Abstract
Kristin Haltinner’s No Perfect Birth: Trauma and Obstetric Care in the Rural United States analyzes “cultural and structural forces at play in producing and exacerbating mothers’ trauma” by centering thirty rural mothers’ voices. In the national conversation around the perinatal health crisis, greater attention is needed to specific complexities and challenges of rural communities, where 19 percent of U.S. residents live: lack of jobs and high poverty rates; reliance on a single industry (e.g., mining, farming, factory) for economic sustainability and vitality; “brain drain” of highly skilled or credentialed people; high rates of unemployment and poverty and, subsequently, high concentrations of people who are uninsured, underinsured, and suffering from chronic illness; and a national physician shortage that disproportionately affects rural communities, with only 9 percent of physicians practicing in them.
The shortage of obstetricians and gynecologists is even more stark, as Haltinner reports: “Half of the counties (mostly rural) in the United States do not have an obstetrician-gynecologist, while 56 percent do not have a nurse midwife. . . . only 20 percent of rural counties have obstetric care” (p. 23). Given this context, Haltinner’s work—each chapter anchored by an opening vignette and supplemented with interview data throughout—makes an important person-centered contribution to understanding rural obstetric care.
The book is theoretically grounded in the work of Michel Foucault, specifically his conceptualizations of biopower, governmentality, and discipline. Power, as Foucault teaches, circulates throughout society by way of social institutions and state governing bodies to produce hegemonic systems of knowledge, discourse, norms, and behaviors that are most felt and experienced on the body. Such power surveils, subjugates, and controls populations, seemingly invisibly, and it is a Foucaultian conceptualization of power that grounds Haltinner’s analysis of traumatic birth experiences: “the structure of a given space, the constraints of time, and the embedded routines—the very themes that arose in my interviews with mothers” (p. 8).
The first three chapters of No Perfect Birth focus on trauma imposed by time, space, and routine, respectively. Chapter One, in great detail, analyzes the history and contemporary operation of the U.S. insurance-based health care system that creates the conditions that overwork physicians by demanding long hours, incentivizing (financial and otherwise) a high patient volume, and regimenting provider-patient time in ways that, as Haltinner’s data illustrate, often leave women feeling unheard, unimportant, dismissed, and disrespected. Haltinner reports that “the average doctor sees nearly 2,500 patients annually, 19 people per day” (p. 28).
Chapter Two analyzes the trauma imposed by space by documenting a history of midwifery, the medicalization of pregnancy and childbirth, and the subsequent rise of obstetric dominance in the United States. Here, the space to which Haltinner refers is birth place, with physician-attended, hospital-based birth standardized in the cultural imagination and by insurance, state licensure, and scope-of-practice restrictions for all midwives—most especially for those primarily practicing in community-based, out-of-hospital settings like private homes and freestanding birth centers. Collectively, Haltinner concludes that “the separation of midwifery and medical-based obstetrics creates two worlds of care” (p. 48).
Chapter Three analyzes trauma imposed by routine, most specifically what Haltinner brilliantly describes as “bureaucratic inhumanity,” by focusing on the United States’s lack of structural investments in its people (read: social determinants of health) and how infant and maternal mortality are among the many casualties. Haltinner writes: “the routinization of health care results in women being unable to access needed care outside the routine practices of obstetrics . . . the U.S. model of insurance-based health care perpetuates existing inequalities between lower-income and wealthier residents whereby Medicaid recipients receive less care, lower-quality care, and face unfair and insurmountable stigma from providers” (p. 62).
The next three chapters make important contributions to emergent and already robust perinatal health literatures. Chapter Four bridges the previous three chapters’ respective foci on time, space, and routine to analyze how these factors contribute to obstetric violence. The chapter’s title is “Open Your Legs,” proactively capturing Erica’s violent, traumatic hospital birth experience characterized by the system’s failures to properly earn her consent for all aspects of her care, thus contributing to her perceived loss of agency. The chapter offers a genealogy of informed consent and obstetric abuse and a discussion of nonconsent in the present, concluding that “this violence toward women is lurking in the invisible ways our society accepts unrelenting control over women’s bodies” (p. 75).
Chapter Five analyzes trauma imposed by societal knowledge, specifically an internalization of hegemonic ideals of a “good” or “natural” birth, so much so that some women who experienced complications or who had an emergency cesarean section reportedly suffered from “anxiety, postpartum depression, flashbacks, nightmares, and memory loss—all common symptoms for trauma survivors . . . self-blame, a sense of alienation from other mothers, and the belief that they failed” (pp. 85–86).
Chapter Six complements the previous chapter by exploring the psychological impact of a traumatic birth on women’s relationships with their partners, infants, other children, and other relationships. The most common findings are that women who experienced a traumatic birth were particularly protective of their infants in an attempt to shield them from further harm and also reported a lack of interest in sexual intimacy with partners. Haltinner’s analysis demonstrates that the implications of birth trauma are multifaceted and far-reaching.
The book’s greatest strength is its person-centered approach to understanding trauma and obstetric care in rural U.S. communities. However, throughout the book, there are missed opportunities to be in conversation with other scholars whose work directly supports or could further explicate Haltinner’s analysis. First, social scientists Barbara Katz Rothman and Robbie Davis-Floyd, as examples, have written classic texts specifically on the medicalization of pregnancy and childbirth that also analyze the vast implications of time, space, and routine.
Second, scholars like Gertrude Fraser and Jenny Luke, among others, have documented non-whitewashed histories of midwifery. Though the history of obstetric care (with some mention of midwifery) section of this book is brief, an acknowledgement of Indigenous and southern Black grand midwives, along with a telling of the early-twentieth-century racist, classist, and sexist construction of knowledge and expertise waged by early obstetricians toward the elimination of midwifery, is essential to accurately documenting this history.
Third, and relatedly, in the very important discussion of the genealogy of the “ideal birth,” Haltinner reports that “until the 1850s, cesareans were performed without anesthesia” (p. 90). It is imperative to acknowledge that cesareans, and other aspects of obstetric practice, were developed by tinkering with the bodies of unconsenting, enslaved Black people. Any documented history of obstetrics must acknowledge its violent intertwinement with chattel slavery. Scholars like Deirdre Cooper Owens document this well.
The book concludes with important illustrations of how, among other things, women have used their power to “restructure obstetric care” and, at times, “claim agency.” Haltinner concludes with implications for structural change. All study participants were identified by the researchers as white, thus leaving the reader to consider how the book’s voiced experiences of agency, trauma, informed consent, and obstetric violence are even more complex for people of color. Haltinner’s book is an important contribution to the social science, public health, and medical literatures, and most especially rural health studies.