Emotional labour: Exploring emotional policy discourses of pregnancy and childbirth in Ontario,Canada

Abstract

In 1991, Ontario became the first Canadian province to pass legislation establishing midwifery as a self-regulated healthcare profession and integrating it into the provincial healthcare insurance plan. Since its implementation, there has been a partial convergence of obstetric practice in the province, where, despite seemingly distinct professional philosophies of care, both midwives and physicians cohere around representations of pregnancy and birth as “normal” or “natural” life events rather than medical conditions requiring treatment. In this paper, I suggest that understanding this convergence and the effects produced by it requires an interrogation of the emotional policy discourses that shape (and are shaped by) the ways we experience the world around us. In doing so, I develop a framework for tracing the emotional policy discourses surrounding pregnancy and birth from the turn of the 20th century until the early 1990s, demonstrating that these representations reflect the merging of two emotional registers, joy and fear, where pregnancy and birth are represented as joyous, life changing events, but where joy is tempered by the fear of complications and potential tragedy. I thus show that contemporary emotional landscapes bind various “birth experts” and bracket “expertise” around particular forms of knowledge, shaping expert and maternal subjectivities along gendered, racialized, ableist, and class-based lines.

Keywords

Canada emotional discourse feminist policy analysis reproductive politics

Until the early 1990s, Canada was the only Western country that did not recognize midwifery as part of its obstetric care system.¹ In 1991, however, Ontario became the first province to pass legislation establishing midwifery as a self-regulated profession and integrating it into the provincial healthcare insurance plan, offering full funding for midwife attended births in homes, hospitals or birth centres. The legislation marked the end of nearly a decade of contentious public debate about midwifery, during which physicians, who had previously enjoyed a monopoly over obstetric care in the province, shifted from a position of vehement rejection to tentative acceptance.

Since the implementation of midwifery, there has been a partial convergence of obstetric practice in the province. On the one hand, midwifery has been criticized for increasingly resembling the biomedicine it initially critiqued, reproducing a hierarchy of knowledge and expertise that privileges biomedical science.² Indeed, some have argued that a new form of birth expert – the professional midwife – has emerged, acting ‘on’, rather than ‘with’, maternal subjects (Paterson, 2010). On the other hand, biomedical approaches to birth have also changed, tending toward fewer interventions and encouraging involvement from birthing subjects and their families. To be sure, despite seemingly distinct professional philosophies of care, both midwives and physicians cohere around representations of pregnancy and birth as “normal” or “natural” life events rather than medical conditions requiring treatment.

In this paper, I suggest that understanding this convergence and the effects produced by it requires an interrogation of the emotional discourses that shape (and are shaped by) the ways we experience the world around us. To do so, I trace the emotional policy discourses surrounding pregnancy and birth from the turn of the 20th century until the early 1990s, demonstrating how emotional landscapes lend coherence to seemingly disparate professional discourses and practices, binding “experts” and bracketing “expertise” around particular forms of knowledge. I illuminate three distinct periods that are differentially shaped by two emotional discourses, joy and fear. Until the mid-20th century, representations of pregnancy and birth were constituted by a discourse of fear, where fear of pain and poor outcomes coproduced birth practices centering on biomedical expertise. From the mid-20th century until the 1980s, a discourse of joy constituted representations of pregnancy and birth, coproducing birth practices emphasizing happiness and, in many cases, empowerment in and through the birth process. In the third period, from the 1980s to the present day, representations of pregnancy and birth reflect the merging of these two emotional discourses, where pregnancy and birth are represented as joyous, life changing events, but where joy is tempered by fear of complications and potential tragedy. I demonstrate that the merging of joy and fear produces a discourse of risk, upon which biomedical science and midwifery converge (e.g. Coxon et al., 2014; Fannin, 2013; Possamai-Inesedy, 2006). I argue that the risk discourse coproduces birth practices that privilege scientific expertise, thereby constituting expert and maternal subjectivities along gendered, racialized, ableist, and class-based lines.

To make these claims, I draw on feminist policy analysis and cultural theories of emotion to develop a framework for investigating how emotional policy discourses are implicated in social processes that situate subjects in complex structures of penalty and privilege. Indeed, policy studies is in the midst of an “emotional turn”, offering a necessary corrective to the neutral bureaucrat archetype that dominates the field. Yet how emotional policy discourses shape and are shaped by power relations remains unclear, despite a vast literature detailing how emotions are gendered and racialized. The case of pregnancy and birth in Ontario, Canada, provides the opportunity to examine how maternal bodies are marked, surveilled and regulated within emotional discursive fields, illuminating how emotional discourses shape what can be said, thought, and felt, and how these limits produce various subjectification and material effects. In what follows, I begin by outlining an approach for conducting emotional policy discourse analysis, followed by an application to pregnancy and birth politics in Ontario. I conclude with some reflections on the potential of emotional policy discourse analysis to provide insight into how policies are lived and how we might reimagine them in more socially just ways.

Discourse and emotions: Towards a feminist framework for emotional policy analysis

There is a growing literature on public policy and emotions. Building on broader multidisciplinary scholarship on emotions,³ this work has identified the emotional dimensions of activism (Anderson, 2014; Orsini and Wiebe, 2014) and networks (Ingram et al., 2015); policy rhetoric (Gottweis, 2012), framing (Gross, 2008) and debate and deliberation (Martin, 2012; Welch, 1998); public administration (Anderson, 2002, 2017; Husso and Hirvonen, 2012); and governance (Durnova, 2013; Durnova and Hejzlarová, 2018; Newman, 2017). In addition, a number of works seek to examine emotions in particular policy fields, such as international relations and foreign policy (Mercer, 2010), social assistance (Hancock, 2004; Small and Lerner, 2008), and social and employment policy (Cook, 2012; White, 2017). Moreover, some have explored how we might ‘do’ emotional policy analysis, identifying some of the potential epistemological concerns that arise from doing so (Newman, 2012).

A dominant strain of this literature demonstrates how emotional discourses mobilize, politicize, and position particular actors. In contrast to instrumentalist approaches, where understanding emotions is promoted as essential to political leadership (Richards, 2007; Westen, 2008) or “nudges” (Thaler and Sunstein, 2008), for example, discursive approaches offer what Newman (2012: 466) suggests are a more “fine grained analysis of how emotional regimes of governance are enacted […].” In this sense, emotions, expectations, and responses are not necessarily separate from rational processes, or something that can be discretely understood, managed and acted on in order to make “better” policies or decisions. Instead, emotions are uncovered through discourse analysis,⁴ rather than assumed or determined in advance. As discourse, defined by Hajer (1993: 45) as, “an ensemble of ideas, concepts and categories through which meaning is given to phenomena” that is produced in and reproduces a set of identifiable practices (Hajer, 2011), emotions are constitutive of meanings shaping how we understand and feel about the world around us, as well as self, other, and community (e.g. Ahmed, 2004; Newman, 2012, 2017). While this work has enriched our understanding of the discursive dimensions of emotions in policy processes and outcomes, it remains unclear how these concepts address an emotional-discursive terrain that is marked by a complex system of penalty and privilege.

This insight is acknowledged within cultural theories of emotions. In these works, emotions are socially mediated, productive forces that act on both individual and collective levels. Ahmed’s (2010, 2008, 2004) work illuminates the discursive and creative dimensions of emotions, exposing how they move between objects, establishing conditions of adherence and coherence, as well as backwards as they invoke particular histories. Thus, emotions have spatial, temporal, material, and relational facets. Moreover, emotions are rooted in the social, bringing individuals into – or out of – collective bodies (Ahmed, 2004, 2008; Brennan, 2004; Nicol, 2011). As Ahmed (2008: 12) explains, “Emotions affect how bodies take shape in social space and how spaces cohere around bodies.” Similarly, Nicol (2011) shows how emotional norms associated simultaneously with fear and desire are key to understanding contemporary subjectivity and broader “socio-emotional formations” that inform governance regimes. She writes, these “[s]ocial economies of emotion designate the social configurations and processes that help shape individuals’ emotional life and actions” (2011: 1).

Emotions thus regulate and govern bodies in ways that position some subjects as more ‘trustworthy’ or ‘fearful’ than others, and these positionings shape and are shaped by social location. Emotions and emotionality are deeply gendered and racialized constructs, serving to scrutinize and discipline the actions of some groups more than others (Mumby and Putnam, 1992). Policies serve to fix emotions to and between objects and subjects; they “surface” (Ahmed, 2008) bodies and problems in ways that make them legible within our complex environments. In so doing, policies are central to emotional regulatory and disciplinary processes that give rise to contemporary subjectivities (Newman, 2012, 2017). We therefore need an analytical framework that not only illuminates emotional policy discourse, but also exposes how power is operationalized through such discourse, sustaining or challenging social politics.

To do this, I suggest modifying a feminist post-structural policy framework, Bacchi’s What’s the Problem Represented to be (WPR) approach (1999; Bacchi and Goodwin, 2016), with concepts established within the broader literature on emotions. The WPR focuses on policy as “productive activity,” asking broadly “What is produced? How is it produced? And with what effects” (Bacchi and Goodwin, 2016: 14). The approach calls our attention to problem representations, which serve to ‘fix’ the meanings of events in ways that render them intelligible and governable (see also Bacchi, 2015; Gottweis, 2003: 260). Bacchi and Goodwin (2016: 17, emphasis in original) explain,

We are talking about how the “problem” is made to be a particular kind of problem within a specific policy, with all sorts of effects. The subsequent claim is that we are governed through these constituted “problems,” meaning that governing takes place through problematizations.

The WPR is premised on six guiding questions,⁵ which interrogate the “unexamined ways of thinking” that undergird policies and expose their implications, including discursive, subjectification, and lived, or material, effects (Bacchi and Goodwin, 2016: 21).

This approach has troubled the technocratic bias of mainstream policy studies, exposing how tacit assumptions about policy problems and subjects, and the power relations on which they are premised, get lodged in and reproduced by policy texts and discourse. From this perspective, policy is discourse; as such, it reproduces or troubles existing power relations by acknowledging (and constituting) the authority and legitimacy of some groups or individuals over others (Bacchi, 1999). Thus, policy and emotions are constitutive of the discursive terrain in which problems are represented and experienced. While the WPR reveals how policy discourse affects what we can think and say, little attention has been given to how it affects what we can feel. Indeed, applications and adaptations of the WPR have not considered the emotional dimensions of policy discourse. Yet, as discourse, policies are always infused with emotional discourses.

To embed emotional discourse analysis in the WPR, I suggest two key areas for extension. First, as shown below, the framework asks how problems are represented, how they emerged, where they have been endorsed and by whom, as well as what and who is rendered invisible or silenced. Thus, we need to consider the emotional discourses (and contingent practices) that shape (and are shaped by) problem representations. Orsini and Wiebe (2014) describe something similar with their concept “emotional landscapes,” which refers to “an environment that includes affect and emotions, sensory experiences, the conscious and the unconscious” (Orsini 2017: 7). Extending Hochschild’s (2012) concept of “feeling rules” to the policy arena, Orsini (2017: 7) explains that emotional landscapes are comprised of a set of discourses, institutions, and subjects:⁶

Embedded in these landscapes are a series of “feeling rules” or norms that communicate the boundaries, albeit shifting, of appropriate expressions of emotion. […] [E]motions can be molded, manipulated and hitched to certain interests. In this respect, the planes of possibility for feeling rules and affective states are neither neutral, nor innocent.

Here affect refers to the unconscious bodily experiences in response to stimuli, which are translated and expressed by emotions (Orsini, 2017: 5–6; see also Jasper, 2011). Expanding our focus to include emotional landscapes makes visible how emotional policy discourse is both structuralized, shaping how we feel about issues, and institutionalized, shaping and shaped by practices and institutions (Hajer, 1993).

The second modification concerns the effects produced by discourse. The WPR identifies three effects produced by representations. Discursive effects limit what can be thought and said about a particular issue. Subjectification effects refer to the processes, the “dividing practices,” in which subjects are “made” and “becoming” (Bacchi and Goodwin, 2016: 49). Finally, lived or material effects describe how discursive and subjectification effects “play out” in everyday life, shaping what subjects actually ‘do’ (Bacchi and Goodwin, 2016: 23). These effects are constituted, at least in part, by emotions. For example, subjects constituted as il/legitimate or un/trustworthy will experience effects “in the real” through access to benefits and entitlements. We therefore need to interrogate the emotional dimensions of these effects.

Nicol’s (2011) felt in/capacity theory offers insight on the emergence and embodiment of “feeling rules,” which can sensitize researchers to the emotional facets of the effects produced by discourse. In particular, Nicol identifies three processes of emotional embodiment, including affective, agential and symbolic attunement, that link emotions with objects and subjects. In simple terms, affective attunement refers to the process by which objects become attached to particular emotional responses. For example, the fear of loss during pregnancy might become attached to uncertainty/certainty, where uncertainty “names the fear produced by the perception that one lacks the ability to confront the forces that cause inconstant effects, while certainty names the desire produced by the certainty that one has the ability to do so” (32). Agential attunement is the process resulting in subjects associating particular means of power with emotional responses. For example, the uncertainty resulting from fear of loss might be associated with participating in proactive behavior aimed at preventing loss, such as healthy eating, limiting alcohol or tobacco consumption, and undergoing fetal testing. Finally, symbolic attunement is a signification process whereby “objects become attached to signs that trigger the experience of the emotional norms and embodied means of power with which these objects of fear and desire are also associated” (4). For example, spotting during pregnancy, weight loss or inability to feel the fetus moving, as well as seeing other pregnant subjects smoking or drinking, become attached to the feeling of uncertainty and are thereby linked with associated behaviours.

These processes map loosely onto the three effects of representations identified by Bacchi (1999), offering tools with which to interrogate their emotional dimensions. For example, integrating affective attunement extends discursive effects to shape what can be felt about an issue. Similarly, in considering subjectification effects, we must acknowledge that subjects are disciplined not only in what they can think and say, but also in what they can feel.⁷ Thus, integrating agential attunement expands our lens for considering how political subjects are constructed through emotional discourse. Finally, integrating symbolic attunement with lived effects illuminates how emotions shape and are shaped by behaviour.

Modifying Bacchi’s (1999; Bacchi and Goodwin, 2016) WPR approach with these concepts, the analytical questions become:⁸

What’s the ‘problem’ represented to be in a specific policy field? How do emotional landscapes shape and how are they shaped by this problematization?

What presuppositions or assumptions underlie this representation of the ‘problem’? How are emotional discourses implicated in these assumptions? Are some emotions more ‘legitimate’ than others?

How has this representation of the ‘problem’ come about? How have the emotional landscapes in which this problematization emerged shifted over time and space?

What is left unproblematic in this problem representation? Where are the silences? Can the ‘problem’ be thought and felt about differently?

What effects are produced by this representation of the ‘problem’? Consider processes/effects, including: affective attunement/discursive effects, agential attunement/subjectification effects and symbolic attunement/lived effects?

How/where has this representation of the ‘problem’ been produced, disseminated and defended? How could it be questioned, disrupted and replaced? (Bacchi and Goodwin, 2016: 20). How have these contexts and proposals been shaped and shape emotional discourses?

In the remainder of this paper, I apply this framework, focusing mostly on questions 1, 3 and 5, to examine how shifting emotional policy discourses shaped the ways that pregnancy and birth came to be represented in Ontario from the turn of the 20th century until the 1990s. In so doing, I illuminate how power operates through these representations, marking, surveilling, and regulating maternal bodies, and constituting expertise through the bracketing, and privileging, of particular forms of knowledge.

Risky subjects: Tracing the emotional discourses of pregnancy and birth in Ontario, Canada

Until the late 19th century, the primary birth attendant in North America was a midwife. In Canada, as biomedical physicians professionalized, they were granted a state sanctioned monopoly over obstetric care, where it was mandatory to hold a licence to practice. These exclusionary measures meant the near erasure of traditional midwifery. Indeed, by the 1950s, nearly all of Ontario’s babies were born in hospitals (Mitchinson, 2002). By the 1960s and 1970s, however, midwifery was re-emerging as an alternative to medicalized births, and the provincial government was looking for ways to cut costs in the area of healthcare. Although the Ontario government had been considering midwifery services since 1970, it was not until the Health Professions Legislative Review, established in 1983 to overhaul the healthcare system, that it became a serious alternative. By 1986, the government established the Task Force for the Implementation of Midwifery in Ontario (TFIMO) to advise on how midwifery services should be implemented in the province. The report of the TFIMO recommended that midwifery be established as a self-regulated profession, funded by the provincial health insurance system, and that midwives be able to attend births in both hospital and birth centre settings.⁹ The Midwifery Act was passed in 1991, adopting many of the recommendations of the TFIMO, and included home birth.

As a profession, midwifery is based on a model of care that includes three principles: informed choice regarding care, which respects the autonomy and decisions of pregnant and birthing subjects; choice of birthplace, including home, hospitals, and birth centres; and continuity of care, which includes complete care by a small team of midwives throughout pregnancy, labour, and the post-partum period (AOM, nd). In contrast, the medical model of care is based on informed consent, where physicians seek consent for procedures; hospital birth; and fragmented care, where patients are seen by a variety of practitioners throughout pregnancy, labour, and post-partum.

Despite these differences, both midwives and physicians adhere to philosophies of care that represent pregnancy and birth as “normal” and “natural” events that, ideally, require little intervention, and that centre on birthing subjects and their families. Consider, for example, the guidelines for practice for the Society of Obstetricians and Gynaecologists of Canada (1998: 2), where it is explained:

In the majority of cases, pregnancy and birth are normal, natural processes. […] it is felt that the hospital should be a non-threatening environment in which the patient can openly express her preferences without feeling that she is contradicting hospital policy.

Consider also the Ontario Midwifery Model of Care, as explained by College of Ontario Midwives (2014: 2):

Midwives view pregnancy and childbirth as a healthy and normal physiologic process and a profound event in a woman’s life. Midwives encourage women to actively participate in their care throughout pregnancy, birth and postpartum period and make choices about the manner in which their care is provided.

Representations of pregnancy and birth as ‘normal’ have also shaped and been shaped by obstetric care practices that are used by both midwives and physicians, such as early pregnancy screening to determine ‘normalcy’, and observational practices throughout pregnancy and birth to monitor both birthing subject and fetus. Such practices are designed to measure ‘risk’. For example, in discussing the potential dangers of pregnancy and birth, the SOGC (1998: 2) notes:

It is our responsibility as obstetricians to inform families of these facts and obtain consent to encourage realistic expectations. […] In every case, informed consent must be obtained, meaning the couple, particularly the woman, makes the final decision. (1998: 2)

Similarly, clinical practice guidelines for Ontario midwives explain:

Midwives facilitate the collaborative process of informed decision-making and recognize clients as primary decision-makers about their care [...] When discussing the risks, benefits and alternatives associated with birth settings with clients, midwives should refer to best available evidence and, when available, should focus on the growing body of robust evidence examining midwife-attended births and the safety of planned home birth in Canada. (Expert Advisory Panel, 2016: 1–2)

In these examples, pregnancy and birth are represented by both physicians and midwives as risky processes best attended by skilled professionals.

The questions I ask here are how has this understanding of pregnancy and birth come about, what effects are produced by it, and how are they implicated in emotional discourses? Applying question 3 of the framework above, I will demonstrate that the risk discourse shaping contemporary pregnancy and birth practice emerged from a merging of two preceding discourses that shaped the emotional landscapes of pregnancy and birth: ‘fear’ and ‘joy’. The fear discourse was dominant in the late 19th century arising with the professionalization of doctors. The joy discourse arose as critiques of the fear discourse during the 1930s. For each of these periods, as well as the current period, I will also apply question 5 of the framework to examine the various effects produced by these emotional discourses. I demonstrate that in each period, emotional policy discourses bracket “expertise” around particular forms of knowledge, shaping expert and maternal subjectivities along intersectional lines, producing at times contradictory and uneven effects across birthing subjects.

Biomedicine and the politics of fear

The emerging dominance of biomedicine in the arena of pregnancy, birth and motherhood has been well documented by feminist historians. Key here was the construction of infant and maternal mortality and morbidity as policy problems that required state surveillance and intervention, and the emergence of scientific motherhood as a solution. This context rendered legitimate newly professionalized biomedical physicians, who were granted a legislated monopoly over obstetric care throughout much of the country. Pregnant bodies were then subjected to surveillance and monitoring for the good of not only themselves and their families, but also their nation (Valverde, 1992).

This shift was premised on two discursive interventions. First, childbirth was reconstructed by the newly unified medical profession as a ‘medical’ problem (Biggs, 1990: 29). Central to its reconstruction was the emergent distinction between ‘normal’ and ‘abnormal’ birth (Cahill, 2001). In short, physicians and policymakers discursively reconstituted birth as a potential crisis to be managed. As such, pregnancy and birth underwent a process of affective attunement through which they became something to be feared. But, as Ahmed (2004) notes, fear is fearsome precisely because it cannot be contained. In the case of birth, there is always difficulty in determining which bodies or which conditions are ‘abnormal’; thus, everyone and no one is in danger. All births, regardless of the bodies that process them, are emergencies waiting to happen (Arms, 1975). Second, in representing pregnancy and birth as something to be feared, physicians were established as ‘experts’ who could effectively manage potential emergencies and the pain associated with ‘normal’ births. In so doing, midwives were recast as, in the words of on Toronto doctor in the early 1930s, “unkempt, gin-soaked harridans, unfit for the work they were supposed to do and a menace to the health of any women they might attend” (Mitchinson, 2002: 96; see also Biggs, 1990; Cross, 2014).

Thus, the emotional landscape that emerges in this period is one in which pregnancy and birth were represented as something to be feared, which both shaped and was shaped by biomedical knowledge and practices constituting physicians as ‘experts’. As such, the fear discourse forged a discursive link between biomedical science and certainty regarding birth outcomes. Lewis (1990) argues, “[In] promoting motherhood as women’s natural task, [the medical profession] both reinforced assumptions regarding sexual divisions and asserted their fitness to ‘manage’ pregnancy, childbirth and childbearing.” In aligning pregnancy and birth with disease, in which knowledge acquired ‘of’ the body was superior to knowledge acquired ‘in’ the body, decision-making was externalized beyond pregnant bodies. This manifested itself not only in the emergence of ‘birth experts’, but also in the removal of birth from domestic spaces as institutionalized birth became the norm.

This representation of pregnancy and birth produced a number of effects. In addition to the discursive effects, where, through a process of affective attunement, pregnancy and birth were discursively constituted as beyond one’s control and therefore something to be feared, subjectification and lived effects created a hierarchy of birth practices that were not only gendered (and gendering), but also racialized and classed. Indeed, representations of pregnancy, birth and motherhood were steeped in racialized, classist, heteronormative, and ableist discourses that differently valued the reproductive experiences of some over others’ (Valverde 1992; see also Katz Rothman, 2014). Mitchinson (2002: 18) notes, “[Physicians] created a hierarchy of birth practices, which were racialized. They differentiated between ‘civilized’ and ‘primitive’ women in childbirth and attached significant meaning to those differences.” Through these processes of agential and symbolic attunement, fear of maternal and infant death, as well as pain and discomfort from labour, prompted birthing subjects to seek care from (predominantly) male physicians who had the ‘knowledge’ and ‘expertise’ to help them (Biggs, 1990; Cahill, 2001; Ehrenreich and English, 2005; Lewis, 1990). Midwives were maligned and displaced, while birthing subjects were objectified, disembodied subjects to be assessed, diagnosed, monitored and treated by knowledgeable (usually male) experts. Fear, then, became a cohering mechanism of authority and legitimacy, and discursively constituted a broader classed, racialized and gender order premised on the control of reproduction.

Alternative birth and the politics of joy

By the 1960s, resistance to the fear discourse emerged as people began questioning birth practice in Canada and beyond. During this period, the emotional landscape shifts as a multitude of birth practices give rise to and legitimize alternative ways of knowing. A number of movements converged in their critique of biomedical pregnancy and birth, emphasizing not fear, but joy and empowerment in and through childbirth. The Natural Birth Movement (NBM), the Women’s Health Movement (WHM) and the Alternative Birth Movement (ABM) constructed birth as something to be celebrated. These movements problematized not bodies but birth practices and, in some cases, biomedicine specifically. If the authority and legitimacy accorded to biomedicine is rooted in fear, then challenges to the fear discourse are, by implication, challenges to the authority and legitimacy of doctors.

The NBM, led by biomedical physicians, did not question the role of physicians in birth, but it did question their tactics. The goal of the NBM was to dispel the fear of childbirth and to deploy more ‘natural’ forms of birth and pain management (Dick-Read, 2005). The movement began in the 1930s in the United Kingdom, with the publication of Dr. Grantly Dick-Read’s Natural Childbirth, which was followed by Revelation of Childbirth, subsequently renamed Childbirth without Fear, in 1942. Read suggested that pain was caused by the stress due to the fear of childbirth. The solution was to address fear, resolve stress and, consequently, diminish pain (Rushing, 1993). By the late 1950s, a variety of natural methods were well known, with the Lamaze method, named after a French physician, taking hold in popular discourse by the early 1960s.

These approaches not only shifted ‘consumer demand’ (Rushing, 1993), but also established a group of childbirth educators who led classes that demystified birth and empowered birthing subjects and their families (personal interviews). In many ways, these classes became radical spaces in which to recentre birthing subjects in pregnancy and childbirth and gave form and voice to the newly emerging Alternative Birth Movement. Many educators had previous experience with the Women’s Health Movement, which aimed to give women more agency in their own healthcare and to create woman-centred services. The ABM added an explicitly political dimension to childbirth, linking medical dominance in reproduction to gender politics. Through the process of affective attunement, the ABM discursively linked the ‘decolonization’ of childbirth to women’s empowerment, explicitly problematizing the role of physicians and biomedical practices in pregnancy and childbirth. Similarly, the Home Birth Movement, an offshoot of the AMB, sought to remove birth entirely from the medical gaze and recentre birthing subjects in pregnancy and birth processes.

From this perspective, what was feared was not birth, but rather physicians, hospitals, and interventions. Here fear-based discourses served to problematize biomedicine, suggesting that poor maternal and infant outcomes were iatrogenic or nosocomial rather than natural. Hazell (1969: 223) for example, argued,

Women come into the hospital healthy and often leave having acquired some sort of infection. […] To remedy this, we need to get obstetrics completely out of the general hospital and make home delivery more feasible for those who wish it.

Through the displacement and subsequent refocusing of fear, birthing subjects were prompted to reclaim pregnancy and birth as something to be celebrated and revered. Birth was something “women do,” not something that “happens to them” (Hazell, 1969) and was therefore an event to be cherished.

Reclaiming births was crucial to ensuring healthy babies and empowered mothers. Thus, the emotional landscape shifted with the introduction of a discourse of joy and empowerment that underlined much of the ABM. Lang’s pioneering Birth Book (1972, 5), noted, “We have taken the joyous task of bearing our young back into our own hands! […] we as women understood it to be a necessary and a good step in the liberation of women.” Similarly, Mason (1990: 19) claimed of the ABM in Ontario, “What was radical and empowering for women was not the adoption of a better program... but the recognition by many women that they could have their babies however they felt like having them.” Reclaiming birth was central to reclaiming ‘womanhood’.

The discursive and subjectification effects of the joy discourse were no less stratifying than those of the fear discourse. According to Ahmed (2004, 2008: 11), where fear drives us away from something, hope pulls us toward, “coher[ing] groups around a shared orientation towards some things as being good” (see also Nicol, 2011). If biomedicine pushed birthing subjects away from their bodies and removed them from the pregnancy and birthing processes, then the ABM affectively attuned pregnant and birthing subjects toward an ideal of womanhood that embraces and celebrates pain as a marker of ‘true’ womanhood and dismisses concerns of poor outcomes by recasting them as either ‘natural’ or ‘unnatural’, resulting from medical practices themselves. Thus, to paraphrase Ahmed (2004: 26), “it is the emotional reading” of joy and empowerment “that works to stick to or bind the imagined” maternal subject and ‘womanhood’ together. It marks and binds a “community of women,” working in opposition to biomedical practitioners (i.e. men), who threaten the happiness and empowerment of the birthing subject.

These discourses and associated practices moved through and across bodies, constituting various subject positions through the process of agential attunement. In so doing, the emotional discourses of joy and empowerment not only responsibilized birthing subjects for pregnancy and birth outcomes, but it also fused sex and gender in ways that essentialized women and motherhood. Indeed, “our bodies are meant to do this” was common refrain, demarcating ‘good’ mothers, those who would not knowingly or willingly harm their infants by exposing them to the harm caused by medical births, from ‘bad’ mothers, invoking notions of ‘empowered agents’ versus ‘disempowered objects’ and ‘natural’ versus ‘unnatural’.¹⁰ Pregnancy and birth were recast in emotional discourses that were premised on white, cis-gendered woman’s experiences, silencing diverse voices and erasing the diversity of reproductive experiences (e.g. Johnson, 2008).

When fear and joy collide: Deinstitutionalized birth and the politics of risk

Attention to emotional policy discourses reveals that the emotional landscapes in which pregnancy and birth took place shifted considerably with the emergence of the ABM. No longer were birthing subjects expecting (or expected) to be passive, fearful subjects waiting to be treated by an all-knowing healer. Instead, through the processes of agential and symbolic attunement, pregnancy and birth practices came to represent a reclaiming of ‘natural’ processes. Moreover, the dislocation and refocusing of fear to physicians themselves prompted both professional and public scrutiny of biomedical practice. Due to public pressure and increasing acceptance of midwifery in Ontario, physicians responded to some of these critiques by encouraging birthing subjects to attend childbirth classes, ‘allowing’ their partners into the delivery room, and in limiting interventions and making birth settings more ‘homelike’ (Fannin, 2003; Rushing, 1993).

This response was first articulated in submissions by various healthcare groups to the TFIMO in 1986. For example, the submission by the Ontario Chapter of the College of Family Physicians of Canada (OC-CFPC) conceptualizes birth as a ‘natural process’ in which intervention should be limited and in which birthing subjects and their families should be involved,

Prenatal classes are encouraged and being expanded. There is less adherence to hospital routines such as shave preps, enemas, the use of an intravenous, and episiotomies. Fewer drugs are being used and fewer repeat caesarean sections are being done. Mothers are being encouraged to handle their babies immediately after delivery and to breast feed as soon as possible. […] All of these changes are to allow labour and delivery to be a more natural process. (1986: 7)

Moreover, biomedical practice increasingly called attention to the “human experience” of birth. Indeed, contemporary guidelines for practice reflect a merging of various birth discourses, citing prominent feminist birth activist Sheila Kitzinger and noting the importance of “the human experience” of birth in conjunction with “evidence-based clinical practice” and “cost-effectiveness” (1998: 1). These passages highlight not only the changes made to obstetric care by biomedical practitioners, but also the silencing of the explicit gender politics articulated by ABM advocates.

At the same time, however, physicians held firm to the notion that birth was an accident waiting to happen that could only be managed by their expertise. Consider, for example, the OC-CFPC response to home births in their submission to the TFIMO:

Deliveries can, unfortunately, become complicated very quickly, jeopardizing the life or health of mother and baby. A delay of minutes between an emergency situation arising and the arrival of either a paramedical or medical team, or a delay in medical care brought about because of the need for transportation of a sick patient to hospital in or shortly after labour, could make the difference between a successful outcome and a tragedy. (1986: 13)

During this time, midwives were also undergoing professional and public scrutiny. Just as midwives were beginning to professionalize, the early 1980s brought two very public inquests into the deaths of infants at midwife-assisted births.¹¹ While both coroners’ reports recommended legalized midwifery, the practice was nonetheless subject to intense media and public scrutiny which often cast midwifery in direct contrast to biomedicine. In effect, midwives were required to address the merits of their practice with respect to biomedical science. For example, early submissions by the Association of Ontario Midwives to the Health Professions Legislative Review in the early 1980s, explained that Ontario midwives had recently standardized “risk assessment tools” (see also Weir, 2006). As midwives sought legitimacy from the state, they were forced to respond to concerns that pregnancy and birth were risky. Fear was reinserted into midwifery discourse not as fear of physicians, but as fear of the unknown.

Collectively, these responses enabled the emergence of a new pregnancy and birth discourse that effectively fused the fear discourse of the earlier period, in which all births are potentially dangerous, and the joy discourse of the subsequent period, in which pregnancy and birth are incredible human experiences. As such, the new discourse acknowledged that pregnancy and birth were joyous events that were, for the most part, ‘normal’ and ‘natural’ events that would not require extensive medical intervention. Birthing subjects were encouraged to participate in their course of care and discouraged from ‘unnecessary’ interventions. At the same time, the new discourse acknowledged that “all hell can break loose in five minutes,” which would require intervention.¹² This allowed both physicians and midwives, “birth experts,” to be present but distant, establishing new healthy pregnancy guidelines and protocols for pregnant and birthing subjects to follow and to be prepared for an emergency. In this context, where pregnancy and birth are joyous events and where birthing subjects are active agents supported by family members, but where fear of poor outcomes remains a constant threat, pregnancy and birth are affectively attuned to risk, which mediates and balances both joy and fear and obscures the positional politics of pregnancy and birth practices.

The risk discourse produces several discursive effects. In affectively and agentially attuning pregnancy and birth to risk, the discourse reaffirms the medical gaze, if only at a distance. Despite recognition of pregnancy and birth as ‘natural’, it is nonetheless subject to technical management and control. Thus, the risk discourse problematizes individuals and their choices, rather than broader socio-political contexts that shape pregnancy and birth experiences. In so doing, it closes off space in which to consider alternative approaches and emotional responses to pregnancy and birth. In addition, the risk discourse produces a particular meaning of midwifery, as a form of expert knowledge that is constituted by (and not necessarily against) the biomedical discourse it was opposing (Daviss, 2001; Marier et al., 2014; Mason, 1990; Paterson, 2010). The risk discourse enabled proponents of midwifery to couch their claims in biomedical science emphasizing risk minimization and safety in ways that served to bolster their credibility and legitimacy in public debates. For example, in their submissions to the TFIMO, midwives and their supporters cast the debate in terms of risk, despite testimonials that reflected the joy and empowerment of the earlier period. A brief presented to the TFIMO, a ‘consumer group’ dedicated to birth advocacy noted,

We trust our midwives for their technical skills and expertise. We believe that the mid-wife’s orientation to birth as a natural process gives us the best chance of experiencing a healthy pregnancy, a safe birth, and a smooth postpartum course. (n.d.: 2)

The risk discourse also produces a number of subjectification effects. In positioning midwives and physicians as ‘birth experts’, or what McCabe (2016), following Rose (1996) refers to as “experts of conduct,” the risk discourse positions other healthcare practitioners, such as unlicensed midwives and doulas, as “outsiders,” those lacking adequate training, knowledge and understanding to guide and inform birthing subjects. It has also shifted relations between midwives and birthing subjects, creating a hierarchy in the pregnancy and birth relationship by diminishing the authority of birthing subjects to make claims based on other forms of authoritative knowledge, such as emotion, intuition or tradition (Paterson, 2010).

In addition, in problematizing individuals and their choices, the risk discourse responsibilizes pregnant and birthing subjects for birth outcomes (Fannin, 2013; Possamai-Inesedy, 2006; Spoel, 2010). Possamai-Inededy (2006: 407) observes, “The expectant woman now has decisions to make with consequences not only for herself but also for her unborn child.” This was similarly noted by Barrington (1985: 20) in her work on the re-emergence of midwifery in Canada, “Midwifery care involves a partnership in responsibility with parents. Acknowledging that they will live with the consequences, parents are encouraged to make their own, well-informed birthing decisions.” The subjectification effects are captured by Fannin (2013: 282), who writes,

The burden of making wise choices in the domain of reproduction is not simply an effect of the expansion of ‘procreative techniques’ or other innovations in prenatal genetic surveillance, but is instead part of a broader transformation of the ethical responsibility for reproduction into a concern of each and every individual.”

That these “wise choices” aim to reflect the rational tempering of joy and fear results in significant lived effects, effects experienced “in the real” (Bacchi and Goodwin, 2016). Pregnant and birthing subjects are agentially attuned to “proactive” risk-mitigating behaviours that impact nearly every dimension of their lives, often even before they become pregnant, such as alcohol and smoking cessation, sleep regimens, and diet. Fannin (2013: 275) refers to this as, “the exercise of emotional and physiological self-governance, a ‘delegated biopolitics’ that extends beyond the spaces of the clinic.” Moreover, McCabe (2016: 178) illuminates the racial and class implications of this discourse,

Women without the social or financial supports to “choose” (Fox and Worts, 1999) or who cannot shoulder the burden of the taxing regimes associated with value-laden “natural” birth ideals (Phipps, 2014; Bobel, 2001) are marginalized within care models that prescribe individualized and consumerist notions of choice and self-control, marking the limit of the field of possibility that enables predominantly white, economically privileged women to claim a moralized maternal identity.

These “dividing practices,” steeped in emotional discourses of fear and joy, are embedded in and reinforced by a normative emotional discourse that blames individuals. As such, the risk discourse reproduces the stratified effects of biomedicine, reducing birth processes and outcomes to individual, yet decontextualized, ‘choice’.

In interrogating pregnancy and birth discourse in Ontario, we see how emotional discourses shifted over time, resulting in (and from) new ways of thinking and feeling about birth, which in turn shifted power relations in important ways. In the early period, when physicians were professionalizing, emotional discourses of fear problematized (some) birthing subjects’ bodies, subjecting them to the scrutiny, control and intervention of birth professionals. In response to this, the NBM and ABM arose to question the interventions and authority of (mostly male) physicians, instead linking birth to joy and empowerment. What was problematized, through an intermingling of both joy and fear, was not birthing subjects’ bodies, but rather biomedical science. Poor outcomes were reconceptualized as iatrogenic or nosocomial, responsibilizing (mostly) male physicians for birth outcomes. The contemporary period is also one of an interplay of emotional discourses that results in important discursive and positional effects. Here pregnancy and birth are represented as joyous, opening space for birthing subjects, but risky, which opens space for birth experts to monitor and intervene where necessary. In the contemporary period, the bracketing of professional expertise from other forms of knowledge not only coheres midwives and physicians as “experts” in pregnancy and birth practice, but also divides maternal subjectivities along gender, race, and class lines that privilege and normalize white cis women’s experiences.

Conclusion

Although policy scholars are paying increasing attention to the role of emotions in policy discourse, processes, and outcomes, this work has not always attended to the ways that power operates through emotional policy discourse. Moreover, while feminist post-structural policy analysis offers promising frameworks that centre power to consider how social categories, such as gender and race, are not natural, but are rather created by policy, the role of emotional discourses in constituting these categories and the various effects associated with them remains unclear. Indeed, the WPR, as suggested by Bacchi and Goodwin (2016: 62–63), “asks what meanings (presuppositions, assumptions, “unexamined ways of thinking,” knowledges/discourses) need to be in place for the categories [of various ‘problems’] to be intelligible, and directs attention to the practices that install those meanings.” The preceding analysis expands this framework, demonstrating how emotional discourses are both an effect of power and a mechanism through which it operates. It was shown that policy practices are premised on emotional representations of problems that produce positional subjectivities that are intersectionally situated.

To be sure, as Orsini (2017) reminds us, emotional discourses and the ‘feeling rules’ that emerge within them are neither neutral nor universally experienced. Thus, interrogating emotional policy discourses provides insight into their role in contemporary governance regimes, constituting both the governing and the governed. In making the emotional dimensions of problem representations visible, we illuminate their contingent basis and make possible their “unmaking” (Bacchi and Goodwin, 2016: 63). The risk discourse, which merges discourses of joy and fear, renders invisible or problematic a whole range of emotional experiences and understandings around pregnancy and birth. Unmaking this discourse might, for example, entail not only contesting and challenging “expertise,” but also open space for other “ways of feeling” about pregnancy and birth, such as ambivalence, indifference, hostility, or alienation, which in turn shape both subjectivities and lived effects. From this perspective, then, emotional policy discourses are key to attending to the questions, “What is produced? How is it produced? And with what effects?”

Notes

Healthcare is federally funded, but provincially administered.

See Mason (1990); Daviss (1999); MacDonald and Bourgeault (2008); Paterson (2010) for discussions.

For overviews of this material, refer to Anderson (2015); Jasper (2011); and Newman (2017).

For detailed discussions of different approaches to discourse analysis, see Bacchi (2015) and Bacchi and Goodwin (2016); as well as Durnova et al., (2013) for an overview of discursive approaches to public policy.

Bacchi and Goodwin (2016) add a seventh question which explicitly asks researchers to engage in reflexivity throughout the analytical process.

Orsini uses the term ‘actors’; however, I refer instead to ‘subjects’ to align with a post-structuralist position that people are subjects in the making and to better capture how ‘identities’ are practiced and performed rather than given (see Bacchi and Goodwin, 2016: 30).

It is important to note that subjectification effects do not ‘determine’ subjects; rather they shape or limit opportunities of becoming. Rejections of and resistance to such effects are an essential part of the analysis. See Bacchi and Goodwin (2016: 49) for a more detailed discussion.

The bolded questions are those that have been added to Bacchi’s original list.

The TFIMO Report recommended further study on the question of home births.

For discussions on the role and impact of nature in birth discourse, activism and practice, see, for example, Johnson (2008); MacDonald (2011).

See Paterson (2010) and Bourgeault (2006) for more detailed overviews of the re-emergence of midwifery in the province.

Dr. Jack Waters, Obstetrician-in-Chief of Ottawa General Hospital, quoted in Lipovenko (1979).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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