Birth on the Threshold. Cecilia Van Hollen
in the postcolonial era has focused on rural areas and has tended to depict childbirth practices as relatively untouched by allopathic institutions.8 Yet allopathy has had a major impact on childbirth in urban and semirural areas throughout India, though the impact has been uneven. By focusing on the major metropolitan city of Madras and a semirural town on the outskirts of Madras, my study looks at the central role which allopathy plays in women’s decisions regarding childbirth and considers how women choose from among different allopathic options as well as non-allopathic practices.
According to Linda Garro, anthropologists interested in decision-making processes can be loosely grouped into two camps: those who are primarily concerned with policymaking issues and those who are interested in the cultural underpinnings of the cognitive processes that go into decision making. While still others, she writes, “see cognition and policy as intertwined, but they discernibly foreground the policy implications.”9 As far as my work addresses questions of decision making, I would place myself in this third group. Although I am interested in the wide range of social and cultural processes which go into decisions about where to go for prenatal care, whom to see during a delivery, and whose advice to seek in the postpartum period, I must make my own “choices” about which of these processes to foreground. In my own selection process, I try to attend to the voices of the women whom I met, to hear what they considered to matter most to them, and to convey as forcefully as possible their concerns, their criticisms, and the problems they faced in pursuit of reproductive health care during their childbearing years.
As a result, this book may at times seem like a litany of complaints and an unsolicited condemnation of the reproductive health services provided in Tamil Nadu, a state which is usually viewed as a success story in maternal-child health vis-à-vis India as a whole. My intent is not to criticize from afar the work of so many hardworking and dedicated health care providers and policymakers. In fact, I am keenly aware of the historical legacy of the damning depiction of maternal and child health care in India used by colonial discourse to legitimize colonial rule. So I present these criticisms with a certain amount of discomfort about my role in perpetuating this discourse in the postcolonial era, despite the fact that I strive to show how international and globalizing forces are intricately implicated in women’s critiques. But as a critical medical anthropologist, my work is first and foremost concerned with issues of social justice. And so, although I hope my ethnography provides what Clifford Geertz has called a “thick description” of the world through the eyes, and indeed through the bodies, of the working-class women whom I met in Tamil Nadu, the “thickness” is not evenly distributed, but, rather, tends to bunch up around those sites where women sense discrimination and desire change.10
In his book about aging in India—the stage both farthest from and closest to birthing in the Indian life cycle—Lawrence Cohen continuously pushes us to ask, “What is at stake” in the social, cultural, and medical transformations of the conceptualization of and practices surrounding old age in India?11 He insists that our conclusions not be simplistically spawned by false dichotomies which force us to take sides, for example, “with medical rationality or its holistic or feminist critics, with cultural autonomy and distinctiveness or world systems theory and the deserving poor, with medicine as a resource or as an ideology.”12 The same question of what is at stake could be asked of my study, substituting “childbirth” for “old age.” And, as mentioned above, my response lies in the multiple and complex ways in which gender, as it intersects with class, is being reconstituted.
In my head, I constantly find myself returning to a simpler, perhaps somewhat simplistic response to the question of what is at stake: lives and the potential for suffering. I know from my research and from my own personal experience that the lives of babies and of mothers can never be guaranteed, regardless of what kind of medical care is given and what kind of material resources are available. And I agree with Ivan Illich when he poignantly argues that we must not lose sight of the art of suffering in the wake of modern medicine’s determination “to kill pain, to eliminate sickness, and to abolish the need for an art of suffering and of dying.”13 But when discriminatory practices based on things like class and gender have the potential to deny women easy access to biomedical reproductive health care and thus to precipitate loss of life and suffering, action must be taken. This action, however, must not entail falling into the trap of representing others simply as victims, a pitfall that Chandra Mohanty and Arthur and Joan Kleinman have helped me to see and, hopefully, avoid.14 This book, then, is my enactment of the action taken by those women who shared part of their lives with me.
THE ANTHROPOLOGY OF REPRODUCTION AND MODERNITY
Because I am interested in emphasizing the specificity of modern birth in this particular ethnographic setting, there is a constant comparative vein which runs through the book. This is, however, an ethnographic tale, not a cross-cultural study. The comparative element hovers in the background as a constant reminder of difference, rather than taking center stage. The scenario with which I contrast my study is the biomedicalization of childbirth in Europe and the United States, not because these are the only valid sites of comparison, but because these are the stories that dominate social and cultural studies of the relationship between reproduction and modernity in medical anthropology, medical sociology, and the history of medicine.
During the first decades of the twentieth century, anthropologists paid very little attention to the study of reproduction in diverse cultural contexts; this is usually attributed to the dearth of female anthropologists at the time and, therefore, to the lack of interest in or access to what was considered an exclusively female domain. It may also be due to the fact that social and cultural anthropologists shied away from studying those aspects of human practice which were so intricately linked to biology.15 To the extent that anthropologists during this period did concern themselves with the study of reproduction, it was within the context of very broad ethnographic accounts and was given only passing mention which was descriptive rather than analytical.16
Anthropologists began to focus explicitly on the study of reproduction within the framework of cross-cultural analyses, around the middle of the twentieth century. These comparative studies sought to discover which aspects of human thought and behavior relating to reproduction are universal and which are culturally specific.17 These anthropologists paid particular attention to how pregnancy, labor, and the postpartum period are managed both physically and socially and to the degree to which these practices are symbolic or biologically based. In short, they established the central tenet of the anthropology of reproduction: reproduction and the management of reproductive processes are not simply biological; they are also always culturally constructed in unique ways in diverse historical contexts.
The study by Margaret Mead and Niles Newton titled “Cultural Patterning of Perinatal Behavior” was particularly noteworthy for the way it used a cross-cultural approach to critique the social and cultural patterning of birth in American society. Though Mead and Newton did not use the term “medicalization,” their analysis of the problems which can arise from defining birth as an illness and from the increasing use of hospitalization and pharmaceuticals during the birth process was a harbinger of later studies which explicitly addressed the issue of the medicalization of birth.18
Medicalization is a key theme which permeates much of this book. What, then, do I mean by “medicalization” in the context of this study? The medicalization of everyday life is the process by which medical expertise “becomes the relevant basis of decision making in more and more settings”19 and has become a key component of the modernizing process throughout the world.20 The medicalization of childbirth is thus the process whereby the medical establishment, as an institution with standardized professional guidelines, incorporates birth in the category of disease and requires that a medical professional oversee the birth process and determine treatment.
The term “medicalization” is often used to refer to a process of “mystification” of social inequities. As Scheper-Hughes and Lock say, “Medicalization inevitably entails a missed identification between the individual and the social bodies and a tendency to transform the social into biological.”21 Thus, such things as hunger, alcoholism, and attention deficit disorder come to be viewed as purely biological disorders and treated