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Cradle to Grave

Why maternal mortality is an oddly American phenomenon

Maternity occupies a strange, paradoxical place in American society: simultaneously valorized, demonized, and neglected, the complexity of motherhood is sidelined in every sphere. The medical consequences of this are severe—the United States has the highest rate of maternal mortality in the developed world. So, too, are the cultural ramifications: as the critic Jacqueline Rose argues in her forthcoming Mothers: An Essay on Love and Cruelty, “motherhood is the place in our culture where we lodge—or rather bury—the reality of our own conflicts, of psychic life, and what it means to be fully human.”

A new study recording a spike in maternal mortality rates in the state of Texas provides a case in point. Published in Birth, and documenting a jump of 87 percent for the years 2011-2015, it has led media analysts to focus on the consequences of funding cuts to reproductive services in states restricting access to abortion. Rightly so: it is estimated that in Texas, where this has been particularly successful, between 1.7 and 4.1 percent of women have tried to self-induce an abortion, attempts that can have serious— sometimes fatal—consequences.

As with abortion, the lack of action on maternal mortality is connected to ideology.

Yet the statistics spike should command our attention for other reasons, too. The battle lines in the fight for reproductive rights are easier to draw around abortion, but the lack of action on maternal mortality is connected to ideology, too. The data reveals a racist and classist dimension to the problem: a recent study found that 60 percent of these deaths, which are mostly concentrated among African American women and women in rural communities, are preventable. Although it is important to note that the statistics themselves are in question, even when the potentially misleading results are discarded the rate is still rising. Indeed, the fact that maternal mortality rates are so badly recorded is in itself significant: ProPublica, in its “Lost Mothers” project, calls the federal government’s “inability or unwillingness” to track these deaths properly an “international embarrassment.” To understand the rising maternal mortality rate is to understand a context that allows these deaths to routinely go untracked: a willingness to sacrifice the bodies of mothers in the service of a socioeconomic order.

As the historian Beatrix Hoffman notes, “feminist activists and women’s organizations have been involved in health care reform debates in the U.S. for over a century.” Alongside issues like maternity pay and insurance reform—America is still in an international minority in not requiring employers to offer paid parental leave— there was a growing pressure to challenge a medical system that appeared to be either indifferent or actively negligent when it came to women’s health, as well as issues of gender, race, and class. In the 1970s, spurred on by the women’s liberation movement, feminist health centers taught self-examination, and practitioners called for the demedicalization of childbirth. This initially seems counterintuitive—it is hard to imagine lives being saved by a removal from expert care—and the unhelpful romanticization of “traditional” childbirth practices often blurs with suspect “noble savage” narratives: Benjamin Rush, the physician and Founding Father, wrote that, for Native American mothers, “nature is their only midwife.”

Yet—although medical advances are crucial in navigating difficult births—in what we can broadly term “normal” labors, traditional practices have their merits. Until the eighteenth century, childbirth was an event that occurred in the home, attended by mothers, grandmothers, and other local women. Slowly, the office of the midwife emerged: women who had acquired and inherited a wealth of knowledge about the delivery of children. Because the laboring woman was not touched internally, cases of infection were low: one of the most significant consequences of the advent of male obstetricians and lying-in hospitals in the eighteenth and nineteenth centuries was the fatal epidemic of puerperal fever. When the medical establishment as we now know it began to form, these women—and the all-female space and knowledge economy they represented—were treated with suspicion: in the Massachusetts Bay Colony in the seventeenth century, midwives were burnt as witches.

As the medicalization of childbirth gathered pace, the effectiveness of lying-in hospitals, forceps, and anaesthetic was a matter of public debate, but the discourse—mostly in professional publications like The New England Journal of Medicine, the British Medical Journal, and The Lancet —took place in a primarily male space. The experiences of mothers and midwives alike were discounted, and so, too, were the suggestions of those physicians who questioned the new status quo: the Viennese doctor Ignaz Philipp Semmelweis was professionally discredited and eventually committed to an asylum for his suggestion that doctors should wash their hands to avoid infecting women on labor wards. When the Scottish doctor James Simpson discovered in 1847 that the contractions of the uterus did not require the laboring mother to be conscious, he began to experiment with chloroform as a method of pain relief, inspiring a fierce theological backlash. As Adrienne Rich notes in her pioneering 1976 study Of Woman Born: Motherhood as Experience and Institution, the suffering of the woman in labor was seen to be both necessary and instructive: the burden of Eve.

Under capitalism, a woman’s body is a means of production like any other.

For centuries, Rich writes, “the labor of childbirth has been a form of forced labor”; the intentional pun linking the processes of work and the processes of birth illustrates that the medical cannot be removed from the economic and the social. Under capitalism, a woman’s body is a means of production like any other. Historians of motherhood, like Ruth Perry in her article “Colonizing the Breast,” argue that motherhood was a “colonial form—the domestic, familial counterpart to land enclosure at home and imperialism abroad . . . a production-geared phenomenon analogous to the capitalizing of agriculture, the industrializing of manufacture, and the institutionalizing of the nation state.”

For middle- and upper-class white women, this was veiled by the idealisation of “gentle” maternity and the “angel in the house”; working-class women and their bodies were more explicitly commodified, often required to put their own child out to nurse to earn money breastfeeding the offspring of their “betters,” frequently resulting in the death of their own child. Race is, of course, crucial here, as “forced labor” becomes a literal description of the harm inflicted upon black women’s bodies throughout history. Before the abolition of slavery, women on plantations were pushed to have more children, particularly after the 1807 Congress ban on the importation of slaves; in 1820, Thomas Jefferson wrote that “I consider a woman who brings a child every two years as more profitable than the best man of the farm.” As Serena Williams’ recent experience highlighted, women of color today still have to fight for autonomy in a health care system that is inherently racist: black mothers are 243 percent more likely to die than their white counterparts are. In all cases the value that was ascribed to maternity, whether explicitly financial or falsely worshipful, relied upon this paradoxical approach to the maternal body that separated it from the individual subjectivity of the woman herself. If the history of obstetrics is a history of the repeated denial of female experience, then maternal mortality is a symptom.

The idealization of motherhood under capitalism is also an idealization of domesticity. The nineteenth century saw the beginnings of a rejection of working motherhood, as the Industrial Revolution created a division between the workplace and the home, erasing women’s labor in the process. The conservative ideal of the family needed gendered economic roles to survive; women’s employment threatened the economic necessity of marriage, and the fantasy of “natural” maternal domesticity was a convenient invention. The legacy of this in present-day America can be seen in the opposition to state-supported childcare that gained ideological strength during the Cold War: a dangerously socialist removal of the child from the family unit would lead to the “Sovietization of American children.” Historically, international conflict has often coincided with a renewed emphasis on maternal welfare: it is the mother’s patriotic responsibility to produce model citizens, soldier-sons and mother-daughters. Foreign policy extends to the female body; once again, this unsettling preoccupation with reproductive bodies reveals how little the lives of mothers themselves are prioritized.

Despite the willingness of some women to side with their oppressors, collusion is no protection against mistreatment.

Today, the rise in maternal mortality and the renewed vigor of the pro-life movement are more than just causally related. However unclear the statistics are about exactly how much of an impact restrictive abortion laws are having on maternal welfare, the common factor here is a total disregard for the autonomy of the mother herself. They claim to believe that life is sacred; that’s at least a partial lie. The pioneering psychoanalyst and feminist campaigner Juliet Mitchell has spoken about her regret that the debate about abortion in the 1960s was allowed to be cast as “pro-choice” versus “pro-life” when the latter movement was, in its approach to the mother’s body, resolutely “pro-death.” This is also impossible to separate from ideas about the “right” kind of motherhood, and the patriotic duty to perform a particular kind of childbirth.

One of the many lessons of the past few years of white feminism and Republican victory is that, despite the willingness of some women to side with their oppressors, collusion is no protection against mistreatment. Bitterly amusing, the recent surprise expressed by female members of the alt-right that they are expected to conform to the traditional gender roles they openly praise, and “produce a pure white baby” to prove their commitment to the cause, demonstrates the blinkers of whiteness and the desperation of internalized misogyny. It also reiterates the strength of the ideological link between right-wing conservatism and the protection of “the home” against imagined agents of destruction. When these threats are perceived to be coming from within the female body itself, this is a fiction with dangerous human consequences.