Dutch, Italian and Mexican women in the Netherlands : their perceptions and experiences regarding the Dutch maternity care

(1)

Dutch, Italian and Mexican women

in the Netherlands:

Their perceptions and experiences

regarding the Dutch maternity care

Master's Medical Anthropology and Sociology

Supervisor: Anja Hiddinga

Second reader: Trudie Gerrits

Camilla D’Atanasio

Defended on 11 August 2015

Student number: 10861750

camilla.datanasio@gmail.com

(2)

(3)

(4)

Acknowledgements

I would like to thank all the women who chose to share their very personal experiences and feelings with me and for guiding me in a world I only knew from literature.

I wish to express my gratitude to all the MAS academic staff, not only for the stunning quality of the program, but also for being attentive and encouraging towards all the students. In particular, I wish to mention Trudie Gerrits for having taken time to guide me since the beginning of the Master’s; Stuart Blume for sharing his wisdom with me and for his friendship; and of course my supervisor Anja Hiddinga, for her illuminating comments, for her patience and flexibility and for being so reassuring, even in difficult times. I could not ask for better!

I am thankful to my fellow students. I must mention Mia’s support all through the year and in particular during my last hours in Amsterdam, and all her valuable help in dealing with the practicalities of the last two months. Thanks to Elisa and Marta, who have always incited me from the distance.

Thanks to John, my loyal, longtime proofreader, for his helpfulness, professionalism and his closeness to me and my family.

Last but not least, thanks to my partner Giovanni and my family, without whom this enriching experience would not have been possible. When I decided, more than one year ago, to go back to school and try to find my way in the world of research, my father was the one who most wholeheartedly supported my decision. He has always believed in me and in my capabilities, even if the professional path I chose was so different from his own. Thank you, Dad for encouraging me to follow my dreams.

(6)

INTRODUCTION

The inspiration for this research is rooted in my own background as an anthropology student. Some years ago, I spent nine months in Mexico, doing fieldwork for my Master’s research. Although my research focused on the sexual education of indigenous women, I got in contact with scholars and fellow students working on childbirth in rural communities. I had the opportunity to share with them ideas and reflections, and this gave me the opportunity to discover the so-called “anthropology of childbirth”.

When I had to choose my research topic for this Medical Anthropology and Sociology master, many possible ideas came to mind. Theoretically speaking, I was developing an interest towards the concept of agency and its relation with existing structure. In particular, I was interested in studying counterhegemonic practices and, in particular, their conceptual bases. How might dissenter agency arise within hegemony? Should we understand it in terms of freedom and spontaneity, or should we look for its roots within the existing antagonist discourses that circulate in a given arena?

My choice of studying the Dutch maternal health system from a cross-cultural point of view derives from the combination of these theoretical concerns with my empirical interest in maternity care. I consider the exceptionality of the Dutch model of birth as a valuable opportunity for me to analyze the institutionalization of a childbirth mode that, in other contexts, plays a counterhegemonic role. I decided to take a further step: I chose to focus on how the Dutch practices and discourses of ‘good childbirth’ are perceived by women coming from countries in which medicalized birth is the norm. In selecting the specific groups, I left room for my own background: my nationality, my previous research experiences, and, above all, my knowledge of both the Italian and the Mexican maternity care systems.

Theoretically speaking, I constructed a framework that encompasses the different discourses that I expected to play a role in how women give sense to their experiences of pregnancy and parturition. My analytic approach is inspired by intersectionality, since I deem it capable of appreciating the role background plays in women’s experience. However, I elaborated a particular variation of it, i.e. the ‘intersectionality of discourses’, due to my special interest for the discursive bases of the mothers-to-be’s decision making. During my fieldwork period, I realized that another concept was emerging as an almost constant element in my informants’ narratives: the notion of uncertainty. It works as a unifying aspect, though the ways women deal with it varies strikingly.

(7)

The first two chapters of this work are devoted to the presentation of the context and the theoretical bases and methodological tools used in my research. Each of the following ethnographic chapters focuses on one group’s experiences and perceptions of the Dutch approach to pregnancy and birth. In the sixth chapter, I discuss the findings already presented, concentrating in particular on the emergence of the notion of uncertainty.

(8)

CHAPTER 1: BACKGROUND AND THEORETICAL FRAMEWORK

1.1. Pregnancy and childbirth in the Netherlands

As the Royal Dutch Organization of Midwifes states, “the Dutch tradition of a free choice of place of birth including homebirth is quite unique in the western world” (KNOV 2012). This approach is strongly rooted in Dutch medical history and some scholars have ventured that it is indeed related to a more general Dutch national character (Abraham-Van der Mark 1993, Benoit et al. 2005).

The reasons for such an ‘atypical’ system have been the object of analysis, also because of its peculiarity in a global western context that has moved in the opposite direction; in other words, while many countries were striving to introduce increasingly medicalized practices, the Netherlands was focusing on improving its exceptional, pluralistic method of childbirth.

Three important aspects characterize the present functioning of the Dutch maternal health system: the possibility of homebirth, the emphasis on choice, and the special, powerful position of midwives. Homebirth is included in the range of choice; it is ‘institutionalized’ as it represents a recognized way of giving birth, well anchored in the Dutch health care system and validated by its long history. Its acceptability is, in part, conferred by the high consideration in which midwives are held in the Dutch society and legislation. Their centrality in the local maternity care system is concretely visible in the fact that the midwife is the first professional health worker that the pregnant woman consults at the first stage of pregnancy. The verloskundige (“midwife” in Dutch) evaluates and assesses the risks entailed by the pregnancy, thus defining by whom the subsequent stages will be followed: only if the midwife considers the pregnancy ‘low risk’ will the woman be able to choose between a delivery at home or in a bevalcentrum (polyclinic). Otherwise, she will be sent to the care of physicians, and will give birth in a hospital. Such assessments are made by the midwife on the basis of a manual, called “VIL”, first formulated in 1959 but constantly updated, which provides the guidelines for the pregnancy evaluation.

In other words, choice, in the Dutch setting, means the possibility exists to opt for delivering in a short-stay polyclinic or at home. The most medicalized of the possibilities, i.e. childbirth in a fully medical setting, under the supervision of obstetricians and nurses, lies outside of the range of a woman’s choice. In fact, coherent with the Dutch idea of birth as a physiological event, this arrangement is provided only to women with a detected situation of high risk, this being the condition assessed by the midwife during pregnancy.

(9)

This wide acceptance of homebirth as a legitimate possibility contrasts with the marginality of such a phenomenon in the majority of western countries. According to the last report issued by the Italian National Institute of Statistic (ISTAT 2014), pregnancy and childbirth care in Italy is highly medicalized. Italy is the European country with the highest rate of caesarean sections1: 36.3% compared with 15.6% in the Netherlands, considerably higher than the European average (26.7%) and over twice the limit percentage recommended by World Health Organization (15% maximum). Moreover, the ISTAT explicitly reports an “excess of medicalization” (ibid: 2), especially referring to the overwhelming use of ultrasounds. 72.7% of women reported at least one intervention procedure during childbirth (e.g. episiotomy or oxytocin, among others). Even if we consider the medicalization of childbirth not as an absolute category – thus recognizing the existence of a wide range of variability in it – it is undeniable that on average, the Italian maternity care system is placed around the top of the range2.

At the moment, Mexico presents a high rate of CS – around 36%. Most of the deliveries happen in hospitals (92.2%) (García Vázquez et al. 2012). In spite of the stunning rise in terms of deliveries’ medicalization in the last two decades, such hospitalization has not proven effective for eliminating the problem of maternal mortality. The mortality rate, addressed by the fifth of the Millennium Development Goals, has decreased significantly but not uniformly; in fact, there is an important gap between states of the confederation, and even within the same state, especially comparing urban and rural areas (INEGI 2013). Moreover, Mexico presents an important tradition of traditional midwifery, and parteras (midwives) play a significant role in accompanying women during pregnancy and delivery, particularly in those rural and indigenous areas that are not sufficiently covered by the official medical services.

Although neither of those two groups is the most numerically significant in terms of immigration in the Netherlands3, for the reasons I have just presented, I considered that observing women socialized in the Italian and Mexican context and dealing with the Dutch system allows us to grasp the variety of discourses that play a role in the global childbirth arena, by means of listening to women’s experiences and perceptions as they deal with such a peculiar system.

1_{Hereinafter I will replace the expression “caesarean section” with “CS”.}

2_{It suffices a quick browsing through Italian pregnancy-related blogs and Facebook pages to get an idea of}

how of the reaction of many women to emergent (but still marginal) alternative birth movement – for instance promoting homebirth - is of surprise and even shock.

3_{Statistics about the Italian and Mexican presence in the Netherlands can be found on the Centraal Bureau}

(10)

My research focuses on prenatal and childbirth care, with particular attention to the level of medicalization women expect and desire. In fact, the Dutch approach to pregnancy and birth present a level of screening and intervention that is significantly lower than in Italy and in Mexico. Concretely, this means that low-risk pregnancies are under the supervision of midwives, which perform a low number of ultrasounds and blood tests. Similarly, childbirth is perceived as a natural event. As a consequence, home is considered a suitable setting for giving birth. Although the possibility of giving birth in a polyclinic is available, the Dutch model of childbirth remains a low-medicalization one, and foreign women perceive it accordingly. The reasons are to be found, e.g., in the existence of homebirth as a possibility, in the centrality of midwives in birth management (even if it takes place in a bevalcentum, and in the reluctance to intervene with a CS. The same low-tech approach can be found in the way midwives deal with uncomplicated pregnancies, i.e. with a large use of their hands to assess foetus’ size and well-being, and a marginal employment of high-tech and medical monitoring (blood tests and ultrasounds).

As Treichler observes regarding midwifery in the U.S., “the midwifery model, seeking to restore a sense of childbirth as a ‘normal human experience’, defines birth as a normal, natural physiological process; though high risk conditions and/or medical complications may occur and necessitate medical solutions, most pregnant women are considered to be essentially healthy beings who usually need little medical management during the birth process” (1990: 121). In the Netherlands, such a ‘childbirth-as-normal’ discourse does not have to be restored, since it is deeply rooted in the local birth culture. Nevertheless, it must defend itself from attacks by the medical risk-reduction approach.

As already mentioned, the most important conceptual bedrock of the Dutch model of childbirth is that pregnancy and birth represent natural events in women’s lives. This makes for a stark contrast with the medical view of them as exceptional and potentially risky processes, requiring the constant attention of medical professionals and the use of high-tech tools. Midwifery’s premise of pregnancy as natural results in a concrete line of action that, instead of being constantly concerned with the possibility of complications, assumes that pregnancy is physiologic until proven otherwise. Among the midwife’s responsibilities, therefore, there is being attentive to detect a change from a physiological to a pathological status; otherwise, she will handle it as a condition not in need of medical or technological intervention. Following Carlton et al. (2005), I call this a “wait and see” approach. As a consequence, Dutch midwives dealing with low-risk pregnancies put into practice such an approach by using low-tech, low-medicalization procedures. Such practices are inherently different from what my Mexican and Italian interlocutors would experience being pregnant in their own home countries, as there both maternal care practices and dominant discourse

(11)

(from which those practices derive) are based on medical knowledge, use of technology and aimed at risk reduction.

Jordan’s notion of “authoritative knowledge” (1993, 1997, Davis-Floyd and Sargent 1997) provides us a helpful analytical tool for understanding the significance of the low-tech discourse in the Dutch childbirth arena: “for any particular domain, several knowledge systems exist, some of which, by consensus, come to carry more weight than others, either because they explain the state of the world better for the purposes at hand, or because they are associated with a stronger power base” (1993: 152). While in most western countries medical discourse represents the most authoritative knowledge in shaping action of maternity care, in the Netherlands such a role is taken by the midwifery approach, at least when low-risk pregnancies are concerned. This concept reminds us that, even though several discourses (or knowledge systems) co-exist, they differ from each other in terms of the ‘weight’ they carry. Moreover, their power can also be identified in their ability to shape pregnant women’s perception of their own pregnancies: the more powerful the discourse is, the more it will shape women’s subjective experience.

1.2 Theoretical framework and analytic approach

My starting hypothesis was that, in a context that allows women to choose between different modes of childbirth (i.e. short stay in a bevalcentrum or homebirth), it is possible to grasp the deep motivations and attitudes about good childbirth, i.e. how women consider childbirth should be performed: where and assisted by whom, ultimately with which level of medical or technological intervention. I assume that personal reasons are the result of a process of appropriation and negotiation of more general discourses in order to make very concrete decisions (Kuipers 1989). According to this line of thought, discourses are both general in their premises and practical in their application. Those discourses are multiple, and they carry different issues of power (Harwood 1988). In the following paragraphs, I will explore some literature concerned with good childbirth, with the aim of mapping some of the discourses I expected to find as present in women’s choices’ rationales. I consider such discourses not as directly constitutive of women’s choice, but as elements to which the women refer when they have to choose between the available modes of delivery.

(12)

1.2.1 Risk

Globally speaking, the risk discourse can be considered dominant in determining how delivery should be performed. Risk is indeed a leitmotif in the promotion of medicalized childbirth in most of the developed and developing world. It powerfully operates in contexts in which hospital birth is the norm (as happens in Italy and high-income parts of Mexico), or when inserted in the scope of global “megarhetoric of developmental modernization” deployed by Appadurai (Davis-Floyd 2001:193) – which works as a model for developing societies, including rural Mexico. Yet, also in the Netherlands it defies the well-rooted low-tech birth model: in fact, the Dutch model of childbirth has not been spared by the heated debate about risk, especially since homebirth has been blamed for the relatively high rate of undesirable outcomes in delivery compared with the other western countries. Lately, this has put morbidity and mortality at the core of the academic and popular debate regarding childbirth (Buitendijk 2011). Therefore, I consider the risk discourse relevant, in different ways, for the three groups of women I met.

In spite of its power, however, it has been shown that, especially when referring to birth, risk is a political and moral construct (Kaufert and O’Neil 1993 :43), whose lay meaning cannot be reduced to a statistical calculation of mortality rates (Obermeyer 2000). “Risk as a mode of discourse […] is a way of conceptualizing the world and attempting to make it intelligible” (Brown 2014:23): indeed, the notion of risk and subsequent efforts to deal with it can be considered as parameters that orient individual and collective behaviour and decision making. Key is the concept of uncertainty: the future is conceived as intrinsically unpredictable and potentially filled with risks. When health is concerned, medicalization becomes the primary way to deal with risk. As Wilkinson has observed (2010), risk and medicalization fuel each other under the conceptual umbrella of rationalization. Medicalization is conceived of as the most appropriate means to deal with risk; on the other hand, risk assessment and management need to be performed by experts. Technology appears as the best tool for risk management (Mitchell 2010).

Especially for pregnant women expecting their first child, pregnancy is a totally new condition, one whose novelty is only partly compensated by the experiences of her female acquaintances. Similarly, childbirth represents, for the childbearing woman, a deeply unpredictable event. Labour and delivery, their psychological and physical components, are deemed as escaping human communication4. From the pregnant woman’s perspective, birth is foreseen as a life-changing event: it is a turning point in the woman’s life and is charged with emotional value.

4_{This incommunicability is intrinsic in birth, and acquires an even bigger value when foreign women are}

concerned, since they often lack access to information about the functioning of the Dutch maternity care system from peers, since most of them have given birth in other contexts.

(13)

Drawing on Giddens (1991) we can also observe that birth is, for the pregnant woman, a “fateful moment” to-be: “fateful moments are times when events come together in such a way that an individual stands, as it were, at a crossroads in his existence” (ibid:113). Moreover, the approaching birth is highly characterized by a sense of uncertainty – another central concept in Giddens’ work.

The risk discourse copes with the unpredictability entailed by childbirth through the application of medical rationality and high technology: “medicine replaces risky natural processes with technological practices that are better because they introduce human control into the birth process” (Mansfield 2008:1085). Hence, according to such a discourse, good childbirth, i.e. the most appropriate approach to birth, focuses on the reduction of risk in biomedical terms. This normative feature, that is, the priority given to risk reduction, can have prescriptive effects on individual decision making: the notion of “good motherhood” (Christiaens et al. 2013:e6) is powerfully linked to good childbirth. In contexts where risk-reduction approach is particularly strong, an estrangement from the norm can lead to blaming the dissident individual5. Non-compliance with the most socially legitimized childbirth model means placing oneself at the mercy of judgement: e.g., in the U.S. homebirthers are often accused of being irresponsible, selfish, or ignorant (Craven 2005).

In sum, in the global ‘good childbirth arena’, risk and biomedicine hold dominant positions. From this perspective, pregnancy and birth are seen almost exclusively as medical facts, in need of medical surveillance (Hammer and Burton-Jeangros 2013, Lupton 2012); according to biomedical definition, a good delivery is one in which the health of the mother and baby, defined in biomedical terms, are the primary goals to pursue. This prioritization often leaves behind a more complex consideration of the mother’s well-being, which would encompass emotional elements.

1.2.2 Risk avoidance as development

There is variation of the risk discourse I have just illustrated that can often be found in the so-called “discourse of development” (Escobar 1997)6. It mirrors the risk-centred argument already presented in the previous paragraph; however, the normative value of risk reduction and medicalization is enriched by several conceptual nuances when it is inserted in the interaction between the ‘developed’ and ‘developing’ worlds.

5

This echoes Beck’s risk theory, and in particular his notion of individualization (Brown 2014).

6_{I initially decided to include this corollary of the main development discourse since I expected it to play a}

role in how foreign women perceive the Dutch maternity care model. As will be showed in the following chapters, this discourse indeed appears frequently in the narratives of my Mexican and Italian interlocutors.

(14)

Maternal and perinatal mortality rates in the so-called developing world are very high compared to the western world (Ronsmans and Graham 2006), and are often taken as indicators to assess the level of development of a country. This global problem has been addressed by several initiatives on a global scale, the last of which are the Millennium Development Goals. Many scholars have criticized methods employed by these numerous programs and their underlying approach. They have been deemed too mechanistic and unable to go beyond mere practical solutions, as they have focused mostly on making biomedical services available for target populations. Such a line of action assumes that the only reason behind the high rates of maternal and perinatal death is the mere unavailability of medical professionals and instruments. However, as shown by Hunt et al. (2002) in the case of Chiapas, women often actively seek the assistance of “traditional birth attendants”7, even when biomedical alternatives are available.

In similar cases, the correlation between behaviours and the risk of undesirable outcomes in childbirth leads to directing the blame toward the mother as an individual – similar to what happens in the mainstream risk discourse. Within the development discourse, however, such a process of individualization is often paired by blame towards the group, or the ‘culture’ it embodies – while e.g. political and historical reasons for refusing medical ‘help’ are unacknowledged8_{. In brief, the}

reason for the bad outcome is identified in the cultural features that make the individual woman refuse medicalization. In other words, who are deprecated are not only the ‘isolated’, irresponsible mothers-to-be, but also the backward system of ‘beliefs’ that make, practically and ideologically, non-medicalized childbirth happen (Obermeyer 2000).

1.2.3 Feminism and anti-medicalization

Another possible discourse from which women could draw to choose and to make sense of their choice is the one that foregrounds the woman as the protagonist of birth. It does so by means of a blend of anti-medicalization and feminist critiques (some of the most important scholars of this school of thought are Martin 1987, Jordan 1993, Davis-Floyd 1994, Rothman 1993, Duden 1994).

This discourse proposes itself as directly antagonist to the risk discourse, whose pretended neutrality makes it particularly difficult to resist. As previously explained, the risk discourse’s validity is constructed on the grounds of rationality and moral consideration of the baby’s health. It is a case of authoritative knowledge in its own right, as “it seems natural, reasonable, and

7_{This label has been strongly criticized, e.g. by Davis-Floyd. According to her, it “diverts attention from the}

wide range of services provided by indigenous midwives – their embeddedness in their communities, and their importance to those communities as wise women, healers and respected authority figures” (1996:124).

(15)

consensually constructed” (Jordan 1997:57). Nevertheless, dissident discourses do exist, even in contexts where the dominant risk discourse seems to dominate, unchallenged.

Some counterhegemonic discourses address medicalization as the primary ‘enemy’, without criticizing the ideal of risk reduction as the purpose of good childbirth choice. For instance, as reported by Viisainen (2001), Finnish homebirthers use medical screening to be sure that non-medicalized birth will not be dangerous for the baby’s health. They do not see any contradiction in this pragmatic attitude; notably, their ultimate aim is assessing the feasibility of their counterhegemonic preference. Moreover, the choice of homebirth itself is motivated by the will to avoid unnecessary stress to the baby, by welcoming him or her into a domestic environment.

A partially different, more ‘intransigent’ discourse is based on the rejection of the idea that childbirth is intrinsically risky. Such a discourse can be found in activist contexts, as is the case of homebirthers who operate in highly medicalized maternity care systems. In the Netherlands, however, it does not represent a counterhegemonic exception, but rather the conceptual foundation of the local midwifery-based line of action – it is a form of authoritative knowledge. In both cases, this discourse leverages its legitimacy with the idea that pregnancy is not a pathological condition but a natural state; as a result, birth should not be approached as a medical event. As a consequence, risk reduction is removed from the centre of the stage. Natural birth proponents view bad outcomes as statistically unlikely, so as a minor component of the human condition that must not prevent people from fully living their lives: “Are you not going to drive your car because you could have a wreck? You’ve got a higher risk doing that than having a baby at home.” (Davis-Floyd’s interviewee, 1994:1133).

These ethical premises mean an overall reconceptualization of the birth event, now deployed as a natural process. As a result, the emotional needs of the mother and the safety of the baby are not juxtaposed, but considered as complementary parts of only one ideal end (Davis-Floyd 1994). As stated by one of Cheyney and Everson’s interviewees, “the midwifery model of care is about acknowledging more than just clinical risk. It’s about the whole person” (2009:7). Hence, risk is taken in its wider sense, which encompasses a notion of well-being that goes beyond the narrow limits of medical definition. The mother becomes the active creator of her baby: no longer a faulty worker in need of expert intervention for the sake of her baby’s health (Martin 1987).

In sum, feminist anti-medicalization discourse demands the recognition of women as central in the whole pregnancy/birth matter; what needs to be taken into account is not just her physical health, but also her emotional well-being, perceptions, and values. According to this line of thought, pregnancy self-surveillance and the moral obligation to medicalize birth are nothing more than another example of patriarchal oppression over women’s reproduction (Rothman 1993, Root and

(16)

Browner 2001). The relativization of risk makes medical experts no longer necessary; instead, birth becomes an empowering experience in which the mother is the protagonist, finally able to defy medicalized authoritative knowledge (Jordan 1997) and its technocracy (Rothman 1993, Davis-Floyd 1994) with her intuitive, “instinctive, body-level knowledge” (Cheyney 2011:533).

1.2.4 Making discourse dialogue: constructing the rationale of choice

My preliminary theoretical framework drew on intersectionality or, more precisely, to an adapted version of intersectionality that I call ‘intersectionality of discourses’. I was particularly inspired by those formulations of intersectionality that take into account the simultaneous presence of oppression and privilege (Nash 2008, Huijg 2012). People’s social situations (Dillaway and Brubaker 2006) shape their decision-making processes not only due to the ‘structural’ conditions of the oppression/privilege in which they live that make their practical access to options more or less feasible; they also have differential access to different discourses. This is why I extend the concept of intersectionality beyond its ontological, socio-economic boundaries.

My hypothesis was that women could be considered as being virtually located in an intersection of discourses. Such discourses have a differential power, some of them being hegemonic while others are more marginal, counterhegemonic or ‘activist’. Therefore, the core interest of studying Mexican and Italian women in the Netherlands is that, while in their home countries non- or low-medicalized pregnancy care/birth are everything but common or hegemonic, in the Netherlands they are inserted into a system of care and ‘birth culture’ which promotes and actually encourages a view of pregnancy and birth as being non-medical events.

The discourses I have reported in the above paragraph are present at multiple levels, from global and national politics, to activist efforts, down to a more individual level. My focus on three groups assumes, here, an additional value, because it will allow me to grasp a broader variety of discourses due to the diversity of the women’s backgrounds.

To make sense of the choice women make, I looked at their position in what I would call an intersection of discourses. According to her background, a woman will have been exposed to different discourses; in this sense, I expected to find some degree of difference between the positions of women from diverse countries. For instance, in Italy childbirth is, in general, highly medicalized (Giacalone 2013), but there are groups that are raising awareness and constructing a counterhegemonic, yet marginal, movement for the de-medicalization of childbirth. In Mexico the situation of midwifery is complex (Hunt et al. 2002) and assumes broader meanings related to development, tradition and identity (Davis-Floyd 2001, Hunt et al. 2002). Given these premises,

(17)

dealing with the Dutch maternity care system means, for Italian and Mexican women, mobilizing discourses in order to make a choice, in a context that erases the structural constraints that they would experience in their home countries, e.g. the high price of homebirth in Italy or the high probability of having access to a planned CS in high-income Mexico. On the other hand, the relatively cheap price (325 euros) of delivery in bevalcentrum in the Netherlands suggests that it represents a feasible option for women of different socio-economic conditions.

More specifically, focussing on Italian women offers the chance to observe how women with a background of high medicalization of childbirth perceive and act within the Dutch system. On the other hand, a Mexican background adds complexity to the research by means of the introduction of the development discourse into the arena.

By exploring the power differential between discourses about childbirth, that is to say the hierarchy that shapes some of them as dominant, while others as resistant or marginal, I aim to suggest that mothers’ choice is political not only in its consequences, but also in the conditions that precede the decision itself. In other words, even in contexts in which the choice is presented as possible (as happens in the Netherlands), the individual decision is shaped by an intersection of discourses. This does not mean that agency is erased from the scene; nevertheless, I venture that the range of possible options is determined by the availability of discourses that make each option meaningful. In my view, mobilizing a discourse in order to make a choice means that the pregnant woman relates to the existent discourses and scripts and constructs her choice by means of affiliating (in a creative negotiation) to some of them while rejecting others.

1.3 Research questions

• How do Dutch, Mexican and Italian women perceive the Dutch model of childbirth? • How does the women’s background influence their choice between modes of childbirth? • How do they construct the rationale of their choice? Which are their priorities in choosing

between polyclinic and home as setting for the delivery? Which of the discourses about ‘good childbirth’ do they mobilize in phrasing their reasons for choice?

• What do they think about the unavailability of hospital birth for low-risk pregnancies? • How does the risk discourse ‘work’ in influencing women’s choice in The Netherlands? • How does the feminist, empowerment-centred discourse influence women’s choice?

(18)

CHAPTER 2: METHODOLOGY, POSITIONALITY AND ETHICAL

CONSIDERATIONS

The methodological relevance of working with discourses is twofold. First of all, it derives from a general awareness about the impossibility to grasp ‘real’ experience. Experience is, in general, inherently personal and singular; in this specific case, more so, I am not a mother, so I can be considered an outsider in some sense. This aspect entails some reflexive and methodological implications: when my research started, I was 29 years old, which, by chance, is the average age of first pregnancy in the Netherlands, and I do not exclude to have a child within some years, which makes me a curious and somehow naive ethnographer. My informant perceived my interest both as scientific and personal, this giving a special emotionally committed value to the information they shared with me: the fact that I am not a mother situated me in a learning position, consequently giving women the possibility to perceive themselves as experts on the basis of their lived experience. I felt that my personal inexperience regarding pregnancy and birth and, at once, my proximity to these topics (in both academic and personal terms) played a constructive role in the encounters. I also think that my own inexperience contributed to compensate, in part, for the usual sense of power imbalance that is inherent in most ethnographic encounters (Harding and Norberg 2005). In sum, I consider my dialogic approach, my learning position and my self-disclosure as capable of adding profundity to my research in each of its stages, including analysis and discussion of empirical data.

The second reason is more theoretical. I think that working with discourses puts the informant at the centre of the stage, giving her the chance to motivate her own actions and choices, much more than an observation-based methodology could do9_{. The relevance of working with discourses,}

in the case of this research, has to be understood in both the acceptations of “discourse analysis” and “analysis of discourse” (Bacchi 2005: 199); however, my analytic interest tends more towards the latter, whose purpose is “to identify, within a text, institutionally supported and culturally influenced interpretive and conceptual schemas (discourses) that produce particular understandings of issues and events” (ibid.). I consider discourse analysis and, in general, dialogic interaction as the locus where agency – in the form of creative mobilization of existing discourses – can be better observed.

In line with my discourse-based approach, I opted for extensive non-structured interviews with a relatively small number of women from each group. The core of my research consisted of in-depth

9_{According to Martin, “instead of the ethnographic gaze, we should have the ethnographic ear. And}

(19)

interviews with mothers and pregnant women. I found them mostly in Facebook groups based on geographical origin (e.g. “Italian mothers in Amsterdam” or “Mexican mothers in the Netherlands”), or on setting (“Mothers in West Amsterdam”). I chose this strategy instead of focusing on more specific groups, such as, for instance, yoga courses, because I considered it an easier way to get in contact with a wider range of opinions and approaches regarding pregnancy and childbirth. I asked the groups’ administrators for permission to publish announcements in which I briefly explained my research topic, with my e-mail contact on the bottom. In the announcement I specified that I was looking for mothers or pregnant women who had experienced/were experiencing low-risk pregnancies.

I conducted a total of 16 interviews with mothers. The following table – in which real names have been replaced by pseudonyms - provides an overview of the situations of the women I interviewed. What emerges already by looking at this scheme is the high level of differentiation among their experiences. It was such a complexity that it led me to make my initial narrow focus on choice of birth setting wider. For instance, I decided to also include a Mexican woman who had two births with CS, as well as an Italian woman who is going to give birth in Italy but at the time of the interview was living in Amsterdam and was attended by a midwife. In other words, I soon realized how variegated the experiences of the women I was meeting were, thus I decided not to close out the opportunity of knowing more about what seemed to me interesting stories, capable of providing important inputs for my reflection.

Italian women Vittoria Hospital

Giorgia 1 Bevalcentrum + 1 Homebirth Gaia Pregnant (will give birth in Italy) Valentina Hospital + Pregnant (now in Portugal)

Federica 3 Bevalcentrum

Claudia 2 Bevalcentrum

Mexican women Carmen Bevalcentrum

Maria Bevalcentrum

Beatriz 2 CS

Alejandra Bevalcentrum + Pregnant Andrea 1 CS (in Mexico) + Hospital

Dutch women Viona Pregnant

(20)

Doortje Homebirth

Johanna Bevalcentrum

Anna Homebirth

All of the interviewees are highly educated (university level) and live in Amsterdam or in Leiden (except for one who lives in Almere).

I did not encounter any obstacles in finding participants; on the contrary, from our first contact they expressed a genuine interest in my research. Particularly in the case of Italian and Mexican women, I had the feeling that several of them almost needed to get something off of their chests or, at least, I felt they wholeheartedly welcomed the opportunity to reminisce about their birth experience in a narrative endeavour of which I never had the pretension to shape as detached nor objective. In fact, especially the conversations with pregnant women and with women who had had a traumatic birth experience were emotionally very cogent for them, and in some cases I saw my informants break down and cry.

The meetings were held at the informants’ home or in cafés, except for a case in which we met at my home and for a Skype interview. Their children were often present during the interviews. In one case also the partner was present, and he actively participated in the conversation, which I did not see as an intrusion but as something I rather welcomed as an opportunity to enrich my data.

Conversations were held in English, Spanish or Italian according to the informant’s native language (since I do not speak Dutch, interviews with Dutch women took place in English).

All the interviews began with a brief explanation about the reasons for my interest in this topic and with the signature of an informed consent form about the use of data. I asked for permission to record the interview and in no case I was refused. The duration of interviews ranged from 40 minutes to 1 hour and 45 minutes. The interviews followed a topic list and I explained at the beginning of our meetings that I did not have structured questions but rather a number of themes that I wanted to explore. I invited them to inform me should they feel uncomfortable talking about anything. In sum, I called upon them to consider my questions as flexible and to feel free to follow their own line of thought and what they considered relevant to share with me. The flexible guide provided by my topic list followed the chronology of the pregnancy - from the first moments to the postpartum. Sometimes I also inserted some more direct questions that explicitly presented the discourses about ‘good childbirth’ or ‘birth ways’ to encourage participants to confront them directly. At times, I asked them to pretend they had to give advice to a fictional friend regarding issues such as pain relief, birth setting, etc.

(21)

I concluded the interviews soliciting my interlocutor to feel free to add anything more or to ask me questions. Many of my informants were curious about my own opinion (“What would you do?”). It was for me just another chance to make myself present in the ethnographic encounter, so I often spoke about my own expectations and ideas, sometimes including details about my personal life. Many of my informants expressed a clear appreciation for the usefulness of my research, and directly asked to read the final dissertation.

Toward the middle of my fieldwork period I decided to meet some childbirth workers. Accordingly, I arranged meetings with a midwife, a doula and a childbirth educator. Although I used their narratives only marginally as primary data for my analysis, those encounters were particularly significant for my research, as they enabled me to share my own reflections and to have insight as to their practical engagement and different angles in supporting pregnant and birthing women. Each of those three women was a mother, and for each of them their birth experiences played a role in their own professional approach.

Childbirth workers Carla Midwife 1 Hospital + 1 Cesarean section

Isabela Doula 2 Homebirths

Maureen Childbirth assistant Birth center (in UK) + Homebirth On the whole, while my interviews covered a wide range of interesting topics, for reasons of word-count constraint I decided to leave out of my analysis those not directly related with pregnancy and birth management, as e.g. partner involvement, after-birth support (kraamzorg care) and breastfeeding.

(22)

(23)

CHAPTER 3: ITALIAN WOMEN

3.1 The Italian maternity care system

As anticipated in the previous chapters, childbirth care in Italy is highly medicalized: probably the most impacting data are the ones about surgical delivery, given that Italy presents the highest rate of CS in Europe (36.3%10, with peaks of 45.2% in the Southern regions11). Statistics also reveal a considerable use of other interventions: for example artificial rupture of membranes (32% of births), episiotomy (34.7%), use of oxytocin for inducing or accelerating labor (22.3%), and manual pressure on the belly (22.3%).

37.6% of women undergo seven ultrasounds during the pregnancy12, while less than one third of women take part in prenatal courses. While many women recur to private gynecological care during the pregnancy (75% according to Grandolfo et al. 2002:4), 90% of them give birth in public hospitals (ibid:7). The hospital stay usually lasts several days, also in case of vaginal delivery.

According to the Italian association of anesthesiology (AAROI 2015), in 2006 epidural was used only in 3.05% of births and only 10% of hospital guaranteed this procedure 24 hours a day, 7 days a week and free of charge. However, the situation will likely change soon as there have been many initiatives to add access to epidural to the list of basic services every region must provide without extra cost for the patient.

As the exposed statistics show, the difference with the Dutch midwifery system is blatant. The linguistic aspect will perhaps give a clearer idea of the difference: in Italian the closest translation for the English term ‘midwife’ is levatrice, but this word is rarely used to refer to hospital-based midwives nowadays, as it more likely identifies the midwives of the past, when homebirth was the norm. Currently, the figure of the childbirth assistant who cooperates with the gynecologist in assisting the birthing woman is called ‘ostetrica’.

Perrotta has observed that this professional figure represents an ancillary role compared with the centrality held by gynecologists: the Italian midwife represents little more than an executor of the doctor’s directives (Perrotta 2009:384). The entrance of the medical system in the birth arena started in the XVIII century and was brought to completion in the Seventies, through a progressive subordination and professionalization of the midwives (levatrici). After the institutionalization of clinical medicine, midwives took on a role of connection between gynecologists and women, since

10_{This and the following data are reported by the National Institute of Statistics (ISTAT 2014).} 11_{It should be remembered that the Italian National Health Service is administered on a regional basis.} 12_{The national guidelines recommend three ultrasounds in case of physiologic pregnancies.}

(24)

they provided the only way to get in contact with those women who lived in rural areas (Cicatiello 2013). It was only in the Seventies that this subjugation to the rational knowledge of medical science started to be contested by activist groups, often inspired by feminist views, which propose to re-humanize the experience of birth.

At the moment, there is some degree of diversification among hospitals (Szurek 1997): some of them have incorporated alternative views and adopt a low-interventionist approach, while others propose themselves as highly medicalized and, therefore, comparatively more able to deal with health risks. Similarly, of course, each gynecologist has his or her own approach and style. However, except for some rare “maternity houses” (five in total), run by midwives, and for some rare pro-homebirth initiatives13, hospitals represent the obvious place for giving birth for most Italian women.

In sum, the biomedical approach seems to hold a dominant role in the provision of maternal health service, and for the majority of women the alternative birth discourse is very marginal because of its scarce presence and its consequently limited impact in women’s views and experiences. What happens, then, when Italian women find themselves in a system that allows them to experience birth in a less medicalized way?

3.2 Italians becoming mothers in the Netherlands

3.2.1 Pregnancy Care

The Italian women I met often showed an ambivalent attitude towards the care they had received in the Netherlands throughout their pregnancy. Notwithstanding the considerable diversification of their commentaries, some key concepts emerge in several of their narratives. In particular, the notions of stress and anxiety are central in a significant number of their recounts. I encouraged them to compare their experience with what they know a pregnant woman in Italy usually deals with in terms of blood exams, gynecological checks and ultrasounds. For some of them, the comparatively lower level of control throughout the pregnancy elicited some anxiety; for others, it was the contrary: they felt relieved by being spared from a quantity of checks that they would have considered excessive and that would have caused in them a sense of uneasiness and apprehension. However, most of them were not that black or white but rather appreciate some aspects of the Dutch approach while criticizing others, sometimes showing a remarkable ambivalence toward some of the key aspects of the local pregnancy care style.

(25)

This is the case of Federica, a mother of three children, all born in the Netherlands. She expresses some concerns that the Dutch calmness could degenerate into neglect:

Camilla: Would you have preferred the Italian approach to pregnancy?

Federica: Yes. […] It is one thing to medicalize too much, as they do in Italy, because sometimes they really exaggerate there, but it is another thing to totally leave it to chance, as they do here.

But later, when she reports that she had to undergo some monitoring toward the end her third pregnancy because she had not felt her baby moving for some days, she adds:

I really wonder how in Italy they can do it that often, because it was stressful having to stay in bed, immobile, with the sensors and see it she was moving, the heartbeats and so on. I found it so stressful. I would prefer not to do it and rely in when I could feel her moving by myself.

This ambivalence is the same observed by Hammer and Burton-Jeangros (2013) in Swiss women. According to their study about prenatal surveillance medicine, some women seek prenatal tests in their need for certainty but, at the same time, recognize the possible downsides of the medical approach, especially in terms of stress for the mother.

Giorgia, the only Italian homebirther I met, was positively affected by the Dutch approach to childbirth. She links this to the lower degree of surveillance and control:

It was nice not to feel ill, not to be subjected to too many tests, and I listened to my friend’s experiences in Italy: blood exams every month, ultrasounds every month, “be careful not to eat this or that!”. All that doesn’t happen here.

Some expecting mothers choose to maintain contact with their doctors in Italy. This often positions the pregnant woman in a mediating role, as in some cases Italian doctor comments on the Dutch approach are very critical, as in the case of Giorgia’s uncle, a doctor who, when informed that Dutch midwives normally use a measuring tape to check the growth of the baby, defined the Dutch system as “backward” compared to the Italian habitual use of ultrasound. Actually, the concept of backwardness recurs with frequency in the narratives of the most sceptical mothers I met, especially when they compare the care they experienced in the Netherlands with what they have been told by their friends and relatives in Italy.

It can happen that the fact that pregnancy is perceived as a normal event has its downsides, as explained by Gaia, a young woman, pregnant at the moment of the interview, who was going to give birth in Italy and therefore was resorting to a mix of Italian and Dutch pregnancy care, since she was living in Amsterdam but had spent some weeks in Italy for Christmas holidays. On the one hand, she appreciates the relative serenity that the midwifery system offers; on the other hand, however, according to her, a mix of language difficulties and “cultural” factors might lead to the neglect of the emotional value of the pregnancy:

(26)

[Referring to a medical appointment in Italy] On a humane level, I don’t know... the cleaning lady who was sweeping the floor congratulated me! While here it’s more, you know… I don’t know if it’s a matter of culture or maybe because I seem shy because I don’t speak the language, so they feel less encouraged [e.g. to congratulate her]. But yes, in Italy I liked the communication part. […] Here it’s very solipsistic, it’s me, my belly, once a month I go to see her [the midwife] and she always says “what nice blood pressure you have!”, and that’s all, very calm, you know. While in Italy you get more stimulated, more things, more information.

Gaia is not the only informant who seems to be affected by the alleged ‘coldness’ of the Dutch approach to pregnancy. Vittoria shared with me her experience with her second pregnancy, which followed a miscarriage. She did not consider the midwives’ reaction to her loss appropriate, so, towards the sixth month of her second pregnancy, she manages to convince her GP to refer her to hospital care for the subsequent months and the birth, probably also because of her relatively high age (40 at the time of her second pregnancy). Vittoria’s recount of her experience is particularly interesting since it mixes mistrust in the low-tech approach of midwives with considerations about the lack of humanity she felt on the part of the midwives themselves.

That’s how it works here: you go to the GP, do the [blood] analysis, then you have to find the midwives by yourself, which in my opinion is something… quite primitive. How is that called in Italian? Levatrice. I think that role doesn’t even exist anymore, in Italy. […] They treat you in a standard way, do those primitive checks, that is, they touch your belly. Hey, it’s 2000, give me a serious check!

It’s a personal matter, and what I noticed is that they don’t care about your emotional condition. I mean, they follow, as all Dutch people, the standard protocol, without taking into account that they’re dealing with a person who can react in different ways. In my case, I’m a foreigner, I come from a country that works differently, I have my own story, my past, my mother had two miscarriages, a lot of stuff in my head. You see an anxious person, worried, I wanted an ultrasound but [they said] ‘it is not needed’. It is not needed, but it’s useful to calm my nerves, why do you care? Let me do it [the ultrasound], I calm down and that’s all. So I had a negative feeling about them, since the beginning. We argued, in fact.

In both Gaia’s and Vittoria’s narratives, then, the normalization of pregnancy, which is sometimes considered one of the advantages of the non-medical approach for its relaxing potential, shows its weak points. Interestingly enough, in the second quote, the lack of attention towards the emotional aspects of pregnancy goes together with what the informant considers an insufficient level of accuracy. In Vittoria’s words, the ‘primitiveness’ of midwives’ care is exemplified by the contrast between touch (or other low-tech devices as the ear trumpet or the measuring tape, mentioned by other informants) and ultrasound as effective tools for screening (Kitzinger 1997). Such a comparison is present in many interviews, and leads to reflections about the perceived potential of touch as a non-rational and non-visual method for guiding the midwife and the pregnant woman throughout pregnancy and birth. In her well-known historical study of the centrality progressively assumed by the foetus as the target of society’s concerns, Duden (1994) evidences how important the visual dimension of experience in detriment of other senses has become, especially compared with touch. As a consequence, the mother’s ability to feel her own baby in a

(27)

non-descriptive, non-numerical and, above all, non-visual way, has been dismissed. Following this line of thought, one could say that some women not only have lost their own ability to rely on their senses, but that they even look with suspicion at ways of screening that differ from visual assessment, since they do not consider the former competent guides throughout the pregnancy. In Vittoria’s narrative, this mistrust for the midwives’ touch drives to her to reject midwifery altogether as a profession, due to her scepticism about the embodied knowledge (Davis-Floyd and Davis 1997) the midwives’ low-tech approach implies.

There is another aspect in Vittoria’s narrative that seems particularly noteworthy: the association of anxiety with the unavailability of exams. Such a link is here presented as exactly the opposite of the sense of naturalness reported by Giorgia, who explained it as a result of the low level of control over the pregnancy. Perhaps because of her previous miscarriage, Vittoria is not convinced by the idea that pregnancy is simply a normal condition. Therefore, non-medicalization causes her more anxiety instead of calming her down. In conclusion, the low-tech discourse does not match with Vittoria’s own conceptualization of pregnancy.

3.2.2 Childbirth

As said, only one of the six Italian mothers I interviewed gave birth at home. Giorgia is 30 and mother of two girls. She was at home during the whole first labor but was transferred to hospital since “it was taking too long”, according to the midwife. Her second baby was born at home. I met her and her family at her home, in Leiden, and the interview was held while she was breastfeeding her second baby, two months old. Her partner, Riccardo, was present during the interview and he took part in the conversation with his own comments and remarks. Giulia and Riccardo consider themselves “predisposed” for choosing homebirth14. Giorgia highlights the safety of the Dutch homebirth system:

We weren’t endangering anyone’s life, we did it following protocols aimed at ensuring safety, otherwise they wouldn’t exist.

Of course, Giorgia does not refuse medical-like screenings and the idea of medical interventions bluntly: nevertheless, she uses them as little as possible, and principally as a condition to confirm the feasibility of the low-tech birth she desires. This pragmatic use of medical resources echoes the results of Viisainen’s study about Finnish homebirthers (2001) and, above all, warns us

14_{Riccardo was born and raised in a dissenter community that since the Seventies occupies some abandoned}

lands in central Italy, adopting a lifestyle inspired to the respect for nature. They also refuse the medical approach to birth, so women give birth within the community, assisted by empirical midwives. Riccardo’s mother is one of the women who assist women during birth.

(28)

against the risk of considering the boundaries between low-tech and medical approaches as too rigid.

One of the aspects Giorgia most appreciates about her homebirth is the experiential dimension of it, and especially the possibility to stay very concentrated, which resulted in a high level of autonomy and the ability to stand up for her own wishes, as she reports in this evocative anecdote about the expulsive phase in the birthing pool:

The midwife told me “Please, could you turn up? Otherwise I can’t see anything!” and I was… no way! No, this is my home, I’ll do as I want, I want to deliver this way! [laughing] I’ll keep staying on all fours. You can’t see? Then crouch down! Do something, I don’t care. […] And she grinned and bore it.

According to Giorgia’s midwife, her birth was unusually solitary and autonomous. She congratulated her and defined it a very beautiful birth, which she attributes to the high level of self-consciousness of her body and to the fact that she was very concentrated and “in control, in spite of the pain”. However, Giorgia thinks that, in addition to the domesticity of the setting, also the fact that it was her second birth had a decisive role in shaping her birth experience.

Hence, Giorgia’s personal background, summed to the perception of Dutch homebirth as safe and controlled, drove her to perceive – and choose – homebirth as a desirable solution. Since she is sure that homebirth does not imply any special risk, she is able to fully concentrate on, and take advantage of, the emotional aspects of the non-medicalized childbirth way. For her, birth is, indeed, more than a medical event – as exemplified by this quote about epidural:

I never considered an epidural. To me, feeling that pain was part of the experience and is part of the unique way in which you’ll remember that experience, and it is an incredible factor of empowerment: managing to accept that pain, to live it, and to survive that pain, because it’s so painful that you think you’ll die. […] This is a natural experience, our body has been created this way by nature, we’ve evolved in this direction, that pain is functional to the fact that you become aware that this baby is being born and it’s not happening to someone else, no one is going to take it out of your body, it’s just you and the baby.

These considerations echo the depiction of birth as a rite of passage (Cheyney 2011), which is one of the central arguments of some homebirth advocates. In Giorgia’s idea of good childbirth, physical and emotional aspects are not separated, thus she considers she and her partner’s desire for homebirth a legitimate will.

Claudia’s experience is different, but her unexpected effects are somehow similar. Both her children were born in a bevalcentrum. Although she is rationally convinced of the safety of homebirth, she does not consider home a comfortable place. She was not prejudicially against the epidural; however, in retrospect, she is happy she did not resort to it:

In my case, both births were very positive experiences. Really, also physically speaking, a big adrenaline rush, more than paragliding![…] A feeling of wonder for what can happen, for what your

(29)

body can do, for what you can endure, because of course the pain is there, and it’s a lot, not a small hassle, it’s a lot of pain. But it’s a pain with a purpose, it’s useful, so at the end it’s doable. I don’t know, for me it was very positive, I didn’t experience it like a trauma. Not at all.

Claudia’s and Giorgia’s narratives could be contrasted with Valentina’s view about epidural. In her opinion childbirth pain does not add anything to the experience nor to the bonding with the child:

I don’t attribute to the birth, to the moment per se, such an extraordinary importance. If I can avoid pain, I will. The moment for empowerment will be all our future life together, our everyday challenges.

Several other mothers express the same idea: they do not consider pain as potentially able to add any special feature to the childbirth experience (Giacalone 2013). Thus, after weighing possible advantages and disadvantages, they opt for analgesia. They are not worried about being in control, as were the women interviewed by Dillaway and Brubaker (2006); rather, they perceive the pain as an unnecessary inconvenience, so they do not find any good reason for embracing it.

In sum, for Italian women in the Netherlands, birth medicalization is often a conscious choice. As a matter of fact, appreciating not to be too scrutinized during pregnancy does not imply that those women will prefer home over a bevalcentrum for the delivery. In other words, even when they appreciate the overall Dutch approach, they do not push themselves further to subvert their own view of birth as an act that should happen in a hospital, since, after all, they consider it the most proper setting for giving birth. Almost none of them conceptualize this preference in direct risk terms, somehow endorsing the Dutch view of birth as non-pathological. Nevertheless, for them, home is still not the right place for giving birth:

Gaia: In my imagination, since I was a child, in my culture, my mother’s culture, except for my grandmother because there wasn’t the hospital… was to give birth in a hospital.

The above quote calls into question the division between culture and medical (objective) knowledge. In Gaia’s explanation of her reasons for giving birth in a hospital, the advantages or technology do not lie in the rationality of medical science as a way to deal with risk; rather, preference for medical setting is linked to historical and cultural background. This makes a striking contrast with the biomedical rationalistic discourse of risk reduction through the employment of high-tech approach.

It is noteworthy that, notwithstanding the possibility to opt for a bevalcentrum, the fact of being in a country that has its specific view on birth entails some practical consequences. A birth culture that considers birth as a ‘normal action’ – thus not one which needs any medical support - is organized accordingly to that principle; the fact that homebirth is possible and the actual

(30)

management of birth, summed to the condition of foreigner, add a degree of uncertainty about how birth will actually happen – which is already a mysterious event for a first-time mother. I allude here to the fact that women are not supposed to call the midwife when the labour starts, but later, when the contractions get regular and intense. According to the protocol, the midwife comes to the parturient’s house to check dilation, and she decides when it is time to move to the polyclinic. Apparently, it is not infrequent that the midwife, finding the woman already too advanced in labour, does not consider it appropriate to go to the birth centre. Therefore, a planned bevalcentrum birth could indeed become a homebirth. For a woman who does not find any appeal in such an approach, e.g., one who does not see any potential of empowerment, bonding, or personal amelioration in the ‘natural birth discourse’, this possibility carries uneasiness and anxiety. As we shall see, such unpredictability plays a relevant role not only for Italian, but also for Mexican mothers-to-be.

Dutch, Italian and Mexican women in the Netherlands : their perceptions and experiences regarding the Dutch maternity care