The Rhetoric of Pregnancy 9780226072074

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The Rhetoric of Pregnancy

The Rhetoric of Pregnancy foreword by jane pincus

Marika Seigel The University of Chicago Press Chicago and London

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 a This paper meets the requirements of ansi/niso z39.48–1992 (Permanence of Paper).

For Annika and Indrek

This is not a how-to book. sheila kitzinger (1978)

Contents

Foreword by Jane Pincus  ix Acknowledgments  xiii 1  Operating Instructions for Pregnancy  1 2  Usable Pregnancy  15 3 The Father of Prenantal Care: J. W. Ballantyne and System-Constitutive Documentation  35 4 The Mothers of Prenatal Care: Elizabeth Putnam, the IDNA, and User-Centered Care  51 5 Getting in the Way: Pregnancy Manuals during the Women’s Health Movement  69 6  What to Expect from Risk Management  91 7  System Error: Troubleshooting the Pregnant Body  105 8  Virtually Pregnant: Consuming Prenatal Care  121 Conclusion: Instructions for Systemic Change  139 Notes  157 References  165 Index  179

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 ix

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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 selfconfidence, 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

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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 selfknowledge 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.

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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 xiii

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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. 

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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

operating instructions for pregnancy  

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 there are certainly procedures that I would, in retrospect, have agreed to again, there are

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others I could have, and probably should have, questioned or refused and still others I should have demanded that were not offered. I had not, in other words, learned critical access. The fact that mainstream documentation on the topic of pregnancy and childbirth facilitates functional, rather than critical, access to the technological system of prenatal care would not be such an issue if the system worked well for all its users; if the system was user centered; and if it achieved what it is supposed to achieve. What is the work of pregnancy within this system (whether carried out by doctors, nurses, midwives, partners, or the pregnant woman herself) intended to produce? What is the telos (the purpose or goal)? For many women, and certainly in most pregnancy manuals, the answer would be a “normal” baby, or the healthiest baby possible. Other things that might be produced by the work processes of pregnancy (work processes such as attending prenatal visits; monitoring one’s diet, exercise and weight; reading pregnancy manuals; following medical recommendations) include an “easier” labor, or a labor in which the pregnant woman has more control and autonomy, or a birth process that results in a healthy mother (a normal mother?). If we accept, though, that the goal of working at pregnancy is, and should be, to produce a certain kind of baby (certainly to produce a healthy baby), then the technological system of prenatal care isn’t working, or isn’t working equally for all of its users. Take, for example, the US Department of Health and Human Services’ data on births for 2006–10 (at the time of this writing, 2009 was the latest year for which final data was available; only preliminary data was available for 2010), which shows that the cesarean delivery rate rose 2 percent from 2008 to 2009 to 32.9 percent of all births, a record high. Although preliminary data for 2010 indicate a very slight drop in the C-section rate (to 32.8 percent), the rate has “risen more than 50 percent” since 1996 (Martin et al. 2011, 2). Although the preterm birth rate (percentage of infants delivered at less than 37 completed weeks of gestation) has declined slightly from 12.33 percent in 2008 to 12.18 percent in 2009 and to 11.99 percent in 2010, the rate “rose more than 20 percent from 1990 through 2006” (Martin et al. 2011, 10). As the authors of the report of preliminary data for 2010 note, “despite recent declines, the preterm rate remains higher than for any year from 1981 through 2001” (Hamilton, Martin, and Ventura 2011, 5). The authors further observe that the decline in 2010 was mostly due to a decline in “late preterm (less than 37 completed weeks of gestation)” births. “The rate for early preterm (less than 34 weeks) births,” the report states, “was essentially stable at 3.50 percent” (Hamilton et al. 2011, 5).

operating instructions for pregnancy  

The percentage of babies born at low birth weight also rose steadily through 2006, to 8.3 percent of all births, “the highest level in four decades” (Martin et al. 2009, 2). The percentage of low-birth-weight babies has declined slightly since 2006 (to 8.15 percent in 2010), but the last couple of years have not shown significant declines (Hamilton et al. 2011, 5). The number of women suffering from pregnancy-related hypertension, which can lead to serious complications in pregnancy (including to maternal and infant death) “has risen more than 50 percent since 1990” to 4 percent of all women who gave birth in 2009 (Martin et al. 2011, 2). Furthermore, according to an October 2008 data brief from the National Center for Health Statistics, “the U.S. infant mortality rate did not decline from 2000 to 2005,” and the U.S., in comparison with other developed countries, ranks a staggering “29th in the world in infant mortality, tied with Poland and Slovakia” (MacDorman 2008, 2). All of this is in spite of the fact that the rate of prenatal care use, and of early initiation of prenatal care (across races and ethnic groups), has, for the most part, risen over the same time period that preterm birth rates, low-birth-weight rates, and cesarean delivery rates have also been on the upswing—from1990 to 2003, for example, “the proportion of women beginning care in the first trimester of pregnancy has increased 11 percent” (Martin et al. 2005, 2).1 All of this is also true in spite of the fact that US women have more prenatal care visits, on average, than women in most other European countries (Hamilton, Martin, and Ventura 2007, 14; Martin et al. 2007, 14; Strong 2000, 7), where preterm birth rates and infant mortality rates are significantly lower. There are also significant racial and ethnic disparities in birth outcomes. For example, the infant mortality rate for black women in the United States is more than twice as high as it is for white women (infant mortality rates for Puerto Rican and Native American women are also significantly higher than those for white women). As the National Center for Health Statistics notes, “many of the racial and ethnic differences in infant mortality remain unexplained” or are not adequately explained by differences in “socioeconomic status” and “access to medical care” (MacDorman 2008, 3). There are similar disparities in rates of preterm births and of low-birth-weight babies (Martin et al. 2010, table 24). All of this is not to say, of course, that prenatal care is the cause of these problems, and it is certainly not to say that women should forgo prenatal care during pregnancy. It is to say, however, that the technological system of prenatal care is in need of change both to facilitate access and to ensure that it is centered on the needs of all of its users. As Thomas Strong has put it, “The conventional wisdom that prenatal care [at least in its current form]

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is crucial to the well-being of mothers and babies is incongruent with the findings of published medical research and our nation’s experience over the last half-century” (2000, 29). The medical-technological system of prenatal care is a system with which a majority of US women will engage during the course of their lives and is a system that is increasingly positioning them in terms of managing their “risky” bodies and practices in order to perfect the fetus, even extending into what is beginning to be known as “preconception care” (Moos 2008). How we define the work of pregnancy has material consequences on women’s bodies and ways of living and, increasingly, has consequences not only for women who are pregnant but for those who are potentially pregnant as well. For example, in April of 2012 the Women’s Health and Safety Act was signed into law in Arizona—among other provisions, the law defines pregnancy as taking place on the date of a woman’s last menstrual period, which is usually about two weeks before conception actually takes place. As Erin Frost observed in a recent presentation to the Council for Programs in Scientific and Technical Communication, although obstetricians have long calculated gestational age from the first day of the pregnant women’s cycle, legally codifying this medical practice “overrides the role of the medical professional and presumes acontextual similarities for all pregnancies.” Although the law’s intent is mainly to limit the time window during which women can legally have abortions in Arizona, it also means that “any menstruating person in Arizona now exists in a state of perpetual pregnancy, legally speaking” (Frost 2012).

Rhetoric, Feminism, and Technical Communication In this book, I tell the story of prenatal care through its documentation and look at how it developed alongside of, out of, and sometimes in opposition to the technological system of prenatal care. I seek to understand how instructions for pregnancy came to be articulated in a certain way and how they might be articulated differently. Because pregnancy manuals seek to persuade their users to undertake certain practices while pregnant, to break old habits and form new ones, to be pregnant in certain specific ways, ways that are usually—but not always—articulated to a biomedical context, this book is situated most broadly in conversations about the rhetoric of health and healthcare. As Judy Segal puts it, “The relations of rhetoric and medicine are various and webbed,” from the banter through which a doctor might attempt to identify with her patient during an office visit to the obvi-

operating instructions for pregnancy  

ous persuasive intent of the ads for sleep aids and antidepressants that pervade daytime television to the citations that contribute to the credibility of an article in a medical journal (Segal 2005, 2). As Barbara Heifferon and Stuart Brown put it in the introduction to their collection of essays titled The Rhetoric of Healthcare, scholarship in this area “initiates inquiry into the role of rhetoric in various health care and medical discourses and examines what rhetoric—as a discipline in its own right—can contribute to this complex and essential field” (Heifferon and Brown 2008, 2). Likewise, I employ methods of rhetorical analysis both to better understand pregnancy manuals and to suggest ways that such methods could be employed to improve communication about pregnancy. (I describe my specific method of rhetorical-cultural analysis in more detail in the next chapter.) This book also draws from and contributes to feminist scholarship about pregnancy, childbirth, and technologies of reproduction that has been conducted in a number of fields, including history, anthropology, sociology, philosophy, rhetoric, and science studies. In some ways, as Alice Adams argues, pregnancy seems “to reassert in some primitive way [a woman’s] functional service to the species” (1994, 80). Many feminist scholars have described how medical, scientific, cultural, philosophical, and technological discourses and developments work to highlight that functionality and to downplay women’s humanity. Scholars such as Janelle Taylor and Barbara Duden have chronicled how technologies of visualization have made the fetus a public figure, disconnected from the maternal environment (Taylor 2008; Duden 1993). Dorothy Roberts has argued that technologies of “temporary sterilization” such as Norplant and Depo-Provera are disproportionately deployed on low-income African American women (as incentive or punishment), whose reproduction is deemed to be a threat to society (1997, 106). Elizabeth Ettorre and Rayna Rapp have similarly observed how technologies like genetic prenatal testing as well as the reproductive technologies such as in vitro fertilization are partially influenced by neoeugenic discourse that dictates who has the right to be born and who has the right to reproduce (Ettorre 2000, 2001; Rapp 1999). Scholars such as Ann Oakley and Emily Martin have described how pregnancy became an object to be dissected by the medical gaze and how the pregnant body became governed by metaphors of machinery, consumption, and production (Oakley 1984; Martin 1992). Within feminist circles, there has also been much critiquing of the medical, technological, and intervention-heavy approach to childbirth, an approach that, critics argue, frequently alienates women, makes them feel out of control of the birthing process, and

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facilitates unnecessary, painful, and sometimes traumatic procedures (Block 2008; Davis-Floyd [1992] 2003; Kitzinger 2006; Leavitt 1986; Martin 1992; Wertz and Wertz 1989). As I will argue in the next chapter, pregnancy manuals are a kind of technical communication—they are concerned with procedure and instruction. Research in technical communication and usability has long been concerned with describing what makes instructions effective and ineffective and, thus, is also essential to understanding these particular instructional documents. Specifically, however, this project is a contribution to feminist research in technical communication, which seeks to expand the scope of what counts as technical writing both to reclaim women’s contributions to the field and to “challenge the dualistic thinking that severs public and private, household and industry, and masculine and feminine labor” (Durack 1997, 257). Some of the work in technical communication that I would characterize as feminist and that has been influential to my own work includes Elizabeth Tebeaux’s work on Renaissance-era household management manuals (Tebeaux and Lay 1992), Kathryn Neeley’s work on women’s “mediated” writing about science and technology in the eighteenth and nineteenth centuries (1992), Durack’s work on sewing machine documentation (1998), Amy Koerber’s work on breastfeeding documentation and discourses (2005), Mary Lay’s work on midwifery (2000), and Kim Hensley Owens’s analysis of birth plans (2009). There is also some work outside of technical communication that has critiqued and analyzed pregnancy guides specifically. For example, in the late 1990s one of the founders of the Boston Women’s Health Book Collective, Jane Pincus, published an extensive critique of what she calls “childbirth advice books” (including What to Expect When You’re Expecting, one of the manuals I analyze here). In her critique, she points out how these books often give the illusion of empowerment and choice in childbirth but then present those choices in such a way as to ensure women’s conformance to the status quo “just in case”: They inform and guide; they also indoctrinate in a subtle way. Often they are confusing and contradictory. We are told that we are strong and capable and then cautioned about all the things that might go wrong. We are advised to fight for that “natural” birth and at the same time confronted with long lists of tests and interventions to circumvent, somehow, if possible. Almost every mention of a woman’s desires and concerns is immediately followed by a discussion of risk and danger. We are counseled to work for change if we

operating instructions for pregnancy   are not satisfied, and to do so coolly, politely, in a lady-like manner. (Pincus [1990] 2010)

Helena Mitchie and Michele Cahn have also argued that pregnancy advice similar to that presented in books such as What to Expect indoctrinate pregnant women (middle-class pregnant women, in particular) with discourses that encourage them to discipline their own bodies and practice (Michie and Cahn 1997). More recently, Denice Copelton has analyzed the advice on prenatal drinking presented in nine popular pregnancy manuals, finding that “although most took a hard line,” they also frequently were more tolerant of “naïve drinking” early in pregnancy (before the woman is aware that she is pregnant; 2008, 14–15). A discourse analysis of the “top-selling childbirth advice books” published in the periodical Birth found, among other things, that “scientific evidence to support recommendations was uneven and sometimes inaccurate,” and that “most of the books placed ultimate authority in medicine, institutions, and physicians” (Kennedy et al. 2009, 318, 322). To broaden the purview of technical communication beyond the workplace (traditionally defined) to include domestic spaces, recreational spaces, political spaces, and so forth—to include texts like pregnancy manuals—means not only making the field more inclusive and relevant to more people, it also means (as we will see in subsequent chapters) reconsidering received knowledge about the purposes and uses of instruction manuals. As I will address in subsequent chapters, there are critical and transformative examples of pregnancy manuals (e.g., those arising out of the women’s health movement) that could serve as a model for technical communicators who want to provide users with critical or transformative access to other technological systems where the stakes are high. Finally, I hope that this book will be of use to the users and designers of the technological system of prenatal care—for pregnant women, and for those doctors, doulas, midwives, fathers, feminist and women’s studies scholars, rhetoricians, and activists who have an interest in providing pregnant women with critical, transformative access to the prenatal care system and in learning how instructions might be written to facilitate this kind of access. (I give suggestions for composing this kind of documentation in the conclusion to this book.) These readers might also be interested in learning more about the history of the technological system of prenatal care in this country as well as about the documentation that has accompanied its growth. This history is presented throughout the book and is

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interwoven with the analysis of the documentation—pregnancy manuals—that supports (or seeks to disrupt) the system. Writing critical, even transformative, documentation means understanding how the technological systems and work processes being documented came to be configured as they are and how they might be configured differently.

Accommodating Prenatal Care David Dobrin (1983 [2004]) has defined technical communication as “writing that accommodates technology to the user” (118).2 It is easy to see how a software manual fits this definition, but more difficult in the case of a document like a pregnancy manual. What technology is being documented in a pregnancy manual? Although they are called guides to pregnancy or pregnancy handbooks or pregnancy manuals, these documents do not simply give information about the cultural or biological processes of pregnancy. Instead, like operating instructions for software, they instruct users how to engage (or comply) with a technology, or in this case a technological system—a term that Ruth Schwartz Cowan uses to describe how “each implement . . . is part of a sequence of implements—a system—in which each must be linked in order to function appropriately” (1983, 13). Examining part of the table of contents of another popular manual, Pregnancy for Dummies, helps to give a sense of the components of the technological system that it documents.3 One implement being documented in figure 1.1 is clearly the pregnant body. Another is the fetus. These are connected to (and, indeed, in some senses engendered by) the technological implements and procedures of prenatal care and, specifically, prenatal testing (ultrasound, amniocentesis, blood tests). All of these implements comprise what I term the technological system of prenatal care. Note that the problems users might encounter—what we might understand as the troubleshooting portion of the manual—all have to do with the malfunctioning maternal body (which bleeds and is congested and incompetent) or with fetal abnormality. None of the troubleshooting focuses on problems that the user might have with medical technologies or procedures (doctors might also be forgetful or clumsy, after all), for example, or with domestic or social situations that might also threaten a pregnancy, such as abuse and poverty. System errors, in this case, originate with the maternal body, itself represented as an apparatus that threatens malfunction—this particular manual supports not only a mechanical view of the pregnant body but also a pathological one. (I will address these views in more detail in chap. 6.) In

operating instructions for pregnancy  11

Figure 1.1: Excerpt from the table of contents in Pregnancy for Dummies (Stone, Eddleman, and Duenwald 1999).

contrast, the various prenatal tests routinely conducted during second trimester prenatal visits are represented as unproblematic and uncontroversial tasks that the user will inevitably carry out. Manuals like Pregnancy for Dummies pose a unique and problematic situation from the perspective of usability because the user’s body is explicitly part of the technological system being discussed. Mainstream pregnancy manuals like Pregnancy for Dummies (search for “pregnancy”—just “pregnancy”—on Amazon.com or similar sites and you will find hundreds more) accommodate the user to the technological system of prenatal care. This system has “produced a single, canonized fetus who has become the inhabitant of each individual pregnant body, as well as a shared, public pregnancy narrative that constitutes and interprets each individual pregnancy” (Kukla 2005, 109, italics in original). Pregnant women are individualized according to their conformance to, or deviation from, this public pregnancy narrative, and they are individualized according to their risk positions. One question that this book explores is how the

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management of pregnancy has become so entwined with testing technologies and techniques for risk management. Technologies such as ultrasound, Doppler, prenatal tests, monitors, scales, and so on provide publicly quantifiable checks to make sure that the pregnant woman is disciplining her body in accordance with this greater social narrative. Signs of deviation from this narrative—things such as abnormal test results, weight gain that is too high or too low, prior cesarean section, being of a particular race or ethnicity, being too young or too old, or being HIV positive—provide warrant for increased surveillance and for intervention. Take these three cases: 1 In 1978, American Cyanamid Company required all women under the age of fifty to undergo tubal ligation surgery if those women wished to keep their jobs; this requirement resulted from a “fetal protection policy” instituted by the Willow Island plant. Chemicals used at the plant were determined to be potentially harmful to developing fetuses (Roth 2000). 2 In 1989, the city of Charleston police department, in collaboration with officials at the Medical University of South Carolina, tested pregnant women admitted to the hospital for evidence of cocaine use, and did so without informing the women of these tests. Pregnant women admitted to the hospital were selected for this testing through risk factors such as “incomplete prenatal care or pre-term labor of no obvious cause” (Sinha 2002, 171). Although race was not an explicit risk factor, forty-one of the forty-two women arrested as a result of this program were black (Gagan 2000, 492). When the program first began, women who tested positive for cocaine use during labor or during pregnancy were immediately arrested, although later in the program they were only arrested if they tested positive a second time or if they “missed an appointment with a substance abuse counselor.”4 Depending on their stage of pregnancy, the women were either prosecuted for “simple possession,” “possession and distribution to a person under the age of 18,” or “unlawful neglect of a child.”5 Some women who tested positive for cocaine use through this covert testing were “chained to their hospital beds during birth” or “dragged away from the delivery room, in shackles, still bleeding” (Gagan 2000, 492). 3 More recently, the New York Times Magazine reported that a New Jersey woman, Donna Branca, sued her doctors for failing to identify fetal abnormalities until after it was too late for her to have an abortion. It was her contention that she was not offered adequate prenatal testing be-

operating instructions for pregnancy  13 cause she did not fall into the over-thirty-five risk category (Weil 2006). Branca’s primary care physician also failed to perform standard procedures such as measuring Branca’s fundal height (the size of the uterus, measured from the top of the uterus to the pubic bone) in order to gauge the size of the fetus and progression of the pregnancy and told her not to worry about her underaverage weight gain and bleeding early in pregnancy. At twenty-eight weeks, four weeks past the time that she could legally terminate the pregnancy in New York, Branca learned through testing at another hospital that her fetus had Wolf-Hirschhorn syndrome, “which commonly includes metal retardation, physical disfigurement, inability to speak, seizures, and respiratory and digestive problems” (Weil 2006). Branca’s doctors were found guilty of “medical negligence,” and “all parties agreed to a multimillion-dollar settlement” (Weil 2006).

These three cases, although taking place at different times, under dissimilar circumstances, and involving different groups of people, illustrate three important assumptions (taken here to the extreme) around which the modern technological system of prenatal care is structured—or perhaps it would be more correct to say assumptions that it has helped to engender. The first assumption is that what we as a society consider to be the “work” of pregnancy has the potential to have an impact on the bodies and practices of not only pregnant women but also potentially pregnant women and that pregnant bodies can become the sites through which social, political, and environmental risks are managed. Second, there is a supposition that in cases where the pregnant woman is seen not to be adequately working to discipline her own body and practices, the role of doctors, employers, law enforcement officials, fathers, and other “enforcers” of prenatal care practices is to impose such discipline. Finally, the telos, or goal, of the work of pregnancy as informed by the medical-technological system of prenatal care is assumed to be not only a healthy fetus (or a healthy mother) but also a normal fetus. Where the role of the user of the technological system of prenatal care— that is, the pregnant woman—is to work at disciplining her body and practices in accordance with public pregnancy narratives and to submit to the authority, guidance, and surveillance of medical professionals, the role of the healthcare practitioner has become to identify abnormality through now ubiquitous testing technologies, and if they fail to do so, they may face lawsuits. Both of these technologies are part of the public pregnancy narrative and are deployed at signs of deviation from the narrative that signal fetal (or maternal) abnormality.

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Given the very material effects that technologies of prenatal care can have on the lives of women, healthcare practitioners, and children, we should be concerned that most documentation surrounding pregnancy attempts to give users functional access to the technological system of prenatal care rather than critical access. In technological systems where bodies are explicitly components of those systems (or even when they are implicitly components, as in computer systems), it is my argument that manuals should provide users with critical access to those systems rather than functional access. I believe that it is important for users to have a critical understanding of the purpose for which they are disciplining their bodies and submitting to such discipline, especially when the technological system with which they are engaging has the potential to have material effects on their physical and mental well-being, as does the prenatal care system. Instructions are one interface through which users could, theoretically, gain the kind of critical access to a technological system that could help them to negotiate it or even to transform it.6 Unfortunately, most (but not all) pregnancy manuals provide users nothing more than functional access—that is, the knowledge necessary to engage with the prenatal care system but not to engage with it systematically, let alone critically. My hunch is that part of the reason pregnancy manuals provide functional rather than critical access is because of notions of what pregnant women want or need that are based on previous instances of the pregnancy manual or based on the structure of the technological system of prenatal care. Too often, the question of how or why users have come to have particular wants or needs in the first place (after all, they come from somewhere) is not asked. So that is the question that begins this book: How did we get here? How did pregnancy manuals come to be the way they are, to be instructions for managing risk and disciplining the pregnant body in order to produce normal babies?

2 Usable Pregnancy

You have to assume we have always balanced experts’ suggestions with the advice given by friends and mothers, not to mention our own gut instincts. randi hutter epstein (2010) In its most basic sense, this book is my exercise regime and selfhelp manual for how not to be literal minded. donna haraway (1997)

Shortly around the time that I began to take personal interest in pregnancy manuals, I began to take academic interest in them as well. As part of my graduate study about risk communication and usability theory I had been reading such manuals, and I began to wonder whether the problems that I had experienced with What to Expect (as well as Pregnancy for Dummies [Stone, Eddleman, and Duenwald 1999], Your Pregnancy Week by Week [Curtis 1994], and The Girlfriend’s Guide to Pregnancy [Iovine 1995]) stemmed from their not being usable or user centered or even user friendly. I wondered if and how one could assess the usability of an instructional document like a pregnancy manual. Usability is often defined as a measurable quality. For example, the International Organization for Standardization defines usability as the “extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use” (International Organization for Standardization 1998, 2). 1 According to this standards organization, effectiveness, efficiency, and satisfaction are usability measures that can be gathered “by objective means, such as the measurement of output” or “by subjective responses of the users expressing 15

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feelings, beliefs, attitudes, or preferences” (the latter measure most closely linked to measuring satisfaction; International Organization for Standardization 1998, 3, 12). In addition to referring to a measureable quality that exists somewhere in the interaction between user and product, the term “usability” can also refer to processes or techniques developed by usability professionals for creating usable products (User Experience Professionals Association 2009). Usability is thus both an outcome and a process. Early usability efforts were initiated by the software industry, specifically by a rising interest there in human-computer interaction driven by the proliferation of personal computers in the 1980s (Barnum 2002, xiv). The term “user-centered design” was coined by Norman and Draper in their edited collection User Centered System Design: New Perspectives on HumanComputer Interaction (1986). As Robert Johnson observes, “The exigency of their user-centered project was rooted in the multitude of problems people have when they use computers” (1998, 12). In his 1993 book Usability Engineering, usability guru Jakob Nielsen identified five key elements of usability that have been influential (indeed, they are evident in the International Organization for Standardization’s definition of usability): · learnability (technological system is easy to learn); · efficiency (system maximizes productivity); · memorability (user can easily remember how to perform certain system tasks); · errors (system errors are few and easily correctable); · and satisfaction (users should enjoy using the system). (Barnum 2002, 6; Nielsen 1993)

For Nielsen, usability is best achieved through a process of what he calls (following Norman and Draper) user-centered design (Nielsen 1993; Norman and Draper 1986). This process involves users early on in the productdevelopment process. Researchers conduct iterative testing to ensure that features of a product or system fulfill the above-identified elements of usability and the product or system is redesigned according to the results of those tests.2 This kind of formal user testing frequently involves observing the user carrying out specific tasks within a controlled environment. The University of Minnesota’s usability lab, which features an evaluation room where tests are conducted as well as an observation room where tests are observed and recorded, is pictured in figure 2.1. This approach to usability testing has many advantages: in a controlled usability lab, the user can more easily be observed and recorded, providing testers with rich sources

usable pregnancy  17

Figure 2.1: Schematic of University of Minnesota’s usability lab showing the evaluation room (where the tests are conducted) and the observation room (where the tests are observed and recorded). Nick Rosencrans © 2012, Regents of the University of Minnesota. All rights reserved.

of data. Controlled environments also ensure that tests with different users are parallel—that, for example, they have the same resources for approaching tasks. The usability of specific product features can more easily be tested in this way, and factors such as time of task completion and number of errors can be easily recorded and quantitatively measured, providing concrete data that a new iteration of a product feature is or is not more usable. This approach has disadvantages as well—most notably, the controlled lab environment does not always actually reflect how a user will act in her or his actual work or home environment when tasks haven’t been predefined by usability testers and when the user is distracted by coworkers, children, pets, telephones, e-mail, and so on. The user is, in other words, somewhat decontextualized (Rubin and Chisnell 2008, 26). In addition to user testing, heuristic evaluation and contextual inquiry are common approaches to usability research (Johnson-Eilola and Selber 2007, 173–75). Heuristic evaluation focuses on the artifact—document, apparatus, website—and evaluates it “against the best practices reported in the published literature” (Johnson-Eilola and Selber 2007, 173). This evaluation usually involves usability experts in conversation with each other rather than with users. Traditionally, text-centered usability research and evaluation might involve evaluating a text against a set of heuristics (Barnum, 35–38) or conducting editorial and technical reviews through which “editorial experts can find style problems” or “technical experts can locate problems with the technical content of a manual more efficiently, and more

18  chapter 2

reliably, than users can” (Sullivan 1989, 260). For example, a heuristic evaluation of documentation would focus on such elements as “consistency in document design and word choice” and “provid[ing] solutions to potential problems in plain language” (Barnum, 40). The text undergoing evaluation is approached as a static and decontextualized entity that can be fairly objectively evaluated as usable or not usable according to the heuristic. This approach is used because it can catch common usability problems and issues before time and resources are invested into user testing. As is evident from these examples, usability testing and evaluation that comes out of the human-computer-interaction tradition generally reflects what Theron Howard and Michael Greer have called accommodationist approaches to usability; usability becomes a “means of locating and recommending ways to ‘fix’ the usability errors” in the product or text being evaluated (Howard and Greer 2011, 68). Another approach to evaluating usability is through contextual inquiry, which broadens the focus of the overall testing from the user in isolation to the user operating within his or her environment. Contextual inquiry approaches usability as a quality “distributed across time and space” rather than a quality that adheres in a particular artifact (Johnson-Eilola and Selber 2007, 177). Ethnographic studies that focus on usability would be an example of contextual inquiry, as they would emphasize observing how individuals use items in the real world versus the controlled lab environment.3 Given many technical communication scholars’ rhetorical training, it is perhaps not surprising that this contextual approach to usability is evident in much of the technical communication scholarship. In a 1999 paper, Clay Spinuzzi coined the term “distributed usability,” arguing that usability is a quality distributed “across the genres, practices, uses, and goals of a given activity” rather than being inherent in artifacts themselves (16). If a user can’t open a door, for instance, it might be because she is in a wheelchair and the entrance is not accessible to her. Or, perhaps there is a ramp entrance and a button that automatically opens the door, but the button doesn’t work because the user can’t reach it or because the button is broken and the institution hasn’t yet sent someone to fix it, or the user can’t find the button because it looks different than other instances of the genre. In any case, the user “unfriendliness” of the door isn’t something that inheres in the technological artifacts themselves (the door, the button, the wheelchair, the ramp), but that is produced by the relation of technological, social, political, economic, cultural, institutional, and even generic forces. According to this distributed view, usability is also not a universal quality: some people will find the entrance easy to use, some will not; in fact, as

usable pregnancy  19

Stephen Schneider notes, entire user groups may be designed out of technological artifacts. Increasing usability for one group of users may mean making a product less usable for others—elegant building entrances that are difficult or impossible to navigate in a wheelchair (or while pushing a stroller) are one example; ballpoint pens that are difficult to operate for left-handed users are another (Schneider 2005, 451). As Spinuzzi puts it, “If the product is difficult to use, does the blame lie within the tool itself, or in the other tools that have to work with it, or the work practices with which these users are familiar, or in the confluence of all of these?” (1999, 16). For scholars such as Spinuzzi, analyzing usability means also taking into consideration the contexts in which users engage with technologies, the activities in which users are engaged, and the “ecologies of genre” that influence how they learn and use new technologies (Spinuzzi 1999, 17). Similarly, Robert Johnson (1998) defines “user-centered design” as design (of a technology, system, document) that starts from the user operating within a specific cultural, political, institutional, and historical context. The user-centered approach begins, then, from assessing the user’s specific needs, goals, constraints, and knowledge. Johnson’s user-centered approach to technology and documentation development does not assume an “ideal” user performing a series of decontextualized tasks that are defined by the system (or the technologies’ designers and distributors). Rather, tasks are defined by the user her- or himself. Ideally, the user would also be involved in decisions about what kinds of technologies should be developed and why. According to the user-centered model of technology and documentation development, knowledge about a particular artifact or system is produced not only or primarily by system designers or by the system itself but also by those who inhabit the system and/or use it (Johnson 1998). All of these approaches to usability, alone or in combination, have the potential to provide users with an important voice in technology and documentation development. By “voice,” I mean that these approaches allow users to articulate their own needs and goals—whether this occurs at the beginning, middle, or end of the development process or throughout it— and have the potential to result in technologies and documentation that reflect those needs and goals. It is also important to note, however, that these approaches to usability accept—to varying degrees—the need to engage functionally with a technological system as a given. They assume that users want (simply) to use technological systems, not to cunningly negotiate, critique, or transform them. Now let’s turn back to my frustration with What to Expect, to my sense that in some way it wasn’t usable. Following are, as examples, ways that

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What to Expect’s usability might be evaluated according to these different models of usability that I’ve just outlined. · Controlled user testing could assess how quickly users can access certain information, such as the risks involved in dying one’s hair while pregnant or the best diet to follow in the first trimester. (One could even survey pregnant women and/or medical professionals in order to determine what information users need to access.) · A heuristic evaluation could assess the manual against the best practices for instruction writing. (Does the manual divide information into manageable units or “chunks” that can help readers use that information effectively? Is the hierarchy of information clearly signaled in the document’s format, such as through the use of self-obvious headings?) · Pregnant women could be observed in the “field” in order to assess how they incorporate, or do not incorporate, a pregnancy manual like What to Expect into their everyday practice, and how the usability of that manual is affected by, and distributed throughout, their localized situations. (Do the manuals help them to carry out the work of pregnancy and to achieve their goals?)

Although these approaches would each yield a different type of information about the usability of What to Expect, they all share a common characteristic: they do not get at the question of how the user comes to have certain needs and goals in the first place, needs and goals that necessitate engaging with a particular practice, a technological system, and its associated documentation. In other words, these approaches to usability would evaluate the usability of the manuals according to the degree that a user has what Adam Banks has called functional access to a technological system rather than critical access to that system. As mentioned in the previous chapter, if a user has functional access to a technology or technological system, it means that she has the basic knowledge necessary to use a tool or engage with a system. A user with critical access knows how to engage strategically with, disengage from, and negotiate a technological system (Banks 2006, 41–42). Reflecting back on my experience with What to Expect, my perception of the book’s lack of usability stemmed precisely from its functional rather than critical orientation to the technological system of prenatal care. The manual was, and is, very usable if one begins from the assumption that, as part of the practice of pregnancy, the user can and should and needs to “use” the prenatal care system and be used by it (rather than negotiate that

usable pregnancy  21

system, for example). According to What to Expect, the best way to troubleshoot the risky pregnant body is to engage functionally and uncritically with the technological system of prenatal care. In essence, as I will discuss in chapter 6 the manual takes a troubleshooting approach to pregnancy, an approach that is similar to what programmers might use to diagnose software glitches. First and foremost, this engagement means attending all regular prenatal checkups: “Even a low-risk pregnancy is put at high risk if prenatal care is absent or poor,” the authors warn. “Seeing a qualified practitioner regularly, beginning as soon as pregnancy is expected, is vital for all expectant mothers” (Murkoff, Eisenberg, and Hathaway 1984, 52). Engaging with the technological system of prenatal care also means following the advice of that practitioner and following a regimen of exercise, diet, “sensible weight gain,” and stress management outside of checkups (Murkoff, Eisenberg, and Hathaway 1984, 38). (I had, in fact, entered the technological system of prenatal care as soon as I purchased my first home pregnancy test.) In order to evaluate the usability of documentation like pregnancy manuals from a critical perspective rather than the functional perspective often used with texts such as software instructions, one must first understand how these manuals were created and how a different approach could have led to a much different product. To examine this issue, I follow Bernadette Longo by observing that the pressing question in this case is Foucault’s: “How is it that one particular statement appeared rather than another?” (Foucault 1972, 27; Longo 2000, 19). Moreover, what alternative statements have been voiced—and silenced—along the way?

Rhetorical-Cultural Analysis and Usability Evaluation As mentioned previously, most approaches to usability research and evaluation assume that users will, and should, functionally engage with technology and technological systems rather than critically negotiate or transform those systems. If a technical communicator wants to facilitate critical or transformative access, then traditional approaches to usability research and evaluation will not be adequate. Rather, the technical communicator should endeavor to understand how the user came to be positioned in a certain way at a certain time so that carrying out a certain practice seems inevitably to mean that she needs to engage functionally with a technological system in the first place. Recent constructivist approaches to usability testing and evaluation, as reflected in movement toward “user experience

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design,” have begun to recognize that technologies and their associated documentation do not just accommodate user needs but, rather, create and shape those needs, especially in complex task environments. As Howard puts it, “All too frequently, we tend to think in terms of accommodation of users’ needs, and tend to overlook the important role that authors and designers play in the construction of users’ task environment. . . . Successful texts and information products create roles and provide interpretive frameworks that users can deploy in order to successfully complete tasks and achieve their goals” (2008, 202). For example, in their usability evaluation of first-year composition handbooks, Howard and his colleagues found that when using the handbooks to cite sources, users believed that the handbooks were usable even when those users were actually not able to cite various sources correctly because the handbooks being evaluated didn’t signal to the reader the complexity of the task—Howard said that the handbooks “asked users to play roles they could not adopt” (202). Howard’s work in constructivist approaches to usability recognize the role that documentation and interfaces have in defining user’s roles relative to a technology and defining what needs it is possible for them to have. The goal of current constructivist approaches to usability, however, still seems to be functional access (that students can correctly cite sources, for example). Constructivist approaches to usability, however, do open the door to critical access: by understanding what roles documentation makes available to the user, for example, a technical communicator could begin to understand how a manual might differently articulate those roles and their associated practices in order to help the user gain critical access to a technological system, to empower her.4 In order to facilitate critical access, documentation must articulate the user as someone who can claim that access. In both his 2003 College English article and 2003 book Risky Rhetoric, Blake Scott outlines a methodology for rhetorical-cultural analysis, which I have adapted for the purposes of usability research. Scott characterizes his approach as a hybrid rhetorical-cultural approach because it draws individual methods for analysis from the fields of rhetoric and cultural studies. This perspective does not mean forgoing rhetorical analysis, but it does mean reading texts less as rhetorical productions of intentional agents, or authors. Instead, rhetorical-cultural analysis emphasizes a text’s conditions of possibility and its possible rhetorical and material effects. As Scott puts it, where a traditional rhetorical analysis might illuminate “cultural entanglements as a way to situate and elucidate texts, a rhetorical-cultural mapping discusses specific texts as a way to elucidate cultural entangle­ ments” (Scott 2003, 355). To put it another way, the goal of rhetorical-

usable pregnancy  23

cultural analysis, like the goal of any usability evaluation, is to better understand the context in which the text is consumed and used rather than to better understand the text itself, independent of context. Central to Scott’s methodology is Stuart Hall’s theory of articulation, which “would read all texts as changing ensembles of relations that produce a range of effects, including subjects” and, including, for the purposes of this study, users (Scott 2003, 355). But what exactly does it mean to read a text as “changing ensembles of relations”? And, even more specifically, how can a technical communicator analyze a piece of documentation, say, an operator’s manual, in order to describe how its user was articulated at a particular moment? Answering these questions involves understanding a bit more about how articulation theory works, and how it might work hand in hand with Kenneth Burke’s more rhetorically focused concept of piety.

Articulation and Piety: User = Drug Fiend Articulation theory is not new to technical communication. In fact, in “The Technical Communicator as Author,” Jennifer Slack (2003) proposes that we (as technical communicators and educators of technical communicators) understand meaning as something that is articulated by various actors and forces rather than something that is transmitted or translated between sender (scientist/technician) and receiver (user/audience) with the technical communicator as transparent conduit or as translator. What we perceive, then, as “coherent forms or structures” (such as what is meant by the term “pregnant”) are actually “produced out of linkages of different elements, such as social formations, ideologies, experiences, and identities” (Scott 2004, 202). Although the term “articulation” is most closely associated with communicating an idea through speech or writing, Hall points out that it has another meaning that has to do with connections between disparate parts to form a whole. Hall uses the metaphor of an articulated truck in order to explain how articulation works in forging meaning through linking disparate elements. Although the cab and trailer of a semi-trailer truck can be connected, this connection isn’t necessary: “The two parts are connected to each other, but through a specific linkage, that can be broken. An articulation is thus the form of the connection that can make a unity of two different elements, under certain conditions. It is a linkage which is not necessary, determined, absolute, and essential for all time. . . . So the so-called ‘unity’ of a discourse is really the articulation of

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different, distinct elements which can be rearticulated in different ways because they have no necessary ‘belongingness’” (Hall 1986, 53). As Hall also points out, just because articulations are, in Hall’s terms, “non-necessary” doesn’t mean that they are irrelevant or easy to change. For example, he points out that the articulation between religion and politics in many cultures is certainly non-necessary, but it is also tenacious (Hall 1986, 53–54): it would be very difficult, if not impossible, for an American presidential candidate to disarticulate his or her identity as a political candidate from his or her religious background or lack thereof. In terms of applying articulation theory to usability evaluation, the key point is that articulation enables us to see how an identity is meaningful at a certain moment and how it facilitates or constrains certain actions. As John Trimbur puts it, “Hall’s theory of articulation conceptualized the conjectures at which people knit together disparate and apparently contradictory practices, beliefs, and discourses, in order to give their world some semblance of meaning and coherence” (1994, 244). For example, if I identify as an environmentalist, that identity might be articulated to—“given meaning and coherence” by—the deep ecology movement, to discourses regarding conservation and preservation, to discussions concerning green consumerism and fast capitalism, to progressive liberal ideology, to conservative ideology, to Christian ideology, and so on (but probably not to all of these things at once). In turn, those articulations help to inform what practices it is possible for me to engage in as an environmentalist. Will I buy energy efficient light bulbs and recycled paper? Will I join Greenpeace and follow whaling vessels? Will I go to church services? Will I protest at the G8 summit? Will I take a walk in the woods? In turn, the practices I engage in as an environmentalist help inform, and reveal, how that identity is articulated. As Slack observed in her critical reflection, “The Technical Communicator as Author,” “what matters is less what something means than what it is possible to do with and to that identity” (Slack 2003, 196). In a usability evaluation informed by articulation theory, the technical communicator would read manuals in order to begin to map how the user’s identity (as computer user, as VCR operator, as farmer, as pregnant woman) has been articulated over time. Because they tend to focus on user tasks and actions, it is possible to investigate articulations by first paying attention to what user practices the manual facilitates. I’m not talking here only about actions that the user is specifically instructed to do (such as “turn on the computer”) but also about more implicit instructions about what it is pious for the user to do—for example, “it is very important to keep a neat work-

usable pregnancy  25

space.” Articulations can be revealed, in other words, through a rhetorical analysis of a manual’s pieties. Let me explain this concept of piety in more detail. In Permanence and Change, Kenneth Burke observes that “piety is a system builder” (1984, 77). He defines “piety,” in part, as the “sense of what properly goes with what” and sees it as a motivating principle that operates in secular as well as in religious life (1984, 74). Based, as Jordynn Jack (2004) has explained, largely on his experiences at the Bureau of Social Hygiene, Burke saw piety as an organizing principle—a form of power, even—operating in many areas of life. Thus, it is perhaps no surprise that references to altars and temples abound in Burke’s writing on health. For Burke, it is possible not only to be a pious Muslim or Jew or Christian or Buddhist, but also a pious atheist or capitalist or chemist or scholar or dancer or doctor . . . or pregnant woman. Pieties are orientations that determine what people can or cannot say and do. For example, “the ‘drug fiend’ . . . may gradually organize around his character about this outstanding ‘altar’ of his experience—and since the altar in this case is generally accepted as unclean, he will be disciplined enough to approach it with appropriately unclean hands” (Burke 1984, 78). In this way, both the religious man and the so-called drug fiend’s actions are constrained and enabled by their senses of piety, by their “sense of what properly goes with what.” Like the religious man and the drug fiend, the pregnant woman’s actions are oriented around the altar of pregnancy and around her sense of what it is pious to do (or not to do) as a pregnant woman: she might stop drinking alcohol and stop smoking; she might change her diet (or feel guilty if she does not); she might keep a close eye on her weight; she might begin meditating; she might read books and websites about pregnancy; she might begin regular (ritual) prenatal care visits to a medical provider. And these senses, or systems, of piety are produced by past education, experiences, and practices that encourage people to see the world a certain way and therefore act a certain way within and on it. As I will explain in what follows, piety is closely tied to the concept of articulation in that it also explains how identities are connected to larger social and cultural formations. Piety is a concept that lends itself easily to rhetorical analysis as texts make arguments or assumptions about what it is pious for their audiences to do. And those arguments about piety, of course, are also informed by and provide clues about articulations of a user’s identity. Articulations, in other words, help to explain why a particular action is rhetorically defined as pious or impious. Below, I illustrate how a

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Figure 2.2: Excerpt from Waring Blendor Cook Book (Waring Products Corporation 1962).

text’s definitional arguments regarding piety can lead to an analysis of how the text’s user is articulated. While researching this book, I asked my parents if I could have a look at any old instruction manuals they’d saved. To my (and their) surprise, they still had the operator’s manual/cookbook that accompanied the blender (or “blendor,” as the manual calls it) they’d received as a wedding present in the late 1960s. Like many operator’s manuals, this manual, combines procedural, reference, safety, and troubleshooting information. This information tells the user what can be done with the technological artifact and how to do it safely. Many of these elements are evident in the excerpts reproduced in figures 2.2 and 2.3. These excerpts combine procedural steps (“Place the glass container . . . Place the ingredients”) with explanatory in-

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formation (historical information about the “blendor,” mechanism description). This procedural and explanatory information could certainly be evaluated for usability through a combination of heuristic evaluation and user testing (which would probably lead to recommendations such as: provide clear procedural steps for attaching and removing the handle and, perhaps, do not imply that the blender is safe for children’s use). In addition to defining what the user can, or could, do with the blender, however, the manual makes arguments about what it is pious to do with the blender. For example, in this excerpt, the long, manicured, painted nails of the hand operating the range signals a piety—a sense of what properly goes with what—woman goes with cooking in the home. Also, the terminology and descriptions of the blender components follow the logic of the system

Figure 2.3: Excerpt from Waring Blendor Cook Book (Waring Products Corporation 1962).

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itself rather than the logic of the user. For example, the description of the detachable handle centers around system features rather than user actions: “The handle is secured by means of two chrome brackets held together under tension.” This system-centered orientation signals another piety: expert knowledge about the system is produced by system designers, not by users. Reading further into the manual, one will find that the pious user of this manual is also a housewife, has children, and entertains company frequently. She prepares a large amount of meat- and dairy-based foods, and she frequently cooks with processed, instant, and prepared foods. She is neat, orderly, and efficient: she keeps the blender scrupulously clean, favors techniques that allow her to prepare food quickly and efficiently, and is motivated to learn new, modern techniques of food preparation. Moreover, she wants to have fun and express her creativity in the kitchen. Above all, she does not want to damage the blender. These pieties, in turn, provide clues to how the identity of the blender user was articulated at this particular moment. For example, within the terms of this manual the user is articulated to discourses about gender that assign tasks like cooking, cleaning, entertaining, and childcare to women and that equate cooking with care for one’s family; the user is also articulated to domestic technologies that decentralize household tasks (Cowan 1983). She is dependent on technological systems of agriculture, food distribution, and packaging that result in meat and produce being available year round, and her values reflect post–World War II discourses that emphasized the importance of efficiency, convenience, modernity, and creativity in the kitchen, that constructed the kitchen as a creative space and as a work space equivalent to workplaces outside of the home (Inness 2001, 147–50). Like operator’s manuals of any kind, pregnancy manuals both reflect and define contemporary pieties surrounding the altar of pregnancy, pieties that shape user practices. That is, the manuals can provide clues to what pieties defined the pregnant woman at particular points in time and, thus, what ideologies, political and social movements, practices, technologies, subjects, and so on have been articulated to the identity “pregnant.” For example, if pieties surrounding pregnancy in a particular pregnancy manual include statements like “pregnant women see doctors immediately,” “get medical confirmation of their pregnancies” and “take advantage of all available prenatal testing,” then it follows that the pregnant woman is articulated at this particular cultural moment, in this particular text, to technologies of prenatal testing and to the medical prenatal care system.

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It is important to note, however, that articulations are always contingent: articulations that constitute the user’s identity will vary from manual to manual, and the user’s articulations of her own identity may be very different from those evident in the manual she is reading. As Spinuzzi has noted, users often repurpose and modify documentation in unpredictable ways—users are not victims (Spinuzzi 2003, 2). In her history of childbirth, which considers the sometimes bizarre “expert” advice that women have received regarding conception, pregnancy, and childbirth from antiquity to the present day, Randi Hutter Epstein similarly observes that just because women were advised to do something (such as to drink “red wine with desiccated rabbit testicles” in order to increase one’s chances of conceiving a boy) doesn’t mean that they actually followed that advice. The advice books do, however, give us an indication of “what was important to women and caregivers about the birthing process” (Epstein 2010, 7–8). They also, I would add, define a possible range of actions for the potentially pregnant/ pregnant/birthing woman. In this way, they act as what Blake Scott (2003) has called “disciplinary rhetorics,” which “can shape subjects . . . and work on and through bodies” (Scott 2003, 7). Scott further explains that “disciplinary rhetorics do more than simply represent or persuade subjects; they transform them, shaping their self-perceptions, bodily practices, and material circumstances” (Scott 2003, 34). Disciplinary rhetorics surrounding the at-home pregnancy test—in the instructions, on the package, in pregnancy manuals, in conversations with other people—might be key in transforming a woman’s perception of herself from woman to pregnant woman, a perception that will likely lead to transformations in her behavior and practices (e.g., changes in what she consumes and where she goes) long before the pregnancy is physically evident. Taking up Scott’s work on disciplinary rhetorics in her study of discourses surrounding breastfeeding, Koerber observes that these rhetorics “define what subjects’ bodies are capable of doing” (Koerber 2006, 91). These disciplinary rhetorics are not only produced by what might be recognized as culturally authoritative or official sources; for example, Koerber notes how “official” medical statements regarding the importance of breastfeeding are in tension with “unofficial” cultural discourses and practices that position bottle-feeding as the norm and that render breastfeeding in certain situations (in public, in a hospital where newborn babies are routinely given formula) very difficult or impossible (2006, 91–93). In a similar vein, Bernice Hausman has observed that “medicine both promotes breastfeeding in its official pronouncements and often mishandles it in practice,”

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which means that official medical rhetoric often “has had an ambivalent effect on breastfeeding as a practice” (2003, 24). Similarly, the disciplinary rhetorics reflected in pregnancy manuals—whether they are written by doctors, midwives, or laypeople—define a possible range of practices in which the pregnant woman may engage and possible articulations of her identity, not the definitive or only possible articulations. Part of the goal of my analysis, then, is to map contingency—how articulations change from manual to manual. Another, perhaps more important, goal is to trace which of the articulations that comprise the identities pregnancy (as practice) and pregnant woman (as user) have been particularly tenacious and resistant to change. The articulations that have remained tenacious over time in manuals are also articulations that are likely to be more socially and culturally pervasive, more taken for granted. In this book, I employ a Burkean rhetorical analysis that focuses on the pieties that pregnancy manuals define for their users: in this case, the pieties that define what it is possible for pregnant women to be and to do. Explicit and implicit arguments about how the pious pregnant women should act signal some of the articulations between discourses, ideologies, practices, and social formations that constitute the identity of the pregnant woman at a particular cultural moment and in a particular text. From chapter to chapter and text to text, I note how pieties shift and build on one another and how shifts in pieties have the potential to change or entrench articulations of pregnancy and the pregnant woman.

Selecting Texts for Analysis Each of the chapters in this book represents a rhetorical-cultural analysis of significant texts in the pregnancy manual genre. I chose each of these texts either because they reflected culturally and politically significant moments within the history of prenatal care or because they marked a rearticulation of the genre itself. Although the chapters are organized chronologically according to the publication dates of the texts that I analyze, beginning from the early 1900s and ending in the early 2000s, I do not mean to imply a causal relationship between the manuals or to impose a narrative of progression on them. In this book, I take a rather long historical view—looking at manuals that span a hundred-year period—but of course the scope of this kind analysis could be limited to a few years or expanded to a few hundred. Within the context of this book, my use of the word “manual” for what could also be termed a “pregnancy guide” or a “handbook” might seem odd,

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as we tend to think of manuals as documents accompanying concrete technological implements like TVs or vacuums or food processors or electric ranges—tools. (Although, in fact, some pregnancy guides do refer to themselves as manuals. The recent Great Expectations [Jones et al. 2004] is one example.) I use the word “manual” for specific reasons, the first of which is because the term is appropriate. The word manual comes from the old French manuel, meaning “performed by hand,” and from the Latin manualis, meaning “of a size to fill the hand.” As an adjective, it usually means “of or relating to the hands” or “worked with the hands,” in the sense of “manual labor” or “manual typewriter.” As a noun, the word manual originally referred to a book that could be conveniently “kept at hand” or literally held in the hands for reference—in other words, a handbook.5 Second, I use the word “manual” because it evokes, more than guide or guidebook, the field of technical communication. This connection to technical communication allows me to highlight the fact that pregnancy manuals are instructions—that they give instruction about the work processes of pregnancy and about how to engage with the technological system of prenatal care. Texts for analysis were selected according to two main criteria. First, they should primarily give instruction about the period between conception and childbirth—the period of gestation. This criterion is important because it is one thing that differentiates twentieth-century pregnancy manuals from their predecessors, as I will discuss in the next chapter. This focus on managing the period of gestation reflects the late nineteenth- and early twentieth-century shift to seeing the whole period of pregnancy (not just childbirth or complications of pregnancy) as a medical event. Second, their primary audience should be pregnant women, rather than the midwives, obstetricians, nurses, lab technicians, politicians, maternalfetal specialists, and other people who are considered (to varying degrees) the experts within the prenatal care system. This criterion distinguishes pregnancy manuals from medical textbooks, and it ensures that pregnant women themselves are seen to be the primary users of the manual (and thus the ones who will carry out its instructions).6 Because of this factor, I focused my research on twentieth- and twenty-first-century manuals. This focus does not mean that pregnancy manuals did not exist prior to the twentieth century or that they did not give any instruction about the work of pregnancy. Rather, giving instruction about the work of pregnancy was not their central concern. Although my study features texts that might immediately come to mind when one thinks of pregnancy manuals, like What to Expect When You’re

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Expecting, it also includes websites, magazines, and pamphlets that instruct pregnant women about the management of their pregnancies. And while these texts are presented in different media, their purpose, content, and audience is similar enough to consider them to be members of the same genre as books like Your Pregnancy Week by Week or Pregnancy for Dummies.7 As a genre, the manual generally assumes an expert-novice relationship between rhetor and reader, respectively (whether that rhetor is an individual or a collective), an unequal power relationship. Manuals also frequently, but not always, as we will see in subsequent chapters, assume uncritical acceptance of the technologies and processes about which they instruct the reader. Instructional texts about pregnancy, whether they are found online, in doctor’s offices, or on the bookshelf at Barnes and Noble, begin with a particular expert-novice relationship that the texts’ authors either uncritically accept (working on the assumption that they are the experts and their readers are the novices) or explicitly call into question. In the final selection of texts for analysis, manuals were classified according to their purposes relative to the system that they document. The manuals might be arguments for constituting a technological system, maintaining it, disrupting it, or replacing it. Chapters 3 and 4 analyze examples of system-constitutive documentation or, in other words, instructions that persuade users to help establish an emergent technological system—prenatal care, in this case. These texts include the 1914 manual Expectant Motherhood: Its Supervision and Hygiene, pamphlets produced by the Children’s Bureau and Johnson & Johnson, and documentation related to prenatal care produced by the Instructive District Nursing Association of Boston. From the perspective of rhetoricalcultural usability research, system-constitutive documentation is especially useful because it is explicitly trying to articulate a set of users to a technological system by articulating the system to ideologies. Because system-constitutive documentation has to persuade users to participate in the establishment of a system, the ideologies around which a system is to be established are readily apparent. In chapters 3 and 4, I analyze these texts not only for key rhetorical features but also for what they reveal about the articulations between pregnancy and technologies of prenatal care that began to rearticulate the identity of the pregnant woman. Once a technological system is firmly established, documentation can take on a more functional role, instructing users how to engage with the system rather than arguing about why they should do so. Documentation that wants to help its users disrupt, or critique, or negotiate the system, however, must make systemic ideologies more explicit. In chapters 5 and 6,

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I analyze key examples of system-maintaining and system-disrupting documentation, focusing on how they employ pieties (and impieties) surrounding pregnancy in order to articulate the user as someone who must functionally engage with the technological system of prenatal care or as someone who can critically negotiate it. These texts include an early prototype of Our Bodies, Ourselves; a midcentury pregnancy manual called A Doctor Discusses Pregnancy that was designed to be handed out by physicians to maternity patients; and the (in)famous What to Expect When You’re Expecting. This analysis begins to illuminate points at which rhetorical and cultural elements could be—and have been, in some cases—rearticulated in order to facilitate critical access. Chapters 7 and 8 focus on rearticulations of the pregnancy manual itself into forms generically influenced by computer documentation and by e-commerce, including Pregnancy for Dummies and BabyCenter. The analysis in these chapters follows how the manuals themselves become rearticulated to something that is usable, or user friendly according to conventional usability heuristics, and also how the documentation begins to perform a system-simulating function, where engagement with the documentation is more important than engagement with the system that it documents. The usability analysis continues to focus on how these rearticulations of the pregnancy manual change, or do not change, pious associations regard­ ing pregnancy, and articulations of the pregnant woman. Ultimately, as Scott (2003) explains, the point of rhetorical-cultural analysis is not merely to account for the conditions of possibility in a given text or to speculate on their rhetorical and extrarhetorical effects. Rather, the aim is, instead, to critique those effects and to intervene in them. I am not, nor do I wish to be, a neutral observer of the prenatal care system and its documentation. I have participated in it as a user, as a pregnant woman (twice); I have consumed it; I have experienced some of its harmful and beneficial effects (in my particular body, as a white, able-bodied, middleclass woman). Drawing on the analysis of pieties surrounding pregnancy and articulations of the pregnant woman developed in previous chapters, the conclusion to this book suggests how a technical communicator might employ perspective by incongruity in order to prepare the ground for rear­ ticulation, for critical access, for transformation. Although the examples employed come from a system-disruptive pregnancy manual, the suggestions could apply to other types of documentation. This emphasis on critique and intervention makes rhetorical-cultural analysis especially appropriate for usability research. For scholars like Robert Johnson, after all, the ultimate aim of usability testing and research is

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to make technologies, systems, and texts more ethical, humane, and just. Similarly, the ultimate goal of rhetorical-cultural analysis is to intervene in harmful rhetorical practices or, at least, to illuminate alternative possibilities and configurations. It is my sincere hope that this book will help technical communicators— whether they professionally identify as technical communicators or not— learn how to provide users with critical access to the prenatal care system (and to other systems), access that might ultimately lead to the transformation of that system. With the help of a doula, I actively sought out and found system-disrupting documentation during my second pregnancy (I will discuss the characteristics of this documentation in more detail in the conclusion), and I believe that it was in a large part due to that documentation that I had a positive and empowering birth experience in which I felt in control and in which I dictated my own terms. And isn’t that, ultimately the aim of technical communication? To give users control over technological systems? To empower?

3 The Father of Prenatal Care J. W. Ballantyne and System-Constitutive Documentation

The subject of pre-natal health which is under consideration in this book can be brought to the test at once, and the effects of caring for the expectant mother of to-day may be visible in the coming generation. j. w. ballantyne (1914) The perceived need for ritualized medical care during pregnancy is more cultural than medical. thomas h. strong (2000)

The first thing to know about J. W. Ballantyne is that he came from a long line of botanists. In fact, a student and biographer of his, H. M. Russell, speculates that his career-long interest in teratology “may have grown in the greenhouses of his family in Dalkeith where the hybridization of plants, especially azaleas and rhododendrons, was studied” (1971, 33). Combine that early education in the greenhouse with trips accompanying his physician uncle “on his country rounds in a dog cart,” and Ballantyne’s obsession with teratology—with the meticulous cataloging and study of various mutations of the fetus and embryo and, later, with prenatal care as a means of preventing fetal anomaly—seems, if not inevitable, at least understandable (Russell 1971, 6). Ballantyne himself wasn’t much of a botanist—in fact, it was due to his lackluster performance in botany at the University of Edinburgh (which he attended from 1883 to 1887) that he missed being the top student in his class (Russell 1971, 6). He displayed his talent for obstetrics early on, however, finishing at the top of his class in pathology, physiology, midwifery, and gynecology. Moreover, his thesis, “Some Anatomical and Pathological Conditions of the New-Born Infant in Relation to Obstetrics,” earned him an 35

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MD degree with top honors. During his early career at the Royal Maternity Hospital of Edinburgh and as a lecturer at Surgeon’s Hall (where he was one of the only lecturers to admit women), his publications focused on diseases of the newborn infant. Toward the turn of the century, however, he began a distinct and decisive turn from pediatrics to obstetrics, “with the aim of preventing abnormalities of pregnancy and labor rather than their palliative treatment after the birth of a deformed child” (Reiss 1999, 387; emphasis mine). He became increasingly convinced that prenatal care, or what he called “antenatal hygiene” and “antenatal therapeutics,” was the key to preventing many birth defects and was increasingly dismayed that there was no institutional space or support for such care. His major publications during the latter half of his career, including his popular pregnancy manual Expectant Motherhood: Its Supervision and Hygiene (1914), advocate for the necessity of medically supervised prenatal care and for strict regimens of what Ballantyne calls “antenatal hygiene.” In 1901, Ballantyne published two pieces that outlined and advocated for his vision for a medical-technological system of prenatal care and that forecasted the pieties around which such care would be based. The first of these pieces, “A Plea for a Pro-Maternity Hospital” (as Ann Oakley notes, “the prefix ‘pro,’ was intended in the Greek sense of ‘before,’ not the Latin one of ‘in favor of’ [1984, 47]), appeared in the British Medical Journal, and the second, “Visits to the Wards of the Pro-Maternity Hospital: A Vision of the Twentieth Century,” appeared in the American Journal of Obstetrics. In these two pieces, Ballantyne forecasts the pieties around which the modern technological system of prenatal care would be based. As we will see, these pieties are in some cases rearticulations of older pieties about pregnancy. · The fetus should be the central patient of prenatal care, and the goal of prenatal care is to produce a normal fetus. · Pregnancies should be medically supervised, and prenatal care should take place in medical institutions. · The pregnant body is a site through which social, political, and environmental threats can be managed.

Treating the Fetus through the Mother In “Plea,” Ballantyne lays out his vision for a hospital, or at least a hospital ward, dedicated to prenatal care, which would have two main purposes:

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first, to treat cases of pathological pregnancy in which the mother’s health is at risk and, second, to practice what Ballantyne calls “antenatal therapeutics” (treating the fetus through the mother), especially in cases where the mother’s behavior might be endangering the fetus. Ballantyne was a staunch advocate for prenatal care at a time when there was literally no space for such care within the medical system. Ballantyne proposes that the pro-maternity hospital will be for the reception of women who are pregnant but who are not yet in labor. In the first place, doubtless it will be for the reception of patients who have in past pregnancies suffered from one or other of the many complications of gestation, or in whose present condition some anomaly of the pregnant state has been diagnosed; but in time it may be taken advantage of by more or less normal ambulants, working women for example who ought to rest during the last weeks of pregnancy, but who are unable from financial reasons to do so, and by patients who clamour for admittance to our maternities, but who are told to come back again when “pains have begun.” (1901a, 813)

Part of the purpose of the pro-maternity hospital, then, would be to give pregnant women a chance to rest, recuperate, and receive treatment. Ballantyne also emphasizes that, although “one of the principles of the promaternity would be the conservation of foetal life,” this would not happen “at the expense of maternal safety” (1901a, 814). The mother, in other words, is still an important patient in this hospital. Ballantyne introduces in this piece, however, the idea that another important goal of medical prenatal care is to better understand the etiology of fetal anomaly. As Georges Canguilhem has observed (although not about Ballantyne’s work specifically), “Once the etiology and pathology of an anomaly are known, the anomalous becomes pathological” (1989, 139). Ballantyne gives examples of several cases from his own practice that centered on antenatal therapeutics (cases where he specifically saw the fetus, not the mother, as being the primary patient) and that he believed would have benefited from the “systematic and scientific investigation of the bodily functions in pregnancy” that a hospital would afford (1901a, 814). These cases included an alcoholic mother, a hemophilic mother, a woman who had given birth to a series of very large children, cases of small pelvis, and a “mostripara, who had brought three monstrous feotuses into the world and had had several abortions” (1901a, 814). Ballantyne’s second piece, “Visits to the Ward of the Pro-Maternity

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Hospital,” is a fictional account of what his proposed pro-maternity hospital might look like later on in the century. It is written in the first person, as if Ballantyne himself has visited the hospital: “The morning upon which I paid my first visit to the Pro-Maternity was one of those perfect mornings” (1901b, 595). The piece describes a small “pro-maternity” hospital (but with room for “the construction of additional pavilions”) connected to a larger maternity hospital in the fictional territory of Weissnichtstadt (State of Not Knowing; 594).1 Interestingly, the focus of this hospital is specifically and solely on antenatal therapeutics; the pregnant woman herself seems to have dropped out of the picture, except as her body serves as a conduit and site of scientific study for treating the fetus. For instance, there is a ward called La Salle des Innocents where a young woman is given mercury to treat a possible case of syphilis in the fetus (her husband is infected; so far, she is not). The attending doctor, Dr. Geburtsmal, observes that “she was being treated with mercury for the sake of her unborn infant in the first place, and for her own sake too” (596). When the fictional Ballantyne asks Dr. Geburtsmal if he is sure that the fetus receives the mercury, the doctor replies, “We are sure that it gets to the placenta, at any rate . . . and a great part of the placenta is truly an organ of the fetus and one of its most vital parts” (596). In another ward, the doctors are trying to prevent premature labors by “attend[ing] to the position of the uterus, the state of the excretory organs, the relation of rest to exercise . . . the relation of the constituents of the food taken to the excreta” (596). About this last “coefficient of nutrition,” Dr. Geburtsmal observes that they “know what the proper relation ought to be to grow a normal fetus” 596). There is also a ward labeled, simply, “Heredity,” in which doctors treat even inherited diseases like hemophilia through antenatal therapeutics.

Pregnancy Is a Medical Event In both of these pieces advocating for the pro-maternity hospital, Ballantyne’s vision is of prenatal care in a medical context: pregnant women would travel to the pro-maternity hospitals where they could rest and be treated and where, most important, their pregnancies could be medically observed, studied, and supervised. For instance, in “A Plea,” Ballantyne describes how the hospital would have to possess “every appliance for the perfection of antenatal diagnosis (skiagraphy, cephalometry), and one member of the staff would require to be a skilled physiological chemist” (1901a,

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814). Being able to study scientifically the pregnant women admitted to the hospital is clearly a priority for Ballantyne. In “A Plea,” however, the health of the pregnant woman is also at least given significant consideration, whereas in “Visits to the Wards,” Ballantyne’s utopian vision (at least for him) of prenatal care, she has disappeared almost entirely: she has become a conduit through which doctors can treat the fetus and thereby counteract the threat of “national sterility and ultimate extinction” on an international level. For instance, patients in the “ward of the habitual inebriates” are “kept from all alcoholic preparations during pregnancy” and live in the ward for their entire pregnancies under medical supervision (1901b, 597).

Social and Political Threats Can Be Managed through the Pregnant Body In “Visits to the Wards,” Ballantyne imagines that the hospital devoted to prenatal care would be constructed in an effort to solve political and social problems—in this case the problem of plummeting birth rates. The pro-maternity hospital he envisions is a result of a collaboration between the Germans and the French, both anxious concerning their fast-declining birthrates and their national futures: “It was the sudden and considerable drop in the birth rate of Berlin which, following soon after that which had given Paris an unenviable notoriety, threw the government of Germany (metaphorically) into the arms of France; in the presence of a common danger—that, namely, of national sterility and ultimate extinction—old animosities were forgotten and possibly also past insults were forgiven” (Ballantyne 1901b, 594). In the face of this “common danger,” treatment in this pro-maternity hospital would focus on preventing miscarriage and stillbirth and on “cur[ing] before birth the diseases and deformities of the fetus” (Ballantyne 1901b, 594). This hospital was an international effort, “furnished within and without by the princely munificence of an American (Chicago), and officered with the most international medical staff that the world has ever seen,” in which the multiethnic cast of doctors have names like Dr. Pathalog, Dr. Feto, Dr. Teras Teratos, and Dr. Embryonowsky (595). The denizens of Weissnichtstadt have patriotic pride regarding the pro-maternity hospital, “like the toast of the Queen to an Englishman, or the Fatherland to a German, so is the naming of the Pro-Maternity to a dweller in Weissnichtstadt” (593). Although Ballantyne’s tone is humorously hyperbolic, he also

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clearly equates medically supervised prenatal care—and medical management of pregnant bodies—to the preservation of national welfare. In these two documents, the technological system of prenatal care is system centered rather than user centered: it is to be modeled according to the needs and expectations of its designers (the obstetricians, in this case) rather than according to the needs and expectations of its users (the pregnant women). Its primary goal is not to improve the health or comfort of its users (although these are important secondary goals) but to improve national health and to provide system designers with information about the mechanisms and pathologies of pregnancy. In fact, we might better conceive of pregnant women as components of this system rather than users of it—their bodies are necessary for its proper functioning. In these pieces, the pious pregnant woman submits to medical scrutiny, she is compliant, and she a nonexpert. Ballantyne’s “Plea” got immediate results: only three months after it was published and as a direct result of the article, a bed was specifically designated for prenatal care at the Edinburgh Royal Maternity Hospital; by 1915, the hospital consistently provided outpatient prenatal consultations, and that one bed had grown to a twenty-three-bed ward by the 1920s.2 In the midst of the expansion of the technological system of prenatal care at Edinburgh, Ballantyne wrote and published a system-constitutive pregnancy manual whose primary audience was pregnant women and potentially pregnant women. It is to this manual—Expectant Motherhood: Its Supervision and Hygiene—that I will turn next, after describing the characteristics of system-constitutive documentation.

What Is System-Constitutive Documentation? In their study of signs, genres, and communities typical to technical communication, Jimmie Killingsworth and Michael Gilbertson classify the manual as, essentially, an epideictic genre. By “epideictic,” they mean that these documents are concerned with facilitating actions in the present rather than investigating past action (as the report does) or promoting future action (as the proposal does). Rather, the manual “deals with activities in the present by helping the reader to implement a project and to operate various technologies” (Killingsworth and Gilbertson 1992, 78). Manuals could be considered epideictic because they do not question the need for a particular technology or the impact that it will have on society; rather, by focusing on the moment of operating a technology, the manual re­

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affirms, even celebrates, the values that a technology or technological system perpetuates. While I agree in general with Killingsworth and Gilbertson’s classification of the manual, I want to refine it somewhat. Some manuals, maybe the majority of manuals, are epideictic—I call these system-maintaining manuals, and I will discuss their characteristics in more detail in following chapters. But what if rather than instructing a user concerning how to operate a technological system that already exists, a manual is advocating that the user help to establish a technological system? In other words, before giving procedural instructions about how a user should behave or what a user should do, a manual must first convince the user that such procedures are necessary. The manual might also show users how to manipulate or negotiate existing systems in order to establish a new one. If that technology or technological system is in (seeming) ideological conflict with entrenched cultural values, or if the need for a given technology isn’t clear, then a manual’s primary purpose may be to persuade a user to accept and establish that technological system. Such manuals, which I categorize as system-constitutive documentation, are more deliberative than epideictic. By deliberative, I mean that they are concerned with future action: they argue for the future establishment of a technological system, or adoption of a technology, as a solution to an ideological, political, or social problem. Katherine Durack’s study of nineteenth-century sewing machine manuals provides one example of what I am calling system-constitutive documentation. Because it was considered improper and even impossible for middle-class women to operate industrial machinery, early sewing machine manuals had to actively persuade them not only that sewing machines belonged in the domestic space but that they were also in line with cultural beliefs about the roles and abilities of women. In order to do this, they told stories that domesticated these machines (Durack 1998). The manuals thus attempted to redefine pious actions for their women users— middle-class women can use machinery in the home, domestic sewing can piously be done with a machine—that rearticulated the practice of sewing. Ballantyne’s Expectant Motherhood, as I’ve already argued, is systemconstitutive. It makes a case for the establishment of a technological system of prenatal care to solve a perceived social problem for which eugenics, as we will see in the following sections, was also a possible solution. In the process, the manual explicitly advocates for a rearticulation of the pieties surrounding the altar of pregnancy (pieties that, as I’ve already mentioned, build on already-established pieties) and implicitly advocates for a

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rearticulation of the discourses, institutions, ideologies, and practices that constitute the identity “pregnant.”

Expectant Motherhood and Medical Supervision of Pregnancy Published in 1914, Expectant Motherhood appears to be the first book-length (as opposed to pamphlet- or leaflet-length) pregnancy manual to focus primarily on the prenatal period rather than on conception, delivery, anatomy, and child rearing. As Ballantyne notes in the opening pages of the book, “It is not the whole of the process of child-birth which has been considered in these pages; the subject dealt with has been the mother in her state of expectancy and the infant before his birth” (vi). This is not to say that earlier manuals did not address the prenatal period at all but, rather, that this topic wasn’t their focus. Instead, they focused on anatomy, conception, and managing childbirth, delivery, and complications thereof. For example, the 1680 pregnancy manual titled The Complete Midwife’s Practice Enlarged, Containing a perfect directory or rules for midwives and nurses. As also a guide for women in their conception, bearing and nursing of children (Chamberlen 1680) devotes a section to explaining “How Women with Child Ought to Govern Themselves.”3 In this text, the author advises women to “choose a temperate and wholesome air,” “choose meat that breeds good and wholesome nourishment,” “avoid by all means, the sleeping after dinner,” and “avoid great noises, as the noise of Guns, or great Bells” (80–83).4 But this section—the management of the prenatal period between conception and childbirth—takes up about three pages of a three-hundred-page text. The rest of the book is devoted to conception, to signs of conception, to labor, delivery, and various complications thereof, to diseases of the newborn, and so on. The proportion of text dedicated to the prenatal period is fairly typical for pre-twentieth-century pregnancy manuals, although the amount of text devoted to prenatal care does begin to increase over the course of the nineteenth century as the obstetrical profession solidifies.5 What is new in the twentieth century, and in Expectant Motherhood, is not the piety that pregnancies must be managed and that pious pregnant women must actively manage their actions and cravings during pregnancy by implementing what Rebecca Kukla calls a technic of pregnancy. (A technic of pregnancy is a strict regimen of hygienic practices that the pregnant woman must both internalize and undertake in order to “compensate for the inherent untrustworthiness and volatility of her passions, body, and behavior” [Kukla 2005, 128]). Authors of obstetric advice books such as Cham-

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berlen had long advocated that women implement a technic of pregnancy in order to prevent marking or miscarrying the fetus. Rather, in Expectant Motherhood, this piety that pregnancies must be managed and that the pregnant body must be disciplined is rearticulated to a medical context. Ballantyne argues that this management should (and could) be medically supervised rather than supervised by cultural and/or religious authorities or by the pregnant woman herself. This medical supervision was made possible and given warrant by technologies of prenatal care developed in the mid- to late nineteenth and early twentieth centu­ ries. For example, the Wasserman test for syphilis made it possible to detect a disease that was devastating to the newborn early in pregnancy and to treat the disease (usually by administering mercury, as Ballantyne described in his “Visits to the Wards” article). Techniques for pelvic measurement through abdominal palpation and later through X-ray allowed doctors to (not always reliably) detect pelvises that were ostensibly too small or deformed to deliver babies, and techniques for ascertaining fetal size and position provided (also not always reliable) information as to whether the fetus was developing normally. Also around this time, tests for detecting pregnancy such as the X-ray, the “discovery” of the fetal heartbeat, and Chadwick’s sign made it possible to strongly suspect or confirm pregnancy much earlier than had previously been possible (Oakley 1984, 25–28). As Ann Oakley observes, “Unless pregnancy could be diagnosed relatively accurately and early, antenatal care could be little more than a last-minute preparation for labor” (1984, 17). These individual technologies of prenatal care that facilitated medical supervision of pregnancy made a large-scale medical-technological system of prenatal care imaginable. In the early twentieth century, then, it began to be possible to understand pregnancy as a medical event appropriately monitored with technologies of prenatal care within medical contexts. These technologies, in other words, created conditions that began to make a larger-scale technological system of prenatal care imaginable and desirable to an obstetrician like Ballantyne. They create these conditions by making it possible for someone besides the pregnant woman herself to confirm and monitor the state of her pregnancy. Expectant Motherhood: Its Supervision and Hygiene begins with the words: “A new discovery calls for a new commandment” (1914, ix). Ballantyne goes on to provide examples of technological systems that necessitate new social regulations. For example, Ballantyne explains how the new technological system of roads and automobiles necessitated “new regulations for the safety and convenience of the traveler on the roads” (viiii). The discovery at

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hand in Expectant Motherhood, however, is not a new means of transportation but, rather, a medical discovery that the pregnant woman’s behavior during pregnancy has consequences for her baby’s development: This book deals with another discovery in medicine and with the laws which will follow or which have already followed it. It has to do with the health value of the nine months which precede birth, and with the commandments in hygiene which the parents, but especially the mother, must obey if their child is to come strong and well into the world. It has to do with the investigation of all the things which may go wrong with the unborn infant, and with the inquiry into their possible prevention or cure. It has to do with the well-being of the babe before birth, and consequently with the care and protection of the mother who bears him in her womb. (Ballantyne 1914, x)

There are two things to note about this passage. First, that Ballantyne equates the discovery of the “health value” of pregnancy with the “discovery” of automobiles and roads. Clearly, automobiles and roads weren’t discovered in the sense of uncovering something that already existed (look, there’s a car buried here!); they were constructed. The discovery that motoring was a pleasant and efficient way to travel came after technologies facilitated that travel. To put it another way, traffic laws would be meaningless without the then-emergent technological system of cars and roads. Similarly, the discovery of the “health value of the nine months before birth” was possible only because of new technologies that facilitated seeing pregnant bodies as always potentially pathological and, therefore, seeing pregnancy as a medical event. The discovery here, too, was enabled by an emergent technological system. The second thing to note in this passage is that the “health value of the nine months before birth” refers to the health of the “babe,” not of the mother. The commandments in hygiene are to be enforced for the “wellbeing of the babe”—any benefits for the mother are coincidental.

Expectant Motherhood and the Fetus Expectant Motherhood is almost three hundred pages long and is addressed to an audience of, as Ballantyne puts it, “women who know much more about themselves than their grandmothers and mothers ever knew, and who . . . have a right to a fuller knowledge of obstetrical matters than they

the father of prenatal care  45

are able to extract from ordinary works which give advice to wives and mothers about their health and that of their children” (1914, v–vi). From the first pages of the manual, then, the pious pregnant woman is defined as one who seeks, but does not produce, knowledge about pregnancy and about her pregnant body. Unlike other pregnancy manuals, however, Expectant Motherhood focuses not on “the whole of the practice of child-birth” but, rather, on “the mother in her state of expectancy and the infant before his birth” (vi)—in other words, on the prenatal period. The book comprises an introduction, fourteen chapters, and an index. Each chapter is divided into subsections indicated by headings set in boldface, but the text does not incorporate any visuals, lists, tables, or other features that would break it up and make it easy to scan. It is clearly a work intended to be read front to back, sequentially. This arrangement is probably at least in part a testament to the expected leisure time for reading that this middle- to upper-class audience would have had. This organization makes sense for a system-constitutive manual such as this one. After all, the reader must first be convinced of the importance of the prenatal months to the baby’s future well-being if she is to be convinced of adopting the technic of pregnancy that Ballantyne proposes in later chapters. The first chapter, “Nine Post-Natal and Nine Ante-Natal Months,” contrasts the development that takes place in the first nine months of an infant’s life with the development that takes place during the nine (or ten) months that the fetus spends in utero in order to make the case that the development that takes place before a baby is born is even more crucial to her future well-being than the development that takes place after she is born. The result is support for the manual’s ultimate argument, again, that the fetus’s development should take place under medical supervision and that the pious pregnant woman should not only submit to but in fact actively seek out such supervision. If the pregnant woman is defined as, within the terms of Expectant Motherhood, a nonexpert, one who seeks knowledge about her body and baby, the doctor is defined as an expert craftsman, or artisan, who crafts the fetus through prenatal care. The next chapter, “Ante-Natal Development,” details week by week and month by month the changes that occur in the embryonic and then the fetal body. This detailed account of fetal development serves to establish that the fetus is, although dependent on its mother’s body, a distinct and independent being. After describing the first six weeks of development, Ballantyne explains why he felt it was important to describe them in such detail:

46  chapter 3 it is very important that it should be realized that before the mother is sure she is pregnant, before she has even a suspicion that she is so, there is already a new life in her womb, a life which is not of a structureless, featureless kind, but is one which is centred in a body that is already furnished with all the organs possessed by the infant at birth. At six weeks one cannot, perhaps, say that the embryo has a distinctly human appearance, but one can assuredly affirm that it has a highly organised and complicated structure, and that it is teeming with life of a most active and specialized kind. . . . Its presence in the womb demands consideration. (24)

Here is another important piety: the pregnant woman recognizes the fetus as a separate and distinct individual rather than a part of her own body. After the fetus has been defined as having a life separate and distinct from its mother’s, the following chapter, “Physiology of the Mother in the Nine Months of Pregnancy,” establishes the intimate connection between the maternal and fetal bodies in order to make the argument “that in so close a connection as the one existing between mother and unborn infant the maternal organism must have a far-reaching effect upon the child growing in the womb” (33). Anything that affects the maternal body, in other words, affects the fetal one as well and has the potential to disrupt its development. The next chapter is occupied with definition, debating the question of whether pregnancy is pathological or an example of “harmonious symbiosis.” Ballantyne comes to the conclusion that, while pregnancy is closer to harmonious symbiosis than to “prejudicial parasitism,” it is “physiology working under high pressure,” and in some cases “at so high a pressure as to be perilously near pathology” (67). These first four chapters work together to forge pious definitions of pregnancy and the pregnant body that necessitate medical supervision through technologies of prenatal care. The pregnant body begins to be defined as risky: it can affect the fetus for good or for ill, depending on its management before and during pregnancy. “If any organ be weak,” Ballantyne writes, “the gestational strain will aggravate matters at once, and in turn the weakened or diseased organ will react injuriously upon the pregnancy, terminating it prematurely or throwing complications into its progress” (68). Pregnancy is “perilously near pathology”—not always pathological, but always potentially pathological. The pious pregnant woman recognizes this potential for pathology. Because the health of the fetus is so closely, and perilously, tied to the health of the maternal body, Ballantyne believes that “ante-natal preparation” begins in the womb: “The first part of the expectant mother’s prepa-

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ration for parenthood was wrought out years before when her own mother was preparing for her child’s coming into the world. If her mother in her pregnancy lived a healthy life, striving cheerfully to bear for her unborn child’s sake some degree of restriction of liberty . . . she will have handed down to her daughter something which will in time help her also to be a good mother in the obstetrical sense of the word as well as in other senses which are more obvious” (71). From here, Ballantyne discusses childrearing in the chapter titled “Preparation for Parenthood,” including during infancy, in the nursery, in school, and during puberty, emphasizing the role that medical supervision and intervention can play in these periods as well. For example, he writes that “many a woman will have easier confinements because her slight spinal curvature was corrected during school days, instead of being exaggerated by working at badly constructed desks and in an insufficiently lighted schoolroom. The care of the teeth in her school days will give the girl a better chance of continuing to masticate and digest her food well in pregnancy, and the correction of many hygienic errors in childhood will make for healthier confinements, lyings-in, and nursing times during the years of reproductive life” (87). The girl’s, and later the woman’s, body is to be cared for not for her own sake, but for the sake of her future children. The next three chapters—“The Hygiene of Marriage,” “Legislation and Marriage,” and “Hygiene after Marriage”—not only make recommendations on how a woman (and her parents) should choose a suitable mate but also contend that “no parent of marriageable daughters shall hand over any one of them into the keeping of a young man until he has satisfied himself that his future son-in-law is free from the worst of the physical impediments to a healthy married and reproductive life” (105). (Ballantyne is most worried here about venereal diseases and alcoholism.) It is interesting to note that because Ballantyne felt so strongly that women should choose an appropriately hygienic mate and because the population of women so far exceeded the population of men at the time that he is writing, he was an advocate of women’s gaining the vote and entering jobs—if, that is, they could not find a suitable husband. Even this decision is to be made with a view to the woman’s reproductive status. Ballantyne then makes recommendations for changes to the laws governing marriage (being primarily in favor of health certificates and raising the age of legal marriage without parental consent) and for the hygiene of the honeymoon. In Expectant Motherhood, not only are decisions and medical treatment during pregnancy to be made with a focus on fetal welfare but all of a woman’s own decisions (or

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decisions made on her behalf) during her entire life should be made with the potential fetus in mind as well.

Expectant Motherhood and Eugenics As is probably already apparent from my discussion of Ballantyne’s various publications and from my overview of Expectant Motherhood, these incipient technologies and institutions of prenatal care were articulated to political as well as to medical ideologies. A passage, again from the introduction of Expectant Motherhood, is illustrative in this regard and worth quoting in full: It will be well if it is recognized at the outset that this is not a book upon eugenics, the fascinating but extremely illusory science which so many of the theoretical minds of the day are investigating with an enthusiasm which, if turned along more practical channels, could and would achieve much. In one respect the two subjects agree: both are concerned with ante-natal affairs. Eugenics, however, looks very far back for its causes and very far forward for its results; whilst ante-natal and gestational hygiene, here dealt with, treats of the present and the immediate future . . . the effects of caring for the expectant mother of to-day may be visible in the coming generation. (xi)

In some histories of obstetrics, it has been observed that Ballantyne was an anti-eugenicist (see, e.g., Speert 1980). This is, in some measure, true: at many points in Expectant Motherhood he takes issue with the eugenicists’ methods of sterilization, restrictions on marriage, and so on. But he takes issue not because he necessarily objects to their ends but because, as we see in the passage above, he believes that their methods are not an expedient means toward those ends. At least according to Ballantyne’s vision, prenatal care is a system that will more expediently arrive at the same end to which eugenics vainly strives: “to improve the race and lessen the number of defectives and derelicts” (Ballantyne 1914, xi). In late nineteenth- and early twentieth-century Britain, the state began to take a direct interest in reproduction, in a large part because the birthrate fell for the first time in centuries. Ballantyne references the declining birthrate explicitly in Expectant Motherhood, explaining that, while it may “be uncheckable, . . . the salvage of the lives which are annually lost through parental syphilis, alcoholism, and the ignorance of the laws of the hygiene of pregnancy would go far to counteract the falling birthrate” (Ballantyne

the father of prenatal care  49

1914, 268). The decline in population numbers and perceived decline in quality of the populace was brought to political and public attention after a full one-third of recruits for the Boer War (1899–1902) were considered “unfit.” There were two major explanations for the perceived decline in population quality. One explanation was advocated by the eugenicists, Francis Galton foremost among them. They believed that degeneracy was inherent in the genetic makeup of individuals; traits like laziness, susceptibility to disease, lust, and criminality were all held by strong eugenicists to be inheritable. Therefore, eugenicists believed that “superior” races must be encouraged to breed while “inferior” races must be discouraged or, even, forcibly sterilized. Either way, reproduction came to be seen as crucial to the success of the imperial project. Others, like Ballantyne, favored “euthenic,” or environmental, explanations for racial decline: they held that the key to national health lay in environmental reform (Mazumdar 1992). As a means toward this end of “race betterment,” Ballantyne’s model for prenatal care provides a sort of middle ground between the eugenicists and euthenicists who sought the same final goal: “to lesson the number of defectives and derelicts.” For instance, in Ballantyne’s vision of the ideal pro-maternity hospital as outlined both in his articles and in his pregnancy manual, even inherited diseases would be treated through antenatal therapeutics: the focus of even environmental reform went back to the woman’s reproductive body. Eugenicists and euthenicists might have disagreed about who exactly defectives and derelicts were and how they were formed, but they seemed to agree that adequate, medically supervised prenatal care could either realize the full potential of a good seed or turn a bad seed good. In fact, Ballantyne saw the effects of the unhygienic maternal body to be more important than heredity: “An infant may be well enough begotten, and yet be so ill-borne for nine months, and so ill-born at the end of that time, as to be no less a derelict than the child of many generations of a morbid heredity” (Ballantyne 1914, xiv). He goes on to explain that, just as the expert potter might do wonders with inferior clay, “the expert workman may do much even with an inferior material” (xiv). Clearly, the workman in this analogy is meant to be not the mother but the expert physician, perfecting the fetus through the medium of the mother’s body. In fact, Ballantyne explicitly calls into question the then pious notion that when there is a “choice between the maternal and infantile life,” the life of the mother should have priority. For example, he questions the wisdom of physicians who recommend terminating the pregnancy of a woman with tuberculosis in order to treat the mother and possibly save her life on the ground that “the child of a tubercular mother is very rarely infected at birth, and his

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right to exist is therefore to be taken into account” (273). Here is another emergent piety: the rights of the fetus may be at odds with the rights of the mother. Although Ballantyne’s vision of prenatal care is certainly a more humane means of so-called race betterment than sterilization or restrictions on immigration, it similarly reduces a complex social problem to a simple genetic (in the case of eugenics) or medical (in the case of prenatal care) one. As Richard Meckel puts it, the attitude underlying early support of prenatal care went something like this: “If pregnant women would submit to supervision and instruction and take advantage of competent medical attendance, then the consequences of either overcivilization or poverty might be countered” (1990, 164). Another important thing to note here about the technological system of prenatal care is that pregnant women, as users of an emergent technological system of prenatal care, do not seem to have a potential voice in its establishment, organization, or mode of conduct. Rather, their role is to insert themselves passively/piously into that system so that they can be observed and monitored for the good of the nation.

4 The Mothers of Prenatal Care Elizabeth Putnam, the IDNA, and User-Centered Care

The core of the user-centered view, then, is the localized situation in which the user resides. robert johnson (1998)

At around the same time that J. W. Ballantyne was trying to establish a system of prenatal care in Edinburgh, “social reformers and nurses” began to actually constitute similar systems on the other side of the Atlantic, most notably in Philadelphia, Boston, and New York (Dawly and Beam 2005; Thompson, Walsh, and Merkatz 1990, 14). In fact, in Expectant Motherhood Ballantyne praises the work of some of these “pre-maternity nurses,” specifically mentioning the work that has been done “by the Women’s Municipal League of Boston, U.S.A.” The work in prenatal care to which Ballantyne was referring was spearheaded by Elizabeth Putnam (often referred to in histories of prenatal care as Mrs. William Lowell Putnam) and carried out by the Instructive District Nursing Association (IDNA) of Boston. Although the IDNA was not the first organization in the United States to offer prenatal care (that honor goes to the Visiting Nurse Association of Philadelphia), it was the first to offer routine and systematic prenatal care during pregnancy. The previous chapter discussed how Ballantyne’s model for the technological system of prenatal care was system centered rather than user centered: pregnant women would have to travel to clinics or hospitals in order to submit to medical supervision; pregnant women did not produce expert knowledge about their bodies or pregnancies; and the goals of the system were primarily to produce normal babies and fit citizens and, secondarily, to preserve maternal health. An obstacle in the way of establishing a large-scale technical-medical system of prenatal care, however, was the long-standing piety that pregnancy and childbirth were the province of 51

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women and that they took place in domestic spaces. Because the IDNA (and other visiting nurse association) nurses were women and because they visited patients in their homes, they were able to take advantage of this existing piety that pregnancy is the domain of women and to begin to rearticulate prenatal care to medical institutions as they brought prenatal care into women’s homes. In a departure from Ballantyne’s vision, however, this care revolved around the woman, making her the primary patient rather than the fetus. The small, localized system of prenatal care established by Putnam and the IDNA conformed to the patient’s environment and accorded her a limited voice in her prenatal care. Their system also, at least to a certain extent, recognized women’s experiential knowledge as a kind of expert knowledge, particularly the experiential knowledge possessed by the nurses who provided care. In the printed documentation that IDNA nurses provided to their patients (and that was available to pregnant women at the time), however, the pieties that pregnant women should submit to medical supervision and that prenatal care could solve social and political problems were very much in evidence.

The Birth of Prenatal Care in Boston Beginning in 1909, the Committee on Infant Social Service of the Women’s Municipal League of Boston, under the leadership of Elizabeth Putnam, began an experiment in intensive prenatal care. The committee secured a nurse who visited certain home delivery patients of the Boston Lying-In Hospital as early in pregnancy as possible, “usually from the sixth month.” The nurse then visited patients at least every ten days, but more often if their condition warranted (“Care of Pregnant Women,” 1912, 292). In November of 1911, Putnam began to collaborate with the IDNA, training their nurses according to her model of intensive prenatal care (Putnam 1911d). Figure 4.1 shows a photograph of the IDNA nurses taken at around this time. Prenatal care was not new to the IDNA at this time. In 1900, nurses from the Boston Lying-In Hospital began to train with the IDNA, and in 1901 (the same year that Ballantyne published his “Plea”) they began to attend deliveries, provide postpartal care, and prenatal care “as time permitted” (Farrisey 1985, 1:1). In 1901 Martha Stark, herself a graduate of the Boston Lying-In Hospital Training Program, became superintendent of the IDNA and put greater emphasis on maternity care. In a 1902 letter to Stark, Dr. William Dwinnell of the Boston Lying-In Hospital praised the obstet-

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Figure 4.1: Photograph of Instructive District Nursing Association nurses taken circa 1910 by an unknown photographer. From the Visiting Nurse Association of Boston Records, John J. Burns Library, Boston College. Reprinted with the permission of the Visiting Nurse Association of Boston.

ric nurses for preventing complications during pregnancy by reporting “abnormalities” to the hospital in a timely manner. “Moreover,” he wrote, “they supplied the mother with much useful information with which young doctors were not familiar” (Farrisey 1985, 1:5). Dwinnel recognizes here the nurses’ expertise that arises from experiential, rather than theoretical, knowledge. Under Putnam’s supervision, however, the prenatal care services provided by IDNA nurses were routinized and systematized. A 1914 report titled “The Blood Pressure during Pregnancy” describes the conduct of a routine visit: The routine of the work is as follows: As soon as a patient is referred to the prenatal committee for care she is visited at her home by the nurse who gives her practical advice, suited to her circumstances, in regard to the hygiene of pregnancy, diet, clothing, exercise, etc. takes the blood pressure and examines a specimen of urine for albumin. This visit is repeated at ten day intervals, or oftener in doubtful cases, until the time of labor. All abnormalities are reported at once to the proper persons so that in case of need the patient shall receive more adequate attention. (Women’s Municipal League of Boston 1914, 1–2)

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By 1914, the IDNA nurses had taken over all prenatal and postnatal home visits. A 1915 report published by the IDNA observed that prenatal visits had risen from 332 in 1901 to 8,256 in 1915 (Instructive District Nursing Association 1915, 11). The intensive prenatal care program as carried out by the Women’s Municipal League and the IDNA had very promising results in preserving both maternal and infant health. For example, only two years after it was instituted, Putnam wrote that the cases of threatened eclampsia had decreased dramatically: “The first year of work it was 10.2%, a fairly average number; the second year it had dropped to 4.8%, and the third year it was only 1.7%—a decrease of 600%” (Putnam 1911b). She also noted that not one case of full-blown eclampsia had developed during that time (Putnam 1911a). Eight years later, an IDNA publication notes that the infant mortality rates among patients receiving prenatal care were much lower than the statistics citywide. In fact, for patients receiving prenatal care, the mortality rate for infants under two weeks of age was 14.14 per 1000 live births. For patients receiving no prenatal care, the infant mortality rate was 32.06—over double the mortality rate of individuals receiving such care (Instructive District Nursing Association 1919, 1).

Prenatal Care and Women’s Health In Ballantyne’s system-constitutive documentation for the prenatal care system, the goal of medical supervision during pregnancy was to better understand the causes of fetal anomaly. In contrast, the primary concern that motivated Putnam to establish and maintain an intensive prenatal care service appeared to be her conviction that frequent visits that included testing for albumin in the urine and hypertension could help pinpoint and treat cases of preeclampsia before they developed into life-threatening conditions. As she explains in an October 18, 1911 letter to a Dr. Wadsworth of the Obstetrical Society of Boston, “I believe, myself, very strongly that the intervals between visits should not exceed ten days, and I cannot help suspecting that it is due to the frequency of these visits that none of the cases of threatened eclampsia have developed” (1911c). It is also worth pointing out that at the secretary of Boston’s Obstetrical Society responded to Putnam’s ideas by denying that there was a convincing link between the presence of albumin in urine and the development of eclampsia: “It can be stated,” he writes, “that 20% of all pregnant women show albuminuria, yet of these only a very small proportion develop eclampsia, so that it cannot be said

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that the presence of albumen [sic] alone is alone of serious significance” (Cheever 1911). Putnam appears to have been one of the earliest champions of routine urine testing during pregnancy, a procedure that is now a standard part of prenatal care visits in the United States. Another significant difference between the system of prenatal care established by Putnam and carried out by the IDNA and the model articulated in Ballantyne’s writings is its emphasis on the patient’s individual environment. One of the IDNA nurses’ primary tasks during the course of a routine prenatal visit was to give the patient “practical advice, suited to her circumstances” (Women’s Municipal League of Boston 1914, 1–2). Nurses from IDNA visited their patients at home, and provided emotional, and often material, support to their patients. In fact, proponents of visiting nurse services during pregnancy recognized that enforced hospitalization of pregnant women without regard to their individual circumstances could actually be detrimental to their and their families’ health: the Visiting Nurse Association of Philadelphia began providing home prenatal care services after “the discovery of a very ill and unsupervised boy at home by a nurse” from the association. The boy’s father worked away from home, and his mother was hospitalized during the last month of her pregnancy, a policy that was instituted by the local hospital in order to “prevent puer­ peral fever” (Dawly and Beam 2005, 804). Again, it is important to note that this piety that pregnant women receive prenatal care in their homes administered by women was not a new one—midwives, of course, also provided care in the home, as did female friends and relatives of the pregnant woman. The IDNA simply rearticulates this piety somewhat to a medical context: pregnant woman should receive regular prenatal care of a medical nature in their homes and they should engage with technologies of prenatal care. A prenatal admittance form for Boston Lying-In home care demonstrates this combination of medical treatment and social/emotional support tailored to the patient’s unique environment. In addition to more traditional fields like name, address, occupation, expected date of confinement, and dates of specimen of urine and results of analysis, the form has fields where nurses could record home conditions, baby clothes given, and articles loaned: the nurses, that is, considered patients as part of their home environments and tailored their care to suit those environments. A story of a nurse’s visit told in the IDNA’s newsletter The Visiting Nurse also emphasizes the importance of nurses’ getting to know their patients individually and gaining their trust: “Because the young woman knew the nurse and had confidence in her, she did what she was told. For the rest of

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the time the nurse literally carried the patient, giving her in addition to nursing care a steady moral support which enabled her to resist the influence of the neighbors, who, with a strange nurse, would certainly have won a second time” (“What Nurses Do,” 1919, 2). In this story, the trusted nurse empowers her patient to heed medical advice and to disregard the advice of her neighbors, advice that, according to the story, resulted in the deaths of her previous two children. The piety that medical knowledge about pregnancy is expert knowledge is certainly evident in this story, but so is another piety: that pregnant women should receive prenatal care and instruction tailored to their individual needs. In the words of Anne M. Stevens, the head of the New York City Maternity Center Association (which provided home prenatal care services to impoverished residents of Manhattan beginning in 1918), home visits were essential because the nurse “learns the patient in her own surroundings, not as an isolated patient, but as a part of her environment” (1919). This emphasis on maternal health and focus on the individual patient and her unique environment mark Putnam’s and the IDNA’s system of prenatal care as a more user-centered one than that envisioned by Ballantyne. The nurses’ focus was on delivering prenatal care in a way that was attentive to the pregnant woman’s individual needs and individual context in which she existed. The pregnant woman was accorded at least limited expertise: she was able (to a limited extent) to dictate the terms under which her care would be given, to voice her individual needs, to stipulate whether care would take place in a home or clinic environment. These attributes, in turn, mark a shift to a more user-centered model for prenatal care. Of course, as I will explain in the next section, it was not entirely user centered in that it sought to replace women’s practical and everyday knowledge about pregnancy with expert medical knowledge and because nurses did not consider their patients to have potentially expert knowledge about their pregnancies or bodies. Another important point to note here is that the nurses’ expertise came at least in part from their experiential knowledge and from their status as women—as users, or potential users, of the prenatal care system. For example, in an address to the IDNA, the then chairman of the State Board of Health, Dr. Henry P. Walcott, emphasized the teacher-student relationship between a nurse and her patients: “And the instruction as to the minutiae of the household, the things that really go to make contagion or remove the causes of it, must be the intimate instruction of which can only come from someone who can herself do the things which she advises the people of

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the house to do” (quoted in Farrisey 1985, 4). The IDNA nurses, in other words, were successful at giving instruction because they were themselves users of the technologies about which they gave instruction: they had not just the theoretical knowledge (episteme) or the practical wisdom (phronesis), but they also possessed the all-important technical, productive knowledge of techné: the knowledge of the reflective practitioner that can be cunningly adapted to different circumstances.

IDNA and Medically Supervised Pregnancy While the actual prenatal care provided by the IDNA and similar visiting nurse associations may have been user centered, the print documentation that supported and helped to constitute this system reflected a more system-centered model similar to Ballantyne’s: medical knowledge about pregnancy is piously defined as expert knowledge, the focus of prenatal care shifts from the mother to the infant, and the goal of prenatal care is articulated to eugenic goals of race betterment. Part of the reason for this difference may be that there is not much documentation to analyze: as already discussed, a major component of each prenatal care visit was individualized, oral instruction regarding pregnancy. Nurses spent a good deal of each prenatal visit on this kind of instruction. As Mary Beard, a superintendent of the IDNA, wrote in her 1920 review, “It is only as a successful teacher, whose instruction of the family makes un­ interrupted good nursing possible, that her hour at the bedside of a maternity patient, or half hour spent in making a prenatal visit, will produce the best results” (1921, 17). When they did hand out instructions, they were less like a manual and more analogous to a quick reference guide: lists of procedures intended to remind the patient about the nurse’s instructions. Because the nurses themselves provided the arguments for and instructions regarding prenatal care to their patients, the printed instructional materials that they provided could be considered more cursory. For example, one two-page pamphlet printed sometime around 1918 (fig. 4.2) begins with a short introduction that reinforces the piety that pregnant women should seek medical supervision: “Motherhood is a natural and normal. If you do as your doctor and nurse ask you to, you have no reason to worry about having your baby” (Instructive District Nursing Association [1918]). This sentence also emphasizes the importance of individualized instruction in pregnancy. The pamphlet then goes on to give one or

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Figure 4.2: “Advice to Expectant Mothers” (Instructive District Nursing Association, circa 1918). From the Visiting Nurse Association Collection, Howard Gottlieb Archival Research Center at Boston University.

two sentences of advice regarding basic topics such as diet (“drink 8 glasses of water every day), sleep (“at least 8 hours every night with windows open”), and exercise (“If possible take a walk out of doors”). These instructions don’t need to argue explicitly for the establishment of a medical system of prenatal care because they were distributed to patients who were already enrolled in the home prenatal care service. They take for granted, then, that pregnancy is a medical event, that the pregnant body is potentially pathological, and that the pious pregnant woman follows medical advice about pregnancy. The pregnant woman also happily accepts her pregnancy as “natural and normal” despite her ticking time bomb of a body. (And indeed, women had good reason to fear pregnancy at this time, given the relatively high rate of maternal and infant mortality.) Another short pamphlet, published in 1914 by the City of Boston Health Department (figs. 4.3 and 4.4), gives similarly cursory advice but emphasizes more stridently the importance of seeking medical attention early in

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Figure 4.3: First page of For Women Who Are about to Become Mothers (City of Boston Health Department 1914).

pregnancy. This pamphlet was, presumably, given to women who had not yet secured medical prenatal care. The first page of the pamphlet gives the names and addresses of prenatal clinics where women who can’t afford a doctor’s services can secure medical prenatal care. At least three times in the pamphlet, the importance of securing medical attention is emphasized, once to expectant fathers and twice to expectant mothers. Also note, below the picture of a healthy baby boy on the first page, this quotation: “As soon as you know that a baby is to come, do everything that you can to bring it into the world well and strong. If your own body is well and strong, it is because your parents gave it to you at birth. Here, as in Expectant Motherhood, medical prenatal care is linked to the health of future adults and citizens. Another important difference between this set of instructions and the set previously discussed is the mention—twice, in boldfaced type—of the importance of not securing a midwife and not listening to one’s neighbors. The leaflet explicitly rearticulates pregnancy to medical institutions and practices. Because the management of pregnancy was considered women’s work (the province of midwives and other female members of the community), the female IDNA nurses were an important bridge to bringing prenatal care under the domain of medical institutions.1

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Figure 4.4: Second page of For Women Who Are about to Become Mothers (City of Boston Health Department 1914).

The story in The Visiting Nurse mentioned earlier similarly enforces the pieties that pregnant women should not listen to neighbors but should instead heed medical advice. Before the unfortunate patient depicted in the story begins to trust the nurse and heed her advice, she listens to her neighbors’ advice with disastrous results: The nurse did what she could to make the patient follow the rules as to diet, etc., but with no success. The neighbors would say, “We never did that, and look at our fine children,” and the young woman would listen to them. She wouldn’t even go to the hospital until the eighth month. The baby was born, a poor miserable little thing, while the mother was ill with bronchitis. The nurse, knowing the child could not live, yet careful not to alarm the mother, advised it to be baptized. This was done. The mother was heart-broken to lose her baby, but grateful for the nurse’s sympathy and thoughtfulness. (“What Nurses Do,” 1919, 2)

In this story, heeding the advice of neighbors rather than the nurse’s medical advice leads to the death of the baby and nearly to the patient’s own demise. When she begins to “follow the rules,” she has a healthy baby “and to increase the mother’s pride—a boy” (“What Nurses Do,” 1919, 2).

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In this story, as in the city of Boston’s pregnancy instructions, pious pregnant women do not listen to the neighbors (who have only the experiential knowledge of having been pregnant or having known pregnant women) but instead listen to nurses (who combine medical knowledge with experiential knowledge) and, ultimately, to doctors (who possess medical knowledge). The pregnant woman is disarticulated from women in her community, and medical knowledge is defined as expert knowledge. Prenatal care is still tailored, however, to the user’s environment.

Prenatal Care Produces Fit Citizens In addition to these quick reference guides, longer pregnancy manuals began to appear shortly after systems of prenatal care began to be established in the United States. One of the most notable of these, and one that visiting nurse associations also occasionally distributed during prenatal care visits (Dawly and Beam 2005), was a pregnancy manual called Prenatal Care (West 1913) first published by the Department of Labor’s Children’s Bureau in 1913. In this manual, there is a subtle but important shift in the focus of prenatal care: unlike in Putnam’s and the IDNA’s internal correspondence, the primary goal of such care is represented not to be preserving maternal health but to be preventing infant mortality. Moreover, the goal of prenatal care becomes, as it was in Expectant Motherhood, to produce not only healthy babies but normal babies. The Children’s Bureau produced the manual after recognizing “that a program of postnatal instruction represented an incomplete approach to the reduction of infant mortality” (Meckel 1990, 166). The U.S. government began to be interested in prenatal care, in other words, as a means to reduce infant mortality, not maternal mortality. I want to be clear that I am not saying that reducing infant mortality is an unworthy goal for prenatal care, or that reducing infant mortality and reducing maternal mortality are mutually exclusive. It is important to note, however, that the focus on reducing infant mortality rather than reducing maternal mortality represents a shift toward the fetus’s, rather than the pregnant woman’s, being the primary patient of prenatal care. In the letter of transmittal that begins the pregnancy manual, Julia Lathrop, the chief of the Children’s Bureau, emphasizes that it was the dire statistics on infant mortality (she says that “300,000 babies less than one year old died last year in this country”) that resulted in the bureau’s being “drawn inevitably to begin its contemplated series of monographs

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on the care of children by a statement regarding prenatal care for mother and child” (Lathrop 1913, 5). It also seems that the manual underwent a type of usability testing, having “been read and criticized by a large number of well-known physicians and nurses, and by many mothers” (Lathrop 1913, 5). Lathrop identifies the manual’s primary audience as “the average mother of this country” (Lathrop 1913, 6). The manual’s main emphases are on hygiene during pregnancy and on identifying complications of pregnancy that should be reported to a physician. In addition to hygiene and complications of pregnancy, the manual discusses signs and duration of pregnancy, preparations for confinement, preparations for childbirth and birth itself, and care of the mother and baby during the “lying-in period.” Recommendations as to the hygiene for pregnancy essentially expand on the brief recommendations for diet, rest, fresh air, and exercise found in the shorter leaflets. For example, West provides elaborate dietary recommendations and remedies for avoiding constipation (thought at this time to be a primary contributor to toxemia, or preeclampsia). Prenatal Care is not quite as adamant as Expectant Motherhood, or even as the quick reference guides analyzed earlier, that the pregnant woman must place herself under medical supervision as soon as she suspects herself to be pregnant. It does, however, subtly position medical knowledge as expert knowledge about pregnancy. For example, after discussing signs of pregnancy that the pregnant woman herself may notice (cessation of menstruation, changes in the breasts, morning sickness, disturbances in urination, and finally, quickening), West emphasizes that, although after experiencing all of these signs “there can scarcely be room for doubt that pregnancy exists, . . . only a physician can make a positive diagnosis” (West 1913, 7). Later, after describing hygienic procedures for care of the breasts during pregnancy (such as wearing loose clothing and “toughening” the breasts by washing them daily), West advices that “it will be well to have the physician observe the condition of the nipples about eight weeks before confinement, in order that he may determine whether or not they require special treatment” (West 1913, 14). West also advises that pregnant women “should insist” that a physician examine their urine for the presence of albumin and sugar “at least once a month during the first half of pregnancy, and oftener toward the end” (West 1913, 15). Later, she recommends that “it is well to engage the doctor as early in the pregnancy as possible,” even though “he may have very little to do beyond giving advice and making the routine examinations of the urine” (West 1913, 21). In Prenatal Care, medical knowledge is piously defined as expert knowledge, and prenatal care begins to be defined

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as a medical event, even though West acknowledges that the doctor, in fact, “may have very little to do” (West 1913, 21). Although Prenatal Care does not place the same direct emphasis on securing medical supervision during pregnancy as Expectant Motherhood does, it similarly defines the pregnant body as potentially pathological and as potentially risky to the developing baby. A very lengthy section of the manual (under “complications of pregnancy”) is devoted to debunking the theory of “maternal impression,” the idea that traumatic sites or experiences, or even strong cravings, could “mark” the baby, “producing deformities and monstrosities that retained the semantic content of the original impression” (Kukla 2005, 13). West goes to great lengths to debunk this myth, emphasizing that “there is no connection between the mother and the child in the uterus by which nervous impressions can be conveyed” (West 1913, 19). Furthermore, West explains, given the “great number of strange and unhappy things that happen about us every day,” if the theory of maternal impressions were true, almost every baby would be “marked” in some way (West 1913, 19–20). The aim of debunking the theory of maternal impressions, however, is not to define the pregnant body as a nonthreatening environment for the fetus but to emphasize that “although the child is undoubtedly protected from direct injury by means of occurrences outside the control of the mother, nevertheless he is subject to harm or benefit from conditions that are usually quite within her own control” (West 1913, 20). West explicitly links infant deaths and other “harm which a mother may do her child in the uterus” to the mother’s “failure to order her own life in the way that will result in the highest degree of health and happiness for herself and, therefore, for the child” (West 1913, 20). West goes on to detail how the pregnant woman’s life should be ordered: “If then she lives in such a manner as to establish and conserve her own health, taking plenty of sleep and exercise, eating sensibly of simple food, and in every way striving to take the best possible care of her own body, so that the digestive, assimilative, and excretory functions are carried on in the highest degree of efficiency, she can be quite sure that the child will be able to build up for himself a sound and normal body and brain” (20). “On the other hand,” West warns, “if a woman neglects these plain rules of health and goes through her pregnancy lamenting or repining her condition, paying but slight attention to her own bodily functions, it is conceivable that the child may thereby be robbed of some of the nutrition it needs for his own best development” (20). Although less explicitly than in Expectant Motherhood, the echoes of eugenic rhetoric are evident in these passages: the “average mother” addressed in this

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pamphlet is to apply scientific principles of hygiene and nutrition to herself in order to ensure that her child will not only survive pregnancy but also be possessed of “sound and normal body and brain.”

Reconciling the System- and User-Centered Models There is a clear tension, then, between the more user-centered model for the technological system of prenatal care established by visiting nurse associations such as the IDNA and the more system- and fetus-centered model articulated in a pregnancy manual like Prenatal Care. Indeed, the public health and progressive maternalist focus of early prenatal care, especially the care provided by visiting nurse associations such as the IDNA in the United States, seems diametrically opposed to eugenic ideology. Putnam and the IDNA nurses, for example, focused on the mother’s health and living conditions. They also provided care to poor, immigrant women—the very class of people about whose health and levels of infant mortality hardline eugenicists such as Charles Davenport were not in the least concerned. And some were very opposed to the IDNA’s work in prenatal care on the grounds that it promoted, as one irate letter writer put it, “the improvident and reckless procreation of the poor” (Saunders 1909). As Alexandra Minna Stern (2002) points out, however, and as Ballantyne’s work illustrates, eugenic discourses and ideologies operated along a continuum that included both eugenic concern with heredity and euthenic concern with environmental conditions and public health. Although Putnam does not link the ends of her program of prenatal care with those of eugenics as explicitly as Ballantyne does she certainly was aware of its rhetorical power. In one letter promoting her work in prenatal care, Putnam writes, “I have this work very much at heart for next to Eugenics, it seems to me of the greatest importance to our future citizens” (Putnam [1911a]). The American Breeders Association, the first American eugenicist organization, was formed under the leadership of Charles Benedict Davenport in 1903, and the First National Conference on Race Betterment, which included proponents of both eugenics and euthenics, was held in Battle Creek, Michigan in 1914 (Selden 1999, 4–9). Historians of eugenics often divide eugenics into two camps: positive eugenics and negative eugenics. The purpose of negative eugenics was to prevent those considered genetically inferior from reproducing through sterilization, marriage legislation, and the like. The purpose of positive eugenics was to “increase the production and survival of healthy babies” (Anglo-Saxon babies in particular; Pernick

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2002, 707). Recently, however, scholars such as Pernick have challenged the positive/negative eugenics distinction on the grounds that “although they used different technologies and were aimed at different audiences, selective pronatalism and selective reproduction restriction often shared the same core values and goals” (Pernick 2002, 707). Likewise, the goals of euthenics and eugenics were similar and their means were often conflated. In the first half of the nineteenth century, for example, “better baby contests” conducted throughout the rural Midwest in the United States served “to reward middle class rural Whites for successful reproduction” and also to reward them for reproducing and rearing their children in hygienic, moral environments—that is, for raising them according to medical, scientific principles (Pernick 2002, 707). In fact, Mary Mills West, the author of the pregnancy manual Prenatal Care that was discussed above, worked with Florence Brown Sherbon, a member of the American Eugenics Society, to organize “babies’ health conferences” in Indiana (Stern 2002, 745). These conferences provided the inspiration for the better baby contests that were held in the 1920s (Stern 2002). Prenatal care was, in fact, a little-known branch of the aforementioned better babies movement. In fact, a footnote in the 1927 pregnancy manual Every Child Has the Right to Be Well Born published by Johnson and Johnson explicitly links the prenatal care to the better babies movement, claiming that “the most important factor in the ‘Better Babies’ movement is prenatal care” (Johnson and Johnson 1927, 13). (I discuss this manual at more length in chap. 7.) Feminist scholars (Ettorre [2000, 2001], Petchesky [1984], and Rapp [1999] among them) have commented on the neo-eugenic rhetoric underlying practices like prenatal genetic testing and the selective application (or withholding) of new reproductive technologies; it is less commonly recognized that the early technological system of prenatal care itself was itself articulated to the positive eugenics movement. The well-ordered, hygienic domestic space promoted in better babies contests and similar events simply extend into the pregnant body itself. In her study of African American midwifery, Gertrude Jacinta Fraser notes how prenatal care was seen during this time as “one means of producing vigorous, smart, and competitive Caucasian stock. From this perspective, any Anglo-Saxon woman could avail herself of nation building by availing herself of prenatal and maternal care” (Fraser 1998, 126). Prenatal care was also seen by obstetricians in the early to mid part of the twentieth century as a way to “get pregnant women away from midwives and into the medical system” and to fill up the expanding obstetrics wards in hospitals (Perkins 2004).

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In fact, the IDNA (as well as similar visiting nurse associations throughout the United States offering prenatal care) often turned to a rhetoric of race betterment in their printed materials in order to garner support for their causes. Take, for example, this excerpt from a 1916 promotional pamphlet for the IDNA’s work in public health—which includes prenatal care. The pamphlet begins with this passage: “The most expensive thing in the world is ill health. In the United States alone, over 750,000 working years are lost annually by illness among the 30,000,000 men, women, and children employed in industry. . . . Sickness impoverishes the individual, the state, and the race. Ill health and immorality spring from a single source. Disease and crime are near kin. Society pays each year a tremendous sick bill, and pays often in ways which it little suspects” (Instructive District Nursing Association 1916, n.p.). Likewise, a rhetoric of race betterment very similar to that employed after the Boer War in Great Britain is evident in a 1917 bulletin issued by the Women’s City Club of New York. The City Club was, at the time, working to establish a prenatal care system in New York City. The club’s system, like that of the IDNA, attempted to tailor prenatal care to the patient’s specific needs. That is, if patients, for example, couldn’t or wouldn’t visit the clinic for prenatal care visits, nurses would visit them at home. This bulletin describes the club’s launching of a maternity center: Every day makes it more apparent that war conditions have made our work in Maternity Protection [e.g., prenatal care] doubly important. A recent letter from the Federal Committee on venereal diseases calls attention to the fact that European armies have lost the services of more men from venereal diseases than from any other one cause. Add to this the great increase in insanity, the crippling and maiming of men, and finally the actual loss of life among the select men of the country and it becomes clear that there was never a time when we need not only to save every life but to see that we produce a healthy, virile new generation. (Women’s City Club of New York 1917)

Here, as in Ballantyne’s writings, we see prenatal care being explicitly linked with racial and national health. On a national level, the system begins to be constituted around this eugenic ideology—that is, around the goal not only of reducing infant mortality but also of producing normal infants and fit citizens. At the same time that a system of prenatal care was actually being established according to a woman-centered model, in other words, the system-constitutive documentation advocating its support and expansion articulated the technological system of prenatal care, and

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the identity of the pregnant woman, to more system-centered goals and ideologies. Ultimately, the system-centered model for prenatal care implicitly advocated for in pregnancy manuals like the ones discussed in this chapter prevailed over the more user-centered model articulated by the IDNA and similar organizations. I certainly don’t want to argue that the documentation caused this: the move toward and establishment of a centralized, institutional model of prenatal care carried out by obstetricians in clinics and hospitals was a result of disciplinary power, gender, economics, baby booms, expediency, technological development, and a host of extradiscursive forces. It is clear, however, that the system-centered model of prenatal care grounded in appeals to political expediency for which these early manuals advocated was incompatible with the more user-centered model that district nursing had established. And indeed, over the course of the next twenty years, clinic-based prenatal care provided by physicians would slowly replace home-based prenatal care provided by district nurses. To conclude, the model for prenatal care established by Elizabeth Putnam, the IDNA, and similar organizations was more user-centered than that envisioned by Ballantyne: prenatal care was tailored to the pregnant woman’s individual environment, pregnant women were potential experts about their pregnancies and bodies, and nurses provided their patients with material as well as medical support. The model evident in end-user documentation and in public relation materials, however, is more system centered: it shifts the focus of the technological system of prenatal care away from women’s health and circumstances and toward the production of “sound and normal” citizens.

5 Getting in the Way Pregnancy Manuals during the Women’s Health Movement

It solves numerous minor problems for me and prevents many unnecessary questions and telephone calls. william j. hargreaves (1957) Feminism offers a long tradition of recognising the power to define, to make distinctions, and to create categories as key to a host of other power effects. sarah franklin, celia lury, and jackie stacey (2000)

On September 30, 1948, the Instructive District Nursing Association of Boston (by then reinvented as the Visiting Nurse Association) discontinued its home delivery and prenatal care services. The discontinuation of these services reflected a post–World War II, nationwide trend toward centralized prenatal care conducted by obstetricians working in clinics or hospitals. In the majority of these cases, nurses were now working immediately under physician supervision rather than semi-autonomously in patients’ homes as they had been for almost forty years.1 As discussed in the previous chapter, the visiting nurse associations had partly provided a means of rearticulating prenatal care to a medical, institutionalized, and ultimately centralized context. This trend was also marked by both a demographic and a socioeconomic shift in the mothers now seeking prenatal care. Historically, prenatal care in the United States had been largely targeted toward working-class immigrant women. Such care, in turn, was largely provided by nurses and social workers within domestic spaces (i.e., the woman’s own home). After the Second World War, however, such care was increasingly provided primarily by physicians and obstetricians within medical institutions, “often outside a woman’s own culture and community” (Thompson, Walsh, and Merkatz 1990, 27). 69

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This centralization of prenatal care also institutionalized the piety that the fetus, not the mother, was the primary patient for prenatal care. Naoko Ono has argued that the solidification of obstetrics as a discipline in the mid-twentieth century was enabled by in part by obstetricians’ “minimi[zing] their dependence on women patients in order to acquire status and power in the medical world” (Ono 2006, 85). The technological system of prenatal care at this time is more reflective of Ballantyne’s systemcentered model, which emphasized “saving the lives of infants rather than those of mothers” and medically supervising maternal bodies and practices in order to ensure normal fetal development (Ono 2006, 85). The post–World War II baby boom caused obstetricians to become overextended and meant they had less and less time to spend with their patients, meaning that prenatal care became less and less about considering the pregnant woman “as a part of her environment” as Anne Stevens (1919) once advised, and more about learning about her out of context, as a patient. Along with the baby boom, there was a midcentury boom in booklength pregnancy manuals, which took the instructive place of the visiting nurse or overtaxed, clinic-based physician and were meant to “serve as a sort of stenographic recapitulation of the doctor’s main instruction” (Eastman 1957, vi).2 Manuals such as Have Your Baby, Keep Your Figure; Nine Month’s Reading: A Medical Guide for Pregnant Women; and Nicholson J. Eastman’s Expectant Motherhood (not to be confused with the Ballantyne manual of the same name) gave advice and instruction on such topics as diet and hygiene in pregnancy, preparations for the baby, and how to telephone your doctor. As discussed in the previous two chapters, written documents such Ballantyne’s Expectant Motherhood and the various publications of the Instructive District Nursing Association (and related social and governmental organizations)—together with the oral instruction and recruitment efforts of the nurses themselves—helped to constitute the technological system of prenatal care. The pieties around which the technological system of prenatal care was constituted were readily evident in this systemconstitutive documentation because its readers/listeners had to be persuaded that such a technological system was necessary (or that they should participate in this emergent system). Following World War II, engaging with technologies of prenatal care had already been established as a “natural” way to be pregnant, so pregnancy manual authors could take for granted that the very fact of being pregnant meant that their particular readers (at least those middle-class, white, Protestant readers whom they seem to target) would engage with the prenatal care system. This meant that pregnancy

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manuals could focus more on how to engage with the system than on why to engage with it. The choice to use the prenatal care system (along with the pious arguments for why users should engage with it) became implicit rather than explicit: as far as the manuals were, and still frequently are, concerned, there was no longer an “outside” to the system. No longer system constitutive, mainstream pregnancy manuals began to represent systemmaintaining documentation.3

What Is System-Maintaining Documentation? System-maintaining documentation is the most familiar type of instruction, and it comes with its own set of pieties, which I will take up over the course of this chapter. In system-maintaining documentation, procedures are phrased as commands, instruction is task oriented, and the objective of instruction is to stay out of the way of users being able quickly and efficiently to complete the task at hand. The purpose of this type of documentation is to keep users engaged with a particular technology or system rather than to critique or change that system. The manual accompanying a software application, for example, provides the reader with instructions on how to use the software. In so doing, it does not comment on the quality of that software or the nature of the task one uses the software to perform. The system-maintaining manual is epideictic, functional, and taskoriented. Manuals become primarily epideictic—that is, concerned with present action—after a technological system (and the pieties that it reflects and reproduces) is pretty well accepted and the manual’s readers will therefore take it for granted that in order to implement a project they must engage with certain technologies in certain ways. The idea is that such epideictic manuals can take on a more typical support role in helping readers use the technologies the manuals describe. This support role entails a functional, or task-oriented, approach to documentation, for it instructs users in the “functional but not conceptual aspects of technologies” (Johnson-Eilola [1996] 2004, 179). Such functional, epideictic manuals can be characterized as system maintaining because their objective is to keep users engaging with technologies in certain ways (e.g., ways that encourage correct use) and thus to maintain the status quo of how a technology should be used and perceived. Such system-maintaining manuals are what most people would probably first think of when they hear the term “instructions”: here is how to operate your camera, your iron, your body.4

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The System-Maintaining Pregnancy Manual A prime example of a system-maintaining pregnancy manual that embodies the pieties of system-maintaining documentation is William Birch’s A Doctor Discusses Pregnancy (1966), a mainstream pregnancy manual that was designed to be distributed by doctors to support their patients’ prenatal care. One of the most striking differences between A Doctor Discusses Pregnancy and its system-constitutive predecessors is its lack of explanation for why pregnant women should seek medical advice during pregnancy and why they should work at disciplining their bodies under medical supervision. Rather, the manual begins by assuming that the user is already pregnant, equates pregnancy with happiness and beauty, and defines it as the ultimate experience of womanhood: “A woman is likely to glow and look more beautiful during this period while her body is fulfilling its ultimate physical function. For each woman pregnancy has its own unique mystery, emotional response, and contentment” (Birch 1966, 1). After a short introductory paragraph extolling the beauties and fulfillment of pregnancy, there is a short paragraph praising “medical science” for “reduc[ing] to a minimum the discomforts and pains your great-grandmother and your grandmother endured during pregnancy” (1). The next paragraph explains that “there are many things you must do to cooperate” with “your doctor,” and from there the manual launches into descriptions of medical tests and examinations that begin prenatal care (1). The manual stays out of the way of users’ engaging quickly and efficiently with the technological system of prenatal care. Note that the manual no longer explicitly advocates for pieties such as pregnant women seek medical care early in their pregnancies or pregnant women engage with technologies of prenatal care because, within the terms of this manual, medical institutions, practices, and technologies are already tenaciously articulated to the identity of the pregnant woman. At the same time that system-maintaining manuals like A Doctor Discusses Pregnancy were becoming standard documentation accompanying the technological system of prenatal care, some users of the medical system were trying to disrupt that system—to rearticulate it. In 1969, during a feminist convention in Boston, a group of twelve women met for the workshop “Women and Their Bodies.” In this workshop, the participants discussed the feelings of alienation, guilt, and frustration that their encounters with medical institutions had produced. As Judy Norsigian, Vilunya Diskin, Paula Doress-Worters, Jane Pincus, Wendy Sanford, and

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Norma Swenson write in a reflection on the history of the Boston Women’s Health Book Collective, “We discovered that every one of us had a ‘doctor story,’ that we had all experienced feelings of frustration and anger toward the medical maze in general, and toward those doctors who were condescending, paternalistic, judgmental, and uninformative in particular. As we talked and shared our experiences, we realized just how much we had to learn about our bodies, that simply finding a ‘good doctor’ was not the solution to whatever problems we might have” (Our Bodies, Ourselves 2005). This group of women decided to take matters into their own hands by spending the summer researching medical questions and writing up their findings. In the fall of that same year, the women presented and collected their papers, which the New England Free Press later printed on “stapled newsprint” under the title Women and Their Bodies: A Course (Boston Women’s Health Collective 1970). In 1971, the authors of the collection changed the name to Our Bodies, Ourselves (in order to highlight the theme of women taking control of their own bodies), and the New England Free Press reissued it. It sold “250,000 copies, mainly by word-of-mouth” (Our Bodies, Ourselves 2005), and was published commercially by Simon and Schuster in 1973 (Boston Women’s Health Collective 1973). Women and Their Bodies, which includes chapters on anatomy and physiology, sexuality, abortion, and pregnancy (among others), is a prime example of instructions whose goal is systemic change rather than system maintenance—it is an example of what I term “system-disrupting documentation.”

What Is System-Disrupting Documentation? The prevailing view that documentation is, or should be, system maintaining stems in part from a tendency to view documentation as subordinate to the technologies that it describes. There is a correlated tendency, then, to view technical communicators and users as subordinate to the scientists, doctors, engineers, and other technical experts who develop technologies. As an antidote to viewing technical communicators as nonexperts, Johnson-Eilola ([1996] 2004) proposes that we think of technical communication as “symbolic-analytic” work and technical communicators as “symbolic analysts.”5 One of the most important aspects of symbolic-analytic work (which is underaddressed within technical communication) is system thinking. System thinking “works at a level beyond abstraction, requiring symbolic analysts to recognize and construct relationships and connections

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in extremely broad, apparently unrelated domains” (Johnson-Eilola [1996] 2004, 186). For example, rather than taking a troubleshooting approach to problem solving, a symbolic analyst “would step back to look at larger issues in the system to determine how the problem develops and in what contexts it is considered a problem” (Johnson-Eilola [1996] 2004, 186). Or, to put it another way, rather than asking, “what’s wrong with what the user is doing” or “what’s wrong with the design of this text,” the technical communicator as symbolic analyst asks, “what’s wrong with the system”? A system, such as the technological system of prenatal care, includes not only technologies but also perspectives on how something should be done with and through technologies, contexts in which these things are done, and the preconditions (such as prior knowledge) required to do things. The goal of system thinking is “to understand (and remake) systemic conditions”; it is systemic change (Johnson-Eilola [1996] 2004, 261).6 Needless to say, it would be difficult, if not impossible, for a technical communicator to remake systemic conditions unilaterally, especially for a technical communicator who may not have a lot of power to effect change within an organization. It may be possible, however, for a technical communicator to draw users’ attention to the systemic conditions that are causing problems and thus disrupt—get in the way of—the user’s uncritical engagement with the system. Documentation that works toward system disruption might help a user to manipulate parts of the system, negotiate the system, or change the system even in a small, local way. In order to do so, it may advocate for a reorientation of user pieties and a rearticulation of user identity. In the introduction to Women and Their Bodies, the collective writes that one of the main purposes of the document was to learn “how we could act together on our collective knowledge to change the health care system for women and for all people” (Boston Women’s Health Collective 1970, 4) Women and Their Bodies works through this goal of systemic change by disrupting the user’s functional engagement with components (or subsystems) of the healthcare system. It questions why, on what grounds, and on whose terms women engage with the system in certain ways, as will be demonstrated in the analysis below. To help individuals understand the importance of system-disrupting documentation, it is important to contrast its rhetorical features with parallel system-maintaining materials. The remainder of this chapter will focus on two documents. One is the newsprint prototype of Our Bodies, Ourselves—Women and Their Bodies: A Course—which includes papers on

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abortion, pregnancy, and childbirth. Essentially, it includes a pregnancy manual as part of a larger document. I focus on this because, as I’ve mentioned, it is an example of documentation that is radically different from both mainstream pregnancy manuals and from most other kinds of documentation in that its goal is not system maintenance but systemic disruption. The second is the paradigmatic example of a system-maintaining manual that I mentioned above—William Birch’s A Doctor Discusses Pregnancy (1966). (I focus specifically on the first nine chapters, which give instruction about the prenatal period.) I’ve chosen this second text because it is exemplary of system-maintaining documentation, designed to be distributed by doctors to support their patients’ prenatal care, and because, as I will discuss below, the authors of the pregnancy chapter in Women and Their Bodies specifically reference it and position their pregnancy chapter in contrast to it. The comparative analysis of the two documents demonstrates how system-disrupting documentation such as Women and Their Bodies has the potential to disrupt not only some of the pieties associated with its users’ engagement with a technological system but also pieties for composing usable instructions. Such pieties include the following: · Instructions should be invisible. · Instructions should focus on user tasks. · Procedures should be written as commands.

In addition to disrupting pieties for composing usable instructions, Women and Their Bodies engages correlated pieties surrounding pregnancy and prenatal care: · Pregnant women’s bodies are invisible. · Medical knowledge about pregnancy is expert knowledge. · Prenatal care can solve political and social problems.

Instructions/ Pregnant Bodies Should Be Invisible In her textbook Writing for the Technical Professions, Kristin Woolever advises students that “when instructions are well written, they work so smoothly that readers (often called ‘users’ for this type of writing) can perform a task without even noticing the prose: it doesn’t get in the way” (2008, 223). Another popular textbook observes that “effective instructions enable users to get the job done quickly and efficiently” (Lannon 2006). In

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fact, many technical communication textbooks carry this same message at the heart of their units on instruction writing: when instructions are good, the user won’t notice them; instructions should stay out of the way of their users’ ability quickly and efficiently to carry out the tasks that they want or need to accomplish. In the previous two chapters, we saw that system-constitutive pregnancy manuals devoted much space to explaining why pregnant women should seek medical attention during pregnancy and why they should follow medical rules of hygiene and conduct during pregnancy. This engagement with the emergent technological system of prenatal care is clearly linked to goals of preserving maternal health, preserving infant health, or producing fit citizens. Earlier in this chapter, we saw that A Doctor Discusses Pregnancy seeks to stay out of the way of its users being able efficiently and easily to engage with the medical system of prenatal care. In contrast, the chapter on pregnancy in Women and Their Bodies begins like this: “Why become pregnant? Why have a child? We as women are talking about having vs. not having children. Some of us feel strongly that there are no good reasons for having children. Some feel it’s self-indulgent for us to have our own children but all right to adopt children who need homes. And some belieye [sic] that giving birth to and rearing our own children can be a creative, even revolutionary act” (Boston Women’s Health Collective 1970, 108). Because pregnancy is one subject addressed among a spectrum of women’s health issues (the chapter on pregnancy comes immediately after the chapter on abortion, e.g.), Jane Pincus and Ruth Bell, the authors of the pregnancy chapter, do not assume that their readers are already pregnant. Pregnancy itself becomes a decision open to deliberation, not a foregone conclusion. In order to help their readers either to decide whether to become pregnant or to come to terms with their current pregnancies, the pregnancy chapter overwhelmingly focuses on questions of definition and evaluation: What are the causes of pregnancy? What is the nature of pregnancy? What value should be placed on pregnancy? For example, the authors observe that women may feel compelled to become pregnant because of societal limitations imposed on them: “Because our opportunities [as women], hence our motivations, are limited we ourselves often begin to believe that in motherhood we will find greater satisfaction than as student, worker, artist, political activist, etc. Often we look forward to pregnancy and motherhood as a time when we can put our identity crises on the shelf and relax, secure in the legitimacy of our maternal roles” (Boston Women’s Health Collective 1970, 106).

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In fact, throughout the chapter Pincus and Bell discuss over and over again what they call the various societal and cultural pressures that lead to pregnancy. One of the cultural pressures that they cite is “biased, traditional definitions” of pregnancy, motherhood, and womanhood. They specifically criticize such definitions exemplified in a pamphlet “handed out by a Boston area doctor” (109). This manual, although they don’t name it, is clearly Birch’s A Doctor Discusses Pregnancy based on the material that they quote. Pincus and Bell quote two passages at length. The first, which I’ve extracted above, uses pious language like “glow,” “fulfill,” “mystery,” and “contentment” to define pregnancy. The second passage that Bell and Pincus reproduce (again from A Doctor Discusses Pregnancy) invokes similar language. In it, Birch claims that “the prospect of motherhood makes [women] mature” as well as making them “poised, proud, confident, and beautiful.” He goes on to explain that the process of pregnancy is Nature’s (with a capital N) way of preparing a woman’s mind and body for motherhood (Birch 1966, 13). Pincus and Bell leverage Birch’s pious definitions of pregnancy as beautiful, mysterious, natural, and so forth in order to define pregnancy impiously as emotionally fraught, uncomfortable, even unnatural—they “get in the way” (109). Furthermore, they specifically engage—and reopen— Birch’s definitional claims regarding pregnancy, womanhood, and motherhood: “Most important, the definition of us is biased in traditional ways. To be a woman equals motherhood which equals fulfillment of destiny as preordained by Nature. These are the definitions most ingrained into us and they provide us with socially-backed positive attitudes toward child-bearing that are a far cry from individual more thought-out attitudes” (109). Pincus and Bell wrench apart pious associations regarding pregnancy. After these pious associations are destabilized, new associations and possibilities can be established. For example, Pincus and Bell raise the possibility that the pregnant woman may feel angry rather than poised, proud, or confident, that she might feel “anger about the takeover of our bodies by something tiny, invisible . . . anger that a cycle has begun over which we have no control” (113). The authors draw attention to the pregnant woman’s body and legitimize her embodied experience. Rather than feeling beautiful and full of mysterious glow, Pincus and Bell observe that the pregnant woman “might think of her body as swollen, distended, deformed, and really hate it” (114). One of the purposes of the manual is to make women think critically about their reasons for getting pregnant in the first place, to make them think twice about whether they want to become pregnant (an act that

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will necessitate their engaging with the technological system of prenatal care) in the first place. A Doctor Discusses Pregnancy also recognizes that pregnant women may feel anxious, guilty, or uncomfortable, but it pinpoints the source of these feelings not in social, cultural, or medical systems surrounding pregnancy and motherhood but rather in the users’ failure to comply adequately with the technological system of prenatal care. The pregnant women’s body and mind must be disciplined to accept pregnancy—any embodied experience that might get in the way of this acceptance is dismissed. For example, anxious pregnant women must remember that “sound medical knowledge and modern care for the needs of pregnant women today have reduced the births of abnormal babies” and that “drugs and modern childbirth techniques have reduced labor discomfort to a minimum” (Birch 1966, 13). Note also here the tenacious articulation of pregnancy to eugenic and euthenic discourses—one of the primary goals of medical prenatal care is to prevent “abnormality.” Another source of anxiety during pregnancy is traced back, as it was in West’s manual Prenatal Care (1913), to the fear of “maternal impressions.” Birch advises that “anytime such groundless fears loom into your subconscious mind simply remember that having babies is a woman’s primary function. It is normal and natural” (14). In A Doctor Discusses Pregnancy, women’s embodied experiences and knowledge are brushed aside, and the technological system of prenatal care documented in the manual focuses on producing (“normal”) babies.

Instructions Should Be Task Oriented/Tasks Should Be Supervised by Medical Experts A second important piety for writing usable instructions is that they must be task oriented: this means that their “organization follows the order of the discrete tasks” the users need to perform. The idea behind the principle of task orientation is that users want to spend a minimum amount of time reading instructions; instead, “they want to be using their new iPod or their new computer” (Gurack and Hocks 2009, 77). As Lannon (2006) advises, effective instructions “focus on the task” rather than “focusing on the product” (544). This advice is based on the assumption that instructions are system maintaining. The previous section (“The System-Maintaining Pregnancy Manual”) observed that system-maintaining documentation focuses more on how to engage with a technological system than on why to do so. On page 6 of

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the very first chapter of A Doctor Discusses Pregnancy, Birch mentions for the first time the importance of following instructions during pregnancy: “Once he [the doctor] is sure you are pregnant he will give you instructions that should be carried out with intelligence and good sense.” Furthermore, the purpose of Birch’s pregnancy manual is explicitly stated to be as follows: to help the user “recall and follow his [the doctor’s] instructions more easily” (6). And, in case the reader has missed the point: “The importance of adhering to prenatal instructions cannot be overemphasized” (6). Pregnant women are advised to “take [your doctor] into your confidence. Discuss problems with him that relate to your pregnancy be they physical or mental, or even an argument with your husband” (24). Even marital problems can be solved by engagement with the technological system of prenatal care. As in earlier iterations of the pregnancy manual, the pious pregnant woman accepts medical knowledge about pregnancy as expert knowledge and accepts her own nonexpertise. In A Doctor Discusses Pregnancy, prenatal care instructions include prescriptions about what to eat and how to control one’s weight (the focus of chap. 5); how to properly work, rest, travel, and exercise (chap. 6); what to wear and how to groom oneself (chap. 7); how to prepare one’s husband for fatherhood (chap. 8); and how to prepare for childbirth and motherhood (chap. 9). Most of the tasks are, indeed, phrased as commands, and many of them encourage the pregnant woman to consult the expert: her doctor. For example, Birch advises pregnant women to “consult the calorie chart to stay within your calorie limit” (34) in order to avoid gaining excessive weight during pregnancy. In order to help women squeeze in exercise between domestic tasks, he suggests, “when you’re at the ironing board or the kitchen counter bend your knees every little while and lean forward at the hips for a few minutes” (45), and he tells his readers to “be prepared to let your physician decide on the proper procedures” during labor and delivery (65). These procedure-oriented instructions—hygienic and technical prescriptions very similar to what we’ve seen in earlier manuals—form the bulk, and purpose, of the manual. Because A Doctor Discusses Pregnancy takes for granted that prenatal care will take place in a doctor’s office within a medical context and that its role is to help its users accommodate themselves to this now-established system of prenatal care, it (rather understandably) treats medical knowledge as the only legitimate knowledge about prenatal care and pregnancy. Users of the prenatal care system are instructed to scrupulously obey their doctor’s instructions even when those directives are at odds with their own experience or with the experience of other pregnant women. For example,

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Birch tells his readers that they should gain no more than twenty pounds over the course of their pregnancy and that they should gain less weight (or even none!) if they are overweight to begin with (Birch 1966, 32). Clearly, this prescription would be at odds with many, if not most, pregnant women’s personal experiences. Definitive knowledge about pregnancy within the terms of the prenatal care system is produced and maintained by those positioned within Birch’s manual as system experts and designers—usually obstetricians—rather than by those positioned as system novices and users—that is, pregnant women. What about Women and Their Bodies? Remember that the stated purpose of Birch’s manual is to stand in for expert instruction. The stated purpose of Pincus and Bell’s manual is “to have some control over the process [of pregnancy] both by learning as much as possible about ourselves and by changing attitudes and institutions to be more responsive to our needs when we decide to have children” (Boston Women’s Health Collective 1970, 108). Given this stated purpose, it is not surprising that there is little taskoriented instruction, at least not related to the management of pregnancy. In fact, Pincus and Bell do not engage task-oriented instruction until about half way through the chapter, when they explain that it is important to find out all that one can about pregnancy. They instruct users to “experience your own pregnancy. Talk to other women who have been pregnant and who are pregnant at the same time as you, but remember there’s no ‘right’ way to be pregnant. Try to learn about everything that happens, everything you don’t understand” (111). Then, Pincus and Bell go on to discuss signs of pregnancy (that the woman might observe herself) and procedures for detecting pregnancy (that a doctor will carry out). They instruct the user to “demand that a urine specimen be taken to be studied” if she feels the need to urinate more frequently, since this condition can either indicate pregnancy or a urinary tract infection, or both (111). Like Birch, Pincus and Bell assume that the nature of pregnancy dictates that the user “will see a doctor when you recognize some of the signs as pregnancy,” that pregnancy appropriately falls under a medical jurisdiction. They describe, like Birch, laboratory tests, as well as the pelvic examination, that can definitively establish the fact of pregnancy. Like Birch, they emphasize the importance of relaxing during this examination in order to lessen discomfort. Unlike Birch, however, they observe that “relaxation involves trust that it is sometimes difficult to have” (112). The manual challenges, in other words, the piety that medical knowledge about pregnancy is the only legitimate expert knowledge.

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On the last page of the pregnancy chapter, Pincus and Bell briefly provide task-oriented instruction again, but in the context of demands that pregnant women should make of their medical care providers and of society more generally. For instance, while describing the content of a prenatal checkup, they observe, “during pregnancy we can become emotionally vulnerable and, as a result of all we’re experiencing and the often impersonal efficiency of the examination, we may be rendered almost speechless. Often both private and clinic doctors treat us as children who know very little and are capable of learning less. It’s a good idea to prepare lists of questions and persist in asking them until the answers are clear and satisfactory” (116). Even this, however, isn’t quite explicitly task-oriented instruction but, rather, a suggestion of what users might do. In fact, the authors of Women and Their Bodies present almost no explicitly task-oriented instruction. When they do provide instruction, they approach it as more deliberative than prescriptive, as their destabilized definitions of pregnancy and prenatal care demand. The user is encouraged to draw on her own expertise and on that of other users (pregnant women and formerly pregnant women) in order to deliberate about decisions regarding pregnancy. Since debates about the nature and quality of pregnancy are not closed, the best course of action cannot be definitively pro- (or pre-) scribed. All of this is not to say that the technical knowledge of users is to be privileged over scientific and medical knowledge about pregnancy: like most other pregnancy manuals, Women and Their Bodies encourages its readers to “sort out the inevitable old wives tales [sic] from the realities” (44). The difference is that Pincus and Bell, and indeed all the authors of Women and Their Bodies, assume that old wives’ tales, or myths, can also be produced by medical authorities (old doctors’ tales?) and that other women do have expertise about pregnancy and prenatal care.7 Although prenatal care is articulated to medical institutions in Women and Their Bodies, the user is positioned as a potential expert who can produce knowledge about the system rather than as a voiceless nonexpert.

Procedures Should Be Phrased as Commands/Medical Procedures Are Political Conventional wisdom within technical communication dictates not only that usable instructions be task oriented but also that tasks should be

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phrased as commands. One recently published textbook observes that “instructions are almost always written in imperative voice (starting with the verb and speaking directly to the reader)” (Gurack 2009, 77). Another tells readers, in its list titled “Five Strategies for Writing Readable Instructions,” to “phrase steps in the imperative, i.e., as commands” (Graves and Graves 2007, 231). So rather than writing “the computer must be turned on” or “the user should turn on the computer,” the technical communicator writes: “Turn on the computer.” The idea is that the imperative mood clarifies when the user her- or himself should be carrying out a particular action. The piety of phrasing procedures as commands, however, also assumes that the instructions carry the weight of expertise, of authority. The instructions stand in for the system experts. Although system-maintaining instructions may still be articulated to political discourses and ideologies, their politics become implicit rather than explicit. For example, although A Doctor Discusses Pregnancy does not explicitly invoke eugenics or euthenics, those discourses are implicit in its frequent references to the fears pregnant women may have that their babies will not be normal. The differing perspectives regarding expertise and knowledge production in A Doctor Discusses Pregnancy and Women and Their Bodies are neatly summarized by graphics taken from the two documents, shown here in figures 5.1 and 5.2). In the illustration from A Doctor Discusses Pregnancy (fig. 5.1), the user is flat on her back, being examined and presumably informed about her pregnancy by medical authorities. They look at her; she does not look back. The context is medical but not particular—the implication is that any (white) user of prenatal technologies could unproblematically insert herself into this situation. In the photograph from Women and Their Bodies (fig. 5.2), it is clear that this is a specific woman’s pregnancy taking place in a particular context: we see the child, the brick wall, the patterned sheets. Some users might identify with this woman, but it is also clear that they are not her. The pregnant woman is again flat on her back, but it is a child, not a medical authority, who sits above her. The woman’s mouth is open; she speaks, perhaps talking to the child about her pregnancy; she looks at her pregnant belly. There is a different model of knowledge creation invoked in this second picture: mother to daughter, female to female, rather than (male) doctor to (female) patient. Indeed, this notion of users, of laypeople, of women being able to understand and employ medical knowledge and that medical procedures had political implications was a cornerstone of the women’s health movement in general, and it was an idea that encountered considerable resistance. Even simple procedures like self-examination with a speculum or using yogurt

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Figure 5.1: Illustration of pelvic exam from A Doctor Discusses Pregnancy (Birch 1966, 4). Image courtesy of CooperSurgical, Trumbull, CT.

as a home remedy to treat yeast infections were suspect. As Margaret Mead once wrote in the Los Angeles Times, “Men began taking over obstetrics and they invented a tool that allowed them to look inside women. You could call this progress, except that when women tried to look inside themselves, this was called practicing medicine without a license” (quoted in Ruzek 1978, 58). Women were prosecuted for practicing menstrual extraction (which is also a way to procure an early abortion) or for attending births (Ruzek 1978, 57–58, 59–60).8 As Kathy Davis notes in her history of Our Bodies, Ourselves (OBOS), “These first editions of OBOS were very much a product of the political climate of the late sixties. In character with the times, there was a strong emphasis on sexuality and reproduction. Abortion was still illegal; birth control was unsafe and not always available. Feminists were beginning to take a critical look at what the so-called sexual revolution meant for women” (2007, 23). In all of the essays that make up Women and Their Bodies, women’s reproductive bodies are explicitly recognized to be politically contested sites. Take, for example, the introductory paragraph to the essay on abortion: “Abortion is our right—our right as women to control our own bodies. The existence of any abortion laws (however ‘liberal’) denies this right to all women. The abortion laws symbolize the oppression of women in America and the lies that support it: sex is beautiful; motherhood is the ultimate fulfillment of women; children are a full-time joy; and

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Figure 5.2: Photograph of pregnant woman and child from Women and Their Bodies (Boston Women’s Health Collective 1970, 107). Photograph by Ed Pincus.

poor black, brown, white women have the same opportunities as rich white women” (1970, 89). The previous section (“Instructions Should Be Task Oriented/Tasks Should Be Supervised by Medical Experts”) alluded to how, if users are to have expertise about the system being documented, they must be able to “talk back” to the instructions and to others in a position of power rather than simply following their prescriptions. It is difficult, to say the least, for a printed manual to treat its users as peers, as people with which the manual’s author, or authors, must negotiate. In fact, the very medium of the pregnancy manual—and of most printed instruction manuals—lends itself to one-way, expert-to-novice communication. In Women and Their Bodies, however, we have an alternative model of instructions as conversation. As Susan Wells observes in Our Bodies, Ourselves and the Work of Writing, “The book drew readers in by breaching its own frame: readers were addressed as ‘we,’ encouraged to identify with personal narratives, and invited to use the book as a prop for the exploration of their own bodies” (2010, 11). As an expert about her own body, the user is encouraged to use the instructions in conversation with other experts—users—and also to be in conversation with the instructions themselves: questioning, revising. This con-

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versation is itself political. In the pregnancy chapter, when discussing fear, anxiety, and depression during and following pregnancy, the authors note that when women don’t talk to one another, they believe they are alone in their feelings: “In our isolation we feel guilty for our ‘unmotherly unnatural’ feelings. When we meet and talk together we discover as a common experience that we have strong negative feelings about having children. Most important of what we are learning is that our feelings are shared, are legitimate” (Boston Women’s Health Collective 1970, 206). Pincus and Bell argue that in learning that many women share the same “unnatural” feelings, they also learn that those feelings are rooted in political, social, and economic inequality: Societal pressures on men as well as women persuade us that we must demonstrate our fertility and immortalize our man’s seed by having children. . . . Further, our limited opportunities and lack of legitimacy in other areas make the traditional role of mother the course of least resistance for many of us. For some of us and most of our third-world sisters very real economic pressures make pregnancy a nightmarish rat-race for survival. The mentally “healthy” pregnant woman must be secure in knowing that all material needs (adequate housing, food, clothing, toys, etc.) will be provided, either by herself, her family, or the society. (Boston Women’s Health Collective 1970, 206)

This conversational model has repercussions not only for the content of the communication, as I’ve discussed above, but also for the very material ways in which it is read and distributed. The instructions analyzed here are not presented as being static; they are in flux. The authors ask for “your ideas, comments, suggestions, criticism, etc.” (1970, 4). A Doctor Discusses Pregnancy, in contrast, is presented as a finished, static document, not one in development. It reveals truths about the system that it documents rather than negotiating those truths with users. “In this book,” Birch writes, “you will find the answers to most of the questions you will have throughout your pregnancy and probably many more you may not have thought of asking” (1966, 1). Not some answers, possible answers, contingent answers, but the answers. In A Doctor Discusses Pregnancy, Birch rigorously limits expertise to the system designers and distributors (the obstetricians, in this case), and specifies that the instructions must be used in conversation with, or under the supervision of, those people only. The following passage is typical:

86  chapter 5 There is no substitute for your doctor’s advice and this is a good time to caution you against well meaning friends who are dying to tell you about their road to motherhood. The old wives’ tales and free advice are worth exactly what they cost. nothing! . . . They erroneously believe that because they have had one child they are the expert on the subject. Receive diagnoses of “bridge table obstetricians” with a sense of humor and a good laugh. If you do have any fears or misgivings confide them to your doctor. Only he is equipped to give you the facts. (7)9

In this passage, not only is medical knowledge about pregnancy and prenatal care carefully defined as the only legitimate knowledge, but the user must also hear (or read) facts about pregnancy from the lips (or typewriter) of a medical expert. The pregnant woman does not even “know” for herself how her baby is growing; rather she is “‘watching’ [her] baby grow through the pages of this book” (15). The user, or patient, is intended to receive expert knowledge in isolation, not to discuss it or share experiences with other users. “Misgivings” regarding pregnancy are disarticulated from their social and political causes and are represented as something that can be addressed with medical reassurance. This is not to say that Birch’s manual completely disregards the user or the user’s knowledge: after all, one of the central tenets of the prenatal care system is that successful pregnancy outcomes—“normal” babies—are dependent on medical supervision during pregnancy and on women actively disciplining their diet, hygiene, and actions according to doctor’s orders when they are outside the office. Pregnant women are not passive receptacles for the fetus but continuously and actively influence its development through their actions. Birch writes, for example, that “your intelligent observations and the information you give [your doctor] are important” to his correctly diagnosing a pregnancy (2). Later, “intelligent observations” are also important in deciding when physical symptoms warrant phoning the doctor immediately (e.g., vaginal bleeding) and when questions can wait until the next office visit (e.g., constipation). In both of these instances, however, users are reporting facts, not creating knowledge from their observations. Users can’t, for example, “know” whether or not they are pregnant; they must have medical verification of this fact. The concern here is that users not bother experts unnecessarily on the one hand and, on the other hand, that they also don’t try to make decisions about whether and how to engage with the prenatal care system on their own or in consultation with other so-called nonexperts (the old wives in particular). This

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manual is to be distributed by physicians and used under the supervision of physicians only. In contrast, users of Women and Their Bodies are expected not only to participate in developing and changing technologies of prenatal care and other medical institutions and systems—as well as the social and political systems that support those medical institutions—but also to be in conversation with other users and with the instructions themselves. In the introduction, for example, the authors specify that “the papers in and of themselves are not very important. They should be viewed as a tool which stimulates discussion and action, which allows for new ideas and for change. . . . It was more important that we talked about our experiences, were challenged by others’ experiences, (often we came from very different situations), raised our questions, expressed our feelings, were challenged to act, than that we learned from any specific body of material” (4). Later, they reiterate that they “don’t consider [the course] a finished product. As more women use, teach, and learn from the course, it must be expanded and revised to meet our needs” (5). In other words, users are encouraged to use the instructions in conversation with other users and to talk back to, to amend, to question the papers that form Women and Their Bodies. Throughout the introduction to the manual, the authors foreground this idea of conversation. They observe, for example, that they “decided on the topics collectively” and that as they wrote the papers “the process that developed in the group became as important as the material that we were learning” (3). As Wells observes, the concept of collective authorship was very important to the members of the Boston Women’s Health Collective; they “describe the book as being spoken in a voice different from any individual author, but personal and distinct” (2010, 63). Wells calls this approach to writing “distributed authorship,” noting how the writing “is done by multiple authors, often removed from one another in space and time,” but that “control of the text is dynamically invested in a central group” (2010, 64). The essays in Women and Their Bodies are represented as both arising out of conversations and as being in conversation with one another. Similarly, most of the demands that Pincus and Bell encourage their readers to make in regards to the prenatal care system have to do with gaining access to and talking with other pregnant women—that is, sharing knowledge, experience, and support. Women and Their Bodies is primarily meant to initiate conversation, to help women seek out other women for help and support. “When we are pregnant we should be able to meet with other pregnant women to discuss our common anxieties and apprehensions. Doctors and

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clinics should make addresses and phone numbers of pregnant women available to each other. . . . We must help each other as much as possible and as women we must demand that society provide us with the rooms, printed materials and group leaders of our choice to make our pregnancies times of learning and growth, and not full of fears” (46). Two pieties are especially evident in this passage: first, pious users (note the use of the collective “we” rather than the directive “you”) are encouraged to try actively to change the prenatal care system, not simply to insert themselves into it; second, pious users of this pregnancy manual are encouraged to seek out other present and past users of the prenatal care system as sources of knowledge and support in addition to doctors. They are to deliberate about the best course of action during pregnancy. In both A Doctor Discusses Pregnancy and Women and Their Bodies, the piety envisioned by Ballantyne that women be supervised during their pregnancies by medical authorities in an institutional context is very evident and, indeed, is implicit in both documents. In Women and Their Bodies, however, the user’s expertise is also important, and the user is encouraged to change the system rather than to simply insert herself into it. Also, the woman, not the fetus, is the central user of the prenatal care system, and prenatal care is articulated to the women’s health movement and to feminist discourses. While Women and Their Bodies doesn’t explicitly engage the piety that prenatal care can solve social and political problems, it certainly recognizes that choices about pregnancy are related to political choices about reproductive rights more broadly. In A Doctor Discusses Pregnancy, in contrast, medical prenatal care and medical supervision of women’s bodies is explicitly articulated to the goal of producing normal babies. Women and Their Bodies: A Course provides an example of systemdisrupting documentation that could prove instructive to technical communicators (whether they professionally identify as such or not) who want to teach or create similar documents. This example of system-disrupting documentation demonstrates that some of practices that we take for granted as best practices in composing instructions are actually best practices for composing system-maintaining instructions. Documentation whose goal is systemic disruption or change requires a rethinking of best practice. Did the pregnancy chapters in Women and Their Bodies succeed in disrupting, even transforming, the prenatal care system according to a more user-centered model? Needless to say, any change that did occur cannot be credited to this document alone but to decades of advocacy as well—in writing, speaking, and collective action. One of the legacies of the women’s

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health movement is choice, and it is true that women have more choices during pregnancy and childbirth than they did in 1970. For example, and perhaps most important, legalized abortions mean that women have more real choice about whether to be pregnant in the first place. Easy access to birth control (at least for some) also makes this choice more of a real choice. Once one is pregnant, though, choices about how, whether, and on whose terms to engage with the prenatal care system still seem inevitable, even if there is a bit more freedom to move within the system. Women and Their Bodies; Our Bodies, Ourselves; Sheila Kitzinger’s work (Kitzinger 1972, 1978); and the many other communications of the women’s health movement may have played an important role in making alternative choices visible. As the next chapter will show, however, the articulation of prenatal care to risk management frequently makes those alternative choices unthinkable.

6 What to Expect from Risk Management As a newly pregnant woman who has likely not even seen her doctor yet, the most important thing to remember at this point is: Don’t panic! This is merely the first section of the only book that your mother ever passed down to you. There are so many more pages. Plus, panicking puts your fetus at risk. allison benedikt (2012) Doublethink means the power of holding two contradictory beliefs in one’s mind simultaneously, and accepting both of them. george orwell, 1984

In September of 1965, one year before A Doctor Discusses Pregnancy was published, Life magazine devoted almost an entire issue to the advances that medical science was making in protecting—or altogether removing—the fetus from its mother’s treacherous body. Visualization techniques like thermographic scanning, ultrasound, and even good old fashioned X-rays were heralded as advances that enabled doctors to “keep watch over their unborn patients” (Gogo 1965, 62). Artificial wombs promised to protect fetuses within environments that could be precisely controlled and monitored— environments that would not be susceptible to the caprices of unreliable mothers and their unreliable bodies. And (mad) scientist Kermit E. Krantz was hard at work on his “robot placenta,” a technology that the article describes in glowing terms: “With his machine, Krantz can see where and how things go wrong and devise ways to improve [the placenta’s] performance. ‘It is not hard to see,’ says Krantz, ‘how any malfunction of the placenta could turn a potential Einstein into a mediocrity. If we learn enough—who knows? Maybe we can turn mediocrities into Einsteins’ ” (67). Underlying the anxiety that pregnant women obey their doctors in system-maintaining manuals of the 1960s (such as A Doctor Discusses 91

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Pregnancy) was a piety that goes all the way back to Ballantyne (and earlier): that the maternal body is unreliable, risky, and dangerous and that left to its own devices, it will produce degenerate, abnormal babies. Technologies of prenatal care such as the ones discussed in the Life article enable doctors “to keep watch over their unborn patients” and also enable the fetus to become a symbol of humanity at risk, the corollary to the images of the vulnerable “blue planet” seen from space that would appear over the next few years, perhaps the most famous of which is Earthrise, the photograph of the earth rising over the moon’s surface that astronaut William Anders took during the Apollo 8 mission (Gogo 1965, 62).1 As Duden puts it, “Just as the Blue Planet—‘seen’ from space—is the environment of all life, so woman is the environment of new life” (Duden 1993, 2). The icons of the fetus and of the blue planet are both vulnerable and at risk: the fragile ecosystem of the blue planet at risk of a quick nuclear death or a slow poisoning via invisible contaminants; the fetus threatened by the treacherous maternal ecosystem in which it resides. In the case of the blue planet, the origination of the threat is difficult to pin down: it is spread across a network of governmental and corporate bodies. In the case of the fetus, the threat is located in specific, maternal bodies. Whereas in the early twentieth century, the social and political risks posted by “defectives and derelicts” were managed by disciplining the pregnant body, in late twentieth-century manuals, global environmental risks are also managed through the site of the pregnant body. As I will demonstrate in the following analysis of the 1980s’ manual What to Expect When You’re Expecting, by 1984 the pieties around which Ballantyne attempted to constitute the technological system of prenatal care had become firmly entrenched: · The fetus should be the central patient of prenatal care, and the goal of prenatal care is to produce a normal fetus. · Pregnancies should be medically supervised and prenatal care should take place in medical institutions. · The pregnant body is a site through which social, political, and environmental threats can be managed.

The technological system of prenatal care and the identity of the pregnant woman have been tenaciously articulated to medical institutions and to eugenic and euthenic ideologies, as we can see in the above description of the robot placenta. In the wake of the women’s health movement, however, the identity of the pregnant woman and of pregnancy are also articulated to feminist discourse, especially to liberal feminist discourse. Pious pregnant

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women are not necessary willing to take medical advice at face value, and they also want to have a voice in and choice regarding their obstetrical care. Also, in the 1980s (as I will discuss below), pregnancy and prenatal care begin to be articulated to discourses of risk management. This articulation is especially evident in the popular pregnancy manual What to Expect When You’re Expecting. By 1984, when the first edition of What to Expect When You’re Expecting appeared, Life was proven right about one thing: while robot placentas and artificial wombs had not become a feasible or regular part of prenatal practice, ultrasound—as well as amniocentesis and other prenatal tests that facilitated the fetus’s being read in terms of deviation from a norm— had.2 Largely because of these technological developments in prenatal care, the first sentence of What to Expect proclaims that “the 1980s are the best years to be expecting a baby” (Murkoff, Eisenberg, and Hathaway 1984,13).3 These years are also, if the contents of the book are any indication, the most anxiety-filled years to be expecting a baby, perhaps because parents can now “see” during their prenatal care appointments whether their fetus is developing normally; they can visualize their fetus as being at risk. In the 1984 foreword to the manual, the primary author, Heidi E. Murkoff, says that she decided to write a pregnancy manual herself after being frustrated that none of the other manuals addressed all of the worries she had about pregnancy, worries about what she ate and drank, about medication she’d taken, about unusual discharge, about the pain of childbirth. Murkoff says it seemed that “threats to the pregnant lurked everywhere: in the air we breathed, food we ate, in the water we drank, at the dentists’ office, in the drugstore, even at home” (16). She claims that she is not alone in her anxiety, that “ninety-four out of every hundred women worry about whether their babies will be normal” (16). Murkoff ’s revisioning of the pregnancy manual essentially stemmed from a desire to make it more usable. Murkoff goes on to say that she went through stacks of pregnancy handbooks trying in vain to alleviate her worries about pregnancy (specifically, worries that her behavior and actions might put her developing fetus at risk) or find answers to them. Since no such manuals existed, Murkoff, along with her mother and sister, decided to write her own. In order to address these concerns, almost every chapter features a section titled “What You May Be Concerned About” that lists worries a pregnant woman might have each month. (Chapters 5–13 each correspond to one month of pregnancy.) These worries might correspond to physical complications (such as fatigue and changes in skin pigmentation), mental complications (such as forgetfulness and dreams and fantasies), or

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maternal practices (such as cigarette smoking, travel, and eating out). The manual’s emphasis on troubleshooting pregnancy concerns is an attempt to make the pregnancy manual more usable for expectant parents who, like Murkoff, are preoccupied with mitigating risks to fetal development. The main innovation that makes What to Expect more usable than such earlier system-maintaining manuals as A Doctor Discusses Pregnancy, then, is its focus on specific problems and concerns that pregnant women might experience. Each chapter, as previously mentioned, frontloads these concerns so that users can easily locate their specific problem. Each problem is set off by a boldfaced, all-cap heading that makes the text easy to scan, and lists of concerns are featured in the table of contents as well. The manual can be read front to back, read according to month, or accessed as needed when a user encounters a particular concern—as a troubleshooting document. In some ways, What to Expect seems more like a system-disrupting manual than a system-maintaining one. It retains some of the rhetorical features of system-disrupting documentation. One of the most important of these features is its emphasis on users’ weighing expert advice in order to make choices and decisions for themselves in pregnancy. In other words, What to Expect does not present rules of hygiene in pregnancy as lists of commands to be obeyed, and it does recognize that choices exist outside of the technological system of prenatal care. What to Expect also acknowledges that users might choose not to engage with certain aspects of the medical system. In fact, the manual emphasizes the choices that 1980s’ women have in pregnancy and childbirth that they did not have thirty years prior, in “the days of no-questions-asked obstetrical care, when the few choices in childbirth were left up to the doctor” (23). They acknowledge that pregnant women might engage the services of a certified nurse midwife, for example, rather than the services of an obstetrician, or that they might decline an amniocentesis. They also encourage pregnant women to “bring a list of questions, problems, and symptoms” (93). They emphasize that pregnant women are responsible for much of the decision making throughout pregnancy and childbirth (23). The manual retains, to be precise, many of the pieties of system-disrupting documentation, especially in its potential to “get in the way” of functional engagement with the technological system of prenatal care. In fact, it has been called it “an ‘Our Bodies Ourselves’ for pregnancy” (Kantor 2005). Unlike earlier system-disrupting documentation, however, What to Expect presents risk management as the basis for decision making in pregnancy. Throughout What to Expect, the authors advise that expectant

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mothers address their problems and concerns by implementing a risk management approach to pregnancy that weighs risks (to fetal development) against benefits (to maternal body and psyche): Of course, nothing in life is totally without risk. But in dealing with risks, we learn to weigh them against benefits. This is never more important than during pregnancy, when each decision potentially affects not one but two lives. When you’re faced with the decision of whether or not to smoke, to have a before-dinner cocktail, to nibble on a chocolate bar instead of an apple while watching TV, you are going to be weighing risk against benefit. Are the benefits, if any, you are going to derive from smoking, drinking, or junk-food snacking worth the risks to your baby? (73)

There is an interesting bit of doublethink evident in this passage. On the one hand, “threats to the pregnant” exist outside of the control of the pregnant body. They are produced by other (governmental, corporate, medical) bodies, and they are “in the air we breathe.” On the other hand, the pious user must manage those risks through the site of her pregnant body, by making choices that weigh the welfare of the fetus against the welfare of the pregnant woman. As they were seventy years ago in Ballantyne’s Expectant Motherhood, threats to normal fetal development are managed through the site of the pregnant body. But how can a user calculate if and when the “risks to fetus” outweigh the benefits to the user herself in order to determine when a particular practice is troublesome and when it is not? Interestingly, the answer doesn’t have to do with actual, material risks to the fetus (such as the risk of miscarriage). For example, within the terms of What to Expect, the risks to the fetus of consuming a chocolate bar do outweigh the benefits to the mother. Before eating a mouthful of food, the authors advise that pregnant women ask whether the food they are about to consume is “the best bite I can give my baby.” If the answer is that the food will “benefit only your sweet tooth or appease your appetite, put your fork down” (Murkoff, Eisenberg, and Hathaway 1984, 76) In contrast, “the benefits of prenatal diagnosis” (such as amniocentesis, which contains a slight but material risk of miscarriage) “can far outweigh risks” if they give worried expectant parents peace of mind that everything is developing normally (47). It turns out that the logic of risk-benefit analysis presented as the basis for decision making in What to Expect almost always favors the status quo, favors functional engagement with the technological system of prenatal care—What to Expect is system-maintaining documentation. The manual

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builds on preexisting pieties not only that the fetus is the central patient of prenatal care but that its rights might be directly opposed to maternal rights. The maternal body is the site for managing social problems posed by “defectives and derelicts” as well as the environmental threats that are the by-product of industrialization.

Prenatal Care and Fetal Rights Another kind of risk was causing public anxiety in the 1980s: the risk that crack smoking, alcoholic, workaholic, and otherwise “unfit” mothers posed to their unborn children. This was the decade that gave birth to the concept of fetal rights, the idea that the fetus has rights that outweigh, and that are frequently at odds with, those of its mother. As we have seen in previous chapters, this idea of the fetus as a separate and distinct individual was not a new piety. The idea that the fetus’s rights be opposed to those of the mother, however, was not something that even Ballantyne envisioned. This was also the decade of crack babies and welfare queens, both concepts that located risk (defined here as risk to unborn children) explicitly in gendered, racialized, and class-marked bodies. I should note here that the recognition of the fetus as a separate legal subject was also not entirely new: unborn children had been able to inherit property since the eighteenth century, and parents had been awarded damages on the basis of injuries sustained by their children in utero (Vedder 2001,122–23). Until the 1980s, however, the fetus’s interests were assumed to be identical to those of its mother and father, and cases were prosecuted on the mother’s and/or father’s behalf, not against them. In the 1980s, pregnant women who were seen to be maliciously threatening their fetus’s normal development through substance use or through other practices—like failing to follow doctor’s instructions—began to be prosecuted for “abusing” their unborn children.4 As Julie Vedder (2001) has observed, this prosecution was predicated on at least two problematic assumptions: first, that mothers who use alcohol or drugs during pregnancy “choose” to do so, that they even willfully want to harm their fetuses; second, that the state and public interests should be in protecting the “rights” of the fetus even if this protection violates the constitutional rights of the mother; indeed, it is often assumed that the rights of the fetus are opposed to those of the mother.5 The deployment of fetal rights in the corporate context highlights how designating groups of people as risky simultaneously defines their actions as choices and limits the choices they can make.6 Probably the most no-

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torious case is the 1978 case of American Cyanamid’s Willow Island Plant (see also previous discussion of this case in chap. 1). This case, in effect, instituted a fetal protection policy in 1978. The language of the documentation surrounding this policy as well as the court decision upholding it represents as inevitable the choices the company makes (choosing to expose all workers to toxic chemicals rather than creating a safe working environment for all workers, for example, or that it is the company’s responsibility to protect fetuses from these risks by making employment decisions for women)—not really choices at all—while it represents the women employees’ predicament as a matter of their choosing. This is an excerpt from the court’s decision: “The company could not reduce lead concentrations to a level that posed an acceptable level of risk to fetuses. The sterilization exception to the requirement of removal from the Inorganic Pigments Department was an attempt not to pass on costs of unlawful conduct but to permit the employees to mitigate costs to them imposed by unavoidable physiological facts” (quoted in Roth 2000, 56–57). Needless to say, this application of fetal rights has negative impacts not only on female workers, who must chose between losing their jobs and losing their reproductive freedom, but also on male workers (and “reproductively unviable” female workers) who must continue to work in a dangerous environment. Within the terms of fetal rights, the risks posed to the fetus by substance use and toxin exposure are represented as results of intentional and malicious maternal choices, even though addiction could be considered just as much an “inevitable” by-product of industrialization as air pollution, even though it is problematic at best to assume that a drug addict or alcoholic continues to “choose” to drink or use drugs, and even though many women cannot “choose” to quit jobs that pose potential health risks to their potential fetuses even if they wanted to. Within the terms of this fetal rights rhetoric, women—specifically pregnant women or women who could potentially become pregnant—are risky. Managing risks to the fetus, then, means managing their behavior: their risk position provides rhetorical warrant for placing them under surveillance and supervision, for making decisions on their behalf. People acting on behalf of industry, government, or the courts, by contrast, having not been designated as risky within the terms of this rhetoric, inevitably act to protect the fetus from risky populations. Risky pregnant bodies, then, threaten not the immediate health of their neighbors, coworkers, and sexual partners, but the development of their fetuses (and in some instances potential fetuses) and thereby the future health of humanity. They threaten to populate society with what

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J. W. Ballantyne would have called “defectives and derelicts” that were seen as a threat to society (Ballantyne 1914, 9). As they were at the beginning of the twentieth century, these “defective” babies were still seen in the 1980s as threats to society. Similarly, populations of pregnant women who fall into “high risk” categories, are subject to more surveillance—more violations of their civil rights during pregnancy—and are less likely to have true choice about the conduct of their labor and delivery. As Kukla points out, “The maternal bodies that are treated as especially dangerous are those that in various ways do not neatly incarnate the canonical pregnancy narrative: those of nonwhite and poor women, unmarried women, women with HIV and other health risks, and women who are above or below the socially acceptable age range for pregnancy, whose purported threat to the well-ordering of the body politic through their wanton and irresponsible reproductive behavior is familiar” (Kukla 2005, 126). In the most extreme cases, women identified as high risk, or especially risky to their fetuses, have been physically jailed during pregnancy or forced into treatment programs (Gagan 2000). In less extreme cases, they may not have the luxury to choose the kind of practitioner (such as a midwife) or birth setting (such as a domestic setting or a birth center) that they would prefer. Risk positions determine not only whether a particular action or decision is defined as a choice but also constrain how and what kind of choices risky groups can make. These groups must first and foremost consider how their choices will put other groups, or society or humanity in general, at risk. In What to Expect, the metaphor of gambling is used to illustrate how pregnant women can threaten fetal development through their “wanton and irresponsible” choices. The following passage is from the section titled “Playing Baby Roulette”: “When a gambler playing roulette puts down a bet on a lucky number, the odds are very high against the wheel coming to a stop there. It’s the same when a pregnant woman plays baby roulette (intentionally or inadvertently), exposing her baby to teratogens, substances potentially harmful to the fetus” (Murkoff, Eisenberg, and Hathaway 1984, 72). The metaphor of gambling here is especially interesting because it allows the subsequent framing of risks to go into two categories: those where the mother is intentionally gambling with her baby’s life, and thus being a “bad mother,” and those where she is unintentionally gambling with her baby’s life in the interest of being both good citizen and a good mother (in this case, other players may be gambling with both her and her baby’s health, and they may be winning big, but, because these players are not considered risky to the fetus, they remain invisible). The difference is one

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of intention. As we have seen, the risks posed to the fetus as a result of substance abuse (drinking, smoking, drug use) are defined as impious unless the mother engages in them unintentionally (the gin and tonics and Provera indulged in before the positive test) or within the context of domesticity (a glass of wine to celebrate one’s anniversary). If it is true that there is no safe level of alcohol use during pregnancy, it would seem that these behaviors would also be unacceptable. The deciding factor here, however, is intention and conformance to the ideals of good mothering. Even working too hard or being overly ambitious in one’s career can be a form of intentionally choosing to play baby roulette—pregnant women must be “wary of the superwoman syndrome”: “Often well established in their careers and highly motivated in everything they do, today’s mothers tend to be overachievers and overdoers. Getting enough rest during pregnancy is far more important than getting everything done, especially in high-risk pregnancies” (Murkoff, Eisenberg, and Hathaway 1984, 52). The contrast between what the pregnant woman “may be concerned about” (the myriad practices and behaviors I’ve been discussing) and what the expectant father “may be concerned about” is also illustrative. At the end of What to Expect is a section called “Fathers Are Expectant, Too.” Like the other chapters, this chapter comprises a list of all the things that should worry the father. This list includes worries like feeling left out, not finding one’s wife attractive, that sex will hurt the baby, and so on. Aside from tongue-in-cheek fears about overenthusiastic sex, fathers, and thus paternal choices, are not defined as potentially risky, even though a father who smokes and drinks heavily, does lots of drugs, is abusive, contracts STDs that he could pass onto his partner, and so on, presumably also would pose a risk to his partner and unborn child. Although he might be anxious about his baby’s and partner’s health, there’s no implication that his practices have any potential impact on their health. The risks as far as the father is concerned are that he will lose sexual interest in his wife and/or that she will lose interest in him. In this case, examining whose practices (the mother’s, the father’s, the practitioner’s, the state’s) are represented as risky illustrates that the document reflects cultural concerns with monitoring risky pregnant women’s behavior, not (only) with protecting fetal health.

Managing Environmental Risk through the Pregnant Body In the 1960s and 1970s, developments in prenatal science that promised to free the fetus from the maternal body were occurring in a climate of

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increasing awareness that the by-products of technoscientific progress could be deadly to both the fetus and the blue planet. The public began to pay attention to the devastating side effects of herbicides and insecticides such as Agent Orange and DDT; of drugs that were once thought to be safe such as Thalidomide and DES; and of improperly disposed toxic waste, such as in the Love Canal of Niagra Falls, New York. 7 The Nixon and Carter administrations produced strings of acronyms to counteract these side effects: NEPA (National Environmental Policy Act), CWA (Clean Water Act), CAA (Clean Air Act), and OSHA (Occupational Safety and Health Administration). The 1970s in particular witnessed a number of acts designed to manage the production, distribution, use, and disposal of the risky by-products of industrialization (toxic waste in particular): the Resource Conservation and Recovery Act of 1976 regulated the handling, transportation, and storage of dangerous materials; the Comprehensive Environmental Response, Compensation, and Liability Act (or the “Superfund” Act) of 1980 (and the Superfund Amendments and Reauthorization Act of 1986) authorized the government to respond to spills for which no one else was taking responsibility and imposed liability on those responsible for the spill.8 The Toxic Substances Control Act of 1976 sought to “regulate toxic chemicals regardless of their status, waste or otherwise” (Swanson 1984, 258). Government regulation of the production, use, and disposal of toxic substances under these acts is dependent on official definitions of a substance as toxic, levels of acceptable risk, and criteria for acceptable use. As scholars who study the rhetoric of risk communication have noted, although acts like Superfund Amendments and Reauthorization Act attempt to involve publics in decisions about risk, those publics are frequently involved only after risks have been defined and assessed. Frequently the goal is to bring public perception of risk in line with expert perception of risk, not to involve the public in defining and assessing risk (Grabill and Simmons 1998; Katz and Miller 1996; Waddell 1996). In 1981, Reagan (as part of the administration’s effort to increase the usability of a system of regulation that had, in their opinion, become inefficient and ineffective) issued his Executive Order Number 12991, which required that all regulations on industry meet a test showing that “the potential benefits to society for the regulation outweigh the potential costs” (Proctor 1995, 83). Not surprisingly, “the cost-benefit tests of specific regulatory measures usually placed inordinate emphasis on the ‘cost to industry’ side of the equation—since short-term financial costs are almost always easier to calculate than long-term health benefits to society as a

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whole” (Proctor 1995, 84). What precisely the “costs” and “benefits” of any regulation are is notoriously difficult to determine. Cost-benefit analysis of industry regulation, as promoted by the Reagan administration, assumes that environmental and health hazards are inevitable by-products of industrial progress and that the appropriate role for government is to somehow regulate or minimize these hazards after they have been produced. If individual people persist in worrying about these hazards, then they can attempt to manage them individually through lifestyle choices. In any case, this assumption of inevitability removes responsibility for risk management from the people and institutions producing risk to the people or institutions who are charged (officially or unofficially) with assessing and managing risks. No body or institution is positioned as risky—responsible for producing risk—within the terms of this rhetoric (that is, something like acid rain isn’t the result of bad choices on the part of governmental or corporate officials); everybody is at risk. In part, What to Expect responded to the growing public distrust of experts as well as to the growing need to take on a project of individual risk management. In the terms of sociologist Ulrich Beck, risk is individualized in What to Expect. Beck claims that, because risks exist only in terms of knowledge and communication about them, social and global risks can be reframed as individual risks. Beck describes the individualization of risk as a phenomenon increasingly common in late modernity that causes people to attach themselves less often to social class and to desire more the right to control their own “money, time, living space, and bod[ies]” (1992, 92). As a result of the individualization process, social crises become personal crises. Social risks are managed individually rather than institutionally: “Inequalities by no means disappear. They merely become redefined in terms of an individualization of social risks. The result is that social problems are increasingly perceived in terms of psychological dispositions: as personal inadequacies, guilt feelings, anxieties, conflicts, and neuroses. There emerges. . . . a new immediacy of individual and society, a direct relation between crises and sickness. Social crises appear as individual crises, which are no longer (or are only very indirectly) perceived in terms of their rootedness in the social realm” (1992, 100). In the passage about worry from Murkoff that appears earlier in this chapter (Murkoff, Eisenberg, and Hathaway 1984, 16), medical risk (seven doses of Provera!) and global environmental risk (“threats to the pregnant lurked everywhere”) become reframed as individual neurosis and anxiety. With its blurring of self and other, public and private, pregnancy

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complicates the notion of the individualization of risk: we are not talking about risks to the individual mother’s health, but to the fetus’s health, and—because of the representational weight that the iconic fetus carries— the future health of humanity. The pious pregnant woman assumes the role of risk manager to her developing fetus. Culturally, pregnancy offers a way to address global health obliquely through individual risk management: It is not polluting corporations who threaten our collective future, after all, it’s unfit mothers who don’t watch what they eat, drink, smoke, and do. In fact, pregnant women’s bodies are frequently invoked as sites of environmental risk management in order simultaneously to acknowledge and downplay certain environmental risks. For example, in 1994, the Maine Department of Human Services issued a warning about high levels of dioxins in lobster tomalley. The advisory warned that tomalley should be avoided entirely by “pregnant women, nursing mothers, and women of childbearing age” and that “others should limit their consumption of tomalley, as dioxin found in tomalley will contribute to . . . cancer risk generally” (quoted in in Sauer 2000, 244). Beverly Sauer argues that since “the threat of cancer would bankrupt coastal communities,” foregrounding risks to pregnant and reproductive age women allowed the human services department to issue the warning without causing general panic. The implication of their warning was not that Maine waterways are severely and dangerously contaminated, but that the contamination is not much to worry about (244). Pregnant women, after all, are told to avoid consuming lots of different things that other people consume without worry. In What to Expect, we see “choice” strategically defined according to risk positions, just as it is within the discourses of risk management that I’ve just been discussing. For example, the manual assumes that certain risks— namely, risks such as air pollution and food contamination—are the inevitable results of medical, scientific, and technical progress and thus are acceptable risks, risks that we should not worry much about: “The threats you and your baby face from the increasing number of environmental hazards, including those in your own backyard, quickly pale when compared to those faced by your great-grandmothers, when modern medicine was in its infancy. All of today’s environmental perils combined (alcohol, tobacco, and other drugs excepted) are far less menacing to you and your baby than one untrained midwife with unwashed hands was to your ancestresses” (66). In this passage, “environmental hazards” are represented as the inevitable trade-off for safe, modern medical care during pregnancy and childbirth. Despite the assurances that these hazards are nothing to worry

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about, however, this passage is followed by an extensive list of environmental and household hazards (cleaning products, tap water, insecticides, paint fumes, air pollution, and occupational hazards) and gives advice on how to avoid or minimize potential risks—again through modifying individual maternal behavior—posed to the fetus by these things or, rather, by women choosing to engage with these things. In these passages, risks are transmitted to the fetus through the individual behavior of the mother (maternal substance use; one midwife’s inadequate hygiene) rather than through larger medical, political, or industrial institutions and configurations. For example, What to Expect says that although “the kind of ‘natural’-oriented care that [midwives] offer might be an advantage to some couples . . . the risk to mother and child can be significant” unless she works under physician supervision (27). This trend continues throughout What to Expect, as strategies for risk management are framed solely in terms of maternal practice. For example, in order to avoid “extraordinarily high doses of most pollutants,” pregnant women are advised to “avoid smoke-filled rooms,” “have the exhaust system on [her] car checked,” “stay indoors as much as [she] can,” and not to “run, walk, or bicycle along congested highways, or exercise out of doors when there’s a pollution alert” (69–70). The maternal body (rather than corporate or governmental bodies, e.g.) becomes here “the focus for the discursive management of bodily and global risks, threats, and catastrophes” (Franklin et al. 2000, 36).

Troubleshooting Pregnancy Manuals What to Expect takes what technical communicators would call a troubleshooting approach to problem solving: a problem exists for users of a particular technology (in this case, the technological system of prenatal care), and the technical communicator responds by “breaking a problem into small, manageable parts to be solved by short, simple help texts” (JohnsonEilola [1996] 2004, 186). Concerned about motherhood? Simply “expect a real baby and not a fantasy” and move on (Murkoff, Eisenberg, and Hathaway 1984, 161). As Johnson-Eilola has argued (see chap. 5), problem solving in this troubleshooting mode is not the only way to address a problem. If a particular problem, worry, or anxiety is recurrent, a technical communicator might also step back—as the authors of Women and Their Bodies (Boston Women’s Health Collective 1970) and Our Bodies Ourselves (Boston Women’s Health

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Collective 1971) did (and do)—and ask, “What are the systemic causes of this problem?” To take an obvious example, anxiety about motherhood is not simply a matter of unrealistic expectations on the part of individual mothers (the “short, simple help text”), but a more complex relation of gender roles, societal and cultural expectations of motherhood and fatherhood, economic realities, and so on (the possible systemic causes). Despite the recognition in What to Expect that choices outside of the medical prenatal care system exist, the book’s focus on cost-benefit analy­ sis and risk assessment as the only legitimate bases for making decisions in pregnancy ensures that its users probably won’t choose to challenge the status quo and that the documentation will continue to perform a systemmaintaining function. Within the terms of this pregnancy manual, pious pregnant women seek to produce normal babies by managing their risky bodies under medical supervision. Pregnancy and the pregnant woman are articulated, as they were in early twentieth-century iterations of the pregnancy manual, to medical institutions and technologies and to neoeugenic discourses. They are also, however, articulated to feminist discourses, to the fetal rights movement, and to discourses surrounding environmental risk management and cost-benefit analysis. By articulating its users as risk producers and their pregnant bodies as a site of risk management, What to Expect encourages them to manage their own risky bodies and practices through functional engagement with the technological system of prenatal care.

7 System Error Troubleshooting the Pregnant Body

This book doesn’t cover the subject of changing diapers. Personally, I’ve never been blessed with the honor of rummaging through some tyke’s soiled shorts. But watch for future editions of this book where this section may actually contain information. dan gookin in dos for dummies (1991) We do not use technologies so much as we live them. One begins to think differently of users when one notices that tools include persons as functioning parts. langdon winner (1977)

Some may remember disk operating systems—more commonly known as DOS—with fondness or fury, as the command-driven operating system that predated the graphic interfaces of Macintosh and Windows. With DOS, you got things done by typing in cryptic commands at the C> prompt. For example, if you wanted copy a file from your hard disk to your floppy disk, you would type something like copy c:\mydocs\pregnancy.doc a: prenatal.doc. Such operating systems were very picky about how commands were formatted: an extra space or misplaced period could lead to a “bad command or file name error” message and are a perfect example of a system-centered technology: in order to use it effectively, users had to understand the logic of the system; they had to memorize strings of often nonintuitive commands. Documentation instructing users how to operate DOS was also often system centered. It might provide, for example, lists of commands without situating them in relation to tasks that users might actually want to accomplish with those commands. So if a user wanted to figure out how to delete a file, he or she would have to wade through reams of documentation looking for that command. 105

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Figure 7.1: “Guide to International Computer Symbols” from DOS for Dummies. Dan Gookin. © 1991 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

In contrast, DOS for Dummies (Gookin 1991) took the system-centered technology and tried to make It—or at least its documentation—userfriendly. I’m using the term “user-friendly” as Robert Johnson does: he describes user-friendly documentation as being “characterized by an emphasis on the clarity of the verbal text, close attention to structured page design, copious use of visuals . . . and a warm, sometimes even excited tone that ‘invites’ the user to enjoy learning the new computer system or software application” (1998, 125). User-friendly documentation is task driven and reader driven; that is to say, it is concerned with the tasks that users need to perform with a particular technology, and it is concerned with presenting those tasks in an easy to read, accessible format. DOS for Dummies exemplifies these characteristics of user-friendly documentation. For example, it makes liberal use of humor to try to make users feel comfortable and to lessen feelings of intimidation. For example, his “guide to international computer symbols” (fig. 7.1) includes, along with graphics that represent “off, on, key lock, hard drive, and power on,” a demon graphic that is supposed to denote “this computer is possessed,” a feeling to which fed-up PC users could certainly relate (Gookin 1991, 4). Each chapter begins with a one-panel comic that similarly expresses user frustration and intimidation in the face of the new computerized world, such as a comic that depicts a mallet threatening to crush a user if she mistypes a password. These instances of humor poke fun at the seeming arbitrariness of the computer world as well as at the intimidation and frustration that users might feel when working with computers.

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Figure 7.2: Excerpt from the table of contents for DOS for Dummies. Dan Gookin. © 1991 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

DOS for Dummies is also characteristic of user-friendly documentation in its task orientation and focus on readability: instead of being structured according to the logic of the system, the chapters and subsections are organized around tasks that users presumably want to complete with DOS, such as running a program or printing a directory. Prominent headings and subheadings make the text easy to scan, and a detailed table of contents (fig. 7.2) and index make information easy to look up. In addition, Gookin uses icons (fig. 7.3) to signal how the text is to be read, what the reader might want to pay special attention to and what he or she can afford to skip over: technical stuff that the reader can skip, tips for shortcuts, remember to do something, and warnings not to do something. To use Janice Redish’s (1989) terminology, Gookin assumes that his audience is “reading to do,” or perhaps “reading to learn to do,” not simply reading to learn. As Gookin puts it: “You don’t have to remember anything in this book. Nothing about DOS is worth memorizing. You’ll never ‘learn’ anything here. This information is what you need to know to get by, and

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Figure 7.3: Icons used in DOS for Dummies. Dan Gookin. © 1991 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

nothing more. And if any new terms or technical descriptions are offered, you’ll be alerted and told to ignore them” (1). Clearly, this user-friendly model of documentation is an improvement over the system-centered model that characterized many other DOS manuals: users who were unfamiliar with DOS at least had a fighting chance at learning how to make it work for them, at learning how to navigate it. But several scholars (e.g., Johnson 1998, Johnson-Eilola 2001 Mirel 2001, Spinuzzi 2001) have criticized this user-friendly model for being unresponsive to the contexts in which users work. According to these critiques, there are two main problems with user-friendly documentation. First, it is pitched to an ideal user: tasks are removed from their contexts of use. Second, it doesn’t take user knowledge—the productive, contingent knowledge of use, of techné—seriously. Rather, this approach positions computer users as novices, as idiots, “as dummies who must have the technologies ‘dumbed down’ to their level, a level that has no knowledge of its own, only that knowledge that is handed down by those who made the object in question” (Johnson 1998, 13) The experts, usually the designers and distributors of a particular technology, are the only legitimate sources of knowledge in this scenario, reflective of a system of technological development where users serve the ends of technology rather than vice versa (Johnson 1998). In other words, within the user-friendly model of documentation there is no room to critique or challenge the technologies being documented because they are represented as preformed, static entities intended for specific purposes. For example, for all the fun he pokes at DOS, Gookin never

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seriously takes up the question of why DOS is so difficult to use if you are not a system expert; why it was developed without the needs and goals of the end user in mind. Also, the tasks around which DOS for Dummies is centered, such as duplicating a file or adding the new line, are not contextualized within any real situations. A student working in an academic setting, for example, might need to perform certain tasks in different ways and for different reasons than a secretary working in a corporate setting. Ultimately, this kind of task-driven documentation may make it difficult for users to carry out higher-order conceptual tasks (Mirel 2001).

The User-Friendly Pregnancy Manual What does this all have to do with pregnancy? Well, in 1999, IDG Books premiered Pregnancy for Dummies (Stone, Eddleman, and Duenwald 1999), the latest installment in its series of instructional texts that began with the 1991 publication of DOS for Dummies.1 By 1995, the For Dummies series had expanded out from computer documentation (like Excel [Harvey 1994], Windows [Rathbone 1992], and UNIX for Dummies [Levine and Levine Young 1998]) and into giving instruction about some of the other arts and technologies of modern life, such as sex, wine, time management, and parenting. The year that Pregnancy for Dummies was published, 1999, yielded a bumper crop of For Dummies books, adding (along with countless explicitly computer-related titles) quilting, yoga, gardening, etiquette, Shakespeare, and astronomy to the list of subjects about which “dummies” need instruction. What I find interesting about this For Dummies series of documentation is that it began with a user-friendly model of computer documentation and then applied this model to all of its texts, whether they give instruction about PowerPoint, Pilates, or pregnancy. In fact, the format of Pregnancy for Dummies is exactly the same as that of the first edition of DOS for Dummies. There is, for example, the same icon system identifying everything from technical stuff to caution (fig. 7.4), the same easy-to-scan, user-friendly format (even the same typefaces). I wonder about the implications of applying a model for documentation originally developed for a cryptic computer operating system to a technological system like prenatal care, a system of which bodies are key components. I noted earlier that user-friendly computer documentation does give users more control over the operating system or program that they are trying to use and navigate, even though this control is limited. But the

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Figure 7.4: Icons used in Pregnancy for Dummies (5–6). Joanne Stone, Keith Eddleman, and Mary Duenwald. © 1999 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

success of user-friendly documentation hinges on an instrumental view of a technology or system as a tool, as something that a user must manipulate in order to accomplish certain goals. It also assumes that the user has already “bought” the tool: a computer with a DOS operating system, say, or a drill. If it is problematic, as Johnson argues, to assume that users of computer systems produce no knowledge about that system, it seems to me even more problematic to assume that pregnant women have produced no knowledge about the prenatal care system, that the only legitimate knowledge about that system originates with its designers and distributors. The pregnant woman’s body, after all, is a key component of that system. As I will outline in what follows, the user-friendly documentation model exemplified in Pregnancy for Dummies reinforces two pieties established in earlier manuals that militate against users’ having critical access to the technological system of prenatal care: (1) pious pregnant women accept medical knowledge about pregnancy as expert knowledge (user as dummy) and (2) pious pregnant women undertake a program of risk assessment and risk management in order to have a normal baby (user as troubleshooter/ user’s body as site of troubleshooting).

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“You’ll Never ‘Learn’ Anything Here” Pregnancy for Dummies comprises five main parts in addition to an introduction and appendix. The introduction first outlines the author’s “worry free” approach to pregnancy and then explains how the book is organized and how to use it. Part 1 describes how to prepare for pregnancy and how to recognize signs of pregnancy. Part 2 describes what happens during each of the three trimesters, and part 3 focuses on labor and delivery. The fourth part details special concerns and complications of pregnancy, and part 5, a standard part of For Dummies books, is “The Part of Tens,” which is a series of top-ten lists that serve as summaries of the book’s highlights: “Ten things nobody tells you,” “Ten old wives tales,” and so on. Finally, the sixpage appendix deals with “having a baby from a dad’s perspective.” Joanne Stone, Keith Eddleman, and Mary Duenwald, the authors of Pregnancy for Dummies, begin by insisting: “It’s ironic that this book is called Pregnancy for Dummies, because the whole idea behind it is that couples today are not dummies (in the traditional sense) and are quite capable of understanding complex medical information when it’s presented clearly” (1999, 1). Presumably, then, couples today are dummies in the nontraditional sense that they are not experts concerning pregnancy, and neither are they capable of having expert knowledge about it. Rather, expert knowledge about pregnancy, defined here specifically and exclusively as “complex medical information” must be dumbed down for them. Further underscoring who the experts in this scenario are, the page immediately preceding this one contains the surgeon-generalesque warning shown in figure 7.5. Of course, part of the purpose of this warning is to protect the book’s authors, as well as IDG Books, from lawsuits. But it also clearly positions the physician or doctor as the technical expert and the pregnant woman (and her partner) as the novice who must always follow expert advice. I am not making the argument that medical professionals do not possess valuable expert knowledge about pregnancy but, rather, that it is only one kind of expertise; the expertise afforded by midwives, doulas, relatives, friends, and the pregnant woman herself is not given voice in this manual, making it far less likely that its user will be able to engage critically with the technological system of prenatal care. For example, in order to enhance the readability of its text, Pregnancy for Dummies employs a similar icon system to DOS for Dummies and the rest of the For Dummies series. So although the authors of Pregnancy for Dummies assure their readers that, when they use the technical-stuff icon, they don’t

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Figure 7.5: Warning to users of Pregnancy for Dummies (xxiv). Joanne Stone, Keith Eddleman, and Mary Duenwald. © 1999 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

mean that the “information is too difficult to understand,” the precedence in previous books such as DOS for Dummies is that this icon signals information that the reader can skim over or afford to skip (5). Furthermore, the technical-stuff icon and the call-the-doctor icon look very similar—both the technical expert and the doctor are represented as white men—and on a quick scan of the book I frequently mistook one for the other. This might cause readers to skip over information that the authors actually want to highlight, such as this: “If you notice some bleeding, you should let your practitioner know” (87). One of the top-ten lists in part 5 of Pregnancy for Dummies is “Ten Key Things You Can See on Ultrasound.” The authors of the manual claim that is the first time that a pregnancy manual has reproduced ultrasound images. I don’t think it’s a complete coincidence that the first pregnancy manual to explicitly adopt a user-friendly model of computer documentation is also the first to display ultrasound images like these. As Rebecca Kukla (2005) notes, at least in North American culture, ultrasound mainly functions as normalizing ritual that allows the pregnant women to connect her individual pregnancy with a shared, public pregnancy narrative and to build a relationship with her individual fetus by connecting it with a public, canonical character: The Fetus. (This is the same fetus who made its debut in Lennart Nilsson’s A Child is Born [1965], who is recognizable on antiabortion billboards, in advertisements, on record covers, and in keepsake ultrasound snapshots.) Captions to these ultrasound images say things like “the fetus is at rest” and “the baby is a boy” (Stone, Eddleman, and Duenwald 1999, 348–50). The ultrasound snapshot in Pregnancy for Dummies reproduced in figure 7.6 shows “an easily recognizable image of the labia” (351). As the numbers along the side of the image imply, the fetus represented through ultrasound is measurable, is quantifiable through expert eyes. Needless to say, this image is only “easily recognizable” to a technician who understands how to read the image and is only “easily recognizable” to the

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Figure 7.6: “It’s a Girl!” ultrasound image from Pregnancy for Dummies (351). Joanne Stone, Keith Eddleman, and Mary Duenwald. © 1999 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

user as labia because the image has been labeled; the user has been taught how to read it. She gains knowledge about her pregnancy from experts who have access to the technologies that quantify it—they produce knowledge about her pregnancy and then present it, dumbed down, to her, as in the case of the ultrasound image in figure 7.6 labeled with “it’s a girl!” and “labia.” Like the fetus, the pregnant body is represented throughout the manual as something that must be expertly read, measured, and quantified. It is tested, measured, and diagrammed (figs. 7.7–7.9). Neither the pregnant body nor the fetus are ever depicted in this manual in a way that does not support their being medically, publicly quantifiable. The manual’s user is put in the awkward position of being both the system documented and the user of that system. As Kukla argues, the intensification of “contemporary technologies and rituals [of prenatal care] have produced a single, canonized fetus who has become the inhabitant of each individual pregnant body, as well as a shared, public pregnancy narrative that constitutes and interprets each individual pregnancy” (2005, 19). Pregnant women are individualized according to

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Figure 7.7: Drawing depicting amniocentesis from Pregnancy for Dummies (104). Joanne Stone, Keith Eddleman, and Mary Duenwald. © 1999 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

their conformance to, or deviation from, this public pregnancy narrative. Technologies such as ultrasound, Doppler, prenatal tests, monitors, scales, and so on provide publicly quantifiable checks that the pregnant woman is disciplining her body in accordance with this narrative. Signs of deviation such as abnormal test results, weight gain that is too high or too low, prior cesarean section, ethnicity, being too young or too old, or being HIV positive provide warrant for increased public scrutiny and medical intervention. Davis-Floyd also emphasizes the ritual nature of pregnancy, arguing that the shift of the “rites and rituals of pregnancy and childbirth” from the private space of the home to the public space of the clinic doesn’t mean that pregnancy is any less “tabu laden and ritually hedged” than it has been in previous times, only that these taboos and rituals are now seen as “medical necessity” or as “educational and scientific procedures” (Davis-Floyd [1992] 2003, 26).

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Figure 7.8: Illustration of practitioner measuring fundal height Pregnancy for Dummies (31). Joanne Stone, Keith Eddleman, and Mary Duenwald. © 1999 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

Frequently, however, prenatal care rituals such as ultrasound and weigh-ins provide important confirmation that the pregnant woman has internalized the public narrative and that she is exercising appropriate self-discipline. Specifically, as we saw in the last chapter, pregnant women increasingly make choices about managing their own particular pregnancies according to “where they fall on various statistical bell curves for various risks and to design their pregnancy regimes around the goal of minimizing their position on those curves” (Kukla 2005, 131). The pious pregnant woman is a risk manager. Where earlier manuals like A Doctor Discusses Pregnancy (Birch 1966) document the medical prenatal care system much more explicitly, instructing pregnant women to become compliant patients, Pregnancy for Dummies focuses predominately on the pregnant body, treating it, as is evident from the images in figures 7.7 through 7.9, as a technology that the pregnant woman must learn to operate properly. But since expert knowledge about the system is medical knowledge, proper operation of the pregnant

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Figure 7.9: “Some common skin changes associated with pregnancy” from Pregnancy for Dummies (97). Joanne Stone, Keith Eddleman, and Mary Duenwald. © 1999 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

body means checking in with the experts regularly to make sure that things are running smoothly. Pregnant bodies as technologies and pregnant women as users of those technologies are interchangeable as long as the pregnancy is progressing normally. Pregnancies and pregnant women are individuated to a certain extent when their pregnancies deviate from the norm. They are individuated, as we will see in the next section, according to their risk positions.

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Troubleshooting the Risky Body Let me reiterate: pregnancies are interchangeable as long as the pregnancy conforms to the standard pregnancy narrative. As the warning that I listed above emphasizes, “because each individual is unique, a physician must diagnose conditions and supervise treatments for each individual health problem.” Each pregnant woman and pregnancy is unique, in other words, based on its relationship to risk. In another representation of the pregnant body taken from Pregnancy for Dummies (fig. 7.10), the “older” pregnant woman is encouraged to individuate her pregnancy and make choices about managing it according to her relationship to a statistical risk. As Kukla argues, “Quantificational and statistical representations of pregnancy make possible sets of concerns and ways of delineating choices and goals that simply wouldn’t be available to us otherwise” (2005, 132). In this case, a thirtynine-year-old pregnant woman might choose to undergo tests that themselves pose certain risks to the developing fetus, such as amniocentesis or chorionic villus sampling, because her risk position has been quantified and made visible. As another example, take the introduction to the section titled “Second Trimester Blood Tests”: “The following blood tests are usually performed during the second trimester. Ideally, your results are normal right away. If they are at all unusual, you may need further testing—an ultrasound examination, perhaps. But keep in mind that further testing does not mean anything is wrong—only that your practitioner is being careful to ensure that everything is okay” (97). The sections following this one describe what specific tests check for, how they are performed, and what their results might mean. But there is no discussion of why or whether a user might choose or choose not to take these tests. They are not represented as potential risks or causes for concern—only decontextualized system tasks that all users carry out in order to be pregnant. Also, although the authors claim that they are trying to move away from the risk-based model of pregnancy that I discussed in the last chapter and that “the guiding principle of our approach has been to put all the facts into perspective and not to create needless anxiety or fear” (2), almost every passage marked by the caution icon alerts the reader to some aspect of her personal behavior that might put her fetus at risk, for example: · If you think you may have a drinking problem, be sure to inform your practitioner. (35)

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Figure 7.10: Table showing how statistical risk for the fetus’s having Down syndrome or other “chromosome abnormalities” increases with maternal age. From Pregnancy for Dummies (263). Joanne Stone, Keith Eddleman, and Mary Duenwald. © 1999 IDG Books Worldwide, Inc. Reproduced with permission of John Wiley & Sons, Inc.

· The carbon monoxide in cigarette smoke decreases the amount of oxygen that is delivered to a growing baby. (34) · The following list tells the basics about the use of various recreational drugs and their effects on unborn babies. (36) · There are a couple of circumstances in which intercourse should be avoided. (42) · If you have any such cravings, do not give into them. (57)

The remember icon serves a similar function, highlighting personal practices of the pregnant woman that might put her fetus at risk. In contrast, the smiley face don’t-worry icon almost always reassures the user that medical and industrial risks should not concern her:

system error  119 · If you’re worried that your prenatal vitamin plus your diet will put you into that “danger zone” of 10, 000 IU per day, rest assured . . . (14) · Getting pregnant with an IUD in place does not put the baby at increased risk of birth defects. (17) · If you took any teratogenic medications before you knew you were pregnant—or before you knew that the drugs could pose a problem—don’t panic. (33) · You don’t need to worry about airport metal detectors. (40) · But you have no need to worry—there is no evidence to suggest that the electromagnetic fields that computer terminals emit is a problem. (41) · If you need routine dental work—cavities filled, teeth pulled, crowns placed—don’t worry. (42) · The probe is perfectly safe. (80) · Only about 5 percent of women with a positive maternal serum screen actually have a fetus with a neural tube defect. (98) · 95 percent of babies are fine if the appropriate testing is done. (297)

To sum up, the layout and organization of Pregnancy for Dummies encourages the user to troubleshoot her own body and practices and to engage unreflectively with the prenatal care system—often to troubleshoot her body by engaging with that system. Although user-friendly documentation might give a user more control over a computer system, or at least make the system easier to access, it seems to me that it gives a user even less control over a technological system like prenatal care because it treats that system as static, not developing, because it because it leaves no room to interrogate the system, and because it reinforces the idea that the pregnant woman’s relationship with her own body and fetus must be mediated and monitored by expert eyes.

8 Virtually Pregnant Consuming Prenatal Care

In recognizing ourselves as computer users, we are also positioned (at least partially) as the used. johndan johnson-eilola (2001)

The 1927 pregnancy manual Every Child Has the Right to Be Well Born is one of the first—if not the first—pregnancy manuals published in the United States to combine advice and instructions regarding pregnancy with product advertising. The manual contains the standard instructions on identifying signs and symptoms of pregnancy and on maintaining proper hygiene during pregnancy and after childbirth. For instance, the manual advises pregnant women: · To see a physician early in every pregnancy, . . . · To have the bones of the pelvis measured, · To have the blood pressure taken every two or four weeks, . . . · To have proper instruction in the hygiene of pregnancy, · To have medical supervision during the entire pregnancy, and . . . · To have proper sterilized supplies on hand after the seventh month. (Johnson & Johnson 1927, 18–19)1

In addition to instructions about the proper management of pregnancy, the manual includes a section advertising Johnson & Johnson products, which are, like the manual’s advice, endorsed by medical experts: “For forty years, Johnson & Johnson have been preparing sterilized dressing and other supplies your doctor uses for surgical and maternity patients. He knows that every article with a J & J label is the best that can be made— worthy of the highest confidence. . . . If you prefer to buy the separate items—not in complete packet form—discuss these pages with your 121

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doctor and he will indicate the items you should obtain” (Johnson & Johnson 1927, 19). In addition to the packages of sterile sheets, gauze, soap, safety pins, and so on called the “First Dressing Packet for Infants” and “First Dressing Packet for Mothers,” the manual advertises bandages, analgesic, lubricating jelly, douche, toothpaste, deodorant powder, and baby soap. Pregnancy is articulated to consumption in this manual: the doctor advises that the pregnant woman have sterile supplies on hand, and there is an ad for Johnson & Johnson’s dressing packets in the manual; the doctor advises that pregnant women take care of their teeth, and there is an ad for Johnson’s & Johnson’s toothpaste. These supplies “represent maximum safety at a minimum price” (Johnson & Johnson 1927, 21). Even in this early manual, purchasing the right products is represented as a means to managing risk in pregnancy and childbirth—pregnancy is articulated to consumption. In Every Child Has the Right to Be Well Born, the piety that proper prenatal care, undertaken with medical supervision, is necessary to produce fit citizens is also very much in evidence. To begin with, the very title of the pamphlet implies that the fetus has its own individuality and rights that it can demand from its mother. The inside front cover of the book features an image of the capitol building and an excerpt from Calvin Coolidge’s address to the Women’s Roosevelt Memorial Association, which begins ”no man is ever meanly born” (Johnson & Johnson 1927, 1). It is also this manual that notes (as mentioned in chap. 4) that “the most important factor in the ‘Better Babies’ movement,” the movement that was part of the positive eugenics movement in America, “is prenatal care” (Johnson & Johnson 1927, 13). Cultural anthropologists Janelle Taylor and sociologist Barbara Katz Rothman have noted how modern prenatal testing technologies such as ultrasound and amniocenteses have transformed the fetus, and the process of being pregnant, into a commodity. The fetus is a commodity we seek to perfect, prenatal testing “separating out those products we wish to develop from those we wish to discontinue” (Rothman, quoted in Taylor 2008, 64). As is evident in Every Child, while modern prenatal testing technologies have intensified the articulation of pregnancy to production and consumption, the piety of fetus as perfectible product builds off of (indeed, is compatible with) the piety of fetus as perfectible citizen. Every Child Has the Right to Be Well Born may have been one of the earliest pregnancy manuals to link instructions about pregnancy to advertising, but it was certainly not the last. Mainstream pregnancy magazines such as Pregnancy and Fit Pregnancy are saturated with advertising, and pregnancy

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manuals handed out during early prenatal care visits are frequently vehicles for advertising.2 For instance, the “New OB Packet” that I received during prenatal care for my second pregnancy includes a manual called As Your Baby Grows from Conception to Birth (American Baby 2006). This manual has the glossy look and feel of a magazine, and it has an advertisement for Enfamil infant formula stapled to the front cover. The manual, from the publishers of American Baby magazine, includes month-by-month descriptions of fetal development (pictures of “your baby”) that are accompanied by images taken from the fourth edition of Lennart Nilsson’s A Child Is Born (2004).3 After each description of fetal development, there is a section called “About You” that contains the standard diet, nutrition, and body related instructions for pregnant women. In addition to the Enfamil ad stapled to the front cover of the magazine, there are ten advertisements for Enfamil products (mostly for different varieties of infant formula) and services throughout the manual. The publisher’s website explains how As Your Baby Grows “reaches expectant moms during one of their first prenatal visits, building consumer affinity for Enfamil and acting as a powerful sales tool establishing the relationship between Enfamil’s representatives and the doctor.”4 There are also ads for Fisher Price products, American Baby magazine, and A Child Is Born. Mingled with the images of “your baby” prebirth, in other words, are advertisements for products that will nourish, entertain, and protect your baby after birth. Increasingly, pregnant women are turning to websites about pregnancy for advice and information. One of the most comprehensive, well designed, and popular of these sites, BabyCenter.com, is in some senses the twentyfirst-century incarnation of Every Child Has the Right to Be Well Born. Although the site does not market surgical supplies like obstetrical sheets and sterile gauze to pregnant women, it similarly links (although more indirectly) expert advice about pregnancy to buying products for pre- and postnatal care of mother and child.

“Can’t Look Away”: The Pregnancy Manual Goes Live BabyCenter Inc., now BabyCenter LLC, a subsidiary of Johnson & Johnson, was launched in 1996 in the midst of the dot.com boom by two MBAs from Stanford: Matt Glickman and Mark Selcow. Recognizing that “the U.S. baby market is an $18 billion annual business,” the two entrepreneurs envisioned a site that would not only provide information for expectant

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Figure 8.1: Screenshot of BabyCenter.com homepage (BabyCenter, “BabyCenter Homepage— Pregnancy, Baby, Toddler, Kids,” BabyCenter, 2013, http://www.babycenter.com).

and new parents but that would also provide products and advertisements targeted to specific consumer segments (Sinton 1999, B1). Today, BabyCenter LLC runs not only BabyCenter.com but also Pregnancy.com, Baby.com, BabyCenter en Español, and nineteen international sites. A print BabyCenter pregnancy manual (Murray et al. 2007)—informed by the website content—was published in 2007. Users can also become fans of BabyCenter on Facebook, follow them on Twitter, or subscribe to mobile content (such as text messages giving advice and information tailored to a user’s stage in pregnancy, and such as the “My Pregnancy Today” smartphone app). BabyCenter claims that it “reaches over 78% of new and expectant moms online” in the United States.5 BabyCenter’s popularity is easy to understand—as the magazine of Online Marketing, Media, and Advertising puts it, “it’s one of those can’t-lookaway sites” with engaging community boards, continuously updated content, and a user-friendly design (OMMA Magazine Writers 2009). All of these elements can be seen in the screenshot of the homepage shown in figure 8.1. According to usability heuristics for interface and web design such as Nielsen’s (2005), the site is very usable. For instance, navigation menus are always present along the top and left-hand side of the page so

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Figure 8.2: BabyCenter “page not found” error message (BabyCenter, “Page not found error,” BabyCenter, 2013, http://www.babycenter.com/asdfjkl).

that it is always clear where a user is in the site and how to navigate away from a page if so desired. Advertisements and sponsored content are clearly delineated from other content. Design elements and terminology are used consistently within the site (e.g., blue to denote links). Errors such as “page not found” are extremely rare, and when they do occur it is easy for users to recover from them. As figure 8.2 demonstrates, the “page not found” error page provides many escape routes for users, including links to the home­page, links to commonly accessed areas of the site, and a search function. The design of the site is clearly usable, but questions remain. How does this reinvention of the pregnancy manual as a content site (funded through advertising sales) have the potential to rearticulate of the pregnancy manual’s users? Does this new medium and format for the pregnancy manual have the potential to provide users with critical access to the technological system of prenatal care? There is one crucial difference between the systemsustaining print pregnancy manual and its online counterpart that helps to answer theses questions: in addition to pregnant women, there is another important user group for the site—advertisers. As I will demonstrate in the following analysis of the BabyCenter.com website, the addition of this user group intensifies some of the pieties around which the technological system of prenatal care has been constituted but has the potential to rearticulate and/or disrupt them as well.

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In The Public Life of the Fetal Sonogram, Janelle Taylor has argued that, particularly where obstetrical ultrasound is concerned, “in the contemporary United States (1) reproduction increasingly has come to be construed as a matter of consumption; and (2) in the process the fetus is constructed more and more at the same time and through the same means, both as a ‘commodity’ and as a ‘person’ ” (Taylor 2008, 117). At BabyCenter .com, the core pieties underlying the technological system of prenatal care are strongly articulated to consumption in a corporate context. As the following analysis will demonstrate, this mostly means that the site provides opportunities to functional access to the technological system of prenatal care, but the rearticulated purpose of the online pregnancy manual as “system simulating documentation” also provides site users with limited opportunities for critical engagement with the system.

Delivering Users to Advertisers As Amy Koerber and Brian Still note in their introduction to a 2008 special issue of Technical Communication Quarterly devoted to health communication, much of the early research in this area focused on the accuracy of health information found online (2008, 259). More recent research in the area, however (including research presented in the special issue), has expanded to explore “questions about the audiences, ethics, privacy, accessibility, usability, and design of online health information” (Koerber and Still 2008, 260). Information may be medically accurate, but if it alienates, confuses, or disempowers its users, that information is useless. As Phillipa Spoel argues in her analysis of midwifery websites in the special issue, the paradigms guiding the design of online information “raise questions about the nature of the communicative relationship between the health-care organization that hosts a website and the members of the public who access the site” (2008, 264–65). At the two midwifery sites that she analyzes, Spoel notes the tension between what Maria Bakardjieva and Andrew Feenberg (2002) have called the “consumption model” and the “community model” for understanding and designing websites. Where the consumption model “positions users primarily as anonymous individuals engaged in private consumer experiences” (whether they are consuming information or products), the “community model exploits the potential of the internet for facilitating interactions and relationships” (Spoel 2008, 264). Sites like Baby Center.com demonstrate how community portions of a site can actually

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work to intensify users’ consumption of goods and services on other portions of the site. There is a staggering amount of information, resources, and tools available for expectant and new parents on BabyCenter.com: separate sections of the website for conception, pregnancy, different stages of child development, and a “For You” section that’s targeted specifically for moms who want “good ideas for nurturing . . . grown-up relationships, dealing with sleep deprivation, making the decision whether to be a stay-at-home mom or a working mom, finding new recipes, traveling with kids, getting in shape, and deciding on more kids.”6 A significant part of the BabyCenter site is its community site, which lets users join groups targeted mostly toward women trying to conceive, women who are pregnant, moms of toddlers, preschoolers, and so forth, as well as “sponsored groups” such as “Johnson’s Sharing Circle” and “Safe Fun in the Sun!” In July of 2008, BabyCenter.com was redesigned “from a 1.0 community site to a 2.0 community one, launching a full-fledged social network” (Klaassen 2008). The screenshots used for this analysis were taken in 2009, shortly after its redesign. (For this reason, some of the text referenced in the following analysis is no longer available on the site.) In her analysis of the ethos of two midwifery websites, Spoel notes the tension in these sites (and in much online health communication) “between a participatory, interactive, community-based model of online communication and a unidirectional information-consumption model” (2008, 284). This tension is also present in the 2009 iteration of BabyCenter.com: although the site provides opportunities for pregnant women to form communities and interact with one another, the community spaces are clearly separated from the main areas of the site where women receive “expert” information about pregnancy. In the fine print links at the very bottom of the homepage (fig. 8.1), there is a link labeled “Marketing and Advertising Solutions.” This link leads to a page targeted to potential site sponsors. It reads, in part: “BabyCenter . . . We know moms. We know impactful mom-marketing. We know the business of parenting. We’ve done the homework so you don’t have to.”7 If prospective advertisers follow links to find out more about BabyCenter’s audience, they will encounter this text: The connection that BabyCenter makes with moms at each stage provides a unique platform to communicate your marketing message at exactly the right time.

128  chapter 8 BabyCenter is your best entrée into this $2.1 trillion market that’s hungry for information, looking for new products, and forming new brand loyalties during the life-changing event of having a baby.8

Whereas in Every Child Has the Right to Be Well Born (Johnson & Johnson 1927), pregnant women manage their pregnancies under medical supervision (and perhaps buy the appropriate Johnson & Johnson supplies) in order to produce fit citizens, at BabyCenter.com they manage their pregnancies under corporate supervision in order to produce fit consumers. Taylor notes that “long before it becomes possible to feel the fetus moving or to see the belly bulging, often before pregnancy is confirmed or even attempted, the transition to hoped-for motherhood may be experienced as a transition to a new, more highly disciplined regime of consumption—it is the movement from being an individual consumer to mother-asconsumer” (Taylor 2008, 127). The pious pregnant woman disciplines her consumption both in terms of the food she eats and the products she buys. As users of the BabyCenter site, pregnant women are articulated to the companies that sponsor BabyCenter as potential customers, as consumers. In fact, all of BabyCenter’s resources, including the community groups, the Facebook fan site, the tweets, the blogs, the weekly newsletter, and the emergent mobile content, have the capability of delivering users to advertisers and advertisers to users. The more women engage with the site, the more they find its information useful, appealing, reputable, and relevant, the more likely BabyCenter’s advertisers are to reach them. In addition, the community-building portions of the site such as community boards, blogs, and polls delineate not only possible pieties surrounding pregnancy—pregnant women play, learn, emote, connect, confess—but they also provide a treasure trove of data for marketing research. Take, for example, BabyCenter’s description (written for potential advertisers) of a marketing solution called “Mom Confidential”: “Today’s moms are connecting, comparing and sharing across BabyCenter through blogs, community boards and even polls. Get your message in front of moms as they spill their secrets and share their tips, short-cuts and absolute parenting no-no’s through this robust sponsorship series of polls focused on Mom confessions.”9 Users might use the polls to connect with one another and to find out who else shares their concerns and secrets—advertisers use them for brand exposure and marketing research. As already mentioned, this articulation of pregnant women to consumer culture is not new in pregnancy manuals. What is new, however, is the potential that sites like BabyCenter may become, or may already be, one of the

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primary ways that pregnant women receive instruction about the management of pregnancy. The next section, then, will consider how the shifting purpose of the pregnancy manual as commercial website has the potential to rearticulate users of the site.

What Is System-Simulating Documentation? One of the key differences between BabyCenter and its 1927 ancestor Every Child Has the Right to Be Well Born is how it encourages its users to consume virtual representations of pregnancy, and how that virtual experience of pregnancy in some ways displaces, or perhaps simulates, an embodied experience of pregnancy. The idea of experiencing pregnancy through a pregnancy manual is not entirely new, to be sure. Chapter 4, for example, discussed how a user of A Doctor Discusses Pregnancy was “‘watching’ your baby grow through the pages of this book” (Birch 1966, 15); Pregnancy for Dummies (Stone, Eddleman, and Duenwald 1999) is saturated with technologically mediated, and standardized, representations of the pregnant body (represented as “your body”) and of the fetus (represented as “your baby”). These representations intensify the piety that the fetus is a distinct individual and also that there is a norm to which fetal development should conform. In BabyCenter.com, pregnancy is articulated not so much to technologies of prenatal care but to the verbal representations and images that those technologies produce. To return to the BabyCenter.com homepage reproduced in figure 8.1 above, on the right-hand side there is a prominently placed advertisement for the newsletter Your Pregnancy Week by Week. Here, site users have the opportunity to sign up for a weekly newsletter that “helps you track your baby’s or child’s development” and that “features articles on important health and safety topics.”10 Figure 8.3 shows an excerpt from a sample newsletter. The description of the developing fetus (“your baby”), emphasizes the fingers and toes, the tiny nails, the peach-fuzz hair beginning to grow on tender skin. The illustration features a fetus (“hands . . . over his heart”) in a cut-away diagram of a woman’s body. This description of “my pregnancy” emphasizes the characteristics of the fetus that make it a separate individual and deemphasizes the pregnant woman’s particular, disembodied experience of pregnancy. On scrolling down further in the newsletter, there is a section called “Your Body This Week,” which focuses on hearing the fetal heartbeat, frequent urination, and excessive salivation. These representations of the pregnant body reinforce long-established pieties

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Figure 8.3: BabyCenter Newsletter Preview (BabyCenter, “BabyCenter Newsletter Preview,” BabyCenter, 2013, http://www.babycenter.com/newsletters).

surrounding pregnancy: that the pregnant body malfunctions and that it is a conduit to the fetus—a piety that originated, remember, in Ballantyne’s fantasy of “antenatal therapeutics.” There are many other areas of the site that similarly equate a standardized experience of pregnancy to the consumption of fetal images. A popular “Inside Your Womb” feature on the homepage (fig. 8.4) provides almost identical fetal images to those in the newsletter, as well as a threedimensional ultrasound image of the fetus. Inside pregnancy videos feature a “3-D animated look at a baby” throughout the trimesters of pregnancy.11 The videos are preceded by a video advertisement for Johnson and Johnson’s baby wash that shows a mother bathing her baby. The link from image of vulnerable fetus (who must be protected from the maternal environment) to image of vulnerable baby (who must be safely bathed with the right shampoo) is quite evident. In system-maintaining manuals such as Pregnancy for Dummies, these images of the vulnerable fetus and the malfunctioning maternal body articulate the pregnant women to the technological system of prenatal care. In BabyCenter.com, they seem to function a bit differently: they serve a twofold purpose of keeping users engaged with the site (and returning to the site to check in on baby’s development) and of

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Figure 8.4: “Inside Pregnancy: Weeks 10 to 14” video (BabyCenter, “Inside Pregnancy: Weeks 10 to 14,” BabyCenter, 2013, http://www.babycenter.com/2_inside-pregnancy-weeks-10-to -14_10308108.bc). (Blurred areas contain advertising for which permission to reproduce was denied.)

helping users visualize baby postbirth in order to sell products to for baby prebirth. Pregnancy has been “denaturalized and renaturalized as a commodity” (Franklin et al. 2000, 22)—these technologically mediated representations (of representations) of the fetus have become second natured as pregnancy. BabyCenter.com and similar sites that merge instruction and commerce represent a new category of documentation, one with interesting possibilities for technical communicators: not quite system constitutive, system disruptive, or system maintaining, but system simulating. As systemsimulating documentation, BabyCenter shares many characteristics with system-maintaining documentation that precedes it, such as A Doctor Discusses Pregnancy and What to Expect When You’re Expecting. For example, it mostly facilitates functional access to the technological system of prenatal care, and it mostly articulates its users bodies and practices as risky. The crucial difference is that its primary purpose is to keep users engaged with the documentation itself rather than to facilitate users’ engagement with the technological system that it documents (this engagement is an

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important secondary purpose, but it is not primary.) Because its primary purpose is no longer to provide functional access to a technological system, system-simulating documentation has the potential to facilitate critical access. Whether it always exploits this potential, however, is another matter.

Users Are Still Risk Managers In the previous two chapters, we saw how recent iterations of the pregnancy manual articulate pregnant women as risk managers who make decisions based on the risks that their potential actions pose to their babies’ development. What to Expect has been most stridently criticized for its focus on risk, anxiety, and worry, but as previously explained, it merely exploited the cultural and political articulation between pregnancy and risk management that was becoming increasingly tenacious in the 1980s (Kantor 2005). The homepage for the pregnancy portion of the BabyCenter site (fig. 8.5) seems to emphasize risk management less than its print counterparts. The pregnant woman featured on this page is smiling, and the text to her right proclaims “Welcome to pregnancy! This is the start of an incredible journey.” Even the blue and green color scheme is cheerful and soothing. Reading on, the user can find information about pregnancy symptoms, weight gain and nutrition, and what’s safe during pregnancy and what’s not, among other things. If a site user mouses over the “Favorites” link to the left, the first two categories that pop up are “Is It Safe?” and “Is It Normal?” If she clicks on the “Is It Safe?” link or the “What’s Safe during Pregnancy and What’s Not” link, she’ll be taken to the page shown in figure 8.6. The “Is It Safe?” page features a list of one hundred maternal behaviors and practices that might pose a risk to a developing fetus. They are posed as questions: “Is it safe to get a manicure while pregnant?” “Is it safe to bowl?” “Is it safe to ride the bumper cars?” “Is it safe to travel to developing countries?” Clicking on an individual question will take the user to two “expert answers” to the question as well as to a series of community answers (here, BabyCenter users can post their own answers to the questions). The experts in these articles are usually medical professionals such as either obstetricians or certified nurse midwives, although sometimes they are also experts on the subject matter to which the particular question pertains (e.g., one of the experts who answers the question “Is it safe to get a mud bath during pregnancy?” is a spa director).12

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Figure 8.5: “Pregnancy” page from BabyCenter.com (BabyCenter, “Pregnancy—Information, Tools and Timeline,” BabyCenter, 2013, http://www.babycenter.com/pregnancy). (Blurred areas contain advertising for which permission to reproduce was denied.)

Because the “Is it Safe” questions and answers always feature two expert answers, and because these answers are sometimes in disagreement with one another, this site feature does define the pregnant woman as a potential expert. She has the authority to weigh opinions and to make choices independent of her own doctor’s advice. Furthermore, this is another area of the site to which users can contribute content—their answers are featured below the expert answers. This inclusion of user advice (most of the users who post seem to be women who have been or who are pregnant) provides room for alternative viewpoints and voices. The pregnant woman is still strongly articulated to discourses surrounding risk management, however. As in What to Expect, risks to the fetus are defined in terms of the pregnant woman’s body, behavior, and practices: even lists of “medical” risks are about medications or vitamins that the pregnant woman might consume, not about, for example, prenatal tests or procedures that also have an element of risk to them. Although the pregnant woman is represented as having potential expertise about the management of her pregnancy, her available choices are restricted because she must make choices based on minimizing risks that her body and practices pose to her developing fetus. Viewed as e-commerce, BabyCenter’s

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Figure 8.6: “Is It Safe?” (BabyCenter, “Is It Safe?” BabyCenter, 2013, http://www.babycenter .com/is-it-safe.htm). (Blurred areas contain advertising for which permission to reproduce was denied.)

partial focus on risk management makes sense. As Ulrich Beck has observed, “Modernization risks from the winner’s point of view are big business . . . civilization risks are a bottomless barrel of demands, unsatisfiable, infinite, self-producible” (Beck 1992, 23). Needless to say, the preoccupation with risk management during pregnancy also has the potential to translate to risk management after pregnancy, especially for companies like the Cord Blood Registry, one of the sponsors of the site.

Critical Access in the Cracks The third crucial difference between a website like BabyCenter.com and its print predecessors is the fact that it brings users in contact with one another through the documentation itself. In chapter 4 we saw how a pregnancy manual produced during the women’s health movement encouraged users to use the documentation in physical conversation with one another; websites like BabyCenter.com can actually bring users into conversation through the medium of the documentation itself. In fact, the “Company Overview” portion of the site explicitly says that BabyCenter LLC’s goal

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is “to support parents through their journey of parenthood with a blend of expert advice and user-created wisdom.”13 Especially in the community pages, the site provides many opportunities for users to connect with and learn from one another, something that it is much more difficult for print manuals to do. BabyCenter recognizes the validity of “user wisdom” and begins to rearticulate the user-mom–pregnant woman as a (potential) expert about her body and her pregnancy. In the community section of BabyCenter.com, there are literally thousands of groups that expectant mothers and parents of babies and young children can join. Any registered user of BabyCenter can create a group. Some are private with only a few members; some are public with thousands. According to a feature on the BabyCenter site where groups can be filtered according to popularity, the most popular group is simply called Pregnancy, with over twelve thousand members. The second most popular group is called Bargain Hunters. Other popular groups include one for people trying to conceive, one for parents of toddlers and babies, and various “Birth Clubs.” But the Pregnancy and Bargain Hunters groups are far and away the most popular, with almost twice as many members as the next most popular groups. The posts in the pregnancy group have to do mainly with anxieties and worries—about symptoms, tests, complications, and the like. While pregnant women may certainly discuss other kinds of topics on the boards, and while women dealing with a certain type of complication during pregnancy—such as diabetes—surely find these boards an important means of support, the boards by and large facilitate (as is appropriate to the site) an apolitical and consumerist view of pregnancy. The pregnancy board guidelines specifically discourage “debate” or “posting on controversial topics.”14 But there are moments of disruption. There are occasional threads where users discuss ways to negotiate the technological system of prenatal care: for example, when one poster complains that the glucose test for gestational diabetes makes her very sick and she wants to refuse it, a couple of users respond that she has the right to refuse this test or to request that it be administered in a different way (many others respond that she should simply follow her doctor’s advice or force herself to take the test, tell her that she cannot refuse the test, or imply that she is selfish and irresponsible for considering its refusal).15 This is may seem a small example of critical access, but it is important to recognize that it as a point at which the possibility of disengaging from an aspect of the technological system of prenatal care, or even negotiating it slightly, becomes visible to a user of the site.

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As one would expect given the sheer number of groups on the BabyCenter communities page, there are groups that seem more likely than the most popular groups to facilitate critical access to the prenatal care system. For example, there are groups devoted to natural unmedicated childbirth and natural pregnancy and childbirth, as well as a small group devoted to homebirth. These groups explicitly focus on negotiating, and on disengaging from aspects of, the technological system of prenatal care. Partly because of the sheer number of these groups and their members, they do provide possibilities to help users critically access the technological system of prenatal care. This critical access, however, is dependent on users’ seeking it out in the first place, on their self-identifying as women who want natural pregnancy or unmedicated childbirth or homebirth, articulations, which have pious associations with which many BabyCenter users may not identify (things like hippie, crunchy, back-to-lander, feminist, natural medicine, etc.). Women who recoil at the thought of an unmedicated childbirth or who associate safe childbirth with images of hospitals and doctors and high-tech equipment probably won’t visit these boards, for example, and they aren’t featured in either the “top groups” or “sponsored groups” sections of the community page.16 Unless users are specifically searching for natural childbirth or unmedicated childbirth, they are far more likely to run across the main pregnancy board, one of the birth clubs, or a board such as “Pregnancy Questions Worries and Complaints,” where users can post questions specifically to be answered by a certified obstetrician. Whether or not the end result is facilitating critical access to the technological system of prenatal care, however, the community boards do emphasize the value of user expertise about pregnancy and recognize experiential, embodied knowledge as a kind of expert knowledge. To conclude, let’s revisit the pieties around which the technological system of prenatal care was constituted at the beginning of the twentieth century: · The fetus should be the central patient of prenatal care, and the goal of prenatal care is to produce a normal fetus. · Pregnancies should be medically supervised and prenatal care should take place in medical institutions. · The pregnant body is a site through which social, political, and environmental threats can be managed.

Almost a century later, these pieties are still very much in evidence on BabyCenter.com—as in earlier iterations of the pregnancy manual, preg-

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nant women are encouraged to manage their bodies under medical supervision in order to produce normal babies. At the same time, the BabyCenter website—especially on its communities page—does offer spaces that support critical access to the prenatal care system in its cracks and crevices—in the unpredictable interactions of users with one another. In some spaces on BabyCenter.com, pregnancy is articulated to feminist discourses arising out of the women’s health movement and out of even earlier midwifery-based models of care. While this potential for critical access provided by websites like BabyCenter.com offers hope of improved access, there are also disadvantages to the virtual experiences of pregnancy that sites like BabyCenter.com provide. If a pregnant woman can find community online, she doesn’t need to demand support from her own, lived, community. If she can get a “third opinion” online, she doesn’t need to demand more engaged, collaborative care—or alternative forms of prenatal care—from her own doctor and community.17 And if she experiences pregnancy and feels emotionally connected to it through idealized, technologically mediated representations of fetal development, then she will be more likely to engage with technologies of prenatal care not because there are (even debatable) medical reasons for doing so but simply to make pregnancy real. Because it is less dependent on the technological system that it documents than system-maintaining documentation is, however, system-simulating documentation provides possibilities for critical access and for coalition building between users. The more users demand information that provides critical access, the more sites like BabyCenter.com are likely to provide it.

Conclusion Instructions for Systemic Change

Stories tell us what technology means. They remind us that it has a meaning before it has a use. If we want to alter the use to which a technology has been put, we must first alter the meanings which authorize that use. david trotter (2012) The redesign of a nation—especially this nation, at this moment— must begin with its technologies. adam banks (2006)

Indrek Alan’s Birth Story . . . as told by Evelyn Ojeda-Fox, Birth Doula Dear Indrek, I met your mom and dad on April 14, 2007. Your mommy was 33 weeks pregnant and on bed rest and your daddy was by her side. Your Birth Day was supposed to be on June 1st, yet you kept giving us reasons to think you had other plans! During the next few weeks, we stayed in touch, and more than once we thought you were ready to be born. I began to hear my cell phone ringing in my sleep! This is how I remember your Birth . . . It was during Marika’s 33rd week that we first met. She called to ask about my doula services and casually mentioned that she was on bed rest at Keweenaw Memorial Hospital. Would I come out to meet them there? The next day, April 14th, I went to the hospital and Marika and Matt shared with me their wishes for a gentle birth, being in the hospital was not what they had

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140  conclusion hoped for. They wanted a doula to assist them in preparing for this birth, someone calm to help them “stay on track” and feel supported. During our visits together I showed Matt some massage strokes, massaged Marika, and we talked about their fears and concerns. On April 26, at 35 weeks, Marika went home. We stayed in touch over the phone and thru emails. On April 30th I went to their home for a prenatal visit and to go over their birth plan. Marika and Matt prepared a wonderful birth plan and discussed it with their doctors. They also took a copy to the nurses accompanied by a coffee cake! . . . To reprogram herself, Marika listened to a meditation CD, read many great birth stories and watched movies of women powerfully birthing their babies. . . . Birthing without drugs and other interventions was very important to Marika and Matt. She continued to look for ways to remain healthy and pregnant. She listened to the Calm Birth CD, did yoga, went for walks and negotiated with the doctors for more time to birth naturally. She even agreed to more bed rest when they became concerned with her blood pressure. . . . Dr. Jill began to talk about induction, which made Marika’s blood pressure rise some more. In response to Marika’s request for a natural induction, an acupuncture treatment was scheduled for Wednesday, May 23. If that didn’t work, Dr. Bonnie planned to break Marika’s membranes on Thursday. Marika called me at 9:50 pm on Tuesday, May 22nd. It seemed her water broke and she was very excited! She decided to wait a bit before calling the hospital. By 11:00 pm the surges were more regular. Marika and Matt began to get ready to go to the hospital. . . . Throughout the night Marika was able to get some good rest between surges. In the morning she agreed to have the doctor finish breaking her membranes. Her cervix was 3 cm dilated and 50% effaced. Marika also agreed to let them monitor baby’s heart with intermittent external EFM (electronic fetal monitor) only during early labor. . . . Dr. Jill wanted to start some blood pressure drugs and Matt asked for time to try massage. We took turns massaging Marika’s back to lower her blood pressure. Nurse Virginia was very impressed to see how well this worked. No meds for Marika! Dr. Jill insisted on a saline lock and Marika agreed. Marika found the way to negotiate what was really important to her, showing a strong presence of mind even in the middle of the surges. . . .

instructions for systemic change  141 Dr. Jill checked Marika’s cervix and it was now 100% effaced. And dilated 7–8 cm. Indrek was in a LOA (left occipital anterior) position. Great progress! Virginia decided it was time to move to the delivery room. Marika walked down the hall with Matt’s support. . . . Marika focused on breathing her baby down. Dr. Jill guided her softly. Marika stopped to rest for a few minutes and did some raspberries, just as she had read in Ina May’s book. Once again, Marika intuitively responded to her body and baby. . . . Marika pushed for 15 minutes and Indrek Alan was born into his dad’s hands. A beautiful gentle birth!

Birth Stories I conclude with a birth story—with my birth story—for two reasons: first, because it demonstrates the results of one, particular user’s having had access to system-disrupting documentation during pregnancy, to pregnancy manuals that facilitated critical access to the prenatal care system. I will explain in following sections how, theoretically, system-disrupting documentation might prepare the ground for critical access. The second reason I begin with this birth story is to propose another way that a technical communicator, or a midwife, or whomever, might prepare the ground for critical access: as a kind of information manager who is able to recognize system-disrupting documentation and to help the user to locate information that helps her, personally, negotiate the system. In other words, this empowering birth outcome was in no small part due to my having had, especially toward the end of my pregnancy, critical access to the prenatal care system that resulted in my being able to negotiate the system during childbirth (a time when it is very difficult to focus on anything outside of one’s body). This critical access was facilitated by a doula who served as a kind of information manager, helping me to find the information that I needed to negotiate—perhaps even transform in some small, local way—the system. A central part of my prenatal care, that is, was learning how to engage critically with the prenatal care system with the ultimate goal of having control over my childbirth experience. The second reason why I conclude with this birth story is because it provides a concrete example of what the result can be of having critical, rather than functional, access to the technological system of prenatal care. For

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me, for one, particular user, it meant having more control—more power— over childbirth. The deck was stacked against my having a low-intervention birth experience: I had gone into preterm labor with my first child and, thus, was high risk for a second preterm labor. In fact, I was on full bed rest for three weeks to prevent a second preterm labor and had every contraction and bodily function monitored. Toward the end of my pregnancy I was beginning to develop signs of preeclampsia (rising blood pressure, albumin in urine) and was a prime candidate for induction. I was able to have the birth experience that I wanted—one where I felt, primarily, like I was in control and empowered to make decisions for myself, no matter what interventions became necessary—because a key component of my prenatal care toward the end of my pregnancy was being exposed to documentation that facilitated critical access to the prenatal care system. Evelyn Ojeda-Fox, my wonderfully supportive doula, presented me with a binder of documentation: pamphlets, articles, and lists that she had composed. She also gave me books, DVDs, and CDs. Once she figured out what I found most useful, she provided me with more of that kind of documentation. Some of that material is mentioned in the story: Ina May’s Guide to Childbirth (Gaskin 2003), the Calm Birth CD (Newman 2006), documentaries such as The Business of Being Born (Epstein 2007) and Birth into Being (Harper 1999). She also put me in touch with other women who had successfully done natural childbirths in hospital settings—that is, she put me in touch with other users. Similarly, as an information manager, the technical communicator can facilitate critical access by providing the user with information that helps her to negotiate technological systems. This means learning to recognizing what kind of documentation is likely to provide such access. This information helped me, as a particular user with a particular history and with particular goals, negotiate not only the technological system of prenatal care but the technological system of childbirth, which is, after all, an extension of the prenatal care system. Some examples of this negotiation evident in the birth story include: · Carefully writing a birth plan and delivering it to the doctors and nurses (with cake); · Negotiating to try natural induction before artificial induction; · Using massage rather than medication to lower blood pressure; · Agreeing to a saline lock (which serves as a placeholder for the IV) but not to a full scale IV (which would have limited movement and made it more difficult to birth without drugs);

instructions for systemic change  143 · Agreeing to intermittent monitoring during early labor but not to continuous monitoring; and · Not agreeing to lie down when it was too uncomfortable.

These may all seem like small examples of critical access, but cumulatively they made it much more likely that I, rather than the technologies, would be in control of childbirth—artificial induction via Pitocin leads to much stronger, unrelenting contractions; blood pressure medication could have interfered with contractions; an IV or continuous monitoring would have limited movement, and so on. The pregnancy documentation with which Evelyn provided me had as its telos helping women to achieve empowering birth experiences and health for mother and baby after childbirth, rather than: producing a normal baby through risk management. (And it is important to note that empowering birth experiences and healthy babies are complementary, not contradictory—in other words, women-centered birth is not at the expense of the baby’s health.) The documentation clarified where I, as a user of the prenatal care system, had the power to disengage, to refuse, to negotiate, both before and during childbirth. Because I had learned these strategies during the prenatal period, I could easily recall and access them during childbirth (a time where it is difficult to think about anything except birthing). Also, the positive images of childbirth that I watched and read in the materials that Evelyn provided made me confident that I could birth without interventions and without medication if I so chose—they provided images not of a pregnant body that malfunctions and that needs troubleshooting but of pregnant women who are capable of carrying and birthing babies without significant technological intervention and surveillance. It is also important to note I did not—nor did I wish to—disengage from the technological system of prenatal care. I negotiated it, even transformed it in some small, local way, so that it accommodated itself to my goals rather than accommodating myself to its goals. At the end of the birth story, Evelyn mentions how I “did some raspberries” as Ina May suggested in her book. (Blowing raspberries—blowing air out through one’s lips so that they vibrate together—is supposed to help the laboring woman relax her pelvic floor as the baby descends through the birth canal.) This book was Ina May’s Guide to Childbirth, and in terms of critical access it was perhaps the most influential pregnancy manual I read during her pregnancy. I can definitively say that it helped to give at least one user—me—critical access to the technological system of prenatal care.

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In what follows I’ll explain how its ability to facilitate critical access might be explained through its use of what Burke (1984) has called perspective by incongruity, or planned incongruity, and how this method might be more widely applied in documentation in order to (begin to) compose documentation that rearticulates users or to draw attention to existing articulations that hamper critical access. In the chapters 3–8 of this book, there was discussion of some articulations of the pregnant woman and of prenatal care that have been particularly tenacious and resistant to rearticulation in the United States over the last hundred years or so. Over the course of the twentieth and twenty-first centuries in the United States, pregnancy has been tenaciously articulated to the technological system of prenatal care, to technologies of prenatal testing, and to medical institutions such as clinics and hospitals. Within these medical articulations of pregnancy, doctors and other medical professionals are usually positioned as experts about pregnancy, while pregnant women (and other, nonmedical women, including midwives) are positioned as nonexperts. Pregnancy has also been tenaciously articulated to discourses surrounding eugenics and to the goal of producing “normal” babies (e.g., an important goal of prenatal care is the production of a normal baby who will be a productive citizen, consumer, etc.). Because of this focus on producing normal babies, the fetus, rather than the pregnant woman, has been articulated as the central patient of prenatal care. While pregnancy has been piously defined as normal and natural, the pregnant body is associated with malfunction, pathology, machinery, and troubleshooting. More recently, pregnancy has also been articulated to discourses surrounding fetal rights and risk management; the pregnant body is piously defined as a risky body and as the site of managing societal and environmental risks. Together, these articulations of the pregnant woman, the pregnant body, and prenatal care practically guarantee that a pregnancy manual user who identifies as pregnant will begin to engage functionally with the technological system of prenatal care. A pregnancy manual for which the goal is providing pregnant women with critical access to the technological system of prenatal care, then, must rearticulate its users—thus rearticulate the pregnant woman—as someone who can, and should, negotiate that access. It must articulate (pregnant) women as experts, articulate the pregnant body as normal and capable, and articulate prenatal care’s goal as ensuring healthy and empowered women and babies rather than producing normal (nondefective) babies. In Gaskin’s book (2003), this disarticulation and rearticulation is achieved through

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employing what, again, Kenneth Burke calls perspective by incongruity, or planned incongruity.

Perspective by Incongruity Explained Perspective by incongruity involves making impious associations in order to affect a reorientation of sense and meaning. If these associations are intentionally impious, then they can be called planned incongruity. Perspective by incongruity creates opportunities to resist or transgress established ways of making sense and to establish new linkages and, possibly, articulations. Burke gives this example: “Where the accepted linkages have been of an imposing sort, one should establish perspective by looking through the reverse end of the glass, converting mastodon into microbes, or human beings into vermin upon the earth” (1984, 120). Such impious perspectives by incongruity could, theoretically, enable resistance by forcing a shift in perspective and a reorientation of pieties. Of course, their effects are unpredictable: in order to succeed in establishing new pious associations, these associations must be accepted to a degree into existing frameworks, or pieties. As Burke observes, an utterance or act cannot be impious without a corresponding utterance or act that is pious (one cannot take the Lord’s name in vain if one does not first accept the possibility that the name is divine). Resistance to established pieties, then, comes from within those pieties—from associations of meaning and sense established by pieties. In her Foucaultian analysis of women’s resistance to disciplinary rhetorics of breastfeeding, Amy Koerber notes how disciplinary power (whether expressed in official or unofficial ways) defines what is possible (in the case for breastfeeding, what is possible regarding women’s bodies). Koerber’s interviewees indicated, for example, that sometimes breastfeeding seemed impossible because although official medical reports declare breastfeeding to be the best option for infant feeding, “unofficially” women receive cultural messages that bottle feeding is the norm and that breastfeeding is unacceptable, even obscene when conducted in public. Like Foucault’s concept of power-knowing, or pouvoir-savoir, piety is (mostly) productive, not repressive. If power defines “a being-able that is made possible by a grid of intelligibility” (Biesecker 1992, 356, quoted in Koerber 2006, 91), pieties could be understood as the individual, constantly shifting and realigning lines of making sense and ways of making self that are both constituted by and constitute that (those) grid(s). These lines may be cobbled together, may conflict, may be in tension, but they exist within a larger (cultural, social,

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political) grid of intelligibility. Impious acts, like resistance to relations of power, are enabled by—already exist within—the meanings and sense established by the “grid of intelligibility.” A resistant act, as Koerber notes, is more than “the occupation of preexisting subject positions” (2006, 96). Rather, acts are resistant because they are distinctly impious, even impossible, within the terms of predominant ways of knowing. As Barbara Biesecker puts it, acts of resistance “defy translation, throw sense of track, and, thus, short-circuit the system through which meaning is made” (Biesecker 1992, 357, quoted in Koerber 2006, 88). An impious act is not necessarily resistant (after all, it may not effect a rearticulation of sense and meaning), but it may be so. Burke’s concept of perspective by incongruity, or planned incongruity, provides a concrete method to (possibly) disrupt received notions of what makes sense (or, in Burke’s terms, “the sense of what goes properly with what”) and thus foster resistance to dominant pieties, opening up new fields of possibility. To put it more plainly, perspective by incongruity provides a moment of disorientation—“But that’s impossible!”— that effects a new orientation: “It’s possible if these things are true . . .”

Perspective by Incongruity in Ina May’s Guide to Childbirth In my introduction to this book, I defined pregnancy manuals as texts that primarily give instruction regarding the period between conception and delivery and that are directed toward pregnant women themselves as a primary audience. Gaskin’s book seems to violate one of these criteria: she calls it a “guide to childbirth,” not a “guide to pregnancy” or “pregnancy manual.” The manual is intended, however, to be read during pregnancy as a kind of prenatal care that facilitates an empowering and healthy birth experience. Guide to Childbirth is divided into two parts. Part 1 consists of birth stories of women who gave birth on “the Farm,” Gaskin’s community of midwives. Part 2 describes why Gaskin believes births on the Farm were so successful and emphasizes that their “woman-centered style of maternity care” was arrived at organically, through experience, and then verified through research. She explains, in other words, why woman-centered maternity care is crucial to good birth outcomes and implicitly gives advice to pregnant women about which aspects of the technological system of prenatal care to engage with and disengage from in order to achieve a good birth outcome. Gaskin advises her readers to read the birth stories in part 1 of

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the book while they are pregnant “because the best way . . . to counter the effects of frightening stories is to hear or read empowering ones . . . stories that change you because you read or heard them” (Gaskin 2003, 4). This is a pregnancy manual, but one that rearticulates the goal of prenatal care as facilitating childbirth experiences that are empowering rather than producing normal babies. In order for Gaskin’s users to have control over their childbirth experiences, they must first gain critical access to the technological system of prenatal care. Gaskin facilitates this access by employing perspective by incongruity that creates new (or that excavates suppressed) pieties about pregnancy and childbirth. These “new” pieties are: (1) experiential knowledge about pregnancy and childbirth is expert knowledge; (2) pregnant women’s bodies are capable, not pathological; and (3) medical technologies of prenatal care are risky.

Experiential Knowledge Is Expert Knowledge On the first page of her book, Gaskin disrupts the pious association between theoretical medical knowledge about pregnancy and expert knowledge, defining experiential knowledge produced by pregnant women, their bodies, and their caregivers as expert knowledge: “Consider this your invitation to learn more about the true capacities of the female body during labor and birth. I’m not talking about a summary of current medical knowledge translated from technical to popular language. You can find plenty of that in bookstores. What I mean by true capacities of the female body are those that are experienced by real women, whether or not these abilities are recognized by medical authorities” (Gaskin 2003, xi). This passage draws attention to the articulation of pregnancy to medical institutions, practices, and technologies in order to disarticulate it. Gaskin says that expert knowledge about the capacities of the pregnant body is not found in medical literature but in the experiences of “real women.” She employs perspective by incongruity in order to define expertise impiously as nonmedical (or perhaps more precisely as not only medical). Medical expertise is called further into question in later chapters that scrutinize the safety and wisdom of routine obstetrical practices such as induction, C-section, and the like. Later, she says that the birth stories collected in the first part of the manual “teach us that each woman responds to birth in her unique way and how very wide-ranging that way can be. . . . They teach us

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the occasional differences between accepted medical knowledge and the real bodily experiences that women have—including those that are never reported in medical textbooks nor admitted as possibilities in the medical world” (Gaskin 2003, 4). Again, this passage disarticulates “accepted medical knowledge” from “real bodily experiences,” impiously defining those real bodily experiences as sources of expert knowledge—indeed, as sources of knowledge that medical literature does not even recognize as being possible. In the first chapter of part 2, Gaskin details what she believes is the powerful mind-body connection that exists during labor, and how she has seen labors stall or progress based on women changing their emotional state (going from joy to fear, or vice versa). She also details how in one birth, when the surges (Gaskin’s word for contractions) became very powerful, a laboring woman shut down and became afraid. Her cervix had dilated to eight centimeters; when Gaskin checked it again it had retracted to about four. When the woman was able to relax, her labor begins progressing quickly again. Gaskin says that she immediately began reviewing medical literature to see if this was a recorded phenomenon and, finding nothing, talked to some doctors, nurses, and hospital-based midwives: “Too many hospital-based midwives and nurses,” she writes, “told me that if there was a difference between their measurement of cervical dilation and that done by a doctor (as there often is), the doctor is always believed (never the midwife or nurse). They also said that doctors in these cases rarely, if ever, believe that the cervix truly had been more open before. For them, it is easier to believe that the nurse or nurse-midwife is wrong than that women have unknown abilities that aren’t always noted in medical textbooks” (Gaskin 2003, 139). Experiential knowledge, according to Gaskin, can bring those “unknown abilities” to light.

Pregnant Bodies Are Capable In addition to demonstrating the value of experiential knowledge, the collection of birth stories that begins Guide to Childbirth is explicitly intended to wrench apart pious associations of birth as scary, technological, medical, alienating, excruciating, and incapacitating and to dispel pious associations of the pregnant body as incompetent and malfunctioning. As Gaskin puts it, “The best way I know to counter the effects of frightening stories is to hear or read empowering ones” (Gaskin 2003, 4) She points out that “tell-

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ing pregnant women gory stories has been a national pastime for at least a century” and that television programs that depict birth can show procedures like C-sections but not normal vaginal deliveries (Gaskin 2003, 3). “It almost goes without saying,” she writes, “that the birth stories told in Part I differ from those of most American women. Overall, the stories are too positive; there is too much talk of joy, ecstasy, and fulfillment. These stories do not describe the usual proportions of forceps, vacuum extractor, or cesarean deliveries that are representative of these interventions” (Gaskin 2003, 129). Note that, as a form of instruction, the birth stories do not command women to carry out their pregnancies and childbirth experiences in a certain way but, rather, they provide an indication of what is possible to do. The birth stories represent what Miles Kimball (2006) has called a “tactical” approach to instruction: “here is how I did it” rather than “here is how it must be done.” But the birth stories are also important because they present the pregnant woman’s body as capable of bearing and birthing babies rather than as a malfunctioning machine that must be monitored and fixed with the application of medical technology. Gaskin observes that, in hospital births, when labor stalls for an unidentified reason, doctors tend not to look for emotional or mental reasons (such as the laboring woman being afraid, apprehensive, or angry), but to physical ones, “that the woman’s body is inadequate—what I call the ‘women’s body is a lemon’ assumption” (Gaskin 2003, 141), the pious association between the pregnant body and pathology, malfunction, risk. This assumption, Gaskin believes, leads to unnecessary surgical intervention or administration of pharmaceuticals “when patience and recognition of the normality and harmlessness of the situation would make for better health for them and their babies” (Gaskin 2003, 141). Gaskin explicitly draws attention to this pious association in order to disrupt it: “Remember this, for it is as true as it gets: Your body is not a lemon. You are not a machine. . . . Even if it has not been your habit throughout your life so far [to think of your body that way], I recommend that you learn to think positively about your body” (Gaskin 2003). Gaskin goes on to explain how, although the births described in the birth stories took place in a community of midwives or in homes, their lessons can be applied to birthing in any context, including in hospital contexts: “Enfolded within these stories are lessons that can empower you, too, to give birth to your own child without technological intervention, wherever you decide to give birth” (Gaskin 2003, 130).

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Technologies of Prenatal Care Are Risky, Users’ Bodies Are Not Like other pregnancy manuals, Gaskin discusses prenatal tests commonly offered to pregnant women—in particular, ultrasound, chorionic villus sampling, and amniocentesis. Again, as seen in the rhetorical cultural analysis of many previous manuals, it has become pious for pregnant women to routinely (ritualistically?) engage with these technologies with the goal of producing normal babies. Pregnancy has become tenaciously articulated to prenatal testing technologies and to risk management (prenatal testing technologies are often presented as tools for risk management). Gaskin challenges this pious assumption, observing that “there is some reason to be cautious about allowing yourself and your baby to be tested, especially is you would be opposed to terminating your pregnancy regardless of the genetic or chromosomal status of your baby” (2003, 190). She employs perspective by incongruity to impiously define prenatal testing technologies such as ultrasound not as safe tools of risk management but as “unregulated,” used despite “lack of scientific evaluation of possible hazardous effects” and as ineffective in making “pregnancy or birth safer for all women” (191). After disarticulating pregnancy from necessary engagement of testing technologies, Gaskin shows her readers how to engage with these technologies critically and strategically and how to refuse them if necessary. She stresses the idea of informed consent, that users of prenatal testing technologies “should be given information about the test to help you decide whether you want to have it done” (201). She also gives ideas about how to negotiate the technological system of prenatal care: “If you would prefer not to have an ultrasound that your doctor or midwife has asked for, I suggest that you ask what specific information they want” and to see if that information can be obtained another way (192). Because the user has been articulated as an expert, or potential expert, and because possibilities outside of the techno-medical model of prenatal care are visible and legitimated in Gaskin’s book, the user is empowered to negotiate the technological system of prenatal care (rather than uncritically engaging with it) and perhaps to begin rearticulating that system.

Rearticulating Pregnancy and Prenatal Care The ultimate goal of making these impious associations (impious within a biomedical model of pregnancy but not within a midwifery model) is to

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disarticulate pregnancy and the pregnant women from what Gaskin calls the “techno-medical model of care” and to rearticulate them to a more woman-centered and user-centered “midwifery model of care”: “It is important to know that there are two distinct ways of thinking about pregnancy and birth in the United States, as well as in many other countries. Out of these very different conceptions of women’s bodies and the meaning of birth have come two separate models of maternity care: the midwifery or humanistic model of care and the techno-medical model of care” (Gaskin 2003, 183). Ultimately, within the terms of this pregnancy manual, the pregnant woman is (somewhat, but not entirely) disarticulated from medical institutions and from the technological system of prenatal care and articulated to what Gaskin calls a woman-centered, humanistic, midwifery model of care, which “conceives of pregnancy and delivery as inherently healthy processes and of each mother and baby as an inseparable unit,” within which “prenatal visits . . . tend to be much longer, allowing more questions to be answered,” and which “emphasizes the importance of good nutrition as the best way to prevent the most common complications of pregnancy” rather than emphasizing the routine application of testing technologies (184). The midwifery model is user—and woman—centered: “The midwifery ideal is to work with each woman and her family to identify her unique physical, social, and emotional needs” (Gaskin 2003, 305). This (re)articulation of pregnancy and the pregnant woman to the midwifery model of care may or may not ultimately lead to systemic change within the technological system of prenatal care in the long term. It does, however, make alternative articulations possible, and thinkable, for the user. For me (for one particular user having a particular pregnancy in particular circumstances), Ina May’s Guide to Childbirth facilitated articulations of my own pregnancy and prenatal care to a midwifery model of care and to feminist, woman-centered ideologies. I felt that I had the right to negotiate, to speak, and to be heard. I was, in some small way, empowered to rearticulate prenatal care on my own terms and to claim critical access to the technological system of prenatal care. In the current political climate in the United States, where women’s reproductive rights are increasingly threatened and their bodies are increasingly subject to political control and surveillance, such rearticulation seems especially urgent. According to a policy brief from the Guttmacher Institute, eight states now require that women undergo ultrasound before they can have an abortion (Frost 2012; Guttmacher Institute 2012). In these states, the use of ultrasound—a prenatal testing technology—is mandated whether women want it or not and whether or not it is medically indicated;

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it is being used to address a perceived social problem that is directly related to the fetal rights movement. As Erin Frost observes, “The fetal ultrasound legislation . . . is largely—and usually blatantly—ideological in nature” (2012). This legislation also takes to the extreme the belief that women are not experts about their own bodies and pregnancies—it is a product of and contributes to current articulations of pregnancy, prenatal care, the pregnant woman, and women’s reproductive bodies in general. The more these articulations are codified into law, the less there will be any possibility for critical access to the technological system of prenatal care.

Rearticulating Usability Based on my usability research into pregnancy manuals, I offer the following recommendations to anyone who is interested in composing documentation (or identifying already existing documentation) that provides users with critical or transformative access to technological systems. In order to provide users with critical and transformative access to technological systems, documentation must make the articulations of those systems visible to users so that users can rearticulate systems rather than simply functionally to engage with them. Although phrased (ironically) as commands, this list is meant to suggest directions for further research in order that our field can come to a better understanding of documentation—and the usability of documentation—that moves beyond a system-maintaining role. Expand Usability Research Usability research should be expanded to include methods such as rhetorical-cultural analysis that explains how users, technologies, and technological systems came to be articulated in certain ways in the first place. Such research helps to explain how and why users have been articulated so that they need to engage functionally with technological systems and also whether such functional engagement is necessary. In addition, expanded usability research could also help researchers to understand which articulations are more tenacious than others and which may be hampering critical access, so that designers of documentation can make alternative articulations visible to users. This type of expanded usability research, even if limited in scope and time, is especially necessary when the goal of a piece of technical communication is to facilitate critical access for its users, a phenomenon that isn’t unique to pregnancy manuals. Most documen-

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tation relating to the body and to healthcare could have critical access as a goal—instructions about exercise, diet, nutrition, health, medications, breastfeeding, and even parenting. But so might instructions for a software application—think about how the help function of a word processing program might look if it facilitated critical, rather than simply functional, access to its users. Within technical communication literature, Miles Kimball has explained how the do-it-yourself automotive enthusiast documentation that he analyzes provides users with a kind of critical access to mainstream systems of automotive maintenance and consumption by articulating the user as “a technological scavenger on the periphery of industrial society” (2006, 67). Investigate Alternative Methods of Usability Research Further research should be conducted into alternative methods of usability research that get at the question of how users and technological systems have come to be configured in certain ways. The type of rhetorical-cultural analysis that I’ve employed here might not apply equally well to all types of situations. Could this approach be modified to use in a corporate or institutional context? Could it be modified to use in the classroom? Are there other approaches that could be employed to extend our methods beyond a functional approach to usability evaluation? For example, in the undergraduate introductory technical communication course that I teach, I frequently give students the assignment (based on an assignment developed by Laurence José, one of Michigan Technological University’s PhD graduates) to create guides for incoming international students that are designed to introduce them to aspects of American and campus culture. Although I don’t invoke the terms piety and articulation in the classroom, I do ask them to think about why we do things the way we do in our culture. The goal is to produce documents that initiate conversation about cultural differences and that also help students to negotiate—and rearticulate—cultural practices (such as using local transportation, placing orders in a restaurant, or participating in campus events and organizations). The documents have a tone of “this is one way to do this and this is why” rather than “this is how it must be done.” Employ Techniques Like Perspective by Incongruity in Documentation Design When designing documentation intended to facilitate critical access, employ techniques such as perspective by incongruity in order to assist

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rearticulation of users and technologies in ways that empower users to access technologies critically rather than functionally. In his dissertation, Steve Bailey describes how the Writing Center (recently renamed the Multiliteracies Center) at Michigan Technological University created in-house documentation for its coaches because existing coach handbooks articulated the identity of the writing coach in reductive ways. The in-house documentation challenges pieties about writing center coaches in order to facilitate a more multilingual and multicultural articulation of the coach’s identity. The pieties—or what he calls “tacit assumptions of coach identity”—revealed in Bailey’s analysis of mainstream coach handbooks included the following (Bailey 2010, 114–15): The coach as female The coach as academic insider The coach as skilled writer The coach as monomodal composer The coach as monocultural The coach as monolingual

The Michigan Tech Writing Center Handbook (Michigan Tech Writing Center 2009) rearticulates the coach as someone who could be multicultural and multilingual, as someone who works together with students on designing often multimodal texts rather than as an expert who dictates rules to the novice writer. Analyze Different Documentation Systems for Rhetorical Features Find and analyze examples of system-constitutive, system-maintaining, system-disrupting, and system-simulating documentation that document other technological systems in order to develop a more comprehensive understanding of their rhetorical features and potential best practices. Examples of system-maintaining documentation are easy to find: look to the instructions accompanying your new MP3 player, software application, or toaster. System-maintaining documentation can also, as we have seen, be found in unexpected places, accompanying a pregnancy or a diet program or in an employee manual. Documentation frequently takes on system-constitutive characteristics when users are asked to adopt a technology or practice that may be new to them or is at odds with the traditional way of doing things, as was the case, as Katherine Durack observed, with sewing machines in the nineteenth century (1998). Documentation

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accompanying something like a new public health initiative would also probably be system-constitutive (e.g., documentation related to safe sex campaigns in the United States during the 1980s). As mentioned in chapter 4, documentation arising out of periods of social upheaval is likely to take on a system-disrupting stance—think of Abbie Hoffman’s Steal This Book (1971). But it can also be found on a more local or institutional scale any time the goal of documentation is to help users critique, negotiate, and transform a system rather than simply to use it (much online, thirdparty computer documentation that discusses work-arounds and even hacks that allow technologies to better fit the needs of their users could fall into this category). Finally, the Internet is filled with examples of systemsimulating documentation: documentation that seeks to deliver users to advertisers, and my hunch is that documentation designed for smart phones (such as the BabyCenter and What To Expect iPhone apps) is also likely to be system-simulating. Develop Multi-Issue Usability Heuristics Develop usability heuristics that reflect the purposes, audiences, and contexts of not only system-maintaining documentation but also systemconstitutive, system-disruptive, and system-simulating documentation. Usability heuristics such as Hans van der Meij and John M. Carroll’s “Principles and Heuristics for Designing Minimalist Instruction” (1995) assume that the user wants to engage functionally with a technology or system—in other words, that documentation is system maintaining. How could heuristics like these be modified to reflect the goals of systemdisrupting documentation? Rhetorical-cultural methods of usability research could also be combined with other types of usability research and testing, including ethnographic studies, focus groups, interviews with users, and empirical user testing. For example, a manual such as Ina May’s Guide to Childbirth could be given to pregnant women from a range of demographics, and then those women could be surveyed or interviewed in order to ascertain whether it helped facilitate critical access to the prenatal care system. Alternatively, users who have gained critical access to a technological system could be interviewed or surveyed in order to determine what, if any, documentation they employed in order to gain that access and what the characteristics of that documentation were. It would also be interesting to learn how users repurpose documentation and how they resist or reconfigure articulations of user identity. A manual intended to provide critical access could be user

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tested with representative users in order to determine whether the necessary information is accessible and understandable to them. Techniques of usability testing that emphasize ease and efficiency as their most important measures used without preliminary usability research into the articulations that forge user identity, however, are likely to entrench existing articulations. People who are involved in creating technical communication of all kinds need to better understand whether those existing articulations empower users to negotiate, critique, and transform technological systems.

Notes

Chapter 1 1. Since 2003, prenatal care utilization and timely initiation of prenatal care have declined slightly. The US Standard Certificates of Live Birth was revised in 2003, and data gathered about prenatal care from that certificate are incomparable with data gathered from the 1989 unrevised version of the certificate. This means that the latest information (2009) about prenatal care is based only on the twenty-two states that comprise the revised reporting area and is “not generalizable to the country as a whole” (Martin et al. 2010, 21–22). 2. “Technical communication” was still called “technical writing” at the time that he composed this definition, however. 3. As I discuss in chapter 7, Pregnancy for Dummies explicitly employs a user-friendly model of software documentation. 4. Ferguson v. City of Charleston, 532 US 67 (2001), 72. 5. Ibid., 72–73. 6. According to Adam Banks (2006), critical access can lead to transformative access.

Chapter 2 1. The Usability Professionals Association is a multidisciplinary association made up of technical communicators, information architects, computer scientists, ergo­ nomists, and professionals from a host of other fields, including medical fields. 2. For example, if usability testing was measuring the usability of a particular feature of a spreadsheet program, say, the sum feature, the feature would be redesigned based on the results of one test and then tested again to see if results improve. Often, informal usability testing is used for iterative testing to save costs and time (e.g., in the early 1990s Microsoft conducted iterative informal tests of product features every week) before formal testing in a usability testing in a lab environment occurs (Microsoft Corporation, 1991).

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158  notes to pages 18–42 3. For example, Spinuzzi describes his study of how Iowa government workers used database software to analyze traffic accidents. He observes the workers in the field—that is, on the job site—in the contexts in which they use the software, “in terms of their activities” rather than in terms of their individual interactions with the software isolated from the contexts in which they work and the activities in which they are engaged (Spinuzzi 2001). 4. I am drawing on Grossberg’s (1987) definition of “empowerment” as “the conditions of possibility that enable a particular practice or statement to exist in a specific social context and that enable people to live their lives in different ways” (quoted in Slack, Miller, and Doak [1993] 2004, 170). 5. Oxford English Dictionary, s.v. “manual” (http://www.oed.com/view/Entry /113735?redirectedFrom=manual&#footerWrapper). 6. Ann Oakley has observed that pre-twentieth-century pregnancy manuals, what she calls “pregnancy advice books,” are frequently addressed to both pregnant women and to midwives or “man-midwives” (Oakley 1984). 7. Like many contemporary genre theorists, I am not so much concerned with a de facto classification of what formal features distinguish one genre from another or what features define the “ideal” instance of a given genre. I am instead interested in what genre does and how perception of genre influences how readers and writers approach a text. As Anis Bawarshi argues, “Genres are both rhetorical actions and recurrent situations” and “genre is largely constitutive of the identities we assume within and in relation to discourse,” either as readers or writers (2000, 357, 343). Generic expectations can be very powerful and very limiting. After all, Sheila Kitzinger had to begin her 1978 book Women as Mothers with the disclaimer that “this is not a ‘how to’ book” (1978, 3). This factor attests to the very strong and entrenched cultural expectations that readers have regarding texts about pregnancy: they automatically assume the role of novice to the author’s (or authors’) expert, and they are ready to receive that expert’s advice. Because Kitzinger wants not to dictate how pregnant women should behave but to explore and expose different cultural assumptions and beliefs about pregnancy and childbirth, she first has to instruct her readers explicitly concerning how to—or, rather, how not to—read her book.

Chapter 3 1. Thanks to my colleague Karin B. Schlenker for providing this translation. 2. In Expectant Motherhood, Ballantyne notes that “a friend who had read the appeal in the British Medical Journal” donated a thousand pounds to the Royale Maternity Hospital specifically for the establishment of “a bed for the diseases of pregnancy” (1914, 241) 3. It has long been pious for pregnant women to discipline or govern their bodies in some way—part of this need stemmed from belief in maternal impression, the belief that unwholesome sites or sounds could “mark” the baby in some way.

notes to pages 42–70  159 4. This book was written by Hugh Chamberlen, of the Chamberlen family who invented the forceps. 5. Ann Oakley sees two major differences between pregnancy manuals written in the nineteenth century and those written in the mid-twentieth—those written in the nineteenth century viewed the “whole period of pregnancy, childbirth, and motherhood . . . as a continuous entity,” and they “make no distinction between what, nowadays, would be called major symptoms of clinical importance on the one hand, and minor symptoms of nonclinical importance on the other” (Oakley 1984, 15). Moreover, they were addressed to both pregnant women and to midwives or man-midwives—they “made no separation between obstetric texts and advice literature” (Oakley 1984, 14).

Chapter 4 1. This was also time when midwives, especially African American midwives, were being “reeducated,” regulated, and restricted, further limiting the African American community’s access to any kind of prenatal care and, should they obtain access, forcing them to submit to medical authority and surveillance. As Gertrude Fraser puts it, prenatal care campaigns had an inherent paradox: “The emphasis on prenatal care formed part of the ideology of ‘race building’ among whites; on the other, it was also used to draw African Americans under the authority of the state and medical science” (Fraser 1998, 128). Read this way, the IDNA’s efforts to provide prenatal care to non-Anglo-Saxon communities (including Italian, Jewish, Slavic, and African American communities in Boston) can be seen at least in part as part of an effort to bring these groups under medical authority, to root out the threat of the midwife, and to ensure a healthy labor force.

Chapter 5 Portions of this chapter originally appeared in the December 2009 issue of College Composition and Communication as the article “Instructions for Systemic Change” (Seigel 2009). The quote from Hargreaves, a physician, appeared as a blurb on the back cover of Eastman’s Expectant Motherhood (1957). 1. In their history of prenatal care, Joyce E. Thompson, Linda V. Walsh and Irwin R. Merkatz note that “non-physician professionals nearly disappeared by the 1950s with loss of influence and autonomy” as the United States “moved from a broad support system of pregnancy care to a physician-directed system of prenatal visits in institutions, often outside a woman’s own culture and community” (1990, 27). In his indictment of the modern prenatal care industry, “second generation obstetrician” Thomas Strong (2000) cites political expediency and economic incentives as the main motivators of this shift. 2. This attitude of the manual standing in for the technology designer or distributor

160  notes to pages 71–74 is typical of the system-maintaining manual. As William Skees writes, “Look upon the user manual as the document which substitutes for your own physical presence, providing everything in the way of guidance and assistance that you, yourself, would provide to the user of the system if you were there” (Skees 1982, 181; quoted in Killingsworth and Gilbertson 1986, 292). 3. Although I present these categories of documentation as relatively discreet, I don’t mean to imply that there isn’t slippage between the categories. For example, although much of the IDNA’s documentation was system constitutive, its “quick reference guide” could also be understood as system maintaining since it was distributed to patients who were already inside of the system. Similarly, although I present the documentation produced by the Boston Women’s Health Collective as system disrupting, it could also be understood as trying to constitute a more usercentered system of care. 4. As an example of this functional, system-maintaining approach, Johndan Johnson-Eilola points to documentation that frequently accompanies word processing programs (2001, 124; [1996] 2004, 249–50). For example, if a user is seeking help in creating a résumé, she is likely to be directed to prepackaged templates in which she simply fills in prescribed information or, perhaps, given task-based suggestions on how to format text, create borders, or insert graphics. According to Johnson-Eilola, the problem with this functional approach is that it does not take into account the rhetorical, visual, cultural, or even ethical complexities of résumé design: the template appears authoritative. In short, this approach is likely to be precisely the wrong solution for many users—the user who has followed a nontraditional career path or who is just entering the job market, for example. In these cases, moreover, the documentation doesn’t empower the user to manipulate the technology with sensitivity to her particular rhetorical situation. Rather, it teaches her to follow the prescriptions of the technology’s designers— prescriptions that might be completely at odds with those of the user. The object of system-maintaining documentation is the continued use of a particular technology or technological system, not (necessarily) critical, context-dependant use. Such use, in turn, is based on a predetermined assumption the developer of that technology has made in terms of who will use the technology and how that technology will (or should) be used. In fact, critical, context-dependent use might be counterproductive from a system-maintaining perspective, for it could actually dissuade individuals from using a technology (e.g., “Perhaps I shouldn’t use this application to compose my resume after all?”). 5. Johnson-Eilola borrows the term from former US Secretary of Labor Robert B. Reich. In contrast to “routine production” or “in-person service workers,” symbolic analysts are trained to manipulate information, to “wor[k] within and across information spaces” (Johnson-Eilola [1996] 2004, 181). The main distinguishing characteristics of their work are experimentation, collaboration, and system thinking ([1996] 2004, 185–86). 6. System thinking and user-centered theory are closely linked here: because system thinking focuses on changing systemic conditions rather than “troubleshoot-

notes to pages 81–96  161 ing” user actions, it would have to take user knowledge of a given system seriously as productive knowledge. Here, we hear echoes of Robert Johnson’s calling for users to be involved in technology development. 7. An example of a myth produced by medical authorities is the following: “Traditionally doctors have asked that women abstain from intercourse 4–6 weeks before giving birth and up till 6 weeks after. . . . This abstention was based on 4 unproven beliefs” (Boston Women’s Health Collective 1970, 43). 8. Mary Lay’s The Rhetoric of Midwifery (2000) demonstrates that this debate about who can and should have knowledge about pregnancy and childbirth is alive and well. Direct-entry midwives who are not licensed by the medical establishment are still prosecuted for practicing their trade. 9. Given the economically grounded definition of expertise in this passage, it is worth (two cents, at least) noting that the next section is called “Fees.” This manual is, after all, selling a product.

Chapter 6 1. As Barbara Duden (1993) has observed, the month of April 1965 was bookended by images of the fetus and of space travel, both featured, again, in Life magazine: “On April 2, the cover shows Gemini and ‘the lift-off to a new era in space’ . . . April 30 shows ‘the drama of life before birth,’” Lennart Nilsson’s photographs of a fetus (apparently) developing in the womb (Duden 1993, 11). Although the April 2 issue does not showcase images of the earth as seen from space, it would not be much longer before these images started to become prevalent. William Anders photo Earthwise (NASA image AS8-14-2383) can be found at http://www.nasa.gov/multi media/imagegallery/image_feature_102.html. 2. The development of real-time ultrasound led to its widespread and routine application in the 1980s. Before this, it was “used only when indicated clinically” (Goldberg 2000, 627). 3. Since its 1984 publication, the What to Expect universe has rapidly expanded to include four editions (and Spanish translations) of its pregnancy manual; parenting manuals; children’s literature; an online community; and, most recently, a romantic-comedy movie inspired by the popular pregnancy manual (Jones 2012). 4. Perhaps the first to be prosecuted for allegedly mistreating her fetus during pregnancy, Pamela Rae Stewart disregarded doctor’s orders to abstain from sex during pregnancy. In her thirty-ninth week of pregnancy, Stuart had sexual intercourse with her husband and began hemorrhaging. Her son died soon after he was born, and Stewart was prosecuted in the state of California in 1986 for failing to follow doctor’s orders. Although the charges against Stewart were subsequently dropped, her case set a precedent for similar prosecutions (Vedder 2001, 130–31). 5. As Duden (1993) has noted, part of the explanation for this new perception of the fetus as a separate subject with rights at odds with those of its mother lies with the widespread and routine adoption of visualization technologies like ultrasound

162  notes to pages 96–123 in a prenatal care context together with the strategic deployment and manipulation of these images (emphasizing those parts of the fetus that are similar to those of a full-term baby, like the feet) allowed the fetus to be represented as a miniature person and as a rights-bearing subject separate from the mother at earlier and earlier stages—far before the point of viability outside the mother. 6. When I use the term “risky,” I use it in the sense of posing risks to others. Pregnant women are risky because they pose risks to their fetuses, not because they themselves are seen to be at risk. 7. DDT stands for dichlorodiphenyltrichloroethane, an insecticide that gained notoriety and was eventually banned in part due to the public outcry caused by Rachel Carson’s 1962 book Silent Spring, which highlighted the dangers posed by DDT to environmental and human health. DES stands for diethylstilbestrol, a drug that, until 1971, was given to pregnant women to prevent miscarriages and premature birth. DES was subsequently found to significantly increase the risk of certain kinds of cancer both in women who had taken the drug and in their offspring. Thalidomide was used as both a sleeping pill and antinausea drug for pregnant women until it was withdrawn in 1962 after having been found to cause birth defects. 8. The Superfund Amendments and Reauthorization Act modified Comprehensive Environmental Response, Compensation, and Liability Act by encouraging citizen participation, increasing states’ involvement and responsibility, and increasing the size of the trust fund.

Chapter 7 1. Pregnancy for Dummies has enjoyed a fair amount of cultural popularity since its publication: it is currently in its second edition, and it was featured on the überpopular sitcom Friends (1994–2004) as one of the pregnancy handbooks (the others were What to Expect When You’re Expecting [Murkoff, Eisenberg, and Hathaway 1984] and The Girlfriend’s Guide to Pregnancy [Iovine 1995] that Rachel, one of the main characters, consults while she is pregnant.

Chapter 8 1. According to the manual’s acknowledgements, most of the “text and figures” for the book were drawn from Suggestions for Prospective Mothers, published by the New York State Department of Health. The manual also drew images from a pamphlet published by the Chicago Commissioner of Health called Better Babies. (Johnson and Johnson 1927, 3). 2. Pregnancy is part of the Future US publishing group, which also publishes titles like Pregnancy Buyers Guide, Crochet Today, Mac|Life, Maximum PC, Guitar World, Nintendo Power, Official xbox Magazine, and PC Gamer. Fit Pregnancy is part of the Weider Publications, LCC, a subsidiary of American Media, Inc., which also publishes titles like Men’s Fitness, Muscle and Fitness, National Enquirer, and Star.

notes to pages 123–137  163 3. American Baby is part of the Meredith Publishing Group, which also publishes titles like Better Homes and Gardens, Family Circle, and Parents. 4. Merideth Parents Network Custom Solutions, “As Your Baby Grows,” Merideth Parenthood Group, 2013, http://www.parentscustommedia.com/client_2.htm. 5. BabyCenter, “About Us—Company Overview,” BabyCenter, 2013, http://www .babycenter.com/help-about-company. 6. BabyCenter, “You and Your Family,” BabyCenter, 2013, http://www.babycenter .com/you-and-your-family. 7. BabyCenter, “Marketing Solutions: The Twenty-First Century Mom,” BabyCenter, 2008, http://www.babycentersolutions.com/. 8. BabyCenter, “Marketing Solution: Our Audience,” BabyCenter, 2008, http:// www.babycentersolutions.com/our_audience.php. (Content no longer available on site.) 9. BabyCenter, “Marketing Solution: Mom Confidential—the Secret Lives of Moms,” BabyCenter, 2008, http://www.babycentersolutions.com/momconfidential_sponsor ship.php. 10. BabyCenter, “BabyCenter Newsletters,” BabyCenter, 2013, http://www .babycenter.com/newsletters. 11. BabyCenter, “Inside Pregnancy: Weeks 10 to 14,” BabyCenter, 2013, http://www .babycenter.com/2_inside-pregnancy-weeks-10-to-14_10308108.bc. 12. Lindsay L. Whitcomb, “Is It Safe to Get a Mud Bath during Pregnancy?” BabyCenter, 2013, http://www.babycenter.com/406_is-it-safe-to-get-a-mud-bath-duringpregnancy_1245306.bc. 13. BabyCenter, “About Us—Company Overview,” BabyCenter, 2013, http://www .babycenter.com/help-about-company. 14. loveange12006, “Pregnancy Board Guidelines.” BabyCenter Community Retrieved October 5, 2009, from http://community.babycenter.com/post/a9813705 /pregnancy_board_guidelines. 15. katlynose19, “refusing to take glucose test,” June 11, 2009, BabyCenter: Community, http://community.babycenter.com/post/a10475735/refusing_to_take _glucose_test. 16. BabyCenter, “Groups Posts—BabyCenter,” BabyCenter, 2013, http://community .babycenter.com/post. 17. In The Wired Neighborhood (1996), Stephen Doheny Farina asks his readers to consider how new (at the time) kinds of virtual realities—found in Multi-User Domains (MUDs), on message boards, in on- and offline catalogues—can disengage us from our lived, messy, geophysical communities.

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Index

advertisers, delivering users to, 126–29 American Breeders Association, 64 American Cyanamid, 12, 97 amniocentesis, 114f. See also prenatal testing technologies antenatal therapeutics/antenatal hygiene, 36– 38, 49, 130 articulation: meanings, 23; piety and, 23–30 articulation theory, 23 As Your Baby Grows from Conception to Birth (American Baby), 123 BabyCenter (www.babycenter.com), 123–26; homepage, 124f; “Inside Pregnancy: Weeks 10 to 14,” 131f; “Is it safe” page, 134f; news­ letter preview, 129, 130f; “page not found” error message, 125f; “Pregnancy” page, 133f Bailey, Steven, 154 Ballantyne, John William, 57, 88, 98; “A Plea for a Pro-Maternity Hospital,” 36–40; on ante­ natal therapeutics, 37, 38, 45–46, 130; back­ ground, 35–36; eugenics and, 48, 49, 64; on prenatal care, 35, 37–40, 49–52, 54–56, 64, 67, 70, 92; vision for a hospital, 36–39, 49, 51–52; “Visits to the Wards of the ProMaternity Hospital: A Vision of the Twenti­ eth Century,” 36–40, 43. See also Expectant Motherhood Banks, Adam, 3 Bargain Hunters (group), 135 Bawashi, Anis, 158n7 Beard, Mary, 57 Beck, Ulrich, 101 Bell, Ruth, 76–77, 80–81, 85, 87 Benedikt, Allison, 91 better babies movement, 65, 122 better baby contests, 65 Biesecker, Barbara, 146 Birch, William, 72, 75, 77–80, 85, 86

birth stories, 139–45; in Ina May’s Guide to Childbirth, 146–49 birth weight, low, 5 Boston: birth of prenatal care in, 52–54. See also Instructive District Nursing Association of Boston Boston Health Department, City of, 58–59 Boston Lying-In home care, 55 Boston Lying-In Hospital, 52 Boston Women’s Health Collective: abortion essay, 83–84; creation of, ix; impact, 88–89; overview, 73–76; photographs, 82, 84f; pregnancy chapters, 80, 81, 83, 87–88; pub­ lication, 73; purposes, 73, 74, 87–88; as system-disrupting documentation, 73–75, 88, 103–4. See also Our Bodies, Ourselves; Women and Their Bodies Branca, Donna, 12–13 Brown, Stuart, 7 Burke, Kenneth, 23, 25, 145 Chamberlen, Hugh, 42–43 Charleston, South Carolina. See drug testing pregnant women without consent childbirth, 148; as the province of women, 51–52; woman-centered, 143. See also birth stories cocaine use, testing pregnant women for, 12 Complete Midwife’s Practice Enlarged, The (Chamberlen), 42–43 constructivist approaches to usability, 21–22 contextual inquiry, 17–18 Copelton, Denice, 9 cost-benefit analysis, 100–101. See also riskbenefit analysis critical access (to medical-technological sys­ tem), 9, 26, 33, 142–44, 147, 151–56; in the cracks, 134–37; vs. functional access, 3, 4, 14, 20–22, 126, 131–32, 141–42, 153

179

180  index Davenport, Charles Benedict, 64 Davis, Kathy, 83 Davis-Floyd, R., 114 dioxins, 102 disciplinary rhetorics, 29–30 distributed usability, 18 Doctor Discusses Pregnancy, A (Birch), 75, 78–79, 82, 83f, 85–86; contrasted with other manu­ als, 72, 88, 94, 115; criticism of, 77; over­ view, 72 documentation design, 153–54. See also perspec­ tive by incongruity documentation systems: analyzing for rhetori­ cal features, 154–55. See also specific systems DOS for Dummies (Gookin), 105–9, 106f, 107f, 108f, 111–12 doulas, 34, 139–42 drug testing pregnant women without con­ sent, 12 drug use during pregnancy, 12, 96 Duden, Barbara, 92, 161n1 Duenwald, Mary, 111. See also Pregnancy for Dummies Durack, Katherine, 41 Dwinnell, William, 52–53 Eddleman, Keith, 111. See also Pregnancy for Dummies empowerment: defined, 158n4 Enfamil, 123 environmental risk management, 12, 97, 99– 104, 162n7 Epstein, Randi Hutter, 15, 29 Ettorre, Elizabeth, 7 eugenic and neo-eugenic rhetoric, 63–65 eugenic discourses, 64, 78, 82, 104, 144 eugenic ideologies, 64, 66, 92 eugenics, 41, 63–64; euthenics and, 49, 64, 65, 78, 82, 92; Expectant Motherhood and, 48–50; goals, 57, 64–65; positive vs. negative, 64– 65. See also “race betterment” eugenics movement, positive, 65, 122 euthenics, 49, 64, 65, 78, 82, 92 Every Child Has the Right to Be Well Born (John­ son & Johnson), 65, 121–23, 128, 129 Expectant Motherhood: Its Supervision and Hygiene (Ballantyne), 36, 40–42, 51, 70, 95, 158n2; and eugenics, 48–50; and the fetus, 44–48; and the medical supervision of preg­ nancy, 42–44; outline and overview, 45–48; piety and, 41–43, 45–46 expert knowledge: experiential knowledge as, 147–48; medical knowledge about preg­ nancy as, 56, 75, 80, 110

Ferguson v. City of Charleston. See drug testing pregnant women without consent fetal abnormalities, testing for, 12–13. See also prenatal testing technologies fetal rights: vs. mother’s rights, 50; prenatal care and, 96–99, 162n5. See also Every Child Has the Right to Be Well Born fetus: as central patient, 36, 70; as perfectible product/citizen, 122; as separate individual, 46, 96, 129; treating the fetus through the mother, 36–38 (see also antenatal therapeu­ tics/antenatal hygiene) For Women Who Are about to Become Mothers (City of Boston Health Department), 59f, 60f Foucault, Michel, 21 Franklin, Sarah, 69, 103, 131 Fraser, Gertrude Jacinta, 65, 159n1 Frost, Erin, 6, 152 functional access to technological system. See critical access: vs. functional access gambling metaphor, prenatal care and, 98–99 Gaskin, I. M., 144–51 Gilbertson, Michael, 40, 41 Gookin, Dan, 105–9 Gore, Ariel, xiii Greer, Michael, 18 Hall, Stuart, 23–24 Hausman, Bernice, 29–30 Heifferon, Barbara, 7 heuristic evaluation, 17–18, 20, 27 home, as site of prenatal care, 55 hospitals/hospital wards devoted to prenatal care: constructed to solve political and so­ cial problems, 39–40; purposes, 36–37. See also under Ballantyne, John William Howard, Theron, 18, 22 Ina May’s Guide to Childbirth (Gaskin), 144–51; perspective by incongruity in, 146–47 individualized instructions, 56, 57 individualized prenatal care, 56, 57 infant mortality, 5 informed consent, 12, 150 instructions: individualized, 56, 57; as invisible, 75–78; as task-oriented, 78–81; usercentered, 56 Instructive District Nursing Association of Bos­ ton (IDNA), 51–52, 66, 67; “Advice to Ex­ pectant Mothers” (pamphlet), 57–58, 58f; and the birth of prenatal care in Boston, 52– 54; discontinuation of home delivery and prenatal care services, 69; Elizabeth Put­

index  181 nam and, 51–55; and medically supervised pregnancy, 57–61; nurses, 52, 53f, 55, 57, 59, 64; opposition to, 64; prenatal care, wom­ en’s health, and, 54–57; and reconciling the system- and user-centered models, 64–67; as system-centered, 57, 64–67; The Visiting Nurse (newsletter), 55 intensive care units, neonatal, 2 “Is It Safe?” questions and answers, 132–33, 134f Johnson, Robert, 16, 19, 51, 106, 108, 110 Johnson & Johnson (J & J), 65, 121–22. See also BabyCenter Johnson-Eilola, Johndan, 17, 18, 71, 73–74, 103, 121, 160nn4–5 Jose, Lawrence, 153 Killingsworth, Jimmie, 40, 41 Kimball, Miles, 153 Kitzinger, Sheila, 89, 158n7 Koerber, Amy, 8, 29, 126, 145, 146 Kukla, Rebecca, 11, 42, 63, 98, 112, 113, 115, 117 labor, 148 Lathrop, J., 62–63 lawsuits, 12–13 low birth weight, percentage of babies born at, 5 Martin, Emily, 7 “maternal impressions”: fear of, 63, 78; theory of, 63 May, Ina. See Ina May’s Guide to Childbirth medical experts to supervise tasks, 78–81 medical procedures as political, 81–89 medical rhetoric. See rhetoric(s) midwifery model of care, 150–51 midwifery websites, 126–27 midwives, 42, 55, 59, 146, 148; African Ameri­ can, 65, 159 Murkoff, Heidi E., 1, 21, 93–95, 98, 99, 101 neonatal intensive care units, 2 Nielsen, Jakob, 16 “normal” babies, focus on producing, 144 nurses, 69, 148. See also Instructive District Nursing Association of Boston Oakley, Ann, 7, 43, 159n5 Ojeda-Fox, Evelyn, 139–42 Our Bodies, Ourselves (OBOS), 73, 74, 83. See also Women and Their Bodies pelvic exam, 83f Perkins, Barbara Bridgman, 65

Pernick, M. S., 64–65 perspective by incongruity, 149; employing, 153–54; explained, 145–46; in Ina May’s Guide to Childbirth, 146–47 piety/pieties, 36, 88, 128–30, 136, 145, 153, 154; articulation and, 23–30; at BabyCenter .com, 125, 126; defined, 25; A Doctor Discusses Pregnancy and, 72; Expectant Motherhood and, 41–43, 45–46; fetus as central patient, 36, 70; fetus as perfectible product/citi­ zen, 122; fetus as separate individual, 46, 96, 129; IDNA and, 55; Kenneth Burke and, 23, 25; “new,” 147; as organizing principle, 25; of phrasing procedures as commands, 82; in Pregnancy for Dummies, 110; resis­ tance to dominant, 145, 146; rights of fetus vs. mother, 50; as system builder, 25; system-centered orientation and, 28, 91– 92; system-disrupting documentation and, 94; system-maintaining documentation and, 70–72; that medical knowledge about pregnancy is expert knowledge, 56, 75, 80, 110; that pregnancies must be medically managed/supervised, 36, 42–43, 52, 57, 88, 91–92, 110, 122; that pregnancy and child­ birth are the province of women, 51–52; that pregnant women receive prenatal care by women at home, 55; that prenatal care and instruction be individualized, 56, 57; that prenatal care can solve social and political problems, 52, 75, 88, 122; The Visiting Nurse and, 60; Women and Their Bodies and, 75 Pincus, Jane, ix–xii, 8–9, 76, 77, 80–81, 85, 89 planned incongruity, 149 pollution, air, 12, 97. See also environmental risk management preconception care, 6 pregnancy, 46; as medical event, 38–39; piety that it must be medically managed/super­ vised, 36, 42–43, 52, 57, 88, 91–92, 110, 122; as the province of women, 51–52; rearticulat­ ing, 150–52; technics of, 42–43, 45. See also specific topics Pregnancy (group), 135 Pregnancy for Dummies (Stone et al.), 11, 129, 162n1; compared with DOS for Dummies, 109–12; icons used in, 110f; table of contents, 11f; and troubleshooting the risky body, 117–19; as user-friendly pregnancy manual, 109–10; warning to users of, 111, 112f; “You’ll never ‘learn’ anything here,” 107, 111–16 pregnancy manuals, 11, 30–31; from nineteenth vs. twentieth century, 159n5; compared with other types of manuals, 26–28, 75–76,

182  index pregnancy manuals (cont.) 154; epideictic, 40–41 (see also systemmaintaining documentation); as technical communication, 8; troubleshooting, 103–4; user-friendly, 109–10. See also DOS for Dummies; specific manuals; specific topics pregnant women: choices regarding interven­ tions, xi; prosecuted for mistreating fetus, 12, 96, 161n4. See also specific topics pregnant women’s bodies: as capable, 148–49; as invisible, 75–78 prenatal care: accommodating, 10–14; as ca­ pable of solving social and political prob­ lems, 52, 75, 88, 122; individualized, 56, 57; as producing fit citizens, 61–64; rearticu­ lating, 150–52; woman-centered, 66–67, 150–51; and women’s health, 54–57. See also specific topics prenatal care technologies, 92; need for change in the system of, 5–6 prenatal screening, 12–13 prenatal testing technologies, 10, 91, 93–95, 117, 122, 150; dangers of, 150. See also fetal ab­ normalities; ultrasound preterm birth rate, 4 pro-maternity hospitals. See hospitals/hospital wards devoted to prenatal care Putnam, Elizabeth (Mrs. William Lowell Put­ nam), 52–55 “race betterment,” 48–50, 57, 63–64; rhetoric of, 66 Rapp, Rayna, 7 Rhetoric of Midwifery, The (Lay), 161n8 rhetorical analysis, 25 rhetorical features, analyzing different docu­ mentation systems for, 154–55 rhetorical-cultural analysis, 33–34, 150; goal, 22–23, 34; nature of, 22; and usability evalu­ ation, 21–24, 32, 33, 153, 155 rhetoric(s): of breastfeeding, 145; disciplinary, 29–30; eugenic and neo-eugenic, 63–65; feminism, technical communication, and, 6–10; of health care and medicine, 6–7, 29–30; of risk communication, 100. See also “race betterment”; fetal rights risk management, 2. See also What to Expect When You’re Expecting risk managers, users are still, 132–34 risk-based model of pregnancy, 117–19 risk-benefit analysis, 95. See also cost-benefit analysis risky pregnant bodies, 21, 97–99 Roberts, Dorothy, 7

Rothman, Barbara Katz, 122 Russell, H. M., 35 Sauer, Beverly, 102 Schneider, Stephen, 19 Scott, Blake, 22–23 Segal, Judy, 6–7 Seigel, Marika, 139–41 Slack, Jennifer D., 23 Spinuzzi, Clay, 18, 19, 29, 158n3 Spoel, Phillipa, 126, 127 Stark, Martha, 52 Stern, Alexandra Minna, 64 Stevens, Anne M., 56 Stewart, Pamela Rae, 161n4 Still, Brian, 126 Stone, Joanne, 111. See also Pregnancy for Dummies Strong, Thomas H., 5–6 symbolic-analytic work, 73–74 system- and user-centered models, reconciling the, 64–67 system thinking and user-centered theory, 160n6 system-centered orientation and piety, 28, 91–92 system-constitutive documentation, 41, 45, 54, 66, 70–72; examples of, 154–55 (see also Expectant Motherhood); nature of, 40–42; us­ ability heuristics and, 155 system-disrupting documentation, 34, 72, 141; nature of, 73–75; social upheaval and, 155; usability heuristics and, 155. See also What to Expect When You’re Expecting; Women and Their Bodies system-maintaining documentation, 72–75, 78, 154, 155, 160nn2–4; in 1960s, 91–92; Baby­ Center and, 131, 137; defined, 41; main­ stream pregnancy manuals began to rep­ resent, 71; moving beyond, 152; nature of, 71; obedience to doctors and, 91–92; What to Expect When You’re Expecting and, 94–96, 104, 131. See also Pregnancy for Dummies; pregnancy manuals: epideictic system-maintaining instructions, 88; politics of, 82 system-simulating documentation, 129–32, 137, 152, 154, 155 Taylor, Janelle, 126, 128 technical communication, 33, 34, 76, 81–82, 153, 156; aim of, 34; articulation theory and, 23; defined, 10; feminist scholarship in, 7, 8; goal, 152; pregnancy manuals as, 8, 9, 31,

index  183 40, 103; rhetoric, feminism, and, 6–10; as “symbolic-analytic work,” 73–74; system thinking and, 73–74; usability evaluation and, 18, 21 “Technical Communicator as Author?” (Slack), 23, 24 technics of pregnancy, 42–43, 45; defined, 42 techno-medical model of prenatal care, 150–51 Thompson, Joyce E., 69, 159n1 troubleshooting: the risky body, 117–19. See also DOS for Dummies ultrasound, 112–13, 113f, 126, 130, 130f, 150–52. See also prenatal testing technologies usability: definitions of, 15–16; elements of, 16; of pregnancy manuals, 15; rearticulating, 152–56 usability evaluation, 16–18, 157n2; goal of, 22– 23, 33–34; rhetorical-cultural analysis and, 21–24, 33, 153, 155 usability heuristics, developing multi-issue, 155–56 usability research: expanding, 152–53; investi­ gating alternative methods of, 153 “user experience design,” 21–22 user testing, controlled, 20 user-centered design, 16, 19; defined, 19; origin of the term, 16 user-centered model, 19, 51, 56, 151; reconciling system-centered model and, 64–67 user-centered theory and system thinking, 160n6 user-friendly pregnancy manuals, 109–10

Visiting Nurse Association, 69. See also Instruc­ tive District Nursing Association of Boston Walcott, Henry P., 56–57 Wells, Susan, 84, 87 West, Mary Mills, 61, 63, 65, 78 What to Expect When You’re Expecting (Murkoff), 1, 92, 93; “Fathers Are Expectant, Too,” 99; focus on cost-benefit analysis and risk as­ sessment, 1–2, 93–95, 98–99, 101–4; focus on women’s specific problems and concerns, 94; gambling metaphor, 98–99; problems with and criticisms of, 1, 15, 19–21, 132; as system-disrupting vs. system-maintaining manual, 94–96; troubleshooting approach to problem solving, 103, 104; virtues, 94 woman-centered birth, 143 woman-centered maternity care, 146 woman-centered prenatal care, 66–67, 150–51 “Women and Their Bodies” (workshop), 72 Women and Their Bodies: A Course (Boston Women’s Health Collective), 74–76, 80; abortion essay, 83–84; creation of, ix; im­ pact, 88–89; overview, 73–76; photographs, 82, 84f; pregnancy chapters, 80, 81, 83, 87– 88; publication, 73; purposes, 73, 74, 87–88; as system-disrupting documentation, 73– 75, 88, 103–4. See also Our Bodies, Ourselves Women’s City Club of New York, 66 Women’s Health Safety Act of 2012, 6 Women’s Municipal League of Boston, 51–55 Woolever, Kristin, 75