The Rhetoric of Pregnancy

By Marika Seigel and Jane Pincus

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.

• Language: English
• Publisher: Open Road Integrated Media
• Release date: Dec 9, 2013
• ISBN: 9780226072074

Book preview

Marika Seigel is associate professor of rhetoric and technical communication at Michigan Technical University.

The University of Chicago Press, Chicago 60637

The University of Chicago Press, Ltd., London

© 2014 by The University of Chicago

All rights reserved. Published 2014.

Printed in the United States of America

23 22 21 20 19 18 17 16 15 14      1 2 3 4 5

ISBN-13: 978-0-226-07191-6 (cloth)

ISBN-13: 978-0-226-07207-4 (e-book)

DOI: 10.7208/chicago/9780226072074.001.0001

Library of Congress Cataloging-in-Publication Data

Seigel, Marika.

The rhetoric of pregnancy / Marika Seigel ; foreword by Jane Pincus.

pages. cm.

Includes bibliographical references and index.

ISBN 978-0-226-07191-6 (cloth : alk. paper)—ISBN 978-0-226-07207-4 (e-book)

1. Pregnancy—Handbooks, manuals, etc.—History and criticism.   I. Title.

RG551.S45 2013

618.2—dc23

2013009129

This paper meets the requirements of ANSI/NISO Z39.48–1992 (Permanence of Paper).

The Rhetoric of Pregnancy

FOREWORD BY JANE PINCUS

Marika Seigel

The University of Chicago Press

Chicago and London

For Annika and Indrek

This is not a how-to book.

SHEILA KITZINGER (1978)

Contents

Foreword by Jane Pincus

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

Foreword

In 1970, when we combined women’s stories with facts about health care to create the book Women and Their Bodies (entitled Our Bodies, Ourselves in the very next edition), there was little information available about health, reproductive issues, or childbearing. Back then, women were beginning to gather together in political and personal groups to talk about our lives. It seemed the most natural thing in the world to turn to one another. We told our stories and realized that we had learned a great deal from our experiences. We discovered that we knew more about our bodies and our health than we thought. Gathering as much information as possible, we began to identify the questions we wanted to ask and the answers we needed to find and started to focus on the situations we wanted to change. In Boston and throughout the country, more and more women joined these conversations, which led to a sharp clear awareness of the negative attitudes toward women held by authorities, especially by the medical and legal professionals whose practices affected our reproductive lives. We really believed that we could change the mindsets of the people who diminished us and, subsequently, the institutions that did not meet our needs. The body of knowledge we drew from our own life situations gave us a collective strength, convincing us that we could—we would—empower all women to work for change. The sense of possibility in the air energized our outrage, optimism, and solidarity and gave us wings.

In the early seventies, we had much to learn about the political, social, economic, and medical systems determining our lives. Over the past four decades, many of the women who read successive editions of Our Bodies, Ourselves joined us in rewriting it; many later researched and wrote their own articles and books. They became midwives and family doctors, sociologists and teachers, historians of women’s health issues or policymakers developing family-friendly health policies. They have grown the sum of our collective wisdom, adding important subject matter, analyses, and insights.

The Rhetoric of Pregnancy finds itself in this excellent company, one of the in-depth studies generated by the vigorous currents of the women’s health movement that has touched us all in one way or another.

The life-altering moments we experience when seeking health care can spark thoughts and feelings about the kind of care offered and received. Many women base their professional work on events that have affected them deeply, compelling them to embark on further investigations. Becoming a mother is one of those significant events. Childbearing brings us face-to-face with a medical system that challenges us to confront the powers and resources that we possess—our fund of knowledge, our self-confidence, our community supports—or, conversely, the powers denied us.

Marika Seigel has been there. She begins the book with a short description of the birth of her daughter and ends with the drama of her second pregnancy and the birth of her second child. But the entire book ventures far beyond her personal story to advocate the reconsideration and questioning of any so-called received knowledge.

Seigel posits that the mainstream US culture’s attitudes toward birth devalue women’s bodily experiences, classifying them according to a mechanistic model of care. The medical establishment has come to define women’s bodies as machines that will probably not work well on their own. Women are seen as baby carriers, monitored and regulated via societal and medical pieties, articulated in actions to be taken, many of them not necessarily in the best interest of most mothers and babies. Compulsory prenatal tests, followed by routine utilization of ultrasound, induction of labor, fetal monitors, epidurals, and cesarean births—all these practices tend to increase and predominate in accordance with the technological bent of obstetrics.

Too often, this model obliges childbirth educators to recommend acceptance and passivity, which can diminish a woman’s strength and autonomy and erode her belief in her own physical, mental, and spiritual powers to birth her babies vaginally by herself—with knowledgeable support, of course. Too many women these days fear the event of giving birth. Why is this still happening?

Seigel guides us through the history of advice books and pamphlets, ranging from those produced in the early 1900s to current Internet sites. She devotes a chapter to each source, teasing out many aspects of the climate of doubt surrounding childbirth. In the light of instruction manuals that tend to proliferate in a mechanical age, she ventures into the nature of informational systems and information itself. Thus, the book deals with the following questions: Why does each era circulate particular instructions? Who originates, maintains, and makes use of them? Since they express and serve particular social and economic schemes, whom do they empower or restrain, protect or endanger, control or liberate? How do they become entrenched, routine practice, frozen into a system? What makes them change over time? Who resists them, who counteracts them? Do users engage with them compliantly, accepting received information, or critically, thus putting themselves at a remove from standard procedures, opening up a whole field of inquiry for themselves and the possibility of seeking the alternatives that will give them choices? And finally, what is expected of pregnant women these days; what are they told?

Women who seek information about childbearing are usually presented with justifications for interference in physiological labor and birth. They must adopt a particular stance in relationship to these interventions, their choices being (1) to accept or (2) to question and then (3) to negotiate with practitioners and hospitals about any practices open to change or (4) to reject completely by giving birth outside the hospital setting.

This book comes alive for me in many ways as I hear about the challenges, struggles, and successes of maternity care providers and of the women they serve. Most immediately, my daughter-in-law, pregnant for a second time, tells me that the obstetrical practice she has chosen requires her to have an ultrasound performed at thirty-six weeks of gestation. Why? she asked. The answer: To reassure you. The point being that she did not feel any need for reassurance—nor did her pregnancy fall into any of the five risk categories requiring ultrasound. But this test, one of the many interventions that emphasized what might go wrong, necessary or not, has been built into the prenatal care system. Why introduce insecurity, and then reinforce it in the name of dispelling it?

The Rhetoric of Pregnancy helps answer that question, among many others. Through the fascinating lens of advice to women, it describes the development of mechanistic views of childbirth and of the ensuing obstetrical routines. Seigel herself learned to negotiate the system of obstetrical care, deciding to comply with some practices while replacing the ones that she could not, in her heart, accept for herself and her baby. With self-knowledge and knowledge of the medical system, it is possible in many instances to determine and choose empowering childbirth experiences.

Her discussion may convince writers of instruction manuals to consider what their messages really convey and to investigate the beliefs underlying the images, wording, and organization of the material they select.

Those of us involved in reforming conventional obstetrics should pay close attention to the philosophies of the books advising women to comply with the prevalent mechanization of childbirth. Our critique can encourage mothers to find the caregivers, books, and websites offering the truly woman-centered information that can lead them to fulfilling childbirth experiences and healthy babies. The Rhetoric of Pregnancy serves to enlighten all of us—childbearing women, practitioners, and activists—as we seek to change and humanize the present maternity care system many of us care about so deeply.

Jane Pincus

Acknowledgments

Because I conceived this project shortly before my daughter was herself conceived and because the book is so much about pregnancy, I have certainly felt the pull of what Ariel Gore calls the book-as-pregnancy metaphor. As Gore is quick to point out, however, the two processes don’t make for tidy comparison. After all, writing a book doesn’t make you vomit, cause stretch marks, compel you to love ice cream and hate eggs, or make you wonder if you’ll ever be the same person again (1998, 18). But, like pregnancy, the success of bringing a manuscript to full term owes much to the village that surrounds and nurtures its author. Certainly, I could never have completed this book without the community of scholars, friends, and family that have supported me throughout its creation.

As my interest in rhetoric and technical communication began at Penn State, I must first acknowledge and give thanks to my teachers and mentors who sparked that interest, particularly Susan Squier, Jack Selzer, and Stuart Selber; to my colleagues and friends from those years, particularly Jordynn Jack, Melissa Littlefield, Jodie Nicotra, and Shannon Walters; and to the rhetoric community at Penn State. As individuals and as a community, you were always available for helpful feedback and moral support, always managed to strike the balance between challenge and encouragement. Thank you.

Likewise, thanks to my colleagues at Michigan Tech, without whom the writing and publication process would have been so much more difficult than it was. Thanks to Ann Brady, Marilyn Cooper, and Bob Johnson for their feedback on my work and for their professional guidance. Thanks to Raeanne Madison and Casey Rudkin for their invaluable research assistance. Thanks to the many excellent graduate and undergraduate students with whom I’ve had the pleasure to work during my time at Michigan Tech, with particular thanks to Steve Bailey, Erik Hayenga, Jim Nugent, Casey Rudkin, and Joanna Schreiber for inspiring me with their innovative work related to technical communication.

I am also indebted to Kirk St. Amant for his careful readings of my work and for his unfailingly good advice.

Many thanks to David Morrow and the editorial staff at the University of Chicago Press for their interest in and support of this project. And I am very grateful to the two anonymous reviewers whose comments helped me to strengthen and refine the manuscript.

I am also grateful to the archivists who helped me to locate the primary materials that were so essential to this study. Thank you to the archivists at the Schlesinger Library at the Radcliffe Institute for Advanced Study and to those at the John J. Burns Library at Boston College. I especially wish to thank Diane Gallagher at the Howard Gottlieb Archival Research Center at Boston University, where the Instructive District Nursing Association’s papers are housed.

Thanks to Jane Pincus, whose work and writing on behalf of women’s health I greatly admire, for taking the time not only to read my work but also to write a foreword for this book. I still can hardly believe my good fortune that she agreed to do so.

And last but not least, thank you to all of my family and friends, who have been a source of incredible support during this entire process. Particular thanks to my father whose excellent advice be there, be early, sit in the front row I haven’t always followed to the letter, but certainly in spirit; to my mother for being my first model of a feminist and of a scholar of rhetoric and technical communication; to my children for being patient with my sometimes very late nights in the office; and to Matt for, well, he knows what for.

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