is that physiological changes and demands prompt behaviour to improve the health of the baby. However, depending on the cultural beliefs, these may be manifest in eating earth in one culture or vitamin pills in another (Henry and Kwong, 2003). See Chapter 5 for a further exposition of this point.

Another sense in which pregnancy is both normal and exceptional is as a natural process which is still highly medicalised for most women in the developed world. In recent decades organisations such as the National Childbirth Trust in the UK have supported pregnant women by providing information and education, and attempting to limit the amount of medical intervention that women experience. However, the National Childbirth Trust itself brings together unlikely allies. It was founded in 1957 to champion the position of doctors, notably Grant d.i.c.k-Read, who felt that middle-cla.s.s women were being put off childbearing through poor preparation for birth, leading to fear, particularly of the pain involved.

This eugenic motivation is far from the motivations of feminist champions of natural childbirth who see the medical model of pregnancy and childbirth as an example of the way that patriarchies control women. The natural childbirth movement has led to changes in the way women are treated and certainly to the way that many women now give birth. At the same time, though, the reproductive technologies described above, the fear of litigation if a baby is not born healthy and the trend for women to have fewer babies have led to the medicalisation of pregnancy on an unparalleled scale.

Is there never a good time to be pregnant?

Women in the developed world now have unprecedented control over the timing of childbearing. Advances in contraception, fertility monitoring devices and a.s.sisted reproductive technology have meant that most women can choose to have children and choose when to have them. However, 21 the timing of pregnancy is hedged around by conicting cultural mores.

Teenagers, older women, women without a job and women with careers are all publicly criticised for choosing to have children when they do.

Similarly, white European women are criticised for having single children; the natalist policies of many European countries, notably France, provide considerable welfare support for families with several children. A similar natalist approach to benets is taken in Australia by the current Conserva-tive administration. However, at the same time, and in the same countries, minority ethnic women are criticised for having several children and beneting from that welfare support. Central to this general disapproval seems to be the a.s.sumptions that women are exercising choice and that once again the avoidance of risk is a matter of personal decision making.

Furthermore, though, the belief is held that in exercising choice women are pursuing their own selsh ends. So older women are a.s.sumed to be putting their career rst, and younger women are portrayed as avoiding earning a living by having children at the times they do. Little credence is given to the view that when heteros.e.xual women choose to have children is inuenced largely by the presence and willingness of men to act as fathers. Indeed, the role of men in the creation of families is rarely considered in these discourses. The importance of the presence of a suitable and willing putative father in the choice to have children was highlighted in Fiona McAllister and Lynda Clarke's (1998) study of childlessness in Britain. They found that those childless women they interviewed who were living alone held conventional views on partners.h.i.+ps and would not contemplate becoming a single parent. In general, decisions to remain childless, and, by extension, to delay childbearing, were not made in a vacuum but rather crucially depended on relations.h.i.+ps with partners and the perceived suitability of women's circ.u.mstances for parenthood.

At the extreme, the view of women caring for their own interests over the interests of their children leads to policies which curtail the rights of pregnant women over their own bodies. Sheena Meredith (2005) in her book Policing Pregnancy: The Law and Ethics of Obstetric Conict makes a powerful case that in recent case law in the US and the UK pregnant women are denied the rights of self-determination and bodily integrity which are enshrined in law for all others. Such cases arise when health professions do not agree with the women themselves on best courses of action or behaviour. Thus, the pregnant woman nds herself in legal con- ict with her foetus, or rather others who regard themselves as more suitable guardians of the foetus.

The debilitated nurturing In reviewing the research literature on pregnancy, one could be forgiven for questioning whether women are t to be mothers. We suggest that beliefs 22 about pregnant women reect wider beliefs about women generally, perhaps because pregnancy provides such clear evidence of femininity.

Traditional beliefs about women in Western society are characterised by beliefs about the weakness and vulnerability of women. So women are seen as theweaker vessel', p.r.o.ne to debilitation, in need of protection from men and governed by irrational and emotional thinking. As reproduction most clearly delineates s.e.x if not gender, these stereotypical views of women tend to be most clearly connected to women in aspects of reproduction: menstruation and the menopause, but above all pregnancy. We are left, then, with the view that women are at their most vulnerable when they are responsible for the wellbeing of unborn children. Researchers seldom discuss or engage with this anomalous position, yet it is a strong inuence on the kind of research which is carried out and how results are interpreted.

Sanctioned behaviour The word 'sanction

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