A critique does not consist in saying that things aren’t good the way they are. It consists in seeing on just what type of assumptions, of familiar notions, of established and unexamined ways of thinking the accepted practices are based… To do criticism is to make harder those acts which are now too easy.

― Michel Foucault

I’ve been thinking about what it means for nurses to be politically engaged. Nurses witness at close hand the inadequacies of the health system and the impacts of the social determinants of health and issues to do with differential quality and access.Yet few nurses see it as their role to challenge the political decisions that contribute to inequalities in health.

Amélie Perron’s Nursing as ‘disobedient’ practice: care of the nurse’s self, parrhesia, and the dismantling of a baseless paradox invites nurses to move beyond the valorising of the liberal autonomous individual of the therapeutic relationship to greater political consciousness and action.  However, political engagement including: “building political awareness, engaging in political discussions and action, presenting and speaking of themselves as political agents, and importantly, tying this political consciousness and involvement to their nursing identity” are seen as taking nurses away from care. However, I believe that it is nursing’s social mandate and professional responsibility to challenge structural constraints and social policies rather than passively accepting them. Contributing to much of this lack of movement is the ways in which much of nurses’ professional autonomy and agency are  constrained by administrivia and regulation within highly monitored health care organizations. The reductionism that this kind of surveilling invites means that there is a focus on the micro at the expense of the meso and the macro, so much that  the ‘bigger picture’ of nursing and health care are lost, let alone one’s role in the sociopolitical arena.

What I love about Perron’s paper is that she concludes this:

nurses are not faced with choosing either caring for their patients or engaging with politics. Instead, I assert that engaging with one automatically binds nurses to the other and vice versa. I base my discussion on the assumption that such dichotomy is meaningless and that engaging with issues of relationships firmly grounds nursing in the realm of politics. I argue that this portrayal of the nurse–patient relationship as a private and apolitical phenomenon could well (and, in fact, does) distract nurses from the bigger picture of nursing and health care, the broader context within which nurses practice their profession and which shapes and governs the ways and the extent to which nurses can do so. It also creates the illusion that the world ‘out there’ is a minefield of political games, while the safe, private, and seemingly more predictable one-on-one relationship with a patient is neutral and devoid of political content and processes. In fact, it seems to be a common saying among nurses that ‘I don’t want to be involved in politics, I just want to care for my patients’, as though the worlds of ‘politics’ and ‘patient care’ are separate and actually possible to disentangle

I am noticing a lot of discomfort around political consciousness and action, in the context of Gaza and Israel, Syria, austerity, global exploitation of resources, climate change and more. I think it is difficult to positively and constructively engage with politics.

Importantly, I think understanding (and distinguishing) the links between oppressive structures and individual experiences is critical. These structures can be patriarchy, capitalism, racism, compulsory heterosexuality, ableism, the nation state etc etc. Therefore, I can like Australians but critique the Australian Government’s stance on asylum seekers, I can have friends who are Jewish but feel devastated at the bombing of Gaza and the heavy handed tactics of the Israeli state; I can like men but despair of misogyny and sexism in the media and the lack of acknowledgement of women’s affective labour; I can like shopping for trinkets but critique the exploitation of labour eg in Qatar and ask what the true cost of my trinket is; I can enjoy romantic comedies but also ask questions about why they are only ever about white men and white women; I can appreciate my remarkable standard of living (not just money, but clean air, facilities etc) but critique why there is an uneven distribution of the world’s wealth and resources; I can love the birds in my garden but be concerned about how the indigenous custodians of the land came to be displaced and how I got to be living on it; I can enjoy flying and travelling on dual carriageways and also critique the valuing of work at the expense of community, I can be concerned about the impact on the environment of dredging the Great Barrier Reef.

I call for our politics to extend beyond the micro-level of interpersonal relationships to consider the meso-level of institutions and nations and the macro-level of international relations. We need it now more than we’ve ever needed it. 

The reluctance of nurses to politically engage could be addressed in undergraduate nursing education, where tools for engaging in politics or broader socio-political health promotion roles or health policy analysis (see Dean Whitehead’s work) could be emphasised. Such preparation would assist nurses to integrate the political, social, economic and environmental into their practice using frameworks such as cultural safety so that health for all would be achievable.

But above and beyond this academic exercise, do we really want our tweets or other social media communications used against us in ideological witch hunts? Do we want to allow a cloud of suspicion to hang over our heads? Do we want to constantly be checking ourselves as we voice our opinions on social media, and worry that by advocating a certain political position our employment might be jeopardized? By not protesting this instance, we are opening ourselves up to a world in which these kinds of denials of employment will be acceptable. What use, then, will social media be but to be a platform for the most mild forms of expression and banality with regard to controversial subjects?

Cite as: DeSouza, Ruth. (2013). Who is a ‘good’ mother?: Moving beyond individual mothering to examine how mothers are produced historically and socially. Australian Journal of Child and Family Health Nursing, 10(2), 15-18.

Introduction

Far from being a matter of individual choice, motherhood and mothering are shaped by larger systemic, social and historic forces. In this paper I suggest that Child and family health nurses (CaFHNs) can more effectively support women and their families through a recognition and acknowledgement of these forces.

The contemporary liberal feminist focus on birth as a space of self-actualisation and empowerment within the context of an individualized, heteronormative, nuclear family, masks the ways in which maternity has been and continues to be a site of scrutiny and regulation. Institutions and nurses that work within them have been complicit in supporting some groups of people to reproduce (pronatalism) while discouraging or coercing others from doing so (antinatalism). Child and family health nurses (CaFHNs) have a pivotal role to play in the wellbeing of families and communities, but they are also implicated in the state’s management of populations. In this article I propose that moving nursing practice away from the individual to instead consider the historical, social and systemic can support CaFHNs to provide more responsive and reflexive care for women and their families. In turn such a manoevre can provide CaFHNs with the tools to better critique their complicity with institutional imperatives and ‘victim blaming’.

In the first part of the article I trace the compulsory ontology of being a choosing and informed consumer in maternity, suggesting that milestones in capitalism predate the social and political activism of liberal feminist and consumer movements of the 1970s. These include pronatalist policies in colonial contexts; Victorian ideals of individual mothering; the advent of the family as a target for state intervention and advances in science and industrialisation. In the second part of the article I will bring this potted historical account of maternity into the present and examine how the contemporary ideal maternal subject—one who is active, choosing and informed—and associated modes of thought and practices service particular political, social and economic interests that unevenly benefit particular kinds of mothers.

Methodology

Using a historical-conceptual institutionalist analysis such as genealogy (Michel Foucault) presents an opportunity to historicise and politicise the operations of power and knowledge that are present in maternity. Subjecting maternity to a genealogical analysis enables the relationship between the maternal body, discourses, and power to be explored, so that the ways in which contemporary definitions of maternity have been historically constructed in order to meet particular purposes can be ascertained and in turn create space for other constructions (Galvin, 2002).

Women as mothers of the nation

Women’s roles as biological and cultural reproducers of the nation are fundamental to the production of citizenship in the context of nationhood. The face of the nation is often viewed as maternal, for example ‘Mother India’, and countries tend to be denoted by the feminine pronoun and language as the ‘mother’ tongue. Mothers reproduce the nation biologically through giving birth, and socially by maintaining and transmitting culture within the domestic or private sphere of home and family as keepers of the hearth, home and culture, (Yuval-Davis, 1993, p.627). Citizenship brings to mind issues of home, belonging and security, and raises questions about who is entitled to be a part of the home or nation (Chantler, 2007). The notion that race can be reproduced is central to the interrelated discourses of racism, nationalism, and imperialism. The concept of nation-as-home constructs the inside of the home and family as a refuge, and the outside as unruly and dangerous, a border requiring policing and surveillance (Chantler, 2007)

Regulating the reproduction of those considered to be a burden on society has been a way to secure and control the well-being of the population, leading to the surveillance and management of women’s bodies. A common theme in early 20th Century white settler societies such as Australia, New Zealand and the United States were fears of ‘race suicide’ due to middle class women not having children while ‘other’ women (migrant, indigenous or working class) were having too many. Reproducing white citizens in the colonies became a patriotic and political duty for white women as it was seen as central to the interests of the nation and the health of the race  superseding involvement in public affairs (Bartlett, 2004). Pronatalist and anti-natalist ideologies often occurred concurrently and led to interventions including the removal of children (most notably in ‘the stolen generation’ in Australia) and forced sterilisations without consent (Pateman, 1992). Another example is breastfeeding in Nazi Germany which was obligatory and where women were awarded a medal (called the Mutterkreuz) for rearing four or more children. At the same time extreme anti-natal racial hygiene doctrines were implemented against ‘unfit mothers’ resulting in forced sterilisations and abortions for women with impairments, or women considered “ethnically other” such as Jews, Gypsies and Slavs.

Individual mothering and the family as nursery

Victorian ideas of the home as a woman’s sphere and moral standards of good mothering were specific to white middle class culture. Before the 19th century women had been primarily associated with “sexuality, cunning and immorality” (Ladd-Taylor & Umansky, 1998, p.7). The pious development of a domestic sensibility gave women a clear role that was linked with more dignity, authority and opportunities for education (Ladd-Taylor & Umansky, 1998). The new Anglo-Saxon middle class individualised mothering in contrast with the shared child rearing that was more common in other societies. This resulted in women from those communities, for example immigrant and indigenous women, being labelled as bad mothers (Ladd-Taylor & Umansky, 1998). Evolutionary theory played a role in demarcating good and bad mothering: Anglo-Saxon and Northern European women were positioned on the top of the hierarchy of the ‘races’ and were the only women capable of being good mothers irrespective of what other mothers did (Ladd-Taylor & Umansky, 1998). Such women bore the responsibility for ensuring the well-being of their families, the future of the nation and the progress of the race. Anglo-Saxon mothers were thus both exalted and pressured.

The high infant mortality rates of the time led to a focus on the management of mothers, rather than the politically challenging public health issues contributing to these rates (Ram & Jolly, 1998). Foucault (Foucault & Rabinow, 1984) noted that the well-being of children in general was seen as a problem of government, and the family provided a link between private good health and general political objectives for the public body (cited in Petersen & Lupton, 1996). The family became the nursery of citizenship, with the family milieu acting as an exemplar for broader social relations (Petersen & Lupton, 1996). The hygiene of the home became women’s work as the emphasis on health implications of domestic space grew in importance from the late 19th century and early 20th century (Petersen & Lupton, 1996). Cleanliness, the orderliness of the home and the bodies inhabiting the home became a duty of citizenship for women. Simultaneously, maternity became defined as caring, altruistic and absorbing and laws were developed in the United Kingdom to punish infanticide, abortion, and birth control (Petersen & Lupton, 1996). Schemes to address maternal malpractice such as health visitors (whose job it was to surveill and educate women) were initiated to ensure that the British working class mother was subjected to the imperatives of the infant welfare movement and became a ‘responsible’ mother. A proliferation of organisations to promote public health and domestic hygiene among the working class thrived, assisted by upper or middle class women. Several researchers have noted (Aanerud & Frankenberg, 2007; Ram & Jolly, 1998) how this class-based maternalism in Europe and North America reflected a race-based maternalism in the colonies, where Europeans challenged and transformed indigenous mothering in the name of “civilisation, modernity and scientific medicine” (Jolly, 1998, p.1). Similarly, in colonised countries the ‘cleaning up’ of birth was achieved through both surveillance and improved hygiene and sanitation (Bartlett, 2004).

The moral regulation of the population through the governance of the family remains a contemporary parenting practice where women are considered responsible for producing, maintaining and protecting others’ health and wellbeing (Ladd-Taylor & Umansky, 1998). Neoliberalism has further increased the responsibilities that are viewed as private and transferred to women when the government retreats (Berger & Guidroz, 2010). Therefore, the Foucauldian expansion of the art of government to include maximising the well-being of populations has a particular resonance in maternity.

Science and industrialisation

The ‘cleaning up’ of birth was a colonial and modernist enterprise, involving not only sanitation but also the governance of women’s bodies (Bartlett, 2005). The discourses of science and government intertwined as techniques of biopower, and came to increasingly engineer maternity. Scientific motherhood evolved as a combination of maternal love and mechanistic scientific knowledge in the late 19th century, and was influenced by two major developments in the 17th Century (Dykes, 2005). The first saw a shift from the embodied knowledge of women to science as the source of authoritative maternal knowledge. Science’s tenets such as dualism, objectivism and reductionism led to the medicalisation of life and a framing of the body as a machine, predicated on the norm of the idealised masculine body (Donner, 2003). The second trend was the impact of increased population, industrialisation and urbanisation that occurred with the growth of economies and colonies under Western capitalism. Productivity to boost profits, and monitoring for efficiency and outputs was increasingly emphasised. This made possible “the controlled insertion of bodies into the machinery of production and the adjustment of the phenomena of population to economic processes”(Foucault, 1977, p.141). Population, production and profit became drivers for the creation of the major disciplines of hospitals, schools and other “techniques for making useful individuals” (Foucault, 1977, p.211).

In the Victorian era in England, the factory and efficient production reached their peak and the ideologies that made industry productive began to permeate into other spheres of life (Dykes, 2005). Factors that enhanced efficiency such as timing, regularity and scheduling were applied to motherhood and parenting, and in turn women’s roles were geared toward producing adults for the factory. Submission to the systems and disciplines necessary on a production line became warranted as part of parenting, eventually joined by tenets from early 20th Century behavioural psychology such as separation, control, routine and discipline. These Enlightenment tenets remain embedded in contemporary health systems and processes. Dykes draws on Martin (1990) to argue that under medicalisation “[maternal] labour is a production process, the woman is the labourer, her uterus is the machine, her baby is the product and the doctor is the factory supervisor.” In a Marxist vein, the labouring woman requires an intermediary who can manage and control the process thus separating her from her birthing (Dykes, 2005). (Kirkham, 1989, p.132) extends the metaphor to suggest that the role of the midwife is as a “shop floor worker” who follows the supervisor’s “instructions”. Dykes (p.2285) theorises contemporary breastfeeding similarly:

 breastfeeding becomes the production process, the woman is still the labourer and her breasts now replace the uterus as the key functional machines. Now breast milk becomes the product, with her baby assuming the role of consumer. If the breasts (machines) are in ‘good-working order’ then they will ‘produce’ the right amount and quality of the ‘product’, breast milk. If the labourer uses them effectively, then they will deliver the ‘product’ efficiently and effectively and in the correct amount to the ‘consumer’, the baby.

This mechanistic view of breastfeeding and birth has two impacts: the first is that because these processes can go awry, a supervisor is needed (such as a midwife or health professional); secondly, the loss of confidence experienced by women as producers through a mechanistic metaphor. The expert/professional discourses of maternity thus produce particular kinds of maternal subjectivities around these impacts.

The neoliberal maternal subject

Being healthy is an important responsibility for a citizen and given that health is unstable, it requires work, effort and various practices (Petersen & Lupton, 1996). The discourse of the modern individual rational subject has created a particular kind of subjectivity that is termed healthism requiring the take up of health-promoting activities as a moral obligation (Roy, 2007). Healthist discourse emphasises an enterprising self who takes individual responsibility for health maintenance and enhancement, by engaging in self-discipline and self-surveillance. This ideology of the individual’s responsibility to keep healthy is dominant in the media as well as professional healthcare discourses (Donnelly & McKellin, 2007, p.173):

 these ideologies and discourses reflect dominant western values for individualism, which, in turn, influence the direction of healthcare practice and the distribution of responsibility and role expectancies between individuals and institutions. Individualism has also influenced how responsibility for health is viewed, and thus how health care is being provided and practiced, and the ways in which people manage pervasive issues of blame and accountability.

This discrete, self-monitoring subject that invites and acts upon expert advice is a dominant feature of neoliberal public health policies, where it is assumed that access to information will result in effective self regulation (Stapleton & Keenan, 2009). This ideology is reflected in the way in which maternity health care systems position themselves as being the bearers of expert knowledge without acknowledging the credibility and legitimacy of other sources of knowledge such as family and community networks. A ‘rational subject’ model is assumed where authoritative professionals transmit information to individual women whose embodied, enculturated understandings and experiences are discounted or devalued. Pregnant and postnatal women are represented as autonomous social actors who are fully in control and knowledgeable about their bodies and ‘free’ to make and justify choices. Individuals and their caregivers are expected to engage in reflexive techniques and /or practices of subjectification, to be accountable for the choices that are made, and to account for their behaviours to those who are tasked with monitoring and validated for monitoring them (Stapleton & Keenan, 2009). However, these ‘universal’ concepts of choice and autonomy are socioculturally constructed, potentially coercive and constrained through the intersections of class, race, ideology and resources (Stapleton & Keenan, 2009).

The emphasis on women as primary carers, who bear responsibility for children, parents and partners through cleanliness, remains a dominant theme in contemporary Western societies (Petersen & Lupton, 1996). The individualising of motherhood has led to the dominance of foetal rights discourses, where the supposed interests of the foetus are put before the interests of women and even other children (Booth, 2010). Pregnant women are charged with ever-increasing responsibility over the health of their foetuses, while they themselves are reduced to being a container for their foetuses. This has led to the restriction of women’s activities, requiring constant self-surveillance to protect the health of their foetus. This responsibility continues through infancy and adulthood and commits women to maximising the moral, social and psychological development of their children (Schmidt, 2008).

This valuing of the individual as a site is privileged in nursing as seen in the concept of individualised care, where the promotion of independence from nursing services through the emphasis on self-care, or the transfer of responsibility for care to informal carers or social care agencies (Gerrish, 2001). Nurses have typically believed that patients owned both the origin and the solution to their health problems. Therefore, neoliberalism can be considered to be both an expression of the biopolitics of the state as well and the standard setter for normative citizenship (Ong, 1999).

What does this selective history of the idealised contemporary maternal consumer mean for maternal and child health nurses? It helps to identify how contemporary middle and upper class mothering standards have been shaped by consumerist, technological, medicalised, and professionalized discourses. These discourses exert a normalising pressure which requires mothers to work and be self-disciplined. This intensive and individualised form of mothering is valorised at the expense of other iterations of mothering. CaFHNs assist the state to govern maternity at a distance therefore nurses can unwittingly collude with institutional policies that only support a narrow repertoire of mothering styles. For example, the contemporary ideology of intensive mothering, requires mothers devote large amounts of time, energy, and money to raise their children and rely on expert advice in child-rearing decisions (Avishai, 2007). However, it is classed and raced, advantaging particular groups of people who have the resources to enter the frame of pregnancy and childrearing as carefully managed projects requiring assessment/research, planning and implementation skills which are supplemented with expert knowledge, professional advice, and consumption (Avishai, 2007). The primacy and valuing of intensive motherhood, can prevent CaFHNs from being responsive to women whose subjectivies have been formed outside white, middle class or western contexts. In place of therapeutic relationships with clients is possible to be under-involved or over-involved in a nurse-client relationship (Alberta Association of Registered Nurses (AARN), 1997). More likely the clients that fit into dominant modes of care are labeled ‘good’ and receive better care whilst those labeled as ‘bad’ or more typically ‘non-compliant’ and ‘difficult’ are avoided or are exposed to greater scrutiny, regulation or neglect.

 Conclusion

Nurses need to consider their own roles and values when they deliver care. As culture-bearers, these values demarcate whether we see our clients as deserving of good care or in turn lead us to withdraw care or place clients under greater state scrutiny. By recognising the historical, social and structural forces that have shaped our ideas about maternity we can avoid individualising blame for those least in a position to shift things. In the same vein moving our interventions beyond the individual to consider the broader contexts of maternity mean that we can more carefully consider how current practice supports institutions rather than families.

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