Part 5 (1/2)

Of course, it is always possible that women were reporting advice and information from health professionals and family or friends that was in line with their own preferred behaviour. There have been suggestions at various times that pregnancy may afford women the opportunity to avoid other life tasks (Artal and Gardin, 1991; Harris and Campbell, 1999). However, our examination of women's responses to advice does not suggest this and nor does work by Rodriguez et al. (2000) on psychosocial predictors of smoking and exercise, which suggests that the same factors predict exercise in pregnancy as predict health behaviours in general. Nevertheless, when we are discussing daily domestic and recreational activity rather than exercise, the women in the study certainly suggested that they were taking the opportunity to avoid doing things they had never liked very much, such as less housework, not going down into the cellar: t's a good excuse really'. Pregnancy can clearly be a time when various forms of advice give legitimacy to particular types of behaviour and pregnancy itself provides a buffer to unwanted activity. It remains to be seen whether the increasing emphasis on tness and exercise will lter through into the context of lay advice on pregnancy, given that existing research which sanctions activity and exercise would seem to make little difference to the cultural stereotypes of maternal responsibility and preparation.

It would be unfair on the women involved to give the impression that they all reduced their activity wherever they could. Although it was certainly the case that some of the women we talked to did relinquish activities, others continued to be active and took the opportunity of nis.h.i.+ng paid work to do household jobs, such as preparing the home for the new baby, and tried to retain their social lives at the same time as taking care of themselves. Effectively we are talking about the way that different individual women negotiated the information and advice they received and the pressure they felt to conform to other people's expectations. In some cases, such negotiation involved adopting the behaviour that was expected of them, such as resting or doing less, while at the same time developing various coping strategies that allowed them to continue to 115 partic.i.p.ate, through, for example: carefully monitoring the consequences of their activities and giving them up if they did not feel comfortable; pacing themselves, by which they meant nding ways to complete a comparable level of activity to that prior to pregnancy, such as dividing it into shorter and shorter episodes (as discussed in Chapter 4); and by forward planning whereby the women considered what they were hoping to do, the context in which it would occur and the implications it might have either physically or socially. Then they would make a conscious decision whether or not to partic.i.p.ate. In this way the women we talked to were able throughout their pregnancy to do most of the things that they wanted to do but with some changes in the speed or location of these activities. In addition, for some other women, pregnancy did give them a licence to leave things to others.

It must also be acknowledged that numerous other factors may discourage women from maintaining their habitual daily activity pattern during pregnancy. Although outside inuences, including family and friends, often served to discourage physical activity in pregnancy, these women indicated that they themselves considered their behaviour to be appropriate during pregnancy t's obvious isn't it' and stated that at least part of their decision to change their activity, either at work or at home, had been their own choice, as much a result of their own personal preferences as it was a response to external expectation or information, activity advice or att.i.tude to healthy behaviours. Thus, for example, a high level of importance was attributed to rest and relaxation and a lower level of importance to physical activity. If a woman also believes that she rather than professionals or chance will determine the outcome, that is, a healthy baby, then the predominance of the highly visible recommendations of rest and the reduction of tiredness may also be regarded as a legitimate priority, whatever the apparent benets of exercise for good health in the longer term.

Concluding remarks There is no doubt, as the ACOG guidelines and all the evidence we have discussed conrm, that a certain amount and level of exercise is a good thing' in pregnancy for women, for labour and delivery and for a healthy baby. In addition, it has longer-term health benets. For the same reasons, maintaining an active lifestyle is also a good thing; even if it does not carry quite the same level of positive benets, it may be much easier to sustain over time. Advice is quite clear on the matter, wherever it is found, and it does address some aspects of daily lives as well as strenuous physical exercise. But, ironically, within the framework of supervision that surrounds pregnancy in the early twenty-rst century (Lupton, 1999), understanding how to behave in response to advice may actually become 116 increasingly difcult. There are competing demands to be met and negotiated by each pregnant woman. The biomedical discourses of pregnancy, in the ascendant with the advent of technologies of reproduction and replete with research evidence, place women as responsible for the pregnancy outcome. Thus, professional health advice, arising from research, exhorts necessary changes in behaviour or at least maintenance of an active lifestyle.

The professional advice gives permission for women to be active, as long as it is in the service of a healthy outcome. At the same time, lay discourses of pregnancy, while paying homage to the power of the professionals, have not yet taken account of the research evidence and place women within the stereotypical feminine role, lacking agency and control, unable to act on any advice but that of family and friends, who in turn have recourse to powerful cultural expectations. By this means, women are granted permission to be inactive in order to ensure healthy outcomes. Moreover, the advice itself is ambiguous. Physical activity is good but fraught with risks, thus caution needs to be exercised in order to prevent damage to themselves or the baby; by contrast, tiredness, a natural concomitant of pregnancy, has high visibility and women are given permission to take advantage of their pregnant role and moderate their behaviour.

7.PREGNANCY UNDER SURVEILLANCE.

In the preceding chapters we have explored how women may or may not change their behaviour during pregnancy. In some cases the changes are founded on information from research. The need to take action in accord-ance with advice can be seen as reasonable. However, it has been our contention that this message to change behaviour reects a number of a.s.sumptions about women's behaviour, their role as mothers and their responsibility to others. We would argue that this apparently reasonable set of requirements actually subjects women to a degree of oversight that could be described as a form of surveillance. In many ways this is integral to much of women's experience inasmuch as their appearance and behaviour are frequently subject to public scrutiny and criticism. This is particularly the case for women who are, for one reason or another, in the public eye. In this chapter we look at the way that pregnancy has been represented in the media and we focus on the images and representations of pregnancy and the pregnancy of public gures, in order to examine how the public sanctioning of behaviour is enacted.

Pregnancy in the public eye.

Pregnancy is highly visible. This visibility reects the ongoing public interest, is amply demonstrated by the comments made to women once their pregnancy is announced and includes extensive coverage of celebrity pregnancies in what is now a global media. Leaving aside the issue of celebrity for a moment, this visibility can partly be explained as inherent in the accompanying physical changes that occur over the nine months of pregnancy. However, in part and more recently, it is also because fas.h.i.+ons for maternity clothing have made this change much more obvious, as Robyn Longhurst (2005: 438) points out in her paper on this topic: 'maternity wear has become maternity fas.h.i.+on' so-called 'b.u.mp chic'. A Danish anthro-pologist, Tove Engelhardt Matthia.s.sen, ill.u.s.trates this s.h.i.+ft by highlighting the way that clothing has moved from veiling or hiding pregnancy, by the loose and shapeless garments worn by women in the twentieth century up to 118 the mid-1960s, to the current point where maternity fas.h.i.+on has become chic, through the use of stretch fabrics and the prevalence of tted women's clothing. Matthia.s.sen suggests that this is because n an era of sports and well-trained bodies you have to survive the bodily changes of pregnancies by being fas.h.i.+onable' (Matthia.s.sen, 2005: 5).

In addition to the visibility created by changes in fas.h.i.+on, we can think in terms of different kinds of visibility, since most women who become pregnant do not attract media attention. The rst type of visibility is that which arises from pregnancies that are considered atypical or abnormal because of their non-adherence to the standard images of pregnancy available to us. As discussed in Chapter 2, unusual or abnormal pregnancies which attract attention are typically a.s.sociated with specic individuals, and include single motherhood, especially where a partner may have died before conception; for example in the UK in 1999 Diane Blood applied to the courts for permission to use her dead husband's sperm for IVF. Other examples are: multiple pregnancies, especially where more than three babies are expected; very young (possibly too young) or teenage pregnancy (for example girls sitting their school exams); or the pregnancy of much older women, for example women who give birth at 58 and older following IVF. Other noteworthy examples are those resulting from new a.s.sisted conception technologies and also include surrogate pregnancies. The infrequency of these occurrences is what makes them visible or newsworthy. It also opens the door to signicant commentary on the women concerned and their behaviour. The commentary is then personalised and referenced with respect to the expected outcome, which is the baby. Thus, the gaze on women permits directed comment towards the pregnancy and clearly emphasises the metaphor of containment inherent within public concerns about pregnancy: 'your baby has grown since I last saw you'.

Second, pregnancy may be made visible because of some feature relating to the nature of the women themselves. In this category, we can place women in the public domain, such as celebrities, wives or partners of well-known or famous gures, such as Cherie Blair (the British Prime Minister's wife) or members of royal families, for example Princess Kiko of j.a.pan.

Thinking of visibility in this way allows us to explore the various aspects of the visibility of pregnancy in relation to the nature of the pregnancy and the nature of the individual. In both cases, we would argue, the nature of this visibility tends to prompt critical comment.

Furthermore, the increased understanding of the developmental signi- cance of the foetal experience in utero, which ranges from genetic and chromosomal effects to the potential toxins crossing the placenta, to the potential for inuencing intelligence and behaviour, has reinforced the pressure on all women to maintain a healthy lifestyle during pregnancy and preconception. The emphasis on containment provokes a plethora of advice to women on how to behave. As the previous chapters have ill.u.s.trated, 119 advice can be viewed as a means by which pregnant women are in effect held publicly accountable for their behaviour, and is recently demonstrated by the US federal guidelines asking women between the onset of menstruation and the menopause to treat themselves as 'pre-pregnant' at all times (Was.h.i.+ngton Post, 16 May 2006).

In the context of the medical/biological discourses of pregnancy this public accountability is perhaps hardly surprising. It has been happening for some time. Katherine Barker (Barker, 1998) ill.u.s.trates how the medicalisation of pregnancy was systematically introduced through a public health campaign in the US in the early part of the nineteenth century. By examining the content of a widely distributed manual developed at the time, Prenatal Care, she shows how pregnancy was conceptualised as a medically problematic state. Woollett and Marshall (1997) present a similar case through examples of this process in their a.n.a.lysis of publications on childbirth and our study of how employment is presented in these types of publications conrms the prevalence of the discourses of personal and public responsibility within a medical discourse of pregnancy (Gross and Pattison, 2001). Once pregnancy is dened as a medical event, its management is devolved to external and expert sources, which simultaneously draw women into the need to partic.i.p.ate in specialised procedures that a.s.sist in ensuring a healthy outcome. It can be argued that once it was removed from the exclusively domestic sphere of home where traditionally women were in control, pregnancy and pregnant women were accorded the increased visibility a.s.sociated with presence in the public domain.

In addition to the routine screening, monitoring, check-ups and the gamut of advice which make pregnancy public, there are a number of other ways that pregnancy is made publicly visible and open to scrutiny. One way that we can conceptualise this scrutiny is to examine how the atypical' pregnancies we identied in Chapter 1 and Chapter 2 are presented and to explore what it is that provokes such attention.

Atypical or abnormal pregnancies In order for a pregnancy to be newsworthy it must in some way be contrasted with what is considered to be normal pregnancy, which routinely receives little media attention although there is ongoing scrutiny in the medical domain. What is normal is obviously a statistical phenomenon. However, as the research by Linnell and Bredmar (1996) highlights and the overwhelming content of pregnancy and birth magazines regularly emphasises, what is normal as a pregnancy is as much determined by the outcome as by the process. Nevertheless, there are some ways that we can conceptualise what is generally understood as a normal pregnancy and this revolves around the notion of the Good Mother and its converse, the Bad Mother.

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While motherhood is highly valued in society, the attribution of that value being a good mother is largely restricted to pregnancy occurring within proscribed boundaries. Outside these boundaries, pregnancy may be seen as deviant. When the criteria of the Good Mother are met, she is accorded little attention. Conversely, women who fail to meet the criteria a.s.sociated with the Good Mother are accorded greater visibility, since being viewed as wanting in comparison brings with it automatic censure.

Thus, the Good Mother status can be bestowed upon women who are pregnant and married, or at the very least in a stable and usually heteros.e.xual relations.h.i.+p, who are of a certain age and who are willing to conform to the required changes in behaviour. Therefore, one potential form of bad mothering is pregnancy outside marriage, as shown by the examples of treatment at work cited in Chapter 4. Given that in 2005, gures from the UK's Ofce of National Statistics suggest that in Britain cohabiting couples equal or outnumber married couples, this places a large number of women who might become pregnant in a position where they will attract comment. The Eurostat (2004) gures also indicate that nearly half of births occurring in the UK are to non-married women. Outside the UK, Australia and the US also have high national rates of unmarried (rather than non-married) women, at 32 per cent and 30.6 per cent respectively (2004/05 gures). These gures in themselves contain the potential for s.h.i.+fting what is considered normal, though this has not typically been the response. Traditional family structures remain paramount. In addition to traditional family patterns, the legitimate childbearing years also clearly exclude girls under 16 and women over normal childbearing age (49). With the average age of rst pregnancy in some European countries at nearly 30 and in Australia at 30.6, these two groups of women, which also include teenage parents more generally, are considered to bebad mothers' and we discuss them in more detail below.

Moreover, it is also considered to be the norm that pregnancy is a positive and even uplifting experience, followed by an organised delivery and quick return to the pre-pregnancy state and appearance. So, good mothers are those who conform to the expectation of a blooming pregnancy, a healthy baby and a return to s.e.xy wife. Despite Jane Ussher's (1992) discussion of the tyranny of such an expectation in imposing on women the feelings of failure if they do not nd it so, only recently is it becoming acceptable to admit to not enjoying pregnancy or nding it hard.

Being a good mother also means enduring all the unpleasant (and sometimes life-threatening) side-effects of pregnancy with good spirits for the sake of the baby.

There are further a.s.sumptions made as part of being a good mother and this is that women will not have to give up their children for adoption and that loss of the pregnancy or infant is a source of serious distress and grief. The possibility of terminating a pregnancy for personal preference or 121 convenience is frowned upon, except in extreme cases of illness. By contrast, for those who are seen as bad mothers, pregnancy ending by termination, stillbirth or even neonatal death can be considered in some circ.u.mstances to be an appropriate outcome for women who fall outside the prescribed boundaries and adoption of children born to single women was the norm until very recently. As lms like The Magdalene Sisters, a ctional account of girls incarcerated in the Magdalene Laundries1 (directed by Peter Mullan, 2002), show us, treatment of young girls was sometimes alarmingly harsh, as their equation with the concept of the bad mother would permit.

Bad mothers are not accorded the same expectations as are extended to women identiable as good mothers. For bad mothers pregnancy can be automatically criticised as abnormal, as pathological and as unsuitable.

Thus, while pregnancy as a good mother attracts positive comment and interest, for women who fall outside the framework, pregnancy can attract criticism and worse, as the discussion in Chapter 4 of women's experiences in the workplace has shown, placing working mothers too as bad mothers in this a.n.a.lysis. Nevertheless, both good and bad mothers may be subject to the same judgements levelled at their appearance, status, beliefs and level of responsibility. In the following sections we examine these dimensions of good and bad mothering in more detail.

Pregnancy in older women In 1993, commentators were suggesting from population trends that by the end of the century (i.e. by 1999) 40 per cent of all births would be to women aged 30 or over and gures quoted earlier show that this point has already been reached in some countries. Even if conception and rst pregnancy are delayed until this time, women are frequently considered to be acting selshly by putting their own gratication rst, rather than acting responsibly, and certainly women who remain childless into their 30s often receive negative comments (Allen, 2005). One explanation for this disapproval may be something we raised in Chapter 1 the low birthrate and the perceived economic dangers of too few people to support public services and nance an increasingly ageing population. Another explanation is that older women in general are viewed as a h.o.m.ogeneous group; typically, women having rst children are aggregated with women having subsequent children, who are older simply of necessity precisely like the prediction of 1993. A further reason may be the power of stereotypes we have discussed in previous chapters. How old is too old depends of course on where the average is at any time and the prevailing expectations of women's other public roles, for example as workers or as parents. Women in contemporary society are expected to partic.i.p.ate in the public domain as 122 well as full their domestic or private roles and their willingness to accommodate public beliefs and expectations can, as we have seen, be extremely stressful.

Contrary to expectations, however, women who have their rst baby later in life are not all ruthless careerists, according to Julia Berryman and her co-authors (1995), who found that in their sample of 340 older mothers only 5 per cent of women had delayed pregnancy for career reasons. Nevertheless, women in their study reported that motherhood over 40 was often seen as inappropriate and that shock, horror and disgust were not uncommon reactions when they announced their pregnancy.

As advances in reproductive technology have enabled a small number of women, who might otherwise be expected to be going through the menopause (and beyond), to become pregnant, older women have attracted attention, almost as curiosities and as potentially bad mothers. The attention is a mixture of scientic pride and moral outrage. Coverage of very late (i.e. over 50) pregnancy is typically censorious and appears to reect pervasive political and societal beliefs that, while pregnancy in much older women may be technologically interesting, such pregnancy is somehow unsuitable, not normal, and strong sanctions may be applied to the individual, their lifestyle and their beliefs. Older women are considered to be irresponsible in becoming pregnant, and this criticism is levelled at the doctors too, for daring to cheat nature and rob the children of their rights to parents. George Monbiot wrote in The Guardian newspaper (25 January 2001: 29) an article ent.i.tled ur strange fear of older mothers', the rst line of which reads: 'No longer attractive to men, they're treated as an offence against nature'. Despite this alarming introduction, the article is in fact criticising negative coverage by other newspapers of announcements of a second pregnancy by a 61-year-old woman, and the birth of twins to another woman aged 56. In an oblique reference to the public perceptions of good and bad mothers, he goes on to say that 'to suggest that late births are unethical, we have rst to say whom they have wronged'.

The answer, we would suggest, is that it is public sensibility that has been wronged because of the expectation of what const.i.tutes the age of normal motherhood.

Where women already have other children, the announcement of a late pregnancy is often a cause of mirth and speculation rather than congratulations. Certainly, the woman's age and the age of any other children is a matter for comment, especially where there may be a large gap in age between the last child and the current pregnancy. As an example, when The Mirror newspaper announced Cherie Blair's pregnancy in November 1999 it had, below the main front-page headlineCherie is pregnant', the sentence (their underlining) 'She's having her fourth child at 45', a phrasing which manages to capture both the shock and amus.e.m.e.nt of being beyond normal childbearing age and late pregnancy and the potential age gap 123 between her existing children and the new baby. Interestingly, as the discussion on celebrities below also highlights, the images and coverage tread a ne line between dening Cherie Blair as either a good or a bad mother.

One effect of delaying rst childbirth is that women may encounter problems of conception; thus, pregnancy in older women may attract further disapproval because it brings together a number of categories of what we are calling abnormal pregnancies. Though statistics indicate that there are more multiple births to women over 35, this is partly explained by the increasing availability and take-up of a.s.sisted conception in this group, particularly the use of fertility drugs and the implantation of several embryos after IVF, which increase the likelihood of having multiple pregnancies. In addition, more fundamental fears of mortality are raised by the juxtaposition of the older woman and the fragility of the unborn baby.

This is emphasised through attention paid to potential risks to the woman's health and the future of the baby. Older mothers (medically those over 35 are considered elderly primigravida) may be presented as being irresponsible through the a.s.sociation with increased risk. There is evidence from the statistics on abnormalities that the incidence of certain defects increases with age, Down's syndrome being the most commonly known.

Other risks include miscarriage and both maternal and infant mortality.

Very recently, not only older mothers but older fathers have been found to increase risks of later problems in children born to older parents. Though statistics indicate that there are more multiple births to women over 35, this is partly explained by access to fertility treatments. In this way older women are visible as bad mothers not just because of their age, since they are expected to have given up on childbearing, but because of their mem-bers.h.i.+p of multiple categories of atypical pregnancy. Lastly, pregnancy in older women also raises interesting questions about what const.i.tutes 'natural' in the context of pregnancy as a natural and biological event or process. Natural may be an archetypal element of the Good Mother here perhaps.

Interestingly too, there is a positive side to later parenting, which gets less coverage. At a primitive or mystical level, the appearance of new life in the context of an older parent can be rejuvenating and exciting. While it is undoubtedly true that it may be more tiring to have young children later in life, there may be other benets of delaying rst pregnancy, for example commitment to parenting, being in a better nancial position to support a child and the demands of family life, as well as living a healthier lifestyle.

Recent research has also suggested that having children later in life may actually benet women's health (Grundy and Toma.s.sini, 2005). These more positive elements tend not to feature in representations of older mothers although their absence is remarked upon repeatedly in another group of potentially bad mothers very young women.

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Younger and teenage mothers Despite the interest generated by pregnancy in older women, not least because of its risks, the greatest opprobrium, certainly in the UK and in the US, is reserved for teenage mothers. Why is this? As Bynner et al.

(2002) point out, it was once a common occurrence for women to be pregnant in their teens, but it is now constructed as a social problem. Part of the concern arises from the numbers. Figures suggest that the number of teenage pregnancies in the UK and the US is considerably higher than in some European countries, notably the Netherlands, and despite efforts to change behaviour it has reached an unprecedented rate. In 1997, the rate of teenage pregnancies among 15- to 19-year-olds was 30 per 1,000 in the UK and only 4 per 1,000 in the Netherlands. This discrepancy has continued to the present day. UK gures published in 2005 which relate to 2003 show that the number of teenage pregnancies in the 1517 age group was 42.1 per 1,000 and 8 per 1,000 for those aged 1315. The gures did go down, slowly, between 1998 and 2003 but they are certainly disturbing, particularly for the younger age group. US gures indicate the rate of births to 15- to 19-year-olds as 30 per 1,000 (US Census Bureau, 2005). However, though absolute numbers may be high, as Ann Phoenix pointed out in 1991, a distinction must be made between those adolescents who become pregnant during their school years and those who choose to become mothers during their teenage years beyond the age of compulsory schooling (in the UK this is 16 years). The subtlety of this argument is not well represented in the way that teenage pregnancy is made visible, whereby all adolescents, like all older women, are treated in the same way.

Sometimes, the tag 'school girl mums' is used to emphasise the extreme youth of the girls being featured. While concern centres on the numbers and the development of strategies to prevent teenage pregnancy, the possible reasons for the high rates of pregnancy in this group are less well understood.

Despite a relatively young average age of menarche (12 years 6 months in the UK and other European countries), there is increasing pressure for young people to remain at school, or extend their education elsewhere, in order to improve their future opportunities. Thus, there is a mismatch between biological maturity and the point of economic independence, which serves to highlight pregnancy as anomalous for this group, since they are not able to support themselves or a baby, thus marking them out as bad mothers. Of major concern is the likelihood that, once pregnant, adolescents will fall into a pattern of dependency on state benets, lowered educational expectations and reduced engagement in the labour market, all of which gives cause for public concern and grounds for public intervention in teenagers' access to contraception advice, s.e.x education or continued partic.i.p.ation in education or employment.

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Another signicant explanation for the very negative comments about young people's lives is that pregnancy is a clear representation of s.e.xuality.

Of course, this is also the case for older women who become pregnant, and it may be partly this symbolism that accounts for the very punitive att.i.tudes expressed in relation to pregnancy which offend public morals.