It wasn’t what I’d hoped for : birth narratives, neoliberalism and medicalization among privileged expatriate women in the Hague, Netherlands

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“It Wasn’t What I’d Hoped For”:

Birth Narratives, Neoliberalism and Medicalization

among Privileged Expatriate Women in The Hague,

Netherlands

Masters Thesis

MSc. Cultural and Social Anthropology

Sara Rice

sara@riceoffiong.ca

10918957

December 11

th

_{, 2015}

Supervisor: Dr. Trudie Gerrits

Readers: Anja Hiddinga and Bregje de Kok

Word count: 24,938

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Acknowledgments

When I think back over the process of researching and writing this thesis, the feeling that

overwhelms me is gratitude. I wish to offer my thanks to the people who have made this journey with me. The help and support I have received from Dr. Trudie Gerrits have been constant and remarkable. To work under such an enthusiastic and intelligent scholar has made the effort a pleasure. The comfort and love I have received from my mother and father, Robin and James Rice, has echoed throughout my life, and I would not have been able to complete this work without their words of encouragement and their confidence in my skills. Rhiannon Rice offered her time and energy in keeping the home fires burning, the girls fed and the teapot clean, and without her efforts I would not have been able to juggle home life and student life. My girls Ruby and Harper have grown and become so independent this year, and have kept my work space well supplied with study buddies and cups of tea. Without their willingness to give me space and live with the constant clatter of the keyboard, this thesis would not have been possible. My best friends, Petra and Serena, have been my stalwarts and my inspiration for starting this work and sticking to it and I thank them for the patience it took to keep listening to my ruminations on childbirth and neoliberalism.

The greatest share of my gratitude I offer to my partner, Jason Offiong. His confidence that I could succeed in this endeavour, his incredible patience, his comfort in rough times and his helpfulness at every bend in the road are certainly the reason that I have been able to produce this thesis. With all my heart I dedicate this thesis to him with deep and abiding gratitude for all that he does and is.

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Abstract

At the beginning of every life, there is a birth narrative: the story of a woman endeavouring to deliver her baby safely into this world. Recent medical advances have ensured that birth is safer and less painful than ever before. However, the medicalization of childbirth has also been implicated in new power relationships for women. In this thesis, I investigate the role that neoliberal technologies of the self play in the continued medicalization of childbirth. Using discourse analysis, I analyze the birth narratives of fifteen privileged expatriate women who have given birth in The Hague, Netherlands. I argue that risk, self-surveillance, individualization and responsibilization are technologies of the self that impact the way women plan for, think about and experience birth, and that for some, the result of these aspects of the neoliberal discourse result in the transformation of their natural birth plans into medicalized birth experiences. The conclusion of my research is that neoliberal discourses are implicated in the continued

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Chapter 1 – Background and Theory

Inception and Inspiration

When I arrived in the Netherlands from Canada ten years ago, I was seven and a half months pregnant with my first child. My encounter with the midwifery and medical system in our new home was both weird and wonderful. I was thrilled to find that my desire to give birth at home was seen as normal, not an act of resistance as it had been in Canada. My partner and I quickly got acquainted with the Dutch system, met our midwife, wrote our birth plan, and prepared our small apartment for the imminent arrival of our bundle of joy. Predictably, nothing went to plan. Despite visions of a natural home birth1_{, despite unyielding confidence that I could do it, despite}

acknowledgement that handing over my power to a medical authority would mean that I would be submitting myself to their dominance and overthrowing my own plans, which I knew to be my true preferences – I was an anthropologist, after all, well versed in this type of rhetoric - I caved.

Well past my due date, impatient and exhausted, I went to an appointment at the hospital. I told the gynecologist I thought my waters had broken. I was hoping it was true. I needed to be done being pregnant. I needed to meet this little person for whom I had been providing the best possible environment for nine long months. I needed the pressure and the tension to be relieved, no matter what the cost. In that moment, in that office, I submitted myself entirely to the opposite of the birth I had planned. An induction led to an epidural and delivery in a bed on my back in a room full of machines following the instructions of the doctors. It was everything I had planned

1_{Terms such as ‘natural’ and ‘medical’ have widely varying definitions depending on the point of view of the}

person deploying them. For the purposes of this paper, when I use the term ‘natural’ in reference to birth, I refer to a birth that is unaided by major interventions (epidural, vacuum, caesarian section, etc.). By ‘medical’ or

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to avoid. And it was amazing. When they handed me my daughter, I felt like I could fly. Ruby’s birth was the most brilliant moment in my life. In that room, with all the wires and the sterility and the machines that I had wanted to avoid, we became a family. Happily, with the birth of my second daughter, Harper, I was not so impatient despite being well over-due again, and I got to experience the homebirth I had been dreaming of, and it was as wonderful as I had hoped it would be.

A decade later, in preparing to do this master’s thesis, I decided to take this personal experience as a starting point and try to understand it more deeply. To that end, I met and spoke with 15 privileged, expatriate2 women who shared with me the deeply intimate, inspiring and significant stories of the birth of their children. I was surprised how many of their stories followed a similar trajectory to mine.

When I originally embarked on the fieldwork period, I was interested in finding out if the feminist birth discourse had overtaken the medical discourse in birth narratives of privileged expatriate women in the Netherlands. I had a hunch, based on some articles I had read, that the feminist discourse had become hegemonic – I thought perhaps it was the feminist discourse that was shaping birth practices in the western world. Because the Netherlands is known for its woman centred birth culture3 (see DeVries et al., 2013), I assumed that women who give birth here would be having natural births because they subscribed to feminist ideologies4. What I found instead was that despite the feminist discourse of birth being in evidence, medicalization was not kept at bay. Many of the women I spoke with used the terms and described the

2_{I explain the significance of their status as ‘privileged’ and ‘expatriate’ in Chapter 2.} 3_{I address the Dutch context further in the second chapter.}

4_{Feminist and natural discourses of birth are close enough in their basic precepts that I find treat them as though}

they are the same. Some authors’ analysis sees them separately - see in particular Malacrida and Boulton, 2014; and Lee and Kirkman, 2008.

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ideologies informed by a feminist/natural discourse of birth – the demand for choice of position during labour and delivery; the opportunity to bond and breast feed with their baby; the

opportunity to make choices regarding pain relief, and so forth. But these choices did not necessarily lead to natural births. Indeed, for some of the women with whom I spoke, feminism in the guise of personal choice justified adherence to the status quo of medicalized birth. Just three or four interviews in, I started to realize that my assumptions were incorrect. It took a further four or five to start to feel the edges of something new emerging.

In the meantime, during the interviews I was hearing a certain pattern emerge from the stories: one overarching narrative that fit every woman’s story to a greater or lesser degree whether she had had a home birth or a hospital birth. I came to think of this as the ‘root narrative5’. Certain phrases were appearing over and over again. These phrases included: “I would never forgive myself if my baby were to die”; “I wanted to give my baby the best possible start”; and “the only important thing is that the baby is ok.” Not every cliché6_{would emerge in}

every interview, but their prevalence was surprising and significant. They appeared so often and in such various narratives that I started to pay attention to them. These clichés sometimes looked like part of a feminist discourse. Sometimes they looked like part of a medical discourse.

Sometimes I did not know how to categorize them. As they continued to emerge, however, I realized that the analysis I wanted to undertake for this thesis focussed on these recurring

5_{Root narrative is a term I believe I have invented to describe an expression of a group’s foundational vision of how}

something, in this case birth, is best done. However, it is possible that I read it in the literature about discourse analysis, although I cannot find it in any of the articles I read. A google search turned up a website for Keith Reynold Jennings, a freelance writer whose work has appeared in Forbes, Gallup Business Journal and Becker’s

Hospital Review (http://keithjennings.com). His definition of the term is in line with mine. For the purposes of this thesis, the root narrative is the most general expression of the commonly held beliefs surrounding birth of the women with whom I spoke.

6_{In the chapter on methodology, I operationalize ‘cliché’ but it is instructive here to state that by this term I mean a}

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statements and the discourses they pointed to. In the next chapter I will discuss this methodology further.

Then I read Dubriwny and Ramadurai’s (2013) article about neoliberalism’s focus on entrepreneurial self-improvement, freedom of choice, and individualized sense of responsibility and I realized that all of the clichés I was hearing, whether influenced by medicalized notions or feminist ones, could be categorized under the technologies of the neoliberal discourse. I had wanted to avoid neoliberalism in my thesis. The buzzword of death, that’s how I thought of it. I wasn’t dealing with the economy or politics or power. I was writing about pink, fluffy, lovely birth, wasn’t I? Indeed, the idea of governmentality (Gane, 2012), with the specter of the puppeteer’s hand manipulating poor, unsuspecting subjects, left me cold. Women have choices, they have agency: I did not want to argue against these facts I cherish so deeply. But I needed to somehow understand why the status quo of medicalized birth was an ongoing phenomenon. The more I read about neoliberalism and the more I spoke with women about their birth experiences, the more distinctly I felt the clichés, whether from a medicalized discourse of birth or a feminist one, could be analyzed within the neoliberal discourse. Risk, choice and responsibility,

individualization, cost benefit analysis and self-surveillance all emerged in these women’s narratives. Added to this was my surprise at how often women were acquiescing, as I had, to medical interventions despite often being evidently aligned with a more natural birth discourse during pregnancy, and the picture began to become clearer.

Since then, I have become comfortable with the theory of neoliberalism. I would argue that it emerged as a solution to earlier problems of racism and sexism inherent in earlier forms of government. Prior to the emergence of the market rationale and the democratization of education during the civil-right and women’s-rights movements which led to “increased fragmentation and

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pluralization of voices and interests” (Holc, 2004) and increased economic power for minorities, white men held the vast majority of political power, and therefore theirs was the only voice with influence. Neoliberalism evolved as a response to this political monopoly. I also sense that neoliberal governmentality, subjectivity, and discourse are not the puppet-master’s hand so much as ways people understand their world and the assumptions they make about how to work most effectively in it. Neoliberalism is hegemonic, and it does shape and circumscribe behaviour, but it is not the result of an omniscient and malign power determining the fate of the population, but rather myriad individuals and groups attempting to meet their own needs and working towards their own best interest. Neoliberalism, as with any hegemonic discourse, causes as many problems as it solves, and so into the debate on neoliberalism I offer my insights on how

childbirth is shaped in this era. In this thesis I ask: How is the neoliberal discourse implicated

in the continued medicalization of childbirth in the narratives of privileged expatriate women in The Hague, Netherlands?

In order to answer this question, I analyze the root narrative, expressed by the women with whom I spoke in telling me the stories of their birth experiences. The root narrative I draw from the data is as follows:

1. Birth and pregnancy are dangerous / 2. therefore, I aim to become the perfect

environment for my fetus / 3. so I must make the right choices for her, without references to wider opinion, / 4. because the child is more important than me / 5. and the medical professional is the expert / 6. and at the end of the day the only important thing is that the baby is born safely7.

7_{This root narrative chimed in all narratives to a greater or lesser degree, with one exception: the case of Miliska, a}

Czech woman I spoke with who home birthed her first and freebirthed her second child. Freebirth is a term for a birth at home that is intentionally unobserved and unattended. Neither medical professionals nor midwives are present (Dahlen et al., 2010: 47). For Miliska, the first and fifth part of the root narrative were transformed into: 1. Hospitals are dangerous… 5. I am the expert of my own body. The rest of the root narrative remains the same. I do not discuss this further in the thesis, but felt it important to note here for accuracy’s sake.

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I will spend much of this thesis exploring how and when this root narrative and its various parts emerged in the data, what the clichés contained within it meant for the women I spoke with, and what impact it had on the medicalization of the births of their children. My thesis spans six chapters. In this first chapter, I have provided (above) a sense of the inspiration for, and evolution of my research. I continue by describing my theoretical framework by

introducing and operationalizing the terms I will be using throughout the analysis: neoliberalism, governmentality, subjectivity, discourse, risk, self-surveillance, individualization and

responsibilization. In the second chapter I introduce the women with whom I spoke and discuss my choice of discourse analysis as methodology. In the third chapter, I begin the analysis in earnest; I parse the first two statements of the root narrative to investigate the technologies of risk and self-surveillance. In the fourth chapter I dissect the second two statements in the root narrative to examine the technologies of individualization and responsibilization. In the fifth chapter, I argue that with the pressure engendered by the technologies of self in the neoliberal discourse, when the voice of risk is encountered during labour and delivery, and because of the dual nature of the hospital as both marketplace and institution, women’s plans for natural birth can be overthrown in favour of medical intervention.

Theoretical Framework

Neoliberalism

Neoliberalism is a powerful and wide-ranging analytic tool that has been used to investigate as widely varying aspects of human life as health and safety in Canada (Gray, 2009), reputation in Barbados (Freeman, 2007), the psychic life of classically trained musicians in the United Kingdom (Scharff 2015), and independence in love relationships for women in Japan (Alexy, 2011) to name just a very few. In particular, scholars using neoliberalism (and its connected

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body of work on postfeminism) have engaged with childbirth and pregnancy in a variety of ways. Whether analyzing maternity wedding dresses (Nash, 2013), reproductive justice in unwanted-pregnancy films (Thoma, 2009), or contradictions in Australian maternity policy (Reiger, 2006), childbirth and neoliberalism have been linked.

In particular, this thesis draws on three articles which explore the articulation between maternity and neoliberalism. Firstly, Malacrida and Boulton (2014) use governmentality framing in their exploration of the explanations for caesarian section rates in Western countries. Their work informs my framing of my own ethnographic data. Secondly, Lupton’s (2012) work on the fetal subject and risk were relevant to my understanding of the focus on the fetus over the mother as well as helping to illuminate the technologies of the self that I discuss throughout this thesis. Dubriwny and Ramadurai’s work on discourse analysis of VBAC (Vaginal Birth After

Caesarian) both informed my discourse analysis methodology and illuminated my understanding of the neutralization of the feminist ideology through postfeminism and neoliberalism. Where my work departs from these articles is that it plants these theories within the ethnographic data collected through interviews with a specific group of women. I analyze their narratives through the lens of four technologies of the self that are part of the neoliberal discourse.

Neoliberalism is a perspective on modern life which prioritizes the entrepreneurial process above all else. Whether that entrepreneurship happens at the state, organizational, group, familial or individual level, the project of increasing value through shrewd investment and the mitigation of losses is the highest priority. Put more formally, neoliberalism is a theory

developed by Michel Foucault to describe changes in the relationship between the government and its subjects under democratic capitalism (Gane, 2012). Neoliberalism can be defined as

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a theory of political economic practices that proposes that human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an

institutional framework characterised by strong private property rights, free market and free trade (Harvey, 2005: 2).

Neoliberalism draws not only on the logic of the marketplace as a governing metaphor for life, it also draws on expert discourses of medicine, science and technology to underpin and rationalize this metaphor (Gurrieri et al., 2014: 532). Neoliberalism is at the heart of this thesis. It is the lens through which I look to analyze the narratives of the women with whom I spoke, but it also underpins their behaviour and choices, as well as being present in the world in which their experiences occur. For the purposes of this paper, it is useful to highlight three aspects of neoliberalism: governmentality, subjectivity and discourse.

The term ‘neoliberal governmentality’ describes the way neoliberalism’s entrepreneurial primacy works to control the behaviour of the population. Governmentality structures the world to reward individuals who undertake the neoliberal project of self-improvement, thus shaping citizens’ behaviour to fit within the framework of an entrepreneur-of-the-self (Türken et al, 2015:2). In the neoliberal era “governing at a distance forgo[es] coercion or direct control in favour of seeking to forge an alignment between the self-interested choices of the individual and the goals of those who govern.” (Teghtsoonian, 2009:29) I would argue that the goal for those who govern, apart from the creation of docile subjects who govern themselves, is

entrepreneurial, as well. The devices through which neoliberalism exerts this control are called technologies of the self8. In this thesis, I will examine four technologies of the self: risk, self-surveillance, individualization and responsibilization (described in detail below). These

8_{I have taken the liberty here of condensing the technologies of self and technologies of power originally described}

by Foucault in his lectures in 1982 into one category to facilitate their use. By technologies of the self, I am referring to the ways the technologies of power are internalized by individuals in order for them to attain a certain state appropriate to the neoliberal era (Foucault, 1982: 18).

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technologies are produced through an interaction between the state and her citizenry, and are incorporated into the personal belief systems of many of the subjects.

The term ‘neoliberal subjectivity’ describes the way neoliberalism’s entrepreneurial primacy is incorporated into the way people see themselves, how they behave and what they think. In other words, how the technologies of the self have been normalised and internalized by the subjects operating within neoliberalism (Schwiter, 2012: 154) as a part of their own personal value system (Türken et al, 2015: 3). I argue that as the technologies of the self are rewarded by governmentality they are accentuated in the personal attitudes and expectations of the

population. In order to be good citizens, individuals strive to increase their capital for which they are rewarded by the state which then increases their desire to strive and so forth, which forms a mechanism of control.

The term ‘neoliberal discourse’ describes the way neoliberalism’s entrepreneurial primacy is iterated in this process of striving and rewarding – it is the conversation between the state and her subjects which is constantly being negotiated and shaped by both parties. It is this interaction between governmentality and subjectivity through discourse that I specifically focus on in this thesis because “the self is produced by, and constituted in relation to, discourse” (Türken et al, 2015: 5). Murphy (2002) asserts that the power of this discourse rests: “in its ability to transport major social conflicts into the cultural system, where the hegemonic process frames them, form and content both, into compatibility with dominant systems of meaning” (Murphy, 2002). Thus, I argue that feminist and natural birth discourses can be subsumed under neoliberal understandings of the subject as free and rights-bearing, enacting choices rooted in personal ideologies, so long as they fit the hegemonic discourse of individual-as-entrepreneur. The result is the blurring of the borders between these subordinate discourses and the dominant

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one, and the creation of the feeling of agency while the status quo is sustained (Fannin, 2013: 273). People are understood not as members of special interest groups but as rational individuals “who are active in making choices in order to further their own interests and those of their family” (Rose, 1999: 142).9 Neoliberal thought not only directs policies and discourses, those discourses and policies transform the subjects they touch, shaping their own sense of themselves. “As a hegemonic discourse, neoliberalism is increasingly taken for granted as common sense and [as Harvey, (2005) states it:] ‘has pervasive effects on ways of thought’” (Türken et al, 2015: 1).

Risk

Risk is the technology of the self most directly implicated in the medicalization of childbirth. Safety is the most important aspect of birth for the women with whom I spoke, and notions of safety – and thus the avoidance of risk – underpinned the majority of the decisions they made. However, risk is heavily implicated in the control exerted by neoliberal discourses. Risk, Dean (1999) suggests, is “a way of representing events so they might be made governable in particular ways, with particular techniques and for particular goals” (Dean, 1999: 131).

It could be argued that there is no such thing as ‘risk’ in reality, but rather a calculation of probability that can be used to represent events and situations in particular ways in an attempt to make them more governable (Dubriwny and Ramadurai, 2013: 255). “The risk argumentative frame is an integral part of the neoliberal shift in medical practice that emphasizes patient

9_{It is because of this sublimation of subordinate discourses under the hegemonic discourse of neoliberalism and the}

subsequent blurring of agency and power that it is sometimes difficult to identify what is alternative to the overarching discourse, as above in my opening remarks. In this thesis, the question I asked myself when trying to tease out narratives that were truly alternative was: where’s the money? Where choices were made outside of the idea entrepreneurship (both governmental and subjective) then I felt confident that the narrative was counter-hegemonic.This does not come up again in the thesis, but I thought it might be worth commenting upon to forestall questions on the matter.

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responsibility. In health discourse, the focus on risk serves to define individuals and/or populations as ‘at risk’, ‘low risk’ or ‘high risk’, labels that then necessitate certain actions or interventions” (Dubriwny and Ramadurai, 2013: 255). I would argue that these actions and interventions, in the guise of personal choice and the mitigation of risk to the individual, are implicated both in the control of populations and the promulgation of certain marketplaces, such as the medical establishment, but are obscured through the rhetoric of choice.

Within this framework, individuals are expected to exert control over their own bodies in order to manage risk and increase health. For the pregnant woman, this is even more so. “As a good health citizen, the pregnant woman is expected to act to manage all risks related to her pregnancy and is ultimately given responsibility for producing a healthy child” (Dubriwny and Ramadurai, 2013: 255). The sense of responsibility creates pressure that can be deployed by doctors. In maternity care, because of the irrefutably precious and vulnerable baby (Malacrida and Boulton, 2014), “professional groups gain control by ‘creating risk’ – that is by emphasizing risk, by redefining life events as ‘risky’.” (Bryers and van Teijlingen, 2010: 489)

Because risk does not exist in a concrete form, it is amorphous and mutable; it can be manipulated and manufactured. “In maternity care, it can be difficult to separate objective and subjective risk” (Bryers and van Teijlingen, 2010:489). I would add that the best interest of the woman and her child, and the best interest of the medical establishment and the state can be difficult to differentiate, making the medicalization of childbirth a difficult issue to tackle. Medicalization of childbirth is intended to render birth safe, ease pain and as a barrier to death (Lock and Kaufert, 1998: 7), goals which are difficult to condemn and often impossible to resist. On the one hand, statistics show that advances in medical technology, knowledge and techniques have been effective in lowering rates of infant and mother mortality (Snowden et al., 2011: 1).

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On the other hand, medicalization is also implicated in power relationships. “Bodily states are labeled by experts as diseases; certain behaviors are defined as deviant, unnatural, immoral, opening up the way for systematic and legitimized attempts at medicalization of both body and behaviour” (Lock and Kaufert, 1998: 7).

Medical professionals deploy notions of safety, which can limit choices (Bryant et al. 2007:1196), and medical knowledge claims a privileged status based “on the belief, shared by medical professionals and the public alike, that scientific knowledge, being factual, cannot be subject to epistemological scrutiny.” (Lock and Kaufert, 1998: 6) I recognize with Lock and Kaufert (1998) that in fact biomedicine and its associated technologies are discourses that spin and weave a reality for and from the individuals who move inside of them. As with feminist and natural birth discourses, the biomedical discourse is subsumed under the rubric of neoliberal discourse. Unlike the former two, however, biomedicine holds a place of distinction in the development and deployment of neoliberal governmentality, as it is explicitly used to underpin the notion of risk and the causal link between our choices, behaviours and actions and their outcomes (Gane, 2012). “Medical ‘knowledges’ have been particularly successful in setting up medico-scientific discourses of the body as unquestionable or self-evident” (Bryant et al., 2007: 1196). These discourses hold a powerful position in the neoliberal era.

Self-Surveillance and the Nature of Hospitals

With the emergence of the neoliberal era, there has been an evolution in the nature of surveillance, devolving it from the state and her institutions (prisons, hospitals, factories, schools, etc.) to the individual as a consumer (Gane, 2012). Institutions once held power over subjects by disciplining bodies, describing norms and mores, and ensuring that citizens fit within

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those moulds (Gane, 2012: 619). In other words, they told citizens how to act, and disciplined them when they failed to comply. I would argue that as the civil and women’s-rights movements gained power, education was democratized and consumer power came into the hands of these new groups. This stimulated new demands for equal representation and the diversification of products and services to fit these emerging groups’ needs. Opportunities for new markets emerged, and in response, institutions diversified their services in order to attract business.

In the process, institutions evolved from monoliths which told subjects how to act, to marketplaces offering a variety of services from which the subjects might choose. However, because of the standing of science, medicine and technology in the neoliberal era, the medical industry did not entirely lose its role as institution, and thus the hospital occupies both roles: marketplace and institution. As I will show in upcoming chapters, during times of no medical crisis, hospitals are seen as marketplaces in which people may choose from a variety of options. In this way, hospitals respond to the agency aspect of neoliberal subjectivity which demands choice and freedom. Agency is seen as key to patient satisfaction, but can obscure new power relations between doctor and patient (Gerrits, 2014: 126). I would argue that this is because hospitals are also institutions. They are endowed with the power to categorize bodies through technological and medical expertise (Lock and Kaufert, 1998: 7), and they are seen as the repository for medical expertise and knowledge which can mitigate risk during times of crisis. This duality in their identity affords them the powerful position of attracting subjects by offering the freedom of choice on the one hand, and the expertise to offer a voice of authority on the other. I will argue that in preparation for birth, women interact with the hospital in its guise as marketplace, but during the birth itself, they often submit themselves to the control of the hospital in its guise as an institution.

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In interacting with the hospital and various other industries as a marketplace, individuals become (health) consumers, free to choose among a variety of options. These choices require “reason and rationality, a weighing up of risks and benefits, and an ordering of preferences based on their utility” (Schwiter, 2013: 1). Self-surveillance is the technology of the self that compels citizens to gather information about risks and outcomes, and strive to be vigilant in their self-discipline in order to manage those risks and outcomes (Lupton, 2012: 330). The gathering of data to inform choices, the discipline it takes to weigh the benefits and the costs, the time and energy required to order the preferences form the new, subtler control of self-surveillance (Gane, 2012). “Whereas discipline works through fixity and confinement, control operates through mobility and speed… control is not moulded to remain in a fixed form” (Gane, 2012: 620). I argue that managing potential outcomes, even when these outcomes are unmanageable or have no calculable measure of success or failure, becomes the entrepreneurial project of the neoliberal subject, requiring constant flexibility as she adapts to the relentlessly advancing information, the undertaking of which becomes a form of control. For pregnant women in particular, this form of control is highly effective. “There is a recurring assumption that women have, or should have, choices over the kinds of birth they will experience and they can or should manage those choices by planning and preparing responsibly” (Malacrida and Boulton, 2014: 42). A pregnant woman must not only undertake self-surveillance as she strives to be a good enough entrepreneurial subject for herself, but she must also be the perfect environment for her precious and vulnerable fetus. Added to this is the unpredictable nature of child birth which means that self-surveillance must be undertaken without any expectation that it will affect the actual outcome.

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Individualization

Another technology of neoliberalism is individualization. Individualization is the technology of the self that compels subjects to see themselves as “free, self-interested, and autonomous” (Türken et al, 2015: 3) which atomizes their interests down to the level of the individual,

divorcing citizens from larger and more powerful special interest groups. As I argued above, the civil and women’s rights movements gained economic power for groups other than white men, and institutions began to shift in order to capture those target markets. In the 1980s and 1990s as these shifts allowed diverse groups (i.e. women, people of colour) to gain power, groups within those groups (i.e. poor women, disabled women, gay women, etc.) asserted their right to be addressed specifically as well. Particularly in Canada and America, the exploitation or

misappropriation of voice became an important focal point of political correctness. Men could no longer speak for women, nor white person for black, rich for poor, straight for gay, able bodied for differently abled, etc. Groups with more and more specific identities affirmed their right to be considered as consumers with specific needs and desires, and responded to by the marketplace10.

I would argue that this atomization of identities resulted in the sense that no one could speak or act on behalf of any other person, resulting in the individualization of the neoliberal subject. Group identity was replaced by individual identity, where the only meaningful reference is personal choice (Dubriwny and Ramadurai, 2013: 247), girded by the priority of

entrepreneurship to improve her position and the position of her family. “Thus, the

entrepreneurial subject is expected to individualize anything to render it manageable. What is

10_{I write this from the personal experience of living through and undertaking my undergraduate degree during the}

1990s, at the height of the post-modern movement where political correctness demanded that no generalization from one individual to another was possible or appropriate unless those individuals shared every aspect of identity, which was deemed impossible. An artefact of this aspect of my education is evident in the fact that I often refer to “the women I spoke with”, refusing generalization to anyone outside the scope of this specific research. In the name of brevity, however, I sometimes refer to ‘the respondents’ instead.

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prescribed for the individual is to develop herself to a more robust subject…” (Türken et al., 2015: 8). In this process of individualization, feminism was atomized as well, as identities other than womanhood emerged as key, and social solidarity gave way to the pre-eminence of personal choice. This new personal-choice focussed post-feminism acknowledges “the importance of key women’s health movement ideals… but at the same time undermines feminist interpretations of women’s health issues.” (Dubriwny and Ramadurai, 2013: 248)

By reducing all decisions to a matter of personal choice, the overarching patterns, and therefore the political meaning behind those patterns is obscured (Gane, 2012: 621). Feminist critiques of medicine, such as Dubriwny and Ramadurai’s article on postfeminism in the delivery room, express concern over the loss of these patterns and the consequential effect on women. Instead of offering a political and moral position in which to moor decisions about childbirth, various aspects of the feminist/natural birth discourse are reduced to a few more options among many in the maternity market; a choice neutralized of its significance because of the focus on personal choice. In this thesis, I show that in the case of the medicalization of child birth, this means that individual women’s actions appear to be unconstrained by mechanisms of control because they spring from the needs of the woman, but the circumstances of those needs are wrought by the central neoliberal discourses within which women are operating, and which deploy these technologies of the self in order to maintain control. Women, therefore, undertake self-surveillance in order to advance their individual entrepreneurial project in circumstances where their choices are neutralized of greater political meaning. Because they are afforded the opportunity to make their own choices, the responsibility for the outcomes of those choices are seen as entirely their own.

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Responsibilization

Atomized away from group ideologies in which to ground action in the name of wider political and moral mandates, and with the freedom to make personal choices in the marketplace, the individual is obliged to take responsibility for the outcome of her choices. Responsibilization is the technology of the self in which individuals are compelled to “take responsibility for

enhancing their capacities, for responding to needs and challenges as these arise, and for monitoring and managing various different types of risks to which they may be susceptible (genetic, lifestyle, environmental)” (Teghtsoonian, 2009: 29). In other words, each individual is busy with her own entrepreneurship, gathering and interpreting information and making rational cost-benefit calculations to extract as much as possible from the marketplace and to reduce risks to herself and her family.

The strategy of rendering individual subjects ‘responsible’ entails shifting the

responsibility for social risks such as illness, unemployment, poverty, etc. and for life in society into the domain for which the individual is responsible and transforming it into a problem of ‘self-care’ (Lemke, 2001: 201).

Obscured in the process are “the social and political culture in which individual responsibility is embedded and experienced” (Gray, 2009: 328). When outcomes are negative, responsibilization creates conditions where individuals are held accountable and blamed (Gray, 2009: 326) for their failure to respond appropriately to the ever-changing information about how to mitigate risks or improve selfhood. “The neoliberal subject then has no one to blame but herself if she fails…” (Türken et al.: 3).

In the case of the pregnant subject, she is “expected to engage in a bewildering array of risk-aversive behaviours to ensure the health and optimal development of [her] foetus.” (Lupton, 2012: 330) She is held accountable not only for failure to improve her own personal self-hood, but is also responsible for the ever precious and vulnerable baby. Pregnant women must

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“stringently monitor and control their body for the sake of their foetuses” (Lupton,2012: 330). The responsibility for the health and wellbeing of the fetus rests on the shoulders of the woman, but the power to shape the outcome does not. As I will show, women are expected to be

responsible even when birth is acknowledged to be unpredictable. I will also show that women are more likely to blame themselves than lay blame at the feet of the medical professional11_.

These technologies of the neoliberal discourse; risk, self-surveillance, individualization and responsibilization; are implicated in the ways the women I spoke with planned for birth, how they experienced birth, and how they described those experiences. Before I turn to an analysis of their narratives, though, allow me to introduce the women whose birth narratives I have had the privileged to explore, the context in which they gave birth, and the methodology I employed in order to understand how neoliberal discourses shaped the way they gave birth.

11_{Of interest here is also the nature of medical litigation and the responsibilization of professionals for negative}

outcomes particularly in the United States, however as this did not emerge in the data (perhaps because the majority of my respondents were British) I have chosen not to explore this topic further due to limited space.

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Chapter 2 – The Women with Whom I Spoke

Sample

For this research, I interviewed fifteen women, twelve of whom are from the United Kingdom, one from Canada, one who was born in Serbia and raised in Canada and America, and one who is Czech. Two of the British women have Dutch partners and the rest have partners from outside of the Netherlands – two are from France, one is from Spain and one is from Morocco. The most significant outlier is the respondent from the Czech Republic (see footnote 7 of this thesis, page 7). Hers is a more complicated case as she gave birth unattended (also known as freebirth) which is a story I was particularly interested in as it is counter to the hegemonic discourse. However, because her story pulls in the opposite direction to the question at hand, and due to limited space in which to explore these issues, I have included her in my overview of respondents, but her story only makes the briefest of appearances in this paper.

I deployed various strategies in order to gather respondents. I attempted to engage friends of mine as gatekeepers which garnered two respondents. At the same time, I reached out to women I knew through my partner’s work, which yielded three respondents. I met another respondent through a chance encounter in our local shopping centre. As these interviews were underway, I emailed the administrators of two Facebook groups based in The Hague that are targeted at pregnant women and new mothers, and asked for permission to post a notice to their members. One of the two failed to respond but the other, Bumps and Babies Den Haag, gave me permission after seeking confirmation from my supervisor. I posted requests for respondents twice. It was from this source that the rest of my respondents were found. I attempted to contact playgroups and other toddler-based activities as well but received no response.

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The sample, therefore, consists of 15 women who have given birth to 26 children total. 19 of the 26 children were born in the Netherlands, one was born in Germany, two in France, and four in England. Each interview lasted between 90 and 120 minutes with two exceptions: one interview took two sessions of over 90 minutes each, and one of the other interviews was a little over 75 minutes. All interviews were conducted in English, at the respondent’s home, except in two cases: one interview took place at a café and one took place at my home. I enjoyed the conversations and felt comfortable in my role as an interviewer. In three or four interviews, the emotional content was more difficult, especially where the woman had suffered trauma during birth. Fortunately, in those cases, some of the women described having the opportunity to speak about their experiences during the interviews as therapeutic.

In order to access plans and preferences as they occurred prior to birth, I analyzed the birth plan of each respondent where one had been written. A birth plan is a document written by the woman and her partner prior to the due date expressing preferences for a variety of aspects of the birth. Birth plans included wishes such as who should be in attendance, where the birth should take place, what pain relief measures will be considered, details about interventions, etc. In most cases, the respondent sent me an electronic copy of her birth plan prior to the interview. In one case, she had no electronic copy but gave me paper copy upon arrival. In three cases no plan had been written; in these instances, I sent a small questionnaire in advance and requested the responses ahead of the interview. Use of birth plans may skew the sample somewhat to individuals more likely to be interested in a natural birth because they were originally introduced by childbirth educators as a tool to help women avoid interventions. Recently, however they have gained widespread use (Lothian, 2005: 295). I found it a useful tool to access assumptions and discourses as they existed prior to the birth experience.

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I recorded each interview, and transcribed them verbatim. I chose pseudonyms for each participant in order to protect their identity. The quotes from the interviews have been gently edited for clarity where necessary (the elimination of ‘uh’s and ‘um’s, for example) but I have taken pains to keep speech patterns, personal style and original meaning in tact. At the end of the fieldwork period, I printed and hand-coded the interviews and wrote first drafts of the first two chapters. However, I found that I had not been specific enough in my coding – for example at first I had coded for all instances of risk including the risk of the neighbours hearing noises during birth or the risk of a partner having to work during the labour, whereas only medical risks ended up being important to my research. Therefore, I reprinted and recoded the interviews in line with new insights gleaned from the writing process, sharpening my focus on the ‘clichés’ that emerged from the data and their connection with the neoliberal discourse. This re-coding, in conjunction with further literature-based research, yielded a deeper understanding of my

argument. In this way, I consider my research to be grounded in the data.

In order to get a sense of the narratives, it will be instructive to give an overview of the overall patterns that emerged from the data. I interviewed 15 women. Five of the fifteen women I spoke with planned for a natural birth and subsequently experienced a natural birth with all of their children. An additional woman had planned a natural birth for her second child and it went as planned. A total of nine children were born to these six women. Of them five of the children were born outside of the hospital, either at home or at the geboortekliniek12. The other four children had been delivered in the hospital. In all four of those cases, the time between arriving at the hospital and the birth of the child was less than three hours.

12_{Geboortekliniek is a birth hotel, often attached to a hospital, where women are supported by midwives in rooms}

that are more homely and comfortable than a hospital delivery room, and where no medical equipment is apparent. The proximity to the hospital means that if there is an emergency, medical staff and resources are available quickly.

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Five of the fifteen women I spoke with preferred to follow what I categorize as

medicalized birth: due to health issues or personal inclination, they saw birth as a medical event from the beginning. A total of eleven children were born to these five women, all in the hospital. Apart from two of the children, one of whom was born within 40 minutes of arriving at the hospital, there were major interventions (inductions, caesarians and/or vacuum assisted vaginal deliveries) in every case.

Five of the fifteen women I spoke with planned for a natural birth and ended up with medical interventions. A total of six children were born to these five women. All six children were born in hospital. Two of these births had been planned in the geboortekliniek but were transferred over to the hospital: in one case because the geboortekliniek was full, in the other because the woman opted for an epidural and was therefore transferred into medical care. In the birth of all six of the children, there were major interventions. Two of the six were delivered by emergency caesarian section, three were induced, and in all cases but one an epidural was administered. In one case, the baby was born vaginally with an epidural but no other

interventions, but then was kept in the hospital for a week in order to administer prophylactic antibiotics. In most cases, these were the first birth experiences for the mother.

Special attributes of the women

In the title of this thesis, I offer two descriptors for the women with whom I spoke: expatriate and privileged. Allow me to address the reason for this.

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Expatriate

The women I spoke with were from overseas, and were living in the Netherlands temporarily13 based on the availability of employment either for themselves or for their partner. In the two cases where the respondent was partnered with a Dutch man, the expectation of the respondent was to eventually move away from the Netherlands.

There are three reasons that I chose to interview expatriate women. Firstly, from a methodological point of view, the fact that they gave birth in a country other than the one in which they were raised allows differences in cultural ideologies to be highlighted by the dissonance between expectations and reality. In other words, the women I spoke with were sometimes surprised by the difference between how they expected birth would go in their home country, and how it went in the Netherlands. The space between these two allows for self-reflection that may not have been possible in other circumstances (Trowler, 2014).

Secondly, the fact that they gave birth in the Netherlands specifically is interesting because the Netherlands has a reputation for an alternative view of birth. The preponderance of home birth, the status of the midwife, and the relationship between the midwifery and medical establishments, have all led to much ado in the scholarly and lay press (see, for example,

DeVries and Barosso, 1997; DeVries, 2001 and 2004; DeVries et al., 2007; Wiegers et al, 1998). That the Netherlands offers such a different version of the maternity marketplace amplifies the space between what is expected by expatriates and what is offered, allowing for deeply held assumptions to be investigated in more profound ways. It is my experience of both hospital and home birth in the Netherlands in particular that originally drew me to research this topic, but as I

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undertook the interviews, the importance of the Dutch context seemed to recede, particularly in light of the fact that only two of the women I interviewed felt that home birth was an attractive addition to the maternity marketplace.

Lastly, from a pragmatic point of view, as I am an expatriate myself, I have access to this population, for the most part I speak their language14_{, and I share certain aspects of their lifestyle}

and history. I am both an insider to this population (Motzafi-Haller, 1997), which means I can empathize with their experiences and understand the stories they tell in a personal way. However, due to my training as an anthropologist, I can also act as an outsider. The analysis I pursue in this thesis regarding neoliberalism is formed along etic categories of understanding; ones that I was not aware of in my birth experience, nor were they addressed by any of the women with whom I spoke. While this insider/outsider position helps me to see both subjectively and objectively, it is possible that it creates blind spots as well. For example, I was surprised to find that the women I spoke with were not interested in giving birth at home, and equally that some were not happy with their life in the Netherlands. Though I have attempted to moderate the effects of these false assumptions and biases, it is probable that my analysis is nonetheless shaped by them.

From the respondents’ point of view, my position as both an insider and outsider was also visible. The women I spoke with took me into their confidence and discussed deeply private matters including bodily functions, personal beliefs and the intimate events surrounding the birth of their children15_{- sharing which may not have been possible with an interviewer with a}

14_{With the exception of Miliska who spoke English as a second language to her native Czech, all of the women with}

whom I spoke had English as their mother tongue or were fluently bilingual.

15_{I also shared my birth narratives with them when I felt it was appropriate to do so, and certainly whenever they}

asked me to. Offering my own story sometimes became a way to highlight an issue, sometimes a way to encourage further sharing. I came to understand more deeply my own birth narrative as I described it over and over.

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different background and identity. My role as an outsider was also apparent; the respondents often assumed more expertise about birth on my part than I actually possess. In the end analysis, I felt that my status as an insider/outsider was a benefit not a burden.

Privileged

None of the women I spoke with claimed a particular class as part of their identity during our conversations, yet it would seem disingenuous to ignore it as a variable in their subjectivities and understandings. The majority of the women with whom I spoke enjoy above average financial security. I postulate that this privilege may increase their perceived and actual consumer power. Presumably, their choices about how to give birth are not constrained or limited due to economic barriers, but by ideological and subjective ones, allowing a deep investigation of the discourses in which they operate without the confounding variable of financial factors. I suspect that

technologies of governmentality are unevenly distributed, and may be distinctly directed towards this socioeconomic bracket because their income allows a greater level of consumption which equates to increased revenue, although that is not an argument I am making in this thesis. Thus it is possible, yet not fully elaborated, that the economic standing of the women with whom I spoke results in a more effective and more profitable governmentality.

Methodology

The goal of this work is to gain access to the underlying assumptions about birth that the respondents hold in order to understand how plans are transformed into actual experiences and how these events and stories articulate with neoliberal technologies of the self. The methodology I use to do so is discourse analysis of personal narratives; a methodology widely acknowledged to access the context-dependent and socially-constructed nature of cultural reality (see for

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example: Talja, 1999; Gill, 2000, Blommaert and Bulcaen, 2000). “In general, the interest in narratives has been motivated by the idea that individuals make sense of their ‘realities’ through the stories they tell and hear” (Mura, 2015: 226). In order to understand and analyze the

narratives of the women I spoke with and how those narratives are shaped by neoliberal

understandings, I explore the language they used to describe their expectations and experiences of birth.

In undertaking discourse analysis, I use the root narrative offered in the previous chapter to reveal assumptions and understandings that underpin for the respondents their experiences and emotional states during pregnancy and child birth. As I stated, I operationalize the term ‘root narrative’ as an expression of a group’s foundational vision of how something, in this case birth, is done. In order to analyze this root narrative, I focus on certain aspects of language as they are deployed and negotiated by the respondents. Firstly, I locate clichés or key metaphors. For the purposes of my research, I operationalize ‘clichés’ to mean sentences or phrases that reoccurred verbatim or close to verbatim in different narratives. I believe that the deployment of clichés indicates what Talja describes as a limited view point, where “the objects, style and themes of talk are selected and common concepts are defined” (Talja, 1999: 467). This limited view - the hegemonic framing of a subject - Talja argues, is the very core of discourse. Secondly, I

highlight statements of basic assumption (often framed by the code ‘of course’ or ‘naturally’) as they express what is assumed by the speaker to be universally true, commonly known and

unequivocal; these can be mined by the analyst to discover deeply held values (Talja, 1999: 467). Throughout the entire thesis, I use discourse analysis to refer back to the technologies of the self that I have described in Chapter 1, and to discover how underlying assumptions about

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neoliberalism served to frame the way the women I spoke with presented themselves and the stories of their births16.

The birth narratives of the women with whom I spoke allow valuable insight into the way neoliberal governmentality shapes and constrains choices and experiences in the maternity marketplace. At last, it is time to hear from the women themselves, and begin to understand what their stories reveal about the continued medicalization of childbirth.

16_{This thesis is also a piece of discourse, intended to convince readers of the validity and accuracy of my point of}

view. Throughout the writing process I have been conscious of the linguistic choices I have made (baby vs. fetus, for example) and the deployment of themes, accents (positive or negative framing of ideas) and basic assumptions. I acknowledge this without agenda, as I hope my discourse has its intended effect, and that you, the reader, are swayed by my argument.

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Chapter 3 – Risky Birth and Creating the Perfect Environment

In this chapter, I parse the first two phrases of the root narrative. In section 1, I explore the assumption that ‘birth and pregnancy are dangerous.’ In order to access this assumption, I

investigate risk as a technology of the self. I argue that risk is used as an explanation for having a hospital birth, which is a necessary condition for the medicalization of childbirth17. I then draw from the data the prevalence and role of horror stories: the reinforcing tales that women share which serve to justify their own experiences and choices, and create the conditions for other women to follow suit. I argue that these cautionary tales are part of the discourse that create social control for pregnant women. I will then offer some examples of women whose births were easier than is generally the case, arguing that counterhegemonic narratives are seen to be

unwelcome, embarrassing or impolite – further evidence of the social control quality of discourse.

In section 2, I analyze the second phrase of the root narrative: ‘I aim to become the perfect environment for my fetus’. Drawing on the self-surveillance technology of the neoliberal discourse, I argue that many of the women I spoke with engage in information gathering and self-discipline in the hopes of mitigating negative consequences and increasing positive ones. I then offer some examples of women who reported instances where they refused to conduct self-surveillance, and were subject to social control for their resistance. I argue that the technology of self-surveillance provides a sense of agency by focussing attention on the need to plan for birth, but the pressure the respondents feel to be the perfect environment can be manipulated by the medical professionals to necessitate action and intervention.

17_{This is particularly true in the Netherlands where home birth is a common option. In other western countries, birth}

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Section 1 – ‘Birth and Pregnancy are Dangerous’

There is no shortage of literature that links risk and pregnancy, and particularly the social

construction of risk and the power of the medical establishment (see for example, Chadwick and Foster, 2014; Handwerker, 1994 and Bryers and van Teijlingen, 2010). Risk is described in this body of literature as a cultural artifact (Handwerker, 1994), the possibility of consequences that are negative or unintended (Bryers and van Teijlingen, 2010), and as formed by cultural and social norms which are locally and historically variable (Chadwick and Foster, 2014: 69). Indeed, Chadwick and Foster state: “nowhere is the pervasiveness of risk more apparent than in the sphere of pregnancy and childbirth” (Chadwick and Foster, 2014: 69). My research reflects and confirms that risk is indeed heavily implicated in the narratives of the women with whom I spoke. In this chapter, I argue that risk appears in the birth plans of the respondents as the justification for giving birth in the hospital, and also in section two, I show that risk underpins their use of self-surveillance. I return to the notion of risk in the fifth chapter, when I analyze the voice of risk – an authoritative opinion that reifies general risk into specific danger.

For the most part, the women I spoke with felt that birth was a high risk event. In order to access this assumption, in this section I will draw from the data the discourse about the choice of hospital or home birth. Discourses regarding the choice of hospital or homebirth are instructive for three reasons. Firstly, birthing in the hospital opens the pregnant body to categorization of normal and diseased states that come from a medico-scientific discourse of risk; one which can be manipulated to make the pregnant body governable (Dubriwny and Ramadurai, 2013: 255). Secondly, home birth is a radical response to neoliberal government because it circumvents commodification. Other than the salary of the midwife, it drives no economic engine. Thirdly,

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one of the main differences between birth practices in the Netherlands and those of other wealthy western countries is the rate of homebirth. Ten years ago, the rate of homebirth was 30%, five years later, the rate had dropped to 23% (DeVries et al, 2013: 1123). Since then it has fallen even further18.

This drop in prevalence notwithstanding, homebirth is one of the important ways the maternity marketplace is different in the Netherlands. However, for most of the women I spoke with, homebirth did not represent an appealing addition to the birthing options. Ten of the fifteen women that I spoke with chose to give birth in the hospital19. Of the others, one was advised to have a hospital birth due to her physique, three chose to give birth at a geboortekliniek (although two of those ended up in the hospital), and two gave birth at home20_.

For Tazma, an older mum of three from England whose two younger children were born in the Netherlands, homebirth wasn’t an option because of:

the slight possibility in case something goes wrong and you need quick attention. Although the probability is so low now, I realize. But then when you are actually pregnant yourself, you don’t want to take that slightest risk. I think that’s what it is…. I don’t take that slightest risk. (Tazma)\

18_{A Dutch midwifery advocate put the number at 17 percent during a symposium with American midwifery guru}

Ina May Gaskin I attended in September, 2015.

19_{In contrast to other countries, giving birth in the hospital in the Netherlands can sometimes incur fees (personal}

communication from Femke, a midwife I interviewed). Midwives are given primacy over birth in the Dutch system and the screening of pregnant women is done by them with reference to the VIL (Verloskundige Indicatie Lijst - a concrete list of conditions under which the woman is referred to a gynecologist). Also, Dutch insurance coverage only pays for gynecological care of birth in cases where the mother or the baby have an indicated condition. (DeVries, 1997)

20_{In one case, the woman’s first child was born at a birth clinic in France and her second was a homebirth in the}

Netherlands. In another case, the woman’s first birth was at a geboortekliniek and the second at the hospital. In all other cases, women were either having their first child or they had all of their children in the same type of place (i.e., in a hospital or at their home – but not necessarily the same hospital or home as the first birth).

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In Tazma’s explanation birth is risky, despite recognizing that the probability of something going wrong is low. Concern over the ‘slightest risk’ led her to feel that the hospital is the safest place to give birth.

For Clara, a mother of three from England, the idea is expressed much more fiercely, having had three difficult births with her sons - all of whom had been born with the cord wrapped around the throat prohibiting breathing. Two had been born in England, and the youngest was born in the Netherlands. She told me:

the idea [of homebirth] for me was just too terrifying because I had been in so much pain with Ian and Noel and it [labour] had been so long, and the idea that they had had

problems. There was little chance that they would have survived if we had had the baby at home. (Clara)

I’ve highlighted part of Clara’s statement in order to draw attention to one of the prevalent assumptions about the difference between home and hospital birth: that a child that had problems in the hospital would have died in a home birth. This connotes that midwives, who are the usual attendants at home deliveries, would be unable to identify risks in time to be able to deal with them. The assumption is that the expertise, knowledge and technology necessary to mitigate risk is only available within the medical establishment. Femke, a Dutch midwife, argued that this is not the case. She told me:

That’s my whole job, is to see what is happening, that everything is going right. I am trained in learning to see the signals if something goes wrong or is not going as well as it should be. So it always makes me angry to hear stories of people saying ‘Oh, I was glad I was in the hospital because if I was at home, I would have bled to death.’ They never would have! I would have got them in hospital in the blink of an eye… (Femke) In Femke’s experience, she can assess the level of risk in time to change plans before harm is done, making it to the hospital if and when needed.

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However, the primacy of medical knowledge and the potential need to race to the hospital emerged in numerous statements about the risks of home birth. For Joanie, a lawyer raised in Canada and the United States, the hospital was the only option because she did not want to move in the middle of her labour:

I just really felt comfortable knowing that if you need an intervention, it’s there. As opposed to having to wait for an ambulance… can you imagine having to move when you are 8 or 10 centimetres [dilated]?… that doesn’t sound like something I want to do, ever. Because we had a C-section with this one, and I’m really grateful we were in a hospital at that time, I wouldn’t consider it [homebirth] [for any subsequent children]. (Joanie)

Ironically, Joanie and her partner did have to move during labour at four centimetres dilated, from one hospital to another because the first one was full. Joanie’s sense that she may need an intervention underlines the sense of risk she feels.

The hegemonic discourse of birth as risky, and the primacy placed on medical expertise as the best response to this risk, underpin medicalization of child birth. One of the ways this discourse is disseminated is through horror stories among women. Many of the women I spoke with were confronted with nightmarish stories about birth from friends, family members, colleagues and even strangers. Joanie put it succinctly when she said:

as soon as I got pregnant, that is when all of the unsolicited advice started coming in and it was so negative. All the women were just happy to share the horror of their birth. No one was saying: ‘you know, actually, I had a good experience.’ (Joanie)

For Hatty, a young business woman from England, her friends were more graphic in their descriptions once she was pregnant. She told me: “I think they are probably more descriptive [about horror stories] with people who either are pregnant or have [babies].” Once a woman is

It wasn’t what I’d hoped for : birth narratives, neoliberalism and medicalization among privileged expatriate women in the Hague, Netherlands