TABLE OF CONTENTS
Acknowledgements i
Epigraph ii
Introduction to childbirth and cinema p. 1
1. Childbirth - physiology, medicalization, history and practice p. 6
1.1 The physiology of childbirth p. 6
1.2 The medicalization of childbirth p. 8
1.3 Current medicalization practices p. 9
1.4 The medicalization of childbirth in historical perspective p. 10
1.5 Childbirth in America p. 11
1.6 Childbirth in the Netherlands p. 12
2. Theory at the base of the research p. 15
2.1 Exploring the field of childbirth representation research p. 15
2.2 Childbirth in the movies p. 17
2.3 Schema theory, scripts and childbirth p. 19
2.4 A cross-disciplinary effort p. 21
2.5 Corpus, methodology, variables and values p. 22
3. Results and a content analysis p. 24
3.1 A brief introduction to the film corpus p. 24
3.2 Childbirth (screen) duration (Variables 1 and 2) p. 24
3.3 Alignment in childbirth (Variables 3 and 4) p. 26
3.4 Location of childbirth (Variable 5) p. 29
3.5 People present at childbirth (Variables 6, 7 and 8) p. 30
3.6 Stages of childbirth (Variable 9) p. 33
3.7 Bodily fluids of labour (Variables 10.3 and 10.4) p. 34
3.8 The crowning and the vagina (Variable 10.5) p. 36
3.9 The bonding period (Variables 10.8, 10.9 and 10.10) p. 38 3.10 Postures in childbirth (Variables 11 and 12) p. 39 3.11 Pain relief methods (Variables 13 and 14) p. 41
3.13 Sounds of the birthing woman (Variable 16) p. 43
3.14 Birth outcomes (Variable 17) p. 45
3.15 Childbirth scripts p. 46
4. Discussion p. 47
4.1 A brief discussion of the results p. 47
4.2 On authoritative knowledge p. 49
4.3 On the disruptive qualities of Wanderlust p. 49
4.4 On that which has not been discussed p. 51
Conclusion p. 53
Bibliography p. 56
Appendices p. 66
Ϩ Appendices belonging to Chapter 1 p. 66
Ϩ.Ϩ Midwifery in America
Ϩ.ϩ Cultural and structural factors in the Dutch maternity care system Ϩ.Ϫ The Dutch media
ϩ Appendices belonging to Chapter 2 p. 68
ϩ.Ϩ The corpus of 61 films
ϩ.ϩ Description of variables and values
Ϫ Appendices belonging to Chapter 3 p. 77
Ϫ.Ϩ Distribution of genres of the films
Ϫ.ϩ Overview of genre, historical setting, opening weekend /total income Ϫ.Ϫ An example of the indication of the duration of childbirth in real-life Ϫ.ϫ The crowning and the vagina
Ϫ.Ϭ Principle component analysis (PCA) graph and data
ϫ Appendices belonging to Chapter 4 p. 93
ϫ.Ϩ Wanderlust, transcript of the childbirth scene
ϫ.ϩ Wanderlust, transcript of the childbirth scene, including analysis ϫ.Ϫ Wanderlust, screenshots of the childbirth scene
i. ACKNOWLEDGEMENTS
This research project has been somewhat of a birthing process. As with the birth of a child, one cannot predict the time it will take to move through the process. It must be welcomed, accepted and met with an open heart, a keen eye and clear vision. And a whole lot of letting go, while stepping into the greatest unknown known to man. To woman, actually. My words of gratitude are for the many individuals who have supported me and my family throughout this extended period in my life in which I placed childbirth at the center of my learning. To the places I have traveled, the women I have had the privilege to journey with and the stories that were told. I share this work in honour of you. Thank you. Grandmother Riet for sharing your many childbirth stories, they instilled in me the reverence for its normalcy. Zonne for teaching me childbirth, every day anew. Grandmother Masouda for giving birth to my mother Dina, and her for giving life to me, raising me and being my mother, always. Kees for being my father and standing behind me and walking with me, always. Marjolein, Timor and Vinqui for being my blood, witches in crime, and for talking vaginas over dinner, at any time. Charles for your years of patience, enthusiasm for this project, guidance along the way - but also for being an inspirational teacher over the many years I have -on and off- frequented the University of Amsterdam. Erik for taking on the task of second reader, and that our paths are crossing yet again. Raymond, sorry you could not be an official reader, but thank you nonetheless for your help. We share this passion and I have a hunch our roads will cross again soon. Now that this phase of my academic journey is coming to an end, I want to thank several teachers who have sparked much joy in me. Ena Janssen (baie dankie!), Kaouthar Darmoni (power to the feminine!) and Joost Bolten (you know why!). Picking up this rMA again was made possible through the exquisite overall help, logistic and emotional support, the many shared meals and occasional hot mama sauna session which my housemates at our collective Wijk7 relentlessly provided. And thanks to all the kids as well for playing with Zonne all the times I was studying. A special thank you goes the SPSS support troops. Darren, Doina and to Pieter - the SPSS dude of the house - and the nights we laughed at the computer screen, hoping that would help make sense of numbers, and axes, and formulas. You were my comic relief. I apologize to my friends who have put up with me being anti-social for the past months. And thank you for granting me that privilege wholeheartedly. Special thank you to Dion, for your friendship, and your help with this project. I also want to thank the sweet colleagues at Soup en Zo, for their soup ‘n support. I especially want to thank Jamie and Margriet, for your remarkable and sincere interest in your workers in general which I felt translated into your support of me and your understanding of the importance of finishing this thesis. A shout out to Scott, yo! Your work is unbelievably important and timely. I am psyched that this thesis is coming into the world as you are finalizing the editing on your groundbreaking, screen shattering one woman’s journey documentary on childbirth - including the placenta, you promised! Finally, birth workers, wisdom keepers, the witches of the 21st century, I think highly of you - all of you.
ii. EPIGRAPH
“Now that women choose motherhood, childbirth is the ultimate threat for its explosive revelation of the primacy of gynocentric space. Birth can no longer be simply elided but must be made fearful, shameful, disgusting, and out of female control”
Robin Blaetz (1992, p.18)
“The movie industry has depicted the grace and glory of the gladiator and the super hero countless times, but has never once accorded the same recognition on the childbearing woman. And beyond film, in all of the humanities there is not one book, play or opera only about one woman giving birth, to validate her experience during labour as deserving the fullness of our attention. The journey of an unshakable woman, determined to receive with her own bare hands the baby she grew for nine months within the garden of her own body. But our culture of birth, our culture of entering this world, is ludicrously rife with negativity and fear mongering. Birth is violent and gruesome, countless labours on YouTube feature the disclaimer ‘warning: graphic content’, birth is slapstick and laughable (...) birth is rampantly censored on social media and online in general. When did the sacredness of birth become tantamount to the explicitness of porn.
Fuck that. Birth is normal. And the best way to prove this in the 21st century is on the big screen”
Scott Kirschenbaum, director of OF WOMAN BORN
INTRODUCTION TO CHILDBIRTH AND CINEMA
Childbirth and cinema have a complicated history together. Since the 1930 motion picture production code stated that ‘scenes of actual child birth, in fact or in silhouette, are never to be presented’ (Production Code 1930), the relationship between cinema and childbirth has been characterized by a continuous exclusion of sorts of childbirth from human cinematic vision. When Brakhage (1933 - 2003) made his first childbirth film WINDOW WATER BABY MOVING (1959), the nature of the images he shot was considered obscene and such a transgression of beliefs and practices around childbirth in the 1950s that the film laboratory where he sent his film stock to be developed threatened to destroy the footage. The film was miraculously saved after Brakhage handed the laboratory a doctor's note saying that the film was made for medical purposes (Segal 2011). Since the 1980s childbirth representation has gradually become more prolific in cinema (Segal 2007), but the complicated relationship between the two remains. This research project sets out to discuss the representation of childbirth in recent American cinema within the context of the changing childbirth practices in the Netherlands.
Maternity care in the Netherlands has since long been regarded as a vanguard upholding the normalcy of childbirth. Where in the rest of the developed world childbirth is considered a medical event, attended by an obstetrician performing a series of technological and/or pharmacological interventions in a hospital setting, the Dutch system instead favours autonomous, independent midwives as primary caregivers who safeguard and promote an optimal childbirth experience, free from unnecessary interventions. The midwife, like a general practitioner, functions as a kind of gatekeeper: she is the default caretaker of any woman and only refers women to obstetric care if pathological conditions should arise, either during pregnancy or in childbirth. Dutch midwives study four years to get their degree, are independent practitioners, and are legally defined as medical professionals. Most pregnant women start their care with a midwife, midwives are present at the majority of births and home birth is generally considered normal and a safe option for healthy women (De Vries, Nieuwenhuijze and Buitendijk 2013).
However, this Dutch maternity care system is undergoing structural changes at the time of writing, which could profoundly alter its unique character. Changes in both the midwifery education as well as in the self-description of the profession by the Royal Dutch college of Midwives (KNOV) in recent years have shifted the focus from
gatekeeping to risk selection
(http://www.knov.nl/fms/file/knov.nl/knov_downloads/1798/file/KNOV_visie_juni_2012_website.pdf?download_catego ry=overig, last accessed in April 2017). This reframes the midwifery practice from being set within a fundamental expectation of physiology to a primary focus on the signaling of pathology. These changes have paved the way for the start of the implementation of the ‘integrated birth care’ (in Dutch: integrale zorg) model in the summer of 2016, which is claimed to cater best to pregnant women. This model of practice, however, challenges the autonomy of the midwife by placing her under the direction of medical specialists in the hospital (De Vries, Nieuwenhuijze and Buitendijk 2013). The obstetrician, trained in pathological as opposed to physiological birth and working within a
medicalized birth paradigm, now extends his/her care to the realm of healthy women, lowering the threshold to the medicalization of normal childbirth of otherwise perfectly healthy women. This is but a brief sketch of an extremely complex debate, which expresses itself in various areas such as government regulations, professional rivalry between midwives and obstetricians, insurance companies’ financial structures, the cultural construction of risk and the attention in the media, to name but a few. Suffice to say that these structural changes are impacting the Dutch maternity care system and consequently the care provided for pregnant women.
These changes over the years have been accompanied by a continuous drop in the home birth rate, being now at an historical low; referral rates from midwifery to obstetric care are going up; and various other signs of the medicalization of childbirth are also on the rise (Christiaens et al. 2013; Offerhaus et al 2015). Despite this development, the Netherlands remains unique, with home birth rates still being the highest - and the intervention rates being amongst the lowest in the industrialized world (Christiaens et al. 2013; PRN 2013). However, in the past years a trend has been initiated that - when continued at this pace - might very well bring the Netherlands closer to the medicalized standard of the rest of the world, losing its distinct character (private communication with Barbara Harper, Barbara Katz-Rothman, Ina May Gaskin and Michel Odent in May 2012).
As a woman who has birthed her child within the comfort of her home, embedded in a maternity care system that valued the normalcy of childbirth, and as a childbirth professional (doula) who is committed to assisting women in experiencing childbirth as an empowering and profoundly normal life event, I am troubled by the direction of the developments of the Dutch maternity care system for several reasons. First of all, this process of medicalization of childbirth implemented in the name of health has been proven not to be unequivocally promoting the health of mothers and babies. Structural medicalization of childbirth does not decrease mortality rates in high-resource countries such as the Netherlands, but is in fact associated with poor health outcomes for women and babies (Requejo et al. 2012).
Secondly, in the context of medicalized childbirth, the authoritative knowledge of the care provider overrides the individual knowledge system of the birthing woman. This brings to the fore ethical and legal issues with regards to decision making, bodily integrity and the human rights of the birthing woman. Authoritative knowledge is a significant concept when discussing medicalization of birth and the autonomy of women, as it devalues other forms of knowledge about childbirth and places the care provider in an uneven relation of power - with authority over the birthing woman (Jordan 1992, 1993). Both the global non-profit organization for the rights of women in pregnancy and childbirth (Human Rights in Childbirth, launched in 2012) and the local Dutch one (De Geboortebeweging, launched in 2015) deal with authoritative knowledge and its consequences on a daily basis. What these organizations show us is that there are increasing numbers of violations of human rights of pregnant women all over the world which to a great degree are related to the impact of authoritative knowledge that accompanies the medicalization of childbirth (Diaz-Tello 2016; Sadler et al. 2016; Vacaflor 2016).
Finally, the nature of the imminent structural changes will make it difficult to preserve precisely those aspects of Dutch maternity care that are so highly praised all over the world. When home birth rates drop even further it becomes difficult, if not impossible, for midwifery students to witness and attend normal, physiological births at home during their internships. Instead their education will consist almost solely of hospital births within a medicalized setting, and this will inherently influence their way of practicing midwifery (De Vries, Nieuwenhuijze and Buitendijk 2013). With their learning pool shrinking and the concept of normalcy in childbirth irrevocably altering, specific midwifery skills will be lost within a generation’s time (Marjolein Faber, private communication June 2017). This impending loss is a threat to the quality of the current Dutch maternity care system.
The structural changes in the Dutch maternity care described above do not unfold in a vacuum. Rather they are the result of an intricate constellation in which the changing Dutch culture - due to things such as the global flow of information and immigration, easy access to other cultures, as well as a changing economy - plays a vital role. Social science and midwifery professor Raymond de Vries, who has extensively studied the Dutch maternity care system over the last two decades, has argued that it is imperative to fully understand how the historical, socio-economic but also cultural aspects of the Dutch society relate to the maternity care system in order to meaningfully theorize about potential improvements of the system (De Vries 2005; De Vries, Nieuwenhuijze and Buitendijk 2013).
In this cultural field, the media are highly influential in directing and shaping the cultural conversation with regards to childbirth. From weekly television birth reality shows, feature documentaries about childbirth, birth scenes in popular films and television series, to newspaper coverage of academic research and celebrity moms sharing their experience in glossy magazines - childbirth can be found everywhere in the (Dutch) media (De Vries et al. 2013; Handfield et al. 2006; Luce et al. 2016). This is relevant, for these media representations of childbirth are arguably one of the few opportunities for women (and men, too) to actually ‘see’ (part of) a childbirth, given that most people do not experience childbirth apart from the birth of their own offspring. Childbirth knowledge comes predominantly from sources outside the realm of their own direct birthing experience, and one of them is the representation of childbirth in the media (Declercq et al. 2006). De Vries has argued that the fact that ‘an increase in media representations of birth originating outside the Netherlands has made women more accepting of medical interventions and more suspicious of the practice of midwives’ (De Vries, Nieuwenhuijze and Buitendijk 2013, p1125). He mentions American television programs such as ‘16 and Pregnant’ and ‘Teen Mother’ as well as American fiction films such as KNOCKED UP (2007). I would argue that the total sum of childbirth representations available in the Dutch media, whether produced in or outside the Netherlands, potentially plays a fundamental role in the creation of a cultural narrative of childbirth and corresponding expectations about childbirth itself, which in turn may influence women’s childbirth experience as well as set the stage for structural changes. But what notions about childbirth actually prevail? How accurate is childbirth physiology represented? What are the basic lessons on childbirth one learns through exposure to these media expressions? And how do these constructed childbirth
narratives relate to our current childbirth practices and ongoing medicalization in the Netherlands? It is these questions that I aim to answer in my thesis.
I have chosen to focus this thesis on the analysis of the representations of childbirth in American fiction films released between 2003 and 2012. This research will answer the following research questions:
i. Which patterns can be detected in the way in which childbirth is represented in American fiction films released between 2003 and 2012?
ii. How do these childbirth representations relate to the physiology of childbirth on the one hand, and the medicalization of childbirth on the other?
My reasons for choosing American fiction films as the corpus for this research are twofold. On the one hand, there are many American fiction films readily accessible in Netherlands; in (commercial) cinemas, on DVDs and via online distribution. This access is not only relatively easy, it also constitutes a considerable portion of all fiction films available and accessible to a broad and diverse range of people in Dutch society. On the other hand, the number of American fiction films including a childbirth scene has actually more than quadrupled over the past decades, when consulting the International Movie Database (IMDb). This substantial increase in the number of representations of childbirth that permeate public space through these fiction films is an interesting development in itself as well as interesting in the sense that it provides this research with a full-bodied corpus to build a piecemeal research on, selected in a randomized way by using the IMDb.
Restricting the corpus of American fiction films to a specific timeframe is necessary in order to keep the number of films to be analyzed feasible within the context of this thesis. I have chosen the timeframe between 2003 and 2012 because this decade both covers current and recently produced films, and gives the opportunity to map patterns and changes over time. Originally, I set out to include Dutch fiction films produced in the same timeframe as well as Dutch and American childbirth TV series, but encountered several difficulties. Firstly, I could find next to no Dutch fiction films including a childbirth; and secondly, there is no Dutch movie database similar to the IMDb, which would enable me to search for the keyword ‘childbirth’ successfully. Finally, I have decided to exclude both the Dutch fiction films and the TV series due to the need to restrict my corpus for practical reasons.
In order to answer the research questions above, this thesis is divided in four chapters. Chapter One provides the context for understanding childbirth physiology, the medicalization of childbirth, and the Dutch and American childbirth practices. Chapter Two traces other research projects in the field of childbirth representation in the media and relevant literature on the subject, and investigates the theories most fitting for the analysis. It further specifies the corpus, discusses the research methodology, and elaborates on the interdisciplinary nature of this research. Chapter Three systematically presents the collected data and produces an analysis by looking at similarities and variations in the way childbirth is represented throughout the corpus of films, formulating patterns and
making generalizations where possible. It contextualizes the findings in relation to the physiology of childbirth on the one hand, and medicalized childbirth practices on the other hand. Chapter Four concerns itself with the discussion of the results and a more in-depth film analysis. Finally, this research project attempts to deduct relevant questions from the collected data, striving at coming to a better understanding of the potential impact of childbirth representations as expressions of - and constructions within - the cultural sphere on maternity care systems and the care women receive in childbirth.
1. CHILDBIRTH - PHYSIOLOGY, MEDICALIZATION, HISTORY AND PRACTICE
As this research project aims to map the representation of childbirth in recent American fiction films and to understand the ways in which these representations may interact with the childbirth practices and structural changes within the Dutch maternity care system, it is essential to briefly discuss childbirth on the universal level of its biology as well as on the local and structural level of the health care system(s) in which childbirth takes place. The first issue pertains to understanding basic questions like: what is childbirth? In what order do its stages unfold? What are its basic mechanisms? How is it designed to work? - and subsequently comprehending in what ways the medicalization of childbirth relates to this basic biological functioning. The second issue provides an insight into the Dutch maternity care system, the structural changes over the years and discusses these in the light of the most recent Dutch childbirth statistics available. Given that the corpus of childbirth representations consists of scenes in American fiction films and that the American maternity care system is representative for most developed countries in terms of medicalization of childbirth, this chapter will also touch upon the American maternity care system. This chapter is structured as follows: first the physiology of childbirth will be explained, followed by an exploration of the medicalization of childbirth in current times and in historical perspective. Both the physiology and the medicalization of childbirth are intricate and complex processes and will inevitably need to condensed, generalized, and selectively highlighted in order to provide useful insights that will assist in the analysis of the childbirth scenes in the subsequent chapters. After this the childbirth practices in America and the Netherlands are discussed. Overall, the exploration in this chapter is essential for deciding on the research parameters with regards to the corpus of childbirth representations as well as enabling a meaningful analysis of these representations in later chapters.
1.1 The physiology of childbirth
Childbirth is a normal biological process which can occur in the adult female life cycle. It does not belong in the field of medicine -which is dedicated to curing disease through the use of interventions-, but rather in the field of physiology (de Vries 2005). Physiology is the branch of biology that deals with the normal functioning of living organisms and their bodily parts. The physiology of childbirth therefore refers to the normal functioning and unfolding of childbirth, vaginal and without medical intervention. The physiology of childbirth is divided into four stages, the start of which is heralded by either the breaking of the amniotic sac or with the onset of contractions. The first stage refers to the contraction of the uterus until the moment the cervix has softened and is fully dilated (10 cm.); the second stage refers to the fetal expulsion, starting when the cervix is fully dilated up until the birth of the baby; the third stage refers to the expulsion of the placenta and in contemporary practice often includes the clamping of the umbilical cord; the fourth stage starts after the expulsion of the placenta and lasts up to two hours after birth (Prins et al. 2004). Within this construction of linear succession of stages there is ample room for birth to halt (staying at a certain
dilation for a while) sometimes over the course of days, seemingly to ‘regress’ (decrease in dilation), only to pick up speed again until the birth of the baby. That is, physiological birth is by definition not a linear and mechanical process (Simonds 2002; Gaskin interview https://www.youtube.com/watch?v=GpARnr353Rk&t=25s last accessed in May 2017). Instead, the rhythm of childbirth is cyclical, which is demonstrated for example by the physiological fact that a contraction is followed by a period of rest in which the sensation of the contraction dissipates, giving the birthing woman a real rest before the next wave - the next cycle. Birth can last from anywhere under an hour up to several hours, sometimes even days (Sarah Buckley 2008). In the Netherlands the consensus is that a woman will spend between 5 and 16 hours birthing - a first child typically taking more time than the second (http://deverloskundige.nl/uploads/deverloskundige.nl/knov_client_downloads/28/file/Jou_bevalling,_hoe_bereid_je_j e_voor_NEDERLANDS.pdf, accessed in June 2017).
There are two key aspects of childbirth physiology which are especially relevant for this research project: the physical and the hormonal. The physical aspect refers to the way the birthing woman’s (pubic) bones, muscles and ligaments need to be optimally aligned to allow the baby to move down the birth canal and be born. Both the position of the baby in the uterus and the woman’s mobility and freedom to adopt a variety of postures during birth are important therein (Zwelling 2010). When the baby moves down the birth canal it pressures the birthing woman’s bowels, causing her to defecate - a physiological sign that the baby’s birth is imminent. Usually the woman also loses some blood during birth as well as amniotic fluid, if her waters have broken already.
The hormonal aspect in childbirth refers to a combination of hormones which facilitate and regulate the process of birth. Scientific interest into this hormonal physiology of childbirth has peaked in recent years with numerous publications by scholars like Moberg (2003 and 2013), gynecologist Odent (1999) and medical doctor Buckley (2008), amongst others. One of the most important hormones in childbirth is oxytocin, which is responsible for the production of the uterine contractions during and after birth as well as for the bonding between mother and baby. Oxytocin is released pulse-wise in the body and thus causes the contractions to come and go, providing the woman and baby ample breaks in between to recuperate from the physical strain of the contractions (Moberg 2003, 2009). Oxytocin is in fact the hormone of love -normally produced during lovemaking, cuddling and the like- and is produced when the birthing woman feels safe and unobserved. Its production can be enhanced by non-pharmacological pain relief methods such as water and massage. When the birthing woman does not feel safe or unobserved, the oxytocin production can stop and as a consequence labour slows down or halts completely (Moberg 2013).
When childbirth unfolds with uninterrupted hormonal activity, at a certain moment in the process the hormone endorphin is released. This is a natural pain killer which helps the woman drop into an altered state of consciousness and takes away the sharp edges of the sensation of the contractions. In this altered state, the woman’s reptilian brain takes over and she becomes animalistic in her behaviour and the sounds she makes.
Towards the second stage of labour, a distinct change in hormonal composition allows the production of adrenaline which help the woman ‘wake up’ and become completely focused and present for the birth of her baby. Directly at birth the woman’s oxytocin levels skyrocket again which ensures optimal bonding between mother and baby, the expulsion of the placenta, and the start of breastfeeding (Buckley 2005; Moberg 2003, 2013). Without this intricate hormonal cocktail childbirth simply cannot take place. The combination of physical and hormonal aspects described above outlines the parameters of the physiology of childbirth.
1.2 The medicalization of childbirth
As mentioned above, childbirth itself belongs within the realm of the physiological, not the medical. However, childbirth in the developed world is defined as a medical event under the care of the medical professional (Conrad 2007) and thus childbirth is increasingly brought into the realm of the medical. The term medicalization literally means ‘to make medical’ and originates in the field of sociology in the late sixties. Sociologist Irving Zola was one of the first to describe this concept as “the process in which the terms ‘health’, ‘disease’ and ‘illness’ are applied to ever more aspects of daily life” (Smeenk and ten Have 2003). For the purposes of this research project I follow Helman’s (1994) definition of medicalization as a process of expansion of medical jurisdiction where problems were previously defined non-medically. Helman further explains how medicalization goes hand in hand with reinforcement of people's dependence on advanced medical technologies - which is indeed the case in childbirth. Interestingly enough, it has been shown that women’s issues, especially relating to their reproductive processes, have been disproportionately medicalized (Riessman 1983; Riska 2003).
Although medicalization in essence describes a process in flux, which is in and of itself neither essentially bad nor essentially good, it does raise several concerns. Firstly, that by transforming everyday life into pathology, the range of what is considered normal or acceptable is narrowed down, and consequently medical social control can be exerted over the individual’s behaviour, body, and states of being, causing the individual to lose his/her agency. The work of Foucault in Birth of the Clinic (1973), his discourse on the medical gaze, on surveillance and on power/knowledge, have been crucial for describing this particular concern of medicalization (Conrad 2007). Secondly, medicalization has boosted profit-making in the pharmaceutical and biotechnical industries (Conrad 2007; Moynihan and Cassels 2005), which have resulted in marketing strategies selling medicalization itself.
Both concerns are discernable when looking at the medicalization of childbirth. Regarding the first concern, there are ample examples of social control in medicalized childbirth practices which manifest themselves as coercion, force and obstetric violence. With regards to the second concern, the medicalization of childbirth is revealing when contextualized in economic terms: on average a caesarean section (completed in about 20 minutes) is almost twice as expensive as a vaginal birth at a hospital (which might take hours) (Declercq et al 2007; Wagner 2006; Wendland
2007) and in general obstetric interventions raise the cost of health care significantly (Tracy and Tracy 2003). A good deal has been written on medicalization theory since its inception in the 1960s, and the field is in motion still with scholars relating issues of health and disease to questions of social power - also with regards to the medicalization of childbirth. For the purposes of this research project, however, it suffices to understand that the two main propelling forces of the process of medicalization of childbirth are the medical establishment’s financial interest and authoritative knowledge.
1.3 Current medicalization practices
The medicalization of childbirth becomes most tangible in its legitimization of the use of technological interventions, which have a huge impact on the delicate physiology of childbirth described earlier. These technical interventions include: the electronic fetal monitoring (EFM or cardiotocogram), which monitors the foetal heartbeat and uterine contractions; induction and augmentation of labour with synthetic oxytocin (pitocin), which prevents resting periods in between contractions; pharmacological pain relief (such as epidural anesthesia or pethidine); assisted instrumental delivery (vacuum or forceps); the cutting of the perineum and the posterior vaginal wall (episiotomy), and the caesarean section, amongst others. Of course, the advances made in science, medicine and technology are potentially life-saving when used appropriately. But the routine overuse of technological interventions within the framework of medicalized childbirth presents some negative health issues to be considered (Adams et al 2015; James 2015; Davis-Floyd et al. 2009; Wagner 2006; Zwelling 2010).
Although the scope and focus of this thesis does not allow for going into detail regarding the exact workings of each of these technological interventions, it is necessary to first briefly expand on a few markers of childbirth medicalization which inform some of the variables for this research, and to critically contextualize them. First of all, there is the lack of mobility in labour and a limitation in possible postures. Some of the interventions described above connect the woman to various machines and drips with a multiplicity of cords, which can significantly diminish the birthing woman’s mobility and limit her posture options - which is not beneficial for the physical aspect of birth (Davis-Floyd et al. 2009; Zwelling 2010).
Another marker of medicalization is the location of the hospital, for almost all the technological interventions used in childbirth, with the exception of the episiotomy, require the setting of the hospital. Location itself is a contested subject in the discourse about childbirth at large, for science has actually shown that the hospital is not the best (read: safest) place for childbirth. According to the Cochrane database of systematic reviews, planned homebirth is as safe an option as planned hospital birth (Olsen and Clausen 2012). There is no significant difference in mortality outcomes, although homebirth has significantly better health outcomes for mother and child, as it does not incur technological interventions and their health implications (Olsen and Clausen 2012). Still, within the framework of
medicalization in the developed world, homebirth is continuously presented as unsafe and even as an irresponsible choice, by national obstetric associations, by the media at large and by personal as well as cultural narratives in the public sphere - all of which help to reinforce the location of the hospital as the only viable option and normalize the ongoing medicalization of childbirth.
Finally, the caesarean section can be regarded as a marker of medicalization. A caesarean section is a major abdominal surgery which -although it originated as a rare and life-saving emergency procedure- has become a routine obstetrical procedure and is currently the most common surgical procedure in America (Hamilton et al. 2014). There is a strong relation between the growing use of technological interventions and the increase in the caesarean sections rates (MacDorman et al. 2008). Despite common belief that the caesarean section is a safe procedure, it carries serious risks of short and long-term morbidity and also mortality for both mother and child (Declercq et al. 2007; Liu et al. 2007; MacDorman et al. 2008). The global consensus is that when national caesarean section rates stay below 15% they are considered lifesaving across the board, but when these national rates rise above the 15% marker, the procedure is understood to incur more health costs than gains. Currently the caesarean section rate is rising in the developed world, with many countries having a national caesarean section rate of 15% or higher (Betrán et al. 2016; Huang et al. 2011; Wagner 2006).
1.4 The medicalization of childbirth in historical perspective
The medicalization of childbirth - although theorized from the 1960s onwards - is historically rooted in the near eradication of midwifery and its replacement by the medical profession in the witch hunts of the Middle Ages. To truly understand the historical significance of the childbirth medicalization trend (in the Netherlands), one must be aware of this broader history of midwifery and its relation to the modern-day concept of medicalization - a history which began well before the rise of scientific medicine as we know it today. The witch hunts took place in Europe between the 14th and the 17th century and in America in the early 19th century. In the Middle Ages women (healers) tended to pregnant and birthing women of all classes; they were called midwives. In Middle English midwife literally means ‘with - woman’, the Dutch equivalent of this is vroedvrouw, literally meaning ‘wise woman’. These midwives were valued and respected, independent women, often working with herbs, potions and incantations, on the edges of life and death. As such they represented a political, religious and even sexual threat to the Church as well as the State. The witch hunts were well organized and their main handbook in the 15th century was The Malleus Malificarum (from 1487) which stated that ‘No one does more harm to the Catholic Faith than midwives’ (Kramer and Sprenger 1971, p.147). On the one hand the witch hunts were a ruling class campaign against the female peasant healers’ population at large as well as a religious campaign against these women's’ sexuality. The Church claimed that witches were deriving all their power from their diabolical sexuality; ‘all witchcraft comes from carnal lust’ (Kramer and
Sprenger 1971) and therefore had to be punished. On the other hand, the hunts served in a struggle for political and economic monopolization of the field of medicine by middle class men; which to the Church were acceptable where female peasant healers were not (Ehrenreich and English 1973). This significant and violent shift from midwifery to medicine is not only a precursor of the medicalization of childbirth, but also reflects a powerful cultural narrative that is ingrained in European and American societies.
1.5 Childbirth in America
Childbirth in America is a textbook medicalization case such as described above, where childbirth is considered a medical condition, to be treated by doctors with authoritative knowledge in the hospital. In her book Birth Models that
Work (2009), the anthropologist Davis-Floyd describes the American system as a technocratic model. In this model,
the natural process of birth is described as being ritually interrupted by technological interventions which are culturally constructed as safe and effective - in a process that befits the process of medicalization discussed above. In the technocratic model the medical establishment's authoritative knowledge is infused with a reverence for and dependence on technological interventions, which translate in high American intervention rates: a 23,3% induction rate (2012); a 3,1% instrumental delivery rate (2015); a 61% epidural rate (2008) and a caesarean section rate of 32% of all births (2015), which is a slight drop from the years before (Osterman and Martin 2008, 2012; Martin et al. 2015). There are no clear nationwide numbers about augmentation, episiotomy and other pharmacological pain relief. Finally, home birth is an anomaly (0,9%) as about 99,1% of the births in America take place in hospital (Boucher et al 2009) and a total of 86% of all births are attended by obstetricians (medical care), 8% of the births are attended by nurse midwives (hospital care), and under 1% of the births is attended by a midwife (independent care) (Martin et al. 2015). This division lies at the core of the ongoing medicalization of childbirth in America. In order to understand the current division between obstetricians, nurse midwives and independent midwives, their relationship needs to be contextualized historically.
When Europeans settled in the New World, they brought traditional European customs with them, including their midwifery customs. This lasted until around the 1750s, when medical doctors were returning to America from having studied abroad and introduced the ‘new midwifery’ practices (Wertz and Wertz 1977; Stover 2011). The relations between the midwives and the male doctors deteriorated and by the end of the nineteenth century it was common for midwives to be accused of witchcraft and tried in court. Similar to the witch hunts in Europe, this was a means for the doctors to ensure their monopoly on birth practices (Wagner 2006). One of these witchcraft cases had far-reaching consequences for midwifery practice: in 1909 in Gardner, Massachusetts, Hanna Porn, an immigrant from Finland, was sentenced to three months in the House of Corrections for practicing midwifery. The
Massachusetts Supreme Judicial Court used Porn’s case to rule that practicing midwifery was illegal. Other states quickly followed and midwifery was ruled illegal across the U.S. in nearly all states (Declercq 1994; Wagner 2006).
Although nurse-midwives entered the childbirth scene in 1955 as doctor’s assistants and independent midwives have made a comeback since 1980s (see Appendix Ϩ.Ϩ), the latter’s professional autonomy is to this day neither legally recognized across the board by the state authorities nor welcomed by obstetricians. The latter have a vested interest in preserving their monopoly position and its accompanying financial benefits and have attempted to discredit midwives mainly -but not exclusively- through attacking home birth itself (Wagner 1995). Since 1975 The American College of Obstetricians and Gynecologists (ACOG) has repeatedly published official recommendations against home birth, claiming it to be unsafe and thereby creating a type of technocratic myth: the culturally constructed image of birth belonging in the ‘safety’ of the hospital. This perceived safety is revealing when looking at the American maternal mortality rates which have increased from 12 deaths per 100.000 live births in 1980 to roughly 24 in 2014 (Hogan et al. 2010; MacDorman et al. 2016). These are exceptionally high numbers when compared to other developed countries. The discrepancy between the cultural narrative supporting the medicalization of childbirth and these mortality statistics, have fueled a growing resistance movement of natural childbirth which started in the 1940s (Wagner 2006). This movement has expressed itself in many ways since then - from celebrity documentaries such as Ricki Lake’s THE BUSINESS OF BEING BORN (2008) to the foundation of client organizations such as the Birth Network as well as ‘new’ forms of birthing such as ‘unassisted birth’ or ‘freebirth’ in which women chose to give birth without medical assistance altogether (Shanley 1994). Their measurable results, however, have not shown a demedicalization process at hand, but rather a transformation within medicalization of childbirth practices (Conrad 2007). Childbirth in America remains within the domain of medicalization, which reinforces itself within the culturally specific system of technocracy.
1.6 Childbirth in the Netherlands
Childbirth in the Netherlands is currently undergoing a process of medicalization. Although historically childbirth has been considered a normal -non-medical- life event, several changes in the past decades as well as the imminent implementation of the integrated care system have placed childbirth into the realm of the medical. Notwithstanding the impact of these (pending) changes, the Dutch maternity care system is still unique in the world and has been described by Davis-Floyd as an example of the midwifery-model - a term originally coined by sociologist Katz Rothman (1979). In the midwifery-model of care, birth is seen as a normal and healthy part of women’s lives, the birthing woman’s agency and authoritative knowledge is respected and midwives are the primary care providers for
pregnant women (Davis-Floyd et al. 2009). The centrality of the midwife within the Dutch maternity care system can only be understood through the specific Dutch historical context.
Although there were witch hunts in the Netherlands, there is little to no documentation pointing to the specific persecution of midwives herein, with the exception of midwives Entjen Gillis and Trijntje van Sittard (Dresen-Coenders 1983). Whereas in other (European) countries midwives were marginalized throughout history, the Dutch regulated midwifery as a profession early on. Already in the mid-fifteenth century municipally appointed midwives provided care for normal pregnancy and birth and in 1643 the first midwife was appointed in Leyden. This trend gradually spread to more municipalities across the country until in 1818 the Health Act was passed. It was the first national law regulating midwifery and providing it with a clearly defined sphere of practice. Soon after the Health Act passed, the establishment of the first midwifery school followed in Amsterdam in 1861, followed by Rotterdam in 1882, by Heerlen in 1912 and finally by Groningen in 2002 (De Vries et al. 2009). The head of the Amsterdam midwifery school from 1947 - 1957, Dr. Gerrit Jan Kloosterman (1915 – 2004), articulated a unique vision on the profession of midwifery. He was a professor of obstetrics and gynecology, an advocate of natural childbirth and he believed that verloskunde (obstetrics) is so universal (in Dutch: universeel) that it cannot be reduced to a single study trajectory in one academic faculty. He consequently rejected the notion that obstetricians, academically rooted in the single faculty of medicine, should be the primary care providers for normal pregnancies and childbirth (Kloosterman 1957). One could say he was describing the perils of medicalizations avant la lettre.
Over the years, both cultural and structural factors have played a role in safeguarding the special position of the Dutch midwife, minimizing interprofessional rivalry and promoting healthy cooperation (De Vries 2005; De Vries et al. 2009, see Appendix Ϩ.ϩ). Although most of these cultural and structural factors remain valid, the Dutch midwifery model of care is currently changing, which becomes blatantly visible when looking at the changes in several childbirth statistics. These show an increase in referral rate (referral from the midwife to the obstetrician at any given point during the pregnancy or during labour) from approximately 19,7% in 1970 to 43,5% in 2015 (Wiegers et al. 1998; Jaarboek zorg in Nederland 2015). As a logical consequence, the percentage of women who completed childbirth under medical, obstetric care also increased from 24,7% in 1964 to 71% of all births in 2015, the autonomous midwife no longer being the main caregiver in childbirth, supporting 29% of all births in 2015 (Jaarboek zorg in Nederland 2015). Home birth, the pride of the Dutch system, decreased in the past decades from 68.5 % in 1965 down to 13,1% in 2015, while hospital birth increased from 31,5% in 1965 to 84% in 2015 (Jaarboek zorg in Nederland 2015). Dutch intervention rates have also increased, with currently (last numbers available, from 2015) a 22% induction rate; a 18,9% birth augmentation rate; a 9,3% instrumental delivery rate; a 34,3% pharmacological pain relief rate; and a 24% episiotomy rate. The caesarean section rate went up from 6,6% in 1985 to 16,6% in 2015, having now crossed the 15% mark (Wiegers 1998; MacDorman et al. 2011; Jaarboek zorg in Nederland 2015). The
total of these numbers and their gradual change over the past years indicate that childbirth in the Netherlands is undeniably undergoing the process of medicalization.
Besides these factual childbirth statistics, there are several markers that point to the cultural constructedness of the medicalization of childbirth and its policies. These include for example the dynamic change over the years in indications in the the Verloskundig Indicatie Lijst (VIL) - the obstetric indication list which describes which deviations from the ‘normal’ course of pregnancy and childbirth are a sound indication for referral from midwifery care to obstetric care. These indications increased from 81 indications for referral in 1973, 119 in 1987, 138 in 1999 and 143 in 2003 (Amelink et al. 2010), effectively referring more pregnancies and births to the realm of the medical. Also, over the course of the different VIL editions, indications were added, deleted, put in other categories, and changed from pathologic to normal and back, testifying to the socially constructed and changing concept of normalcy in childbirth.
Another marker is the shifting position of Dutch obstetricians in the face of the changing culture of obstetric science in the Netherlands, which is becoming more international. The almost absolute notion that birth is safer in a hospital setting under the care of an obstetrician has begun to erode the Dutch obstetric foundations laid out by Kloosterman, resulting in few obstetricians willing to defend home birth to their colleagues abroad (de Vries and Buitendijk 2012; David-Floyd et al. 2013). But perhaps the most relevant marker of the cultural constructedness of the Dutch medicalization process is the relationship between the Dutch media and their treatment of childbirth. Relatively recently the media have focused framing childbirth in the Netherlands as a debate on where and with whom it is safest to give birth. In doing so, the media have reinstated the dichotomy between medical obstetric care in the hospital and midwifery care at home, which historically speaking was not a dichotomous issue before in the Netherlands (see Appendix Ϩ.Ϫ). The most recent focus in the Dutch media with regards to childbirth has been the ‘integrated care’ system, which, ironically, has only further emphasized this dichotomy (Pop, Volkskrant 2014; Kingma and Marland, Volkskrant 2016; Broersen, Medisch Contact 2016). Interestingly enough, the dichotomous nature of childbirth debate in the media has been accompanied by considerable hostility between obstetricians and midwives in real-life - revolving mainly around the challenging of the VIL and the midwives position of gatekeeper of normal, physiological birth by the Dutch obstetrics association (NVOG) (de Vries et al. 2013).
From the above it transpires that the process of medicalization of childbirth in the Netherlands is both culturally constructed and enabled through an ideological hegemony. As today the Netherlands is at the eve of structural changes which may push the medicalization of childbirth further still, it is urgent to deconstruct the images and sounds fueling our culturally inscribed notions of childbirth, which otherwise remain passively consumed.
2. THEORY AT THE BASE OF THE RESEARCH
2.1 Exploring the field of childbirth representation research
Academic attention for the representation of childbirth in general spans several decades and concerns itself with the ways in which childbirth is represented in health research (Kumar 2013; Miller 2000), informative childbirth books (Kennedy et al. 2009; Sbisa 1996), fictional literature (Cosslett 1989), popular magazines (Handfield and Bell 1996; Williams and Fahy 2004), newspapers (MacLean 2014; McIntyre et al. 2011), and most recently, women’s stories (Happel-Parkins and Azim 2017). The first scholarly works specifically dealing with the representation of childbirth in audiovisual media can be traced back to 1992 with the publication of two articles in The Velvet Light Trap and one in
Cinema Journal, after which there seems to be a pause in interest until 2007 when the subject resurfaces. The three
1992 articles deal with the sounds of childbirth as represented in cinema (Blaetz 1992), the way female bodies are constructed in instructional childbirth videos (Shorr 1992), and the alternative and darker sides of childbirth: pain, depression, anxiety and victimization analyzed through Polanski's ROSEMARY’S BABY (1968) and framed in the feminist movement of the 1970s (Fischer 1992). Fischer’s article later became a chapter in her book Cinematernity –
Film, Motherhood, Genre (1996). Blaetz, Shorr and Fischer build on an already rich body of works by various feminist
writers of the time, such as Kaplan (1983) and Rich (1976), who have explored the discourse of the maternal as relating to feminism, motherhood and patriarchy.
From 2007 onward scholars have regularly written on the representation of childbirth in audiovisual media. I have searched the online library of the University of Amsterdam and google scholar using “childbirth” and “media” as search terms, sought out references to additional articles in works found and have put a request through the
ReproNetwork (a global network connecting scholars working in the field of reproduction studies) for scholarly work.
This approach yielded 11 published academic articles, one unpublished yet presented paper (VandeVusse 2008) and one unpublished bachelor thesis (Walker 2012). Besides a literature review on the representation of childbirth in the media, which excluded cinema (Luce et al. 2016) and an article on cognitivist frames and health communication in relation to the representation of childbirth (Sanders and Meijman 2012), where the manner of compiling the corpus remains unclear, the bulk of this research can be roughly divided into the categories of representation of childbirth in: (1) home movies and experimental cinema (Segal 2007 and 2011); (2) internet-based media (Holdsworth-Taylor 2010; Longhurst 2009); (3) television (Kline 2007 and 2010; Morris and Mclerney 2010; Nall 2014; Sears and Godderis 2011; VandeVusse 2008; Walker 2012); and (4) fiction film (Walker 2012; West 2011; Nall 2014; Segal 2007). Some of these works discuss the representation of childbirth in light of the information they convey about childbirth itself to prospective pregnant women (VandeVusse 2008; West 2011), but mostly they discuss the ways in which pregnancy and childbirth are represented within the patriarchal medical model with little room for resistance or alternative readings and point out that the birthing women are represented as conduits for social hegemony. These works are primarily framed in a qualitative feminist approach to pregnancy and/or childbirth and focus on the female
body, the reproductive process and gendered relations between the pregnant/birthing woman and her care provider. Several major issues are highlighted throughout these works, which are often presented as themes, tropes or frames. These include - but are not limited to - the malfunctioning female body; the affliction of childbirth as a bitter experience; the trivialization of women’s births; normalization of both patriarchal gender roles and medicalization (Nall 2014); childbirth as both terrifying and painful; and obstetrics needed to control childbirth (West 2011).
There is immense value in the work of these scholars who engage with childbirth representations in audiovisual media from within a feminist framework. Their work is situated in a rich scholarly and feminist tradition which looks at dominant discourses while also exploring counter-narratives and resistance through the text itself and through the modes of production. These in-depth qualitative analyses are valuable in their unravelling of specific elements in the childbirth representations which point to an apparent schism in a patriarchal society where the female body is generally speaking either sexually objectified or subjectively diminished. They are embedded in a discourse on gender inequality in which the normalization of existing power and social relations as well as the female body are anything but neutral occurrences and need to be deconstructed (Aulette and Wittner 2009; Sbisa 1996). I am aware that the fact that this research project deals with the audiovisual representation of women (and their female bodies) necessitates an active acknowledgement of this discourse so far.
Nonetheless, there are some critical remarks that I would like to discuss regarding the common denominator of methodology and corpus-selection in most of the research on the audiovisual representation of childbirth so far. Apart from three projects (Morris and Mclerney 2010; Sears and Godderis 2011; VandeVusse 2008), where the corpus comprises a larger number of childbirth scenes (respectively 85 episodes, 40 episodes, and 24 episodes) which are mostly randomly selected, all 8 other research articles have a corpus which comprises only selectively chosen audiovisual media expressions. Although this is common practice within film and cultural studies, I find it problematic in these cases, as the authors proceed to make generalizing statements on the nature of childbirth representation on the basis of a handful of films. These generalizations tend to focus on the issue of medicalized childbirth, such as: childbirth representations shape the public’s perception of childbirth to (falsely) believe it is inherently dangerous and in need of technological interventions (Segal 2007), or: childbirth conventions in comedy films endorse the medical model of birth (Walker 2012, following West 2011). These generalizing statements are made on the basis of a minimal, not-randomized corpus, lacking sound quantifiable research on which these claims to generalizations can actually be made. They also repeatedly mention mainstream narrative, dominant discourse and dominant cultural representation in audiovisual childbirth representation without being able to refer to an actual baseline research project setting forth this mainstream or dominant narrative. This is both problematic -as no such research has been done so far- and unproductive - without establishing a mainstream narrative first, it is nearly impossible to attempt to analyze a counter narrative, or a reading against the grain. Finally, without downplaying the validity of the arguments themselves on the level of non-generalized, in-depth, discursive film analysis, I would argue
that the a priori central position conferred upon medicalization in the claims of a mainstream narrative, might preclude an open investigation of a range of childbirth markers besides the ones associated with medicalized childbirth.
2.2 Childbirth in the movies
Zooming in on the research done so far on specifically the cinematic fiction representations of childbirth, this type of corpus selection reveals several remarkable facts. Firstly, only a handful of American films are analyzed in these works: SHE’S HAVING A BABY (1x), NINE MONTHS (1x), KNOCKED UP (2x), JUNO (2x), BABY MAMA (1x), WAITRESS (1) and THE TWILIGHT SAGA: BREAKING DAWN - PART 1 (1). These were all popular, box-office success films, so one might argue that these films are more influential than other films with a childbirth scene, and thus have been chosen in the analyses. This seems like a valid argument, however, it does not fully account for the films chosen, as for example in 2008 (the year of release of BABY MAMA, grossing 60.269.340 dollars), SEX AND THE CITY had a more than double total income, grossing 152.637.269 dollars, yet is not mentioned. Same goes for THE BACK-UP PLAN from 2010 (grossing 37.481.242 dollars), as in the same year DUE DATE was released (grossing 100.448.498 dollars) as well as LEGION (grossing 40.168.080 dollars) - both of which are not mentioned. So yes, in these articles popular films are used in the analysis, but they simultaneously exclude several other (more) popular American fiction films containing a childbirth scene. Secondly, these are -with one exception- all comedies. Thirdly, all films were produced between 1988 and 1995 and between 2007 and 2011, and are situated in current, modern times. And finally, in each of these films the pregnancy and the childbirth are central to the plot of the film. Two things which stand out in the analyses themselves is (1) that biological factors are often not taken into account and definitely not in a structural manner and (2) that there is a persistent and singular focus on the medicalization of childbirth. However rich in material for analysis these films prove to be, this repeatedly chosen narrow corpus omits a great deal of (American) fiction films in a variety of genres, set in a variety of times, that contain a representation of childbirth at various levels of direct relevance to the plot. These omitted films and childbirth scenes are no less part of the cultural representation of childbirth which permeates the public sphere. Therefore, the research done so far provides no systematic insight into the representation of childbirth in cinema at large, precluding the production of generalized observations.
My research project takes notice of the past research done on the subject of representation of childbirth in audiovisual media in general and cinema in particular and - notwithstanding my criticism of issues of corpus and methodology - builds on the insights these works have provided through thorough analysis. This research project concerns itself with finding generalizations and patterns in audiovisual childbirth representation, as this cultural contribution to a formation of (socially constructed) knowledge about childbirth potentially influences the organization of the maternity care system in the Netherlands - and beyond. In order to be able to make generalizations, the scope of the audiovisual media I am concerned with has to be narrowed down to a feasible area of focus, yet large enough
to render generalization possible, and randomized to limit possible bias. In choosing American fiction films I am well aware that I am omitting documentary film, television and web-based media - ranging from professional entertainment and instructional videos, through reality programs to home-videos on YouTube.
Furthermore, the research must be a “piecemeal” type of research, instead of an in-depth analysis of a handful of films and childbirth scenes. Here I turn to Noel Carroll’s seminal chapter Prospects for Film Theory: a
personal assessment (Carroll 1996) in which he calls for a new prospect for film theory. Carroll argues that in order to
go beyond the restrictive and totalizing system of classical film Theory, one needs to ‘follow the lead of piecemeal theorizing wherever it takes us’ (p. 41), urging film theorizers to engage in interdisciplinary exploration and come to form generalizations pertaining to interesting phenomena in film. Thus, this research, rather than meticulously analyzing a handful of media representations of childbirth, focuses on a larger, albeit very specific group of media representations in order to be able to make generalized statements and detect patterns within the representation of childbirth in American fiction films. This quantitative approach does not preclude the possibility for qualitative theorizing about film in a discursive manner. On the contrary, working in this way directs our attention to those poignant phenomena, uncovered from the data, which call for in-depth analysis and theorizing. My point of departure is not the discursive structures, but the representation of the physiology of childbirth itself. This informs the variables chosen to research in a piecemeal manner and will consequently direct the discursive film analysis which, due to the scope of this research project, is necessarily limited.
This research project sets itself apart from earlier research firstly, by the corpus selection and piecemeal approach described above and secondly, by the focus on physiology as opposed to medicalization. I believe that to be able to say something meaningful on the level of medicalization in childbirth representation, we must first understand the level of physiology that is represented. This is because medicalization in childbirth has more to do with the relation between childbirth physiology and the socio-cultural agreements about -and perceptions of- what childbirth is, than with merely checking for overt markers of medicalization such as technological interventions or pharmacological pain relief. Hence the way in which childbirth representations interact with childbirth physiology may provide us with a better understanding of these agreements and perceptions and consequently of the process of medicalization itself. Practically, this means that I am collecting data from the physiological beginning to the physiological end of the childbirth scene. Where other studies have analyzed only part of the childbirth (such as until the birth of the baby in the second stage) or have drawn upon other scenes from the film as well, I choose to focus primarily on the representation of childbirth itself.
2.3 Schema theory, scripts and childbirth
In order to be able to perform a textual analysis of the childbirth scenes I need to decide upon and articulate which elements will be looked at, in order for all scenes to be examined in exactly the same manner, thus making it possible to make statements about the differences and/or similarities between the scenes. For the purpose of this research project I am in need of a theory that facilitates the schematic construction of representation of childbirth scenes and allows me to compare a large number of scenes across different films and genres. The theory I found best equipped for this is based in cognitive psychology: schema theory. It allows for the dissection of each individual childbirth scene into different, temporally ordered segments. It will enable me to compare the segments found in different films as well as their frequency and narrative order. As such, schema theory provides practical tools to systematically compare the scenes, check them for patterns, perform a quantitative analysis, and define those aspects in all childbirth scenes which can then be addressed through film and discursive analysis.
Schema theory is a theory of the organization of knowledge which informs our perception of the world and our daily interaction with it. As such it allows for the addressing of the issues of expectation and action, which allow me to make inferences about the ways in which childbirth representation in cinema may influence Dutch women (individually) and the Dutch maternity care system (nationally). Schema theory emphasizes the fact that our understanding of certain situations, events, places or objects is influenced by our previous encounters with them and thus by the so-called schema we have created for them in our minds. Schemas form tightly interconnected organizational structures, based on a combination of horizontal (serial or temporal) connection as well as vertical (part-whole) connection (Mandler 1984). Although, like many cognitive theories, schema theory is based on verbal and linguistic texts and utterances in the form of sentences and (short) stories, it has proved to be of great value to multimodal forms of expression too. Bordwell recognized the value of schema theory to film analysis and introduced it in his now classic study Narration in the Fiction Film (1985) in order to explain how schemas inform hypothesis making in the course of the viewing and comprehending of a film. In this research project, I intend to use Bordwell’s synthesis of cognitive and film theory in an inverse manner. Instead of using real life schema as a cognitive tool in film analysis, I am using film analysis in order to (re)construct cognitive schema pertaining to the real-life event of childbirth.
Many types of schemas have been theorized so-far by various cognitive psychologists, such as the person schema, role schema, story schema, event schema, scene schema and the self-schema. For the purposes of this research project, I find event-schemas most suited to analyze childbirth representations. According to Mandler (1984) an event schema is ‘(...) a hierarchically organized set of units describing generalized knowledge about an event sequence. It includes knowledge about what will happen in a given situation and often the order in which the individual events will take place’ (p.14). Taking into account that the baseline focus of my research is the physiology of childbirth, the ‘event sequence’ nature of the event schema appears to serve this project best, as it allows me to
