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Maureen O'Dougherty University of Minnesota 1334 Eckles Av. St Paul Minnesota 55108 firstname.lastname@example.org Plot and Irony in Childbirth Narratives of Middle Class Brazilian Women ______________________________________________________________________________ Br azil's rate of cesarean deliveries is among the highest in the world and constitutes the majority of childbirths in private hospitals. This study examines ways middle class Brazilian women are exercising agency in this context. It draws from sociolinguisti cs to examine narrative structure and dramatic properties of 120 childbirth narratives of 68 low to high income women. Surgical delivery constituted 62% of the total. I focus on 20 young middle class women, of whom 17 had C sections. Doctors determined mo de of childbirth pre emptively or appeared to accommodate women's wishes, while framing the scenario as necessitating surgical delivery. The women strove to imbue C section deliveries with value and meaning through staging, filming, familial presence, atte mpting induced labor, or humanized childbirth. Their stories indicate that class privilege does not lead to choice over childbirth mode. The women nonetheless struggle over the significance of their agency in childbirth. [ childbirth narratives, ces arean de livery, agency, middle class Brazilian women ] ______________________________________________________________________________ Brazil's rate of ces arean deliveries 36% in public hospitals ( World Health 2005 ) and 70% and higher in private ones ( Belizan et al 1999; Ministrio da Sade 2006) places it among the nations with the highest rates in the world and far beyond the recognized need for C section delivery in approximately 15% of childbirths, where vaginal delivery would pose a risk for the mother or baby ( World Health 2005; Bailey and Paxton 2002 ) Public health research finds that the inflated recourse to surgical delivery in Brazil is not the result of choice (see e.g., Dias et al. 2008) Anthropological approaches question the framing of childbirth dec isions in terms of "choice" through research placing the decisions in context (McCallum 2005; Hopkins 2000). The contribution I hope to make revolves around women's agency over childbirth. I ta k e as a starting point a similar questioning of women's choice in childbirth in Brazil My project aims to shift our attention to what women are doing, that is, in what ways they are exercising agency in this context where C sections predominate Questions driving the research are : How, in their narra tives of childbir th, do Brazilian women represent their own agency and the agency of others ? W hat do key structural features of the narrative and dramatic properties suggest of a woman's sense of agency and her perspective on the experience? What are women doing to create the conditions of their childbirths an d the meaning childbirth holds for them? S tudies of medicalized childbirth have underscored the need for attention to women's experience s (Brubaker and Dillaway 2009; Rdlfsdttir 2000; Akrich and Pasveer 2004; Name y and Lyerly 2010). My sense too is that beyond our own interpretations, we need to learn how women themselves represent agency in childbirth and in turn integrate this understanding into reconceptualiz ations of this contemporary trend and into efforts to im prove childbirth. I gathered childbirth narratives from 68 women in Rio de Janeiro between 2004 and 2009 to gain an "agent centered" approach to these life events (Garro and Mattingly 2000: 16 )
Seventy four of the 120 childbirths (62%) were by ces arean del ivery. Among the 31 low income women interviewed 53% of childbirths (29 out of 55) were by C section; among the 37 middle and upper middle class women, 69% of deliveries (45 of 65) were by C section. Just 3 of the 20 younger middle class women (born betw een 1973 and 1984) had vaginal childbirths, compared to 8 of the 17 older middle class women (born between 1953 and 1968). One guaranteed plot for the younger middle class women, with "complicating events," "evaluative statements," "resolutions" and "codas (Labov 1997), was ces arean delivery. In what follows, I f ocus mainly on the young middle class women among whom private sector surgical births predominate The stories illustrate that these relatively privileged women, like other Brazilians currently do not have a choice over form of childbirth. N onetheless they are caught up in the debate over "normal ," natural" versus surgical childbirth, an d they are active in efforts to create conditions for meaningful childbirth I start by situating this study in the context of research on ces arean deliveries in Brazil and I describe my approach to agency in narrative I then turn t o seven women's stories to explore ways they responded in this context where C sections have become the norm and vaginal deliveries the alternative. Debates on Ces arean D elivery in Brazil The high rate of ces arean deliveries in Brazil has prompted intense scrutiny. Studies with diverse methodologies have found that t he majority of Brazilian women do not choo se ces arean delivery B astos Dias et al (2008) report from a survey with a sample of 437 low income women that 70% favored vaginal childbirth but few went into labor; they were instead persuaded in the health care setting that circumstances indicated C section. A survey of 909 women found that 76 % had not prefer red C sections because of the difficulty recuperating ( Barbosa et al. 2003:113 114 ) Interestingly, 19% who had delivered vaginally had actually asked for a C section, a finding revealing "the limited power of women in d etermining the type of del ivery they have, be it vaginal or caesarean ( Barbosa et al. 2003:116 ) An important part of the Brazilian debate revolves around the role of middle class Brazilian women in setting the trend for increases in C section delive ry f rom 1980 forward According to Mello e Souza (1994) who interviewed 20 women and 20 obstetricians in Rio de Janeiro middle class women contributed to the initial inflation of C sections by wanting to avoid surgery on the perineum She reports that doctor s attributed the rise in C sections to women's lack of preparation for labor pain and to a belief that their sexual attractiveness would be diminished by a "stretched vagina" following vaginal childbirth Although Mello e Souza finds that the physicians we re remiss in failing to present surgical risks, she argues that middle class women were exercising agency for C sections together with doctors, who benefitted financially and in scheduling from planned surgical births. Because of their higher status, this middle class practice would have beco me an ideal for poor women. Several works attribute the high rates of C section in Brazil in good part to instituti onal and professional practices. A prime suspect for the inflation of C section delivery is financial. While as of 1980 the reimbursement at public hospitals for C sections and vaginal deliveries were equalized hospitals receive twice the revenue from C sections because of t he longer hospital stay Moreover, time is saved through surgical deliveries, espe cially scheduled ones Wh ile these factors are critical, Bhague (2002) criticizes the terms of the C section debate in Brazil, fi nding it tends to quantify preferences and lay responsibility solely on financial questions Doing so, she argues, may "diver t attention away from investigation of how
definitions of and indications for the use of the c section technology have themselves been medically and socially altered" through active negotiations on the part of th e women, as well as providers ( Bhague 2002: 498 ) Also questioning the individualist assumptions underlying the debate, McCallum (2005) observes that we need to better situate providers and women within their wider context McCallum maintains that Brazilian doctors are better trained for and thus mo re confident about performing surgery, that hospitals place time limits on the progress of labor, and that a potentially viable recourse to obstetric nurses to assist with labor has m et with resistance by doctors and obstetric nurses. Systemic factors appe ar to contribute importantly to the rise in C sections. Case control studies ( D'Orsi et al. 2006 200 0 ) and surveillance studies ( e.g., Padua et al. 2010) have found ces arean deliveries associated wi th numerous non medical reasons. Researchers underscore t he use of C section precisely where least indicated at first childbirth, with better educated women and they suggest that the register of breech presentation is inflated to justify surgery ( Freitas et al. 2008 ) Commonly used but questionable justification s for a C section include slow progress of labor and a wrapped umbilical cord ( Dias et al. 2008; Bhague 2002 ) 1 It is in relation to these many conte xtual factors that one on one interactions of women with doctors over mode of delivery need to be viewed. In fieldwork in public and private hospitals in Natal and Porto Alegre, Hopkins (2000) surveyed 321 women postpartum and made direct observations of 29 deliveries, including 15 C sections She found t hat doctors' decisions for ces arean deliveries were oft en "obscured, most typically by their own power to frame the hospital birthing situation in terms of a women's cho ice or in terms of medical need ( Hopkins 2000:727 ) B oth Hopkins (2000) and McCallum (2005) report that Brazilian doctors present themselves a s receptive to vaginal deliveries; they use the phrase "let's try" in regard to them but later introduce decisive evaluations against them Regarding low income women, Bhague suggests that obtaining a C section may be "empowering" in a context lacking a supportive environment for vaginal delivery. In the South of Brazil, she found from interviews with 80 mainly low income women that those who actively se ek medicalized birth do so with the knowledge that this will enhance their chances at better qua lity o f care during birth ( Bhague 2002:494 ) McCallum and Reis (2005) offer a powerful illustration of the poor conditions in public hospitals of Northeast Brazil They emphasize the lonely and fearful experience of vaginal childbirth in a public setting, where family is not allowed to be present and women are subjected to insulting evaluations by health care providers ( see also Diniz and Chacham 2004 ) McCallum's statement t hat stark race and class inequalities "mark the symbolism of birthing arrangements, and they sustain the system as a whole" ( 2005:235 ) registers that race and class frame childbirths. Concerning the apparent lack of contestation among Brazilian women to surgical delivery McCallum conclude s that "what some read as women's 'cultural' inclinati on towards abdominal birth may simply be compliance, born in the absence of both a coherent, culturally appropriate critique of existing practices and knowledge about vaginal d elivery" ( 2005:230 ) The literature on ces arean delivery in Brazi l has made pro gressive gains in interrogating the terms of the debate, sh ifting it from a narrow focus on individual "choice" to a deeper contextualization of decisions for surgical delivery My own research findings of the decisions over mode of delivery offer a simila r array of doctor s explanations leading to C section delivery, as I discuss below Before examining the narratives, I t urn to two areas guiding this research: theories of agency a nd approaches to narrative analysis.
Me dicalization and/or Agency, as Emer ging in N arrative R ecent Brazilianist perspectives on medicalized childbirth have sought to situate doctor patient interactions in context. Anthropologists conducting work elsewhere underscore complexity and diversity in women's responses to medicalizatio n Lock and Kaufert assert that "ambivalence coupled with pragmatism may be the dominant mode of response to medicalization by women" ( 1998: 2). Si milarly, Root and Browner find from pregnant women in the United States a "dialectic between partial resistanc e (the voicing of one's subjugated knowledge as possibly equal to and a part of an authoritative knowledge) and partial compliance (the desire for authoritative affirmation of this knowledge)" ( 2001:202 ) Davis Fl oyd argues in relation to U.S. women who c hose technocratic childbirth and those who chose home births, that "all were active agents in their birthgiving, albeit in radically different ways" (1994:11 36). These formula tions register the centrality of structure and agency to examinations of women a nd medicalization I find Ahearn's (2001;112) concise definition of agency as "socioculturally mediate d capacity to act" a useful starting point and I draw on feminist and practice theories to consider how women act in ways that can produce effects. Coole reconceptualizes the dynamic, interactive quality of structure and a gency, with attention to agent potentiality and limitations She says: "a gents do not act on a field as if from the outside, but rather "emerg[e] from within it . even resistant strat egies are shaped by the logic of a field they may nonetheless transform" (Coole 2005:1 37 ; see also Lovell 2003 ). McNay emphasizes that agents in any social field can generate effects. McNay asserts that "in order to draw out a more active conception of age ncy, it is sufficient to make the weaker case that individuals have the potential to respond in a non defensive and occasionally creative fashion to complexity and contradiction regardless of whether these differences are effectively reconciled or not" (200 0 :102 ) In h er work on pregnancy experiences Rdlfsdttir notes (recalling Butler) that "subjecthood . tends to exceed the power involved in our subjectification" ( Rdlfsdttir 2000:338 ) I share with these approache s a concern to register the diver se actions of women in relation to agents of biomedicine and to acknowledge potentialities and challenges to effect change Life s tories offer a privileged m eans for understanding th e storyteller's sense of her own and others' agency. I adopt aspec ts of sociolinguistic analysis in order to focus on the telling of the story rather than solely the content ( Riessman 2000:129 130 ) For the analysis of the women's narratives, I draw first on sociolinguist William Labov's work ( Labov 1997 ) Labov identified key structural feature s of oral, personal narrative: com plicating events, evaluation, resolution and coda For the se narratives, the complicating events concern how and possibly why each woman believed she came to have a C section Evaluations of events and one's ow n and other people's acts are integral to narrative structure. I was attentive to statements of what should or should not have occurred in the childbirth process Narrative resolution places closure on the story and coda brings the story back to t he present. A resolution and coda signal a full narrative structure I considered whether the hap py ending (a healthy baby) made it all fine or whether there were unresolved aspec ts. Another way I approached the examination of childbirth narratives concer ns dramatic properties. Akrich and Pasveer (2004) co nsider how actions and agency are "distribute d" within childbirth narratives. Similarly, by reflecting on where the woman, the main protagonist, is located in the dramatic stage vis vis others, I found another means of ascertaining how she
understood her own agency. As Mattingly says If narrative offers an intimate relation to lived experience, the dominant formal feature that connects the two is not narrative coherence but narrative drama" ( in Garro a nd Mattingly 2000:269 ) The childbirth stories I present here were especially compelling to me for their heightened dramatic ality some s erious, others light to comedic. Still others appeared to be a mixed genre, seeming to incorporate iron y in the relayin g of events. B y considering the dramatic genres through which that the story is conveyed, I found it led me closer to the possible underlying significance that surgical delivery had as their c hildbirth experience ( in the version of it that I heard ) It i s good to bear in mind that the narratives were produced in a context where the interactive process (Riessman 1993) involved the teller s (diverse Brazilian women living in Rio de Janeiro ) and a U.S. anthropologist, who was unknown to them prio r to the first interview. For my purposes, the advantage of retrospective, constructed memories is that the stories are produced with some time and distance and are told as the teller wished for the stories and themselves as protagonists to be understood. Most women I i nterviewed began cautiously but soon became absorbed in telling their stories and took charge of the conversational flow. One third of the interviews with low income women were conducted with employees of a Flamengo neighborhood beauty salon (with renewed contacts over the years). Another third took place in a shantytown above Santa Teresa and the remaining third at a maternity clinic in Laranjeiras among women waiting for an ob gyn check up I met the middle class women through two sources: most through fr iends (several of whom I interviewed repeatedly) and some through announcements by a Flamengo fitness club instructor at her classes. These women resided in the Zona Sul, Zona Norte (Tijuca) and Niteri. The New Normal? "Complicating E vents" and the D ecis ion for Ces arean C hildbirth Carla born and raised in Botafogo (with a monthly household income equivalent of US $2,500) had three babies when she was between the ages of 21 and 26. At her second childbirth in 2000 she waited to go to the hospital until the contractions were 10 minutes apart. S till [the doctor] waited eight more hours I could have waited longer but he thought it was too much of a sacrifice for me. I don't know, but I think it's the policy here in Brazil, to do all ces arean, people choose it much more than normal delivery, but I thought natural childbirth was more natural [ sic ], and I wanted to try, and I said this to him, so much so that we tried until the end . I had all the contractions, it wasn't a scheduled ces arean nor planned . I felt all the pain, just didn't manage to become dilated, so he did a C section. The 120 childbirths described by the 68 women in this study occurred between 1975 and 2009; of these 74 were by ces arean delivery. The complete set of reasons they gave for the decision to have a surgical childbirth and frequency is as follows: slow progress of labor, described by women as contractions but little dilation (20, includ ing 5 "no passage"); prior C section (13); 39 weeks of pregnancy or more (11); umbilical cord (could be) wrapped around the neck (6); the woman's choice independently of physician (5); abnormal positioning of baby (5); high blood pressure ( 4) ; bag of waters burst but labor did n o t begin (3); and tubal ligation following surgical birth (Janowit z 1982) (3). Four explanations were prior femur injury;
exhaustion with labor after seven hour s and epidural analge sia; advanced age of woman (39 years); group b beta streptococcus The women's descriptions of the complicating events leading to surgical de livery ranged from a brief mention, such as "there was no passage to fuller narratives like Carl a 's entailing constructed dialogues with their physicians. From the women's accounts which often included me ntion of the level of dilation, it seems likely t hat t he decision for a C section was made based on a p rolonged latent or early phase of labor (with fewer than 4 centimeters of dilation and fewer than 24 hours in duration ) rather than stalled active labor (Enkin et al. 2000 :233 ) 2 Five mostly low income women described the decision for C section as owing to "no pa ssage." Although one might imagine the phrase refers to feto pelvic disproportion, a Brazilian doctor I consulted said it generally meant "lack of sufficient dilation in the expected or awaited t ime period." In the accounts I gathered, it was the doctors who made this the basis for a C section; wit h one exception (see Cira below) the woman herself did not give up. The next mo st commonly presented reason for surgical delivery was a C section fol lowing a C section Nearly as frequently, the doctor said that if labor had not begun by week X ( week 39 on), it would have to be ces arean. ( Post term pregnancy with possible risks is understood to begin at 41+ weeks ) Just one woman insisted on a vaginal birth in this circumstance and she was of the older generation She objected to doctors applying strong pressure ( forao de barra dos mdicos ) for C sections. T he common event of the umbilical cord wrapped around the neck ("nuchal cord") i s not usually considered an indication for C section From the women's stories, all these decisions were made unilaterally by the doctor. Ces arean delivery appeared to be a kind of generalized solution to many factors possibly affecting the trial of labor. M any decisio ns appear to have been made pr e emptively, prior to labor, hence before circumstances indicated need or were presented by the doctor as if the re were no alternatives It would be remiss not to recall that although the actual risks of ces arean delivery are not great, they are still greater than those of vaginal birth 3 Returning to the excerpt above, we find Carla mainly uses the active voice, both in reference to herself and to the doctor. As she says "I had all the contractions, it wasn't a scheduled ces arean nor planned . I felt all the pain, just didn't manage to become dilated." The doctor, however, decides for her that her suffering was "too much a sacrifice" even though she disagree s (silently) Carla also suggest s that in the end it was her unre sponsive body that led the doctor to perform a C section This account of the woman's agency vis vis the doctor's leads us to consider that the language women use to formulate the lived experience of their bodies during childbirth may itself contribute t o the retrospective justification of the surgical delivery, as well as may contrib ute to a retrospective critique, as the next two stories illustrate. Serious Drama in Opposition to C Section D elivery An Anxious La bor and an Accusation of Medical Error, R esolved A high level legal professional, Regina resident of Copacabana took a decisive, argumentative approach to life and this included her pregnancies. For example, she informed me that during her pregnancies she had one cigarette every day or ever y other day "because I started to get very nervous. And when my spirits ( animos ) get overexcited ( exaltados ) then a cigarette calmed me, so it was bette r." She switched doctors in the first trimester of her first pregnancy annoyed at his recommendation a gainst taking medication for an allergic reaction. During the 36th week of her
second pregnancy (at 29 years of age ) her doctor told her to rest following t he passing of the mucus plug (a sign that the cervix was dilating) She said she told him: I'm not going to rest. It's carnaval, it's hot and sunny. It's time for the baby to be born. I'm very fat and I don't want to gain more weight So get ready, as I could be calling you any time. F ive days later, Regina arrived at the hospital having lots of contr actions. T he doctor . said: Wait a little until there's space in the maternity ward. I said, Doctor, you don't understand, I'm going to have the baby here in the reception, I can't wait. . So finally, they brought me to the delivery room, gave me anesthesia a nd started in on the C section without ev en checking the dilation. [M: Really?] They thought the second baby would be like the first, without dilation, and as I was always very hyst erical they thought it was ridiculous on my part [to be sa ying her baby was nearly born], when nothing was going on. So when they opened me up, I heard them say, "W e have to push it back. The baby was already coming down and they had to push it back. It shouldn't have been a C sectio n. It was a medical error. [M : Were you upset? ] Today I think perhaps it was better. I always feared normal childbirth because I wanted the baby monitored. As it was, there wasn't monitoring. He could have come out with the cord around him, I didn't have heart rate monitoring, nothing Because here in Brazil, they don't have ex perience with normal childbirth, they are afraid of medical error in normal childbirth, so they immediately opt for ces arean, understand? So, since he didn't reassure me much, I wasn't very s ecure or sure of what I wanted . At the time I was annoyed; later I thought twice. So I didn't really know what I wa nted. It wasn't to be, you see? I present Regina's childbirth stor y above almo st without ellipsis to show i ts compressed dramatic style, yet complete with clear illustrations of all components of narrative structure The first complicating event was, of course, Regina's being ready to deliver, without having a delivery r oom available The second was that the medical team did not c heck her state of labor and pushed the baby back in order to continue with the C section. Just at this dramatic height of the story where evaluative statements are usually made, Regina decisively pointed out what should not have occurred: I t shouldn't have been a C sec ti on. It was a medical error." After this climax Re gina launched into a critical evaluation of cur rent inadequacies of obstetricians in Brazil Although recognizing that she was about to have a vaginal delivery, and while annoyed, Regina did n't dispute the C section S he was unsur e of what she wanted. As noted Regina used authority clearly and consistently defying doctors and relying on her own embodied knowledge ( Browner and Press 1996 ) Her u ncertainty over mode of childbirth stood out all the more Let us review agency in the account Regina tries unsuccessfully to demand the doctor' s immediate attention In the delivery room, Regina appears only to listen to t he medical staff's shocking revelation that the baby was already descending the birth canal. Regina herse lf quickly supplies a resolu tion to the complication and to the question of agency with a post hoc evaluation of her surgical delivery She says she did n o t object in part because of the doctor's lack of reass urance evidently, that she could g ive birth "no rmally." Regina also says she would n o t have wanted a vaginal delivery without fetal monitoring (see Lazarus 1994) In a sense Regina recuperates her own usual au thoritative stance through this explanation T hrough the coda, she resolves the conflict betwe en what should have been (a vaginal childbirth) and what was (a surgical childbirth that in her mind constituted a medical error). B y suggesting that neither she
nor the doctor determined the childbirth method but rather, the hand of fate ("it wasn't to b e"), Regina regains some authority and her place as main protagonist in the story. An Anguished Childbirth with Unresolved D epression I met Sandra in her tiny apartment in So Gonalo, Niter i, along with the nanny that had raised her an d her four month old baby. Her crises were multiple: first the unintended pregnancy itself to a young couple with low income and uncertain prospects. Her monthly household income was the second lowest in the middle to upper middle class sample (the equivalent of US $1000 compared to Regina's $8000 ). She was one of the youngest mothers of this sub sample giving birth at 23 years of age One com plicating event prenatally concerned the obstetrician. Sandra switched do ctors in the ninth month of pregnancy She was dissatisfi ed with her first doctor as he "didn't give the attention that I needed, you see? I didn't have his cell, he wasn't attentive I'd get panicky . . So, I went to my mother in law's doctor. I actually already knew him. I only had three consults with him, but he gave me confidence, he gave me his cell number, his sec retary's number, his home phone After this decisi ve act, Sandra's effectiveness diminished He r new doctor told her during an office visit that she wouldn't be able to have a vaginal delivery She recalled him saying I'm going to be honest with you, the size of your baby [52 centimeters] and the size of the passage you have, there is no w ay the baby can pass through. It 'll be a sacrifice for the baby. The doctor said this and schedule d the ces arean," Sandra said. 4 Th e doctor's denial of a normal" childbirth provoke d a n internal crisis in Sandra She felt a scheduled surgery was wrong, "as it didn't come from God. I put s uch ideas in my head, you see." T he date came, and Sandra became anxi ous when the bag of waters did n o t burst and she didn't feel anything. V ery apprehensive on arrival at the hospital and during the delivery, she says she kept thinking No, no, it's not the right time. At the moment the baby was coming out, I felt a very big sadness. I cried a lot with my mom after. Days after, I said, "G ood grief, they yanked ( arrancaram ) the baby out of me. Because I heard one doctor say, "H e's really high up. I heard her say this. As if he was still really high up, you see. And she we nt up to push him down. That sensation at the beginning, when they pulled him from me, they yanked him from me, understand? It wasn't time. So this got into my hea d, it stayed there for a month. Sandra's final point was se lf critical, but her evaluative s tatement s strikingly convey the experience of violation with the doctor forcibly pulling the baby out thereby countering God's will. Later, in this first interview, S andra mentioned having depression. When I asked how lon g t he depression had lasted, she s aid simply that it was n o t over. What I want to point out firs t is that the form of chi ldbirth was not the choice of any Brazilian women I met unless their choice coincided with the physician's. The women could be openly or passively resistant, a mbivalent or acquiescent, they could be wealthy or not, but most still had C sectio ns Despite differences in relative wealth, Regina 's and Sandra's relationships with their doctors were parallel. Both changed doctors during their first pregnancies, out of dissat is faction. N ote that this form of agency is not available to low income women, who use the federally funded universal health care system. Both were critical of t heir childbirth s and
bolstered their evaluations with reference to powerful authorities. Regina a lludes to malpractice of the C section performed too late; Sandra invokes G od's will against the C section performed too soon. Neither openly objected at the time of childbirth; instead they made retrospective evaluations. The negative evaluation of these experiences led them to make subsequent changes in provider as did others. After an unsatisfactory childbirth, the women would invariably change doctors. Childbirths following a C section delivery, however, are most often C sections in Brazil ( see e.g., P adua et al. 2010 ) The parallels in the two stories extend to their starkly serious dramatic style I t seems to me that the differing dramatic properties themselves registered something about the meaning of the experience In both stories, the protagonist s remained central albeit ineffectual. Th e experience s produced negative internal emotions of anxiety and anguish. But w hen we consider the resolution and coda to the childbirth experience itself, Regina and Sandra responded very differently. Regina found an intellectual resolution Sandra's story lacked a resolution or coda. S he was trying to distance herself from her belief that G od had not ordained a surgica l birth, but at the same time she struggled with depression ( which she later overca me with the hel p of her mother ) It is instructive to consider one of the three young middle class women in my sample who did have a vaginal delivery: Laura's doctor had scheduled her to have a C section b ecause she had hyperthyroidism. When Laura went into labor earlie r, instead of informing her doctor (about whose t reatment she had disputed weeks earlier), she walked the three blocks from her home in Tijuca over to the Veterans Hospital with her husband, who was employed in the military, and had a vaginal childbirth in the care of the attending physician. While we may count this as a rare example of resistance to surgical childbirth, Laura emphasized that the attending physician made the decision, countering the orders that she presented from her own doctor. A s there se emed to be very limited potential for the young women to determine chil dbirth method t he question became in what other ways were they exercising agency? Let us turn to n a rrative s where the women shape d the condition s for their childbirths. Ironic Drama: Efforts to R ecuperate A gency in C hildbirth vis vis the A gen cy of O thers A D eluxe Filmed and Scheduled Ces arean Where, Ironically, the Mother is P eripheral Marcela a resid ent of Leblon and liberal professional not working outside the home ( w ith a ho u sehold income the equivalent of US$4000 ), prefaced her account of childbirth at age 29 in week 40 of her pregnancy with these comments : I wanted a normal childbirth But here in Brazil, I don't know how it happens, but I think that it's a question of co nvenience for the doctors ; they like to set up ces areans. For them it's easy T hey work all day and at night they go to the hospital I had my C sectio n on a Friday, I chose the day . because then I could tak e advantage of the weekend at the hospital [ L aughs ] I didn't actually go into labor. I didn't even insist on a normal childbirth ; I regret it. Marcela frequently conveyed a duality of perspective s. She commented that her yoga instructor who espoused natural childbirth which Marcela herself did not had made her "paranoid that the baby should n' t come out too soon, that this would constitute a "trauma." But
she contested this view: A fter all e veryone goes through this [at birt h], but at the time I thought, I want the best' at least I want induc ed labor. I said, T ry to induce. W e can induce, the doctor said but I ended up not trying. When I got to the 40 th week, I became very anxious about the birth, so when he said, L et's s et it up I said L et's As others have found, these reports ill ustrate how Brazilian doctors formulate the decision for a C section as if in response to the woman. This doctor's wording is one of joint decision mak ing coupled with a characterization of risk with late term pregna ncy Marcela continued jovially : That morning, I went to the beauty salon, got my hair done, a manicure, had a nice lunch, my husband came for me and we went. [ I t was ] really great ( super tranq ilo ) there were 50,000 people at my [laughing ] because there, at the perinatal clinic, they have a baby arrival room, a restaurant I t's a really great space E veryone called me, and I told them "I t's on Friday, stop by. I think there were more than 30 peop le in the perinatal restaurant. Marcela went on to explain that the father takes the baby do wn the elevator and holds the baby up to the big window for everyone in the arrival room to see that the mother is shown on the TV and fireworks go off. Marcela said H e went down and I didn't even see At this moment, s he broke off her train of thou ght and good humored tone and then turned to what I believe was the central dramatic moment of her story. Marcela was disappointed because she had heard that they would bring the baby to her directly on delivery B ut instead they took the baby away for a l ong time and then gave the baby to her as she recalled "in a green blanket. I was sort of confused ; I thought I was going to cry ; I was sort of paralyzed ; my daughter already [in a blanket] . I was confused." While her husband had a fabulous time ( cu rtiu horrores ) assisting with the cutting of the umbilical cord, takin g the newborn to the c heering crowd Marcela was first c onfused by the medication they gave her after the birth, which made her silly and stupid ( bobalhona ) an effect she emphatically disliked and then she fell asleep : "If it had been normal ch ildbirth, I wouldn't have slept, Marcela concluded. Although Marcela began her accoun t with a critique of C sections as existing for the convenien ce of doctors, she made herself out to be the r esponsible party for not pressing for a vaginal delivery or induced labor. She was among many who had wanted to indu ce labor. Why do so when a C section will probably occur? A woman with a breech presentation (Ktia, below) said E ven knowing I would end up having a ces arean, I wanted to ex perience the feeling of labor." B y inducing labor, the women were striving for active embod iment and possibly to thereby e xperience childbirth as an achievement ( Rdlfsdttir 2000:346 ) Marcela indicated several efforts to create conditions surrounding her childbirth. She scheduled her C section, which allow ed social planning and, with the hospital accommodations, foster ed a staging of festivities complete with fil m, soundtrack and viewing room T his reproductive ritual in the making (Davis Floyd 1992) as played out however, left Marcela a spectator at her own childbirth and kept her peripheral to the central events even "off sce ne." Hers was a somewhat disembodied, even a lienating experience In Marcela's story the c entrality of others ends up prevail ing leaving her a discursive agency of retro spective, ambivalent eva luation H er story lacked a resolution and coda, y et notably, Marcela co nveyed her story to me with wry ironic humor.
An Alternative C Section, Where the Mother Is G rateful Cira a resident of Botafogo and unemployed graduate student (with a household income equivalent of US$2,600 ), framed the account of her efforts to have a natural childbirth ( at age 33) by a forceful assertion: I think that one of the strongest experiences of my pregnancy was this course my doc tor and the course instructor it's impossible to speak of my pregnancy without speaking of them." The course the instructor and her doctor, all proponents of humani zed childbirth (see Diniz 2005) were "fundamental" to Cira 's pregnancy and childbirth. The instructor, Cira said in a curious phrasing "forms the opinions of the pregnant women." Like Marcela, Cira was keen on being able to be with the baby right away. She did not have her bab y put in an incubator for two hours, which she said was "standard with middle class Braz ilians" and added, "T his was som ething that I was very concerned about, this thing of being the perfect mother. Now all babies are born and go to the incubator and cont inue being normal people ; it doesn't really make such a difference B ut with this thing of being the perfect mother, you want to do everything that's the best possible, and childbirth has to be a fairytale. T he course instructor had told her all these st ories (about breastfeeding, having the baby immediately at the breast, having the husband give the first bath choosing the pediatrician and ob gyn ), and I bought these stories that she told [emphasis added] and I managed to do things the way she was sa ying, and it was better, and I loved it, every time I went to the cl ass Cira ended up having a C section becau se as she put it "In fact, I was psychologically prepared for a natural childbirth, but I wasn't prepared for a difficult natural childbirth so I opted for a ces arean." She provided a fuller context: S he'd spent a long night with contract ions, but little progress with dilation Her doctor explained that i t therefore was n o t possi ble yet to give her anesthesia and that it would be a slow labo r. Cira noted H ere in B razil, it's very easy to opt for ces arean ; it is outside the mainstream standard to opt for natural childbirth T he standard is ces arean, as a matter of fact, the standard is a scheduled ces arean ( cesareana marcada ) The doctor sa id: I'm going to be frank with you. I always try to have it be natural childbi rth ; I always try to encourage it, bu t in your case, I think it'd be diffi cult, a difficult scenario. It could be that we'd try for four more hours and it'd be ces arean anyway." Cira said she didn't feel she had it in her to wai t two more hours for anesthesia. Cira 's wasn't a natural childbirth, but she presented the final decision as her own Without questioning the sincerity of the doctor's preference for vaginal childbirth, one can nonetheless register her persuasive outlining of the scenario that would ensu e we re Cira not to opt for ces arean S till Cira felt affirmed by her experience of humanized childbirth Cira's complicating event had a resolution I was perplexed how ever, by her insistence on the centrality of others in her pregnancy and childbirth and her choice of words: "It's [the course instructor] who se lls this idea .' I followed the w hole primer of [the course instructor], she said. Finally, I ask ed Y ou're s aying that you bought' and that she sold' this idea. You seem to have a somewhat ironic relation (to this childbirth model). Cira cut me off : "No! N ot at all, I did buy the idea ; I loved having done it ; I would do it all the same, an other time." I remai n ed puzzled that she was self critical of her ideal of being a perfect mother, yet not critical of the "fairytale" of childbirth and motherhood she "bought H er self representation is one in which she is on the receiving end, fundamentally through the te achings and expertise of the doctors she chose, to whom she felt greatly o bliged. Cira's characterization of her own position raises the question of agency. Despite many differences between Marcela's and Cira's childbirth narrati ves, both women appeare d pe ripheral to the events Both also appeared to distance
themselves from the experience, t he one with irony and a nearly literal sense of being margi nal, the other by characterizing the experience as mediated by consumption and grateful dependence on the fun damental agency of others. Let us re consider irony in the stories Muecke finds th a t in the "irony of events . the ironic incongruity is between the expectation and the event. We say it is ironic when, after we have more or less explicitly or confiden tly expressed reliance in the way things go, some subsequent unforeseen turn of events reverses and frustrates our expe ctations or designs" (1969 :102 ) Muecke emphasizes that an unexpected event itself is n o t ironic. It depends on innocent or overly c onfid ent expectations thwarted. (We see from Cira's perspective versus mine that irony also depends on the eye of the beholder.) Marcela's representation of herself initially as happy go lucky but clueless provides the perfect protagonist for an ironic turn of events; the situation itself i s an ideal set up precisely because it is so unanticipated that irony would be linked to a childbirth story. Marcela's self irony can be seen as a way to recapture power after it was diminished (Taylor 2001) Perhaps more usu ally, it is seen as s elf protective Muecke underscores the distancing effect: "The stronger his sense of irony the more he will be enabled to detach himself from his situation and become, by a kind of double think, the ironical observer of himself as vict im [of circumstance] (1969 :39 ) An ironic telling provides emotional counterbalance, but never a complete one: "an ironist is never completely detached" (Muecke 1969 :218 ) Marcela's shift in tone, from a high to a low poin t, registered the emotional weigh t of the event. Her humor offered an energizing counterbalance. Although the one account was not expressly ironic and the other was, both stories employed a great deal of critical observ ation Both Cira and Marcel a held some critical distance from circula ting ideas of childbirth. Yet both were self critical even of their own fantasies of the moment of transition to new motherhood. It is inte resting to note that in subsequent pregnancies, both Marcela and Cira wer e uninterested in the experiential aspects Cira said T he first time you have patience for the pain, because you still think you are curious, there's the business of trying to discover what is happening. The second no more curiosity. You know what you want. You want to get it over fast, and that's it. It was the same with recovery No patience for it." While not assuming "alienation" per se, one can still note the withdrawal from an "embodied self" (Akrich and Pasveer 2004:63 84 ; see also Sargent and Stark 1989:46 ) The final two brief examples pre sent what counts as idy llic C sections, both for breech presentation Idyllic C Sections: One Woman Compliant, One T ruant A Secure Delivery Thanks to Family and Fictive Kin as Attending D octors Ktia, special needs teacher and resident of a beach front apartment in Niter i (with a household income equivalent of US$2100 ) said her C section ( at age 28 ) for breech presentation was "really smooth" ( super tranqilo ) Her father, himself an ob gyn, and husband were there, and the medical team work ed with her father. "So, the anesthesiologist, the doctor are my aunts and uncles.' I have known them since childhood, a very nice atmosphere, pleasant, I felt really secure about everything. It was really good!" Ktia also had a sense of security from her pregnancy course taken from an "aunt" (a family friend) who had kno wn Ktia since infancy Family involveme nt assuring Ktia's security went further While Ktia wanted to work up until her due date, her father convinced her husband that Ktia should stop in her fi nal month of pregnancy to
avoi d the risk of going into labor in transit Ktia gave in to the pressure. Although Ktia wanted to experie nce labor, as h er due date drew near, like Marcela she became anxious and scheduled the C sect ion, foregoing labor induc tion. Kti a appeared to adhere to "compliance as strategy" in childbirth ( Tanassi 2004 ) Ktia's strong r elationship with the medical team was celebrated as one of fictive kinshi p; the childbirth became a family event. Ktia's family connections gave her a sense of security, if not autonomy or control 5 over the childbirth conditions (see also Gama Ade et al. 2009; Namey and Lyerly 2010 ) Although her father's agency prevailed, concern surrounding Ktia kept her center stage as a receptive protagonist. A F airytale Story of Improvised Beauty and J oy B ookends the C S ection Resident of Barra da Tijuca and fashion designer (w ith a monthly household income equivalent of US$3800 ) Tatiana had a doula accompany her pre gnancy at age 29 She said "I wanted [my so n] to be born by normal childbir th . but [it] . was bree ch ." Tatiana 's efforts to get th e fetus to turn around through yoga and acupuncture were unsuccessful. She also said her ob gyn didn't think it was a good id ea [ no achava interessante ], in h er first pregnancy, to try to turn the baby during childbirth ; it wasn't very advisable, in her opinion, and as she was someone entirely in favor of normal childbirth, I believed her, so it wa s ces arean, but it w as great. I didn't schedule it, I waited unt il it was time." On the day her baby was born, Tatiana awoke around 2 a.m. realizing h er bag of waters had burst. Her husband called the ob stetrician who told them to go to the maternity ward. I got up, got dressed, got my maternity bag ready fixed up the baby's room a bit more. I felt some light contractions. It w as about five in the morning. She then woke her husband back up but he said, I'm going to make an aa juice first Tatiana's stor y then took a turn. "W e lived in an apartment that had a view of the sea, the day was beautiful, dawn was breaking, so he said, L et's take some pictures.' I was pregnant, nude, that beautiful light, so we took some pictures, without hurrying, and at about 6 :00 6:30, we left the hous e, and when we were on our w ay . my doctor called and said, Tatiana where are you? I'm in the car, almost there.' And she [said] You are crazy! I told you to get dressed and come to th e maternity ward.' And I said, I tho ught you meant in the morning.' She and the whole tea m were there waiting for me since 4 a.m. . When we got to the delivery room the whole time, we'd planned on various things for the birth, that it would be in the dark, no strong lights, there would be ambient music, the sound of water, nice for the ba by to be born in t o, the room would be aromatized my doctor had just taken a course in the U S about how to improv e the atmosphere for the baby there wasn't time Another thing we wanted was in stead of the baby being cleaned up initially, that he'd come im mediately to my breast, to humanize the birth. This we did. We started at 8:15 and the baby was born at 8:48. . The birth was great, he came right to my breast, it was wonderful, the emotion is indescribable, we cried an absurd amount, we three, t he ba by obviously, I did and [ husband 's name ] it was wonderful." Discussion and Conclusion This work examine s young middle class Brazilian women 's agency vis vis others as represent ed in childbirth narratives A key plot complication and focus for evalu at ion was the decision for the C section The women interviewed for this study themselves raised the topic of
the trend in C sections, identified it as the preference of Brazilian doctors, and generally, but not always, as a break with a higher ideal held by them. The frequency of the commentary in the sample suggested first th at my being a foreigner led women to provide this context S econd, it suggests that C section delivery had not become a normative cultural script, but rather, was a cultural debate amon g the women whatever their position Thus a woman who c hose C section for herself vociferously criticized a friend over the age of 40 who she believed had nearly caused perinatal endang erment by attempting v aginal childbirth. Even those who were taking it as a non i ssue took a position ( as one said of C sections, I don't have anything against them" ) The c r itical commentary on mode of delivery in personal narratives reminds us that childbirth s a re culturally situated T he women represent ed the agen cy of doc tors in determining mode of delivery in two ways: as pre emptive or accomplished through a langua ge of mutuality coupled with a language of risk These findings align with studies on the framing of C section deliveries in Brazil (McCallum 2005; Hopkins 200 0); they extend them by indicating that the framing occurs not only during labor, but beforehand, in clinic visits. I would also suggest that the doctors' language of mutuality where a C section is highly probable may have an unfortunate effect: the woma n sees herself as responsible ("failing" to induce, or "failing" in the trial of labor). F ew women directly questioned the reason provided for their C section, including in relation to circumstances that are not indicators (e.g., wrapped umbilical cord) or that are in debate among obstetricians (e.g., stalled labor). The accounts suggest t hat the women are critically engaged in the debates on mode of childbirth without having specific understandings of valid versus doubtful reasons for C sections. Yet even without such information, women may reasonably question (as did Regina and Cira) the doctors' skill and experience in vaginal delivery. After registering that the se middle class women did not prevail in the form of childbirth I consider ed in what ways wo men exercise d agency to create meaningful childbirth conditions Cira proactively sought to have a "natural" childbirth by taking educational classes for vaginal childbirth and choosing a doctor who promoted it. O thers worked within the context of pre dete rmined C sections Some insisted on or considered induction of labor even if C section delivery was predetermined. Some did and some did not schedule the delivery. Whatever direction the decision took, they all offer testimony to ways Brazilian women strug gle to retain agency and meaning in their childbirths Marcela, Ktia and Tatiana strived to i mbue C section deliveries with value and meaning variously through an alternative childbirth by accepting familial presence in the delivery and improvising delay s to ensure the delivery started and ended in intimacy and beauty. In so doing, they illustrated agency that was nondefensive and "creative" al though with out changing the broader conditions (McNay 2000 :12 ) Regina 's and Sandra's unvoiced o b jections to C section delivery, and the retrospective evaluations they made in their narratives offer a belated, moral recuperation of agency. Attention to narrative resolution and coda as well as to dramatic genre signal a sense of the woman's perspective on the even t Regina's and Sandra's serious drama s stood out as the clearest counter narratives to idealized ch ildbirt h stories In their accounts critical evaluations of the d octors performing C sections and the wrongness of C sections themselves were central Marc ela and Cira described their own elaborate efforts to stage and enact what for them w ould be perfect childbirths : one conveyed disappointment (in herself and others) when her expectations were n't met; the other resolved the unexpected turn of events by acc epting her decision to give up on a vaginal childbirth. Marcela's irony and Cira's phrasing of her pregnancy and childbirth as "fairytales" suggested critiques of the idea of an ideal childbirth T hese
critiques were as much directed at themselves as at th e context producing such idealizations. The lack of irony or c ritique in Ktia's and Tatiana's idyllic stories suggests that when surgery was seen as completely justified the C section experience was posi tive. Theories of agency remind us that we can prod uc e effects in our social fields I found from the woman's stories that perhaps first a nd foremost, the effects were on thems elves. Th e women's accounts of their agency were often quite complic ated and in some cases, seemed ambivalent While registering t he doctors' agency, the women often appeared to t ake responsibility for their mode of childbirth I would argue following Simkin, that they did not have the necessary means to prevail as transient stakeholder [s] in the maternity care system" ( Klein et al 2006:247 ; see also Lazarus 1994 ) Simkin underscores limits to the possibilities of acts in this space especially by separately acting social agents. The scrutiny at the individual level a limitation of this work brackets off the necessary community lev el f or effective agency in relation to biomedical institutions and medical professionals. At the same ti me, the in dividual experience provides some compelling grounds for social change Coole underscores that agents' capacities "emerge and endure within co rporeal experience . [they] describe a dimension of power whose medium is bodily effects/affects: one that is both the site of a body politics in its own right and one that incites or inhibits the emergence of individual or collective political actors as bearers of agentic properties" ( 2005:131). In closing, o ne hope s that the efforts of medical anthropolo gists and childbirth activists (Davis Floyd et al. 2009) and new public health policy in Brazil (see Gama Ade et al. 2009 ) will be more effective than individuals in reversing this trend toward a majority of surgical childbirths In the meantime, as we assess the magnitude of biomedic al power enforcing surgical childbirth in contemporary Brazil, we can appreciate the strength, humor critical edge and creativity of the se young Brazilian women as they strive to retain their a gency and create meaningful celebration of the moment of transition to motherhood. Notes Acknowledgments: I would like to thank the Medical Anthropology Quarterly editor and anonym ous reviewers for their excellent critiques and suggestions. This work has also benefited from presentations of earlier versions at the New England Council of Latin American Studies (2008) and the meeting of the Society for Medical Anthropology (2009). The Institutional Review Boards of the University of Minnesota and the Maternidade Escola (Rio de Janeiro) approved this research. The Maternidade Escola also facilitated introductions to some of the women I interviewed. Martha Abreu, Lena Amorim, Fernanda Bi calho, Martha Bicalho and Lys Portella also helped connect me with contacts for the interviews. Special thanks to Lena Amorim for being my wonderfully gracious host in Rio. I would like to thank Dr. Carrie Ann Terrell, M.D. (obstetrics and gynecology), Dr. Melissa Avery, Ph.D., R.N. (nurse midwifery) and Dr. Maria Lcia Lins e Melo Torres, M.D. (Brazilian women's health) for their assistance in the interpretation of the reported childbirth procedures. Finally, my warm thanks to all the women who shared thei r stories. 1 Wendland's report that considerations extraneous to the pregnant woman's bodily state determine mode of delivery, and her conclusion that the C section is becoming the "unmarked" procedure and vaginal delivery "unpred ictable, uncontrolled, and therefore dangerous, appropriate for only a select few" (2007:224) resonate strongly with research on C sections in Brazil.
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