Labour Pain,‘Natal Politics’ and Reproductive Justice for Black Birth Givers

Abstract

The reception of Elaine Scarry’s landmark text, The Body in Pain, focuses in part on exploring how pain might be understood as beneficial or therapeutic. Childbirth is often cited as the paradigmatic instance of this kind of beneficial pain. This essay examines conceptualizations of labour pain in biomedical, natural childbirth and reproductive justice movements that explore the limits of Scarry’s description of pain as ‘unshareable’. Political struggles over pain in childbirth centre on the legibility of pain in labour. Feminist and natural childbirth activists have developed an understanding of pain at birth as central to maternal subjectivity, where pain is a biopolitical force and its management a means of self-transformation. Alongside calls for reproductive justice, the essay considers how the visibility and expressivity of labour pain could contribute to what Imogen Tyler and Lisa Baraitser term a new ‘natal politics’ that addresses concerns for the disproportionate injury and death experienced by Black birth givers.

Keywords

biopolitics birth childbirth pain race reproduction reproductive justice

Elaine Scarry’s book The Body in Pain has been described as a magisterial work on the philosophy of pain. One of the most important contributions of Scarry’s work, taken up by scholars of the sociological and phenomenological dimensions of pain, is her description of pain as that which breaks down the subject’s ability to communicate. Pain is described as the limit of language: ‘Intense pain is also language-destroying: as the context of one’s world disintegrates, so the content of one’s language disintegrates; as the self disintegrates, so that which would express and project the self is robbed of its source and its subject’ (1985: 35). Although Scarry describes pain in this way through an extended exploration of the intense pain inflicted through torture, the capacity of pain to ‘destroy a person’s self and world’ is also present in what Scarry terms the ‘non-political contexts’ of intense pain accompanying disease or accident.

This essay examines Scarry’s thesis on pain and the making and unmaking of a subject and his or her world in another of these ‘non-political contexts,’ that of pain during childbirth. Labour pain has been described as the ‘perfect model of acute pain’; its duration varies but it is finite (Gibson, 2014 citing Giamberardino, 2000). Although the political context for torture and labour pain are vastly different, this essay argues that labour pain, and the efforts to alleviate, manage, embrace and narrate this pain, reveals pain’s centrality to the creation of new forms of maternal subjectivity, as well as potentially new forms of ‘natal’ politics. Like the pain of torture described by Scarry, labour pain too has the capacity, I argue, to ‘make’ and ‘unmake’ a subject. Labour pain and its management, control and expressivity have become a means of constituting maternal subjects. In this sense, pain in labour has been made biopolitical, critical to processes of self-constitution and enfolded within efforts to govern life.

The treatment of pain is more often approached, as in Scarry’s work, through an interpretation of pain as pathological and senseless rather than as directed and purposeful, as in the case of labour pain. This essay thus offers a rejoinder to Scarry’s thesis on the ‘inexpressibility’ of pain by examining how pain in labour, and different approaches to it, is made culturally meaningful and central to the constitution and expression of maternal subjectivity. Yet these individual accounts of labour pain as constitutive of maternal subjectivity, I suggest, also tend to obscure the possibility of collective orientations to pain at birth, neglecting the social conditions under which pain is differentially experienced and thus seemingly unshared.

I begin with a discussion of the treatment of pain in childbirth, reading efforts in the late 20th-century to politicise the experience of enduring labour pain as attempts to articulate the relationship of pain to maternal subjectivity. Pain in childbirth has been analysed as an historical phenomenon through which to explore the efforts to professionalise the practice of obstetrics and promote the application of surgical anaesthesia to childbirth (Caton, 1999). Scientific advances in pain relief in the late 19th and early 20th centuries raised questions among proponents and critics of anaesthetised birth about the moral dimension of pain in labour. As this scholarship shows, elite women and their physicians sought to promote pain relief in labour as a socially acceptable transformation of the religiously inflected notion that childbirth must be painful (Leavitt, 1986; see also Pernick, 1985).

By the mid-20th century, criticisms of the medical treatment of labour and birth by activists identified the elimination of pain as symbolic of the alienation of birthing women from their bodies. Activists in natural birth movements articulated diverse registers for remaking pain as both a welcomed and generative experience and sought to transform labour pain into a vehicle for expressing and narrating new experiences of being a mother or birth giver. The literature on the history of pain and pain relief in labour demonstrates how pain was deeply implicated in the making of maternal subjects as moral, in the case of early 20th-century pain relief campaigners, and as autonomous, in the efforts of natural birth advocates from the mid-20th century onwards. Narrating one’s experiences of pain at birth was thus central to the efforts to constitute new forms of maternal subjectivity, suggesting that the biopolitical regime of maternity is organised in and through the expression of pain.

Yet this pain is articulated most often as a problem for the individual birth giver, obscuring how the expressivity of labour pain could be mobilised for collective projects. In the middle section of this essay, I turn to the work of anthropologists of labour pain who articulate the possibility of configuring labour pain as relational and social. This relational and social approach to pain also informs social movements for reproductive justice in the US and elsewhere that critique the overly individualistic approaches to pregnancy and birth in late 20th-century women’s health movements, emphasizing instead how the labouring body in pain is figured within specifically gendered and racialised understandings of torture and violence.

Differential access to pain relief, reproductive justice activists argue, determines who suffers and who is relieved of pain. The now established evidence of disparities between White and ethnic minority women’s experience of pain during childbirth, however, cannot be explained solely by women’s differential access to methods of pain relief (Morris and Schulman, 2014). In a study of epidural use and the failure of anaesthesia during labour, women’s reported experiences of the offer of pain relief evidenced no significant differences between women. The assertion that White women experience less pain in labour is therefore not a disparity between their access to pain relief and the ability of women of colour to access pain relief. Rather, Black, Asian and Hispanic women were far more likely to describe being pressured to accept epidural pain relief, or more seriously to experience epidural failure, including during C-sections (Morris and Schulman, 2014). In this research, the experience of pain is a consequence of social differentiation in which one group’s pain is deemed more worthy of sensitive treatment than another’s.

More generally, pain researchers document how these racial disparities occur in the treatment of other kinds of pain: Black patients were 34% less likely to be prescribed opioid pain relief for migraines, backaches and abdominal pain. In more acute circumstances such as surgery or injury, Black patients were again 14% less likely to be prescribed opioid pain relief (Hoffman et al., 2016). The same is true of research investigating the treatment of pain relief related to workplace injury, where Black workers were treated less and for shorter periods of time than their White colleagues (Tait et al., 2004). It is in this light that the continued practice of shackling women prisoners during labour, a practice that evokes the history of slavery and disproportionately affects minority women because of their already disproportionate incarceration compared to White women, is articulated as a specifically gendered and racialised form of torture (Ocen, 2012).¹ The efforts of reproductive justice movements to redress the differential treatment of Black and White birth givers’ labour pain treats these accounts of pain as symptoms of living in a racist society, thus exemplifying what Talal Asad argues is the often under-recognised social and relational dimensions of pain.

In the concluding section of the essay, I turn to Imogen Tyler and Lisa Baraitser’s recent examination of the proliferation of visual and media representations of birth in order to problematise the invisibility of racialised pain. Although Tyler and Baraitser highlight how many of the visual depictions of childbirth remain sanitised for public consumption, they also consider how other aspects of labour and birth are now presented with a frank openness that marks a distinctive shift from presenting and interpreting birth as abject, following the writings of philosopher Julia Kristeva and others. Rather than viewing pregnancy and birth as abject, the visibility of pregnancy and birth, for Tyler and Baraitser, offers possibilities for exploring and imagining a new kind of ‘natal politics’. I take up Tyler and Baraitser’s compelling invocation of the possibilities of a new natal politics to ask how such a public politics could acknowledge the disparities between whose pain is regularly expressed in the public cultures of natality, and whose pain is not.

Pain as Moral Burden

Pain in childbirth is understood as both neurophysiological and sociocultural. The contraction of the uterine muscles during childbirth is involuntary and unwilled, and the variation in the duration and length of these sensations during labour is extreme: labours may be as brief as 30 minutes and as long as several days. Furthermore, the sensations of pain have been described as equally variable. Some accounts of labour pain might draw analogies with indigestion or with a ‘curious’ sensation; other accounts describe labour pain as so painful it feels like dying or splitting into two.

Historical accounts of efforts to alleviate pain in labour signal how the introduction of anaesthesia used in surgery to alleviate or eliminate the pain of labour also shifted social and cultural expectations surrounding childbirth. Michele Basile (2012: 55) recounts how pain was generally viewed by 19th-century physicians as an ‘essential component of general health and healing, both physical and emotional’. Therapies designed to inflict pain and irritation (emetics, blistering agents) were perceived to be effective in treating a range of ailments. Basile writes, ‘Many physicians believed that pain sensations in childbirth were not the effect, but the trigger of uterine contractions, and that the screams of women in labour eased pressure on the perineum, reducing the chance of tearing’ (2012: 55–56). Pain, in this sense, was viewed as functional to the progress of childbirth.

By the late 19th and early 20th century, pain and its treatment by technological means was becoming central to the transformation of practices surrounding medical approaches to childbirth. The introduction of pain relief in labour in the United States and Europe began primarily among elite women whose physicians were able to supply anaesthetic agents, such as diethyl ether, nitrous oxide and chloroform, that were commonly used in surgical procedures (Leavitt, 1986). Public campaigns for pain relief in labour in Europe and the United States thus involved the participation of elite women from the start (Caton, 1999). By the early part of the 20th century, the introduction of a new method of pain relief, a combination of morphine and scopolamine called ‘twilight sleep’, was popularised by middle- and upper-class women in the United States, often drawing on rhetorical tactics of appealing directly to women that had been developed in the suffrage movement (Johnson and Quinlan, 2015). Twilight sleep did not eliminate pain; rather, it worked as an amnesiac, eliminating the memories of painful sensation.

Further development of methods of pain relief in labour sought to allow women to retain consciousness during birth but with the diminution or loss of sensation, either through the administration of epidural anaesthesia that blocks the nerve endings below the waist, or through the refinement of the use of ‘milder’ methods of pain relief such as nitrous oxide that diminish the sensation of pain yet do not fully eliminate it (Skowronski, 2015). The introduction of effective methods of pain relief was pivotal in moving birth from home to hospital, a significant social and spatial shift in birth practice. In the United States especially, access to new methods of pain relief was part of the transformation to medical regulation and social custom that led to the replacement of midwives by doctors as the primary attendants at birth (Leavitt, 1980).

Even at the beginning of efforts to introduce twilight sleep, however, there were concerns that the elimination of painful sensation would call into question cultural sensibilities of the moral necessity of women’s pain during childbirth and the virtues of self-sacrifice that surrounded women’s endurance of pain. There were also fears that painful sensations themselves played a role in the healthy progression of labour. Pain was not just a moral and spiritual burden that women needed to endure or a transformative experience and event essential to women’s transition to motherhood. Pain was also – possibly – a physiologically necessary and even beneficial dimension of childbirth. This concern, that the alleviation of pain was in fact harmful, gained greater attention during the 1950s and 1960s when prominent obstetricians, primarily in Europe, began to promote the ‘active’ and ‘natural’ methods of childbirth preparation and labour.

Changing conceptions of the role of pain in labour thus distinguish early 20th-century women’s efforts to remove pain from the labour scene from mid-20th-century efforts to reassert the ‘value’ of pain as a ‘natural’ phenomenon.² Accounts of the iatrogenic or harmful effects of pain relief would shape the emerging ‘natural childbirth’ movement. Pain relief and the search for methods to diminish the sensation of pain during labour were not completely rejected; rather, non-pharmacological methods were sought through alternative or non-Western medical practice. Acupuncture, meditative or controlled breathing exercises, hypnosis and other efforts to work around and with the pain of childbirth, once recognised as a beneficial physiological sensation, if not a ‘valuable’ one, were the focus of practices of childbirth which proponents hoped would eliminate the risks and potential harms associated with pharmacological methods of pain relief.

‘Natural’ Birth and Empowering Pain

Reclaiming the experience of labour pain as a form of bodily self-fashioning, women’s health activists in the 1970s and 1980s sought to redistribute power over birth to birthing women themselves. Activists in the natural birth movement sought to articulate diverse registers for remaking pain as both a welcomed and a generative experience and to transform the experience of labour pain into a vehicle for expressing and narrating new experiences of being a mother or birth giver. These efforts were associated with the struggles by health and patients’ rights activists to demand greater participation in decision-making around healthcare. To an extent, activism around ‘natural’ birth continues to remain skeptical of the use of pharmacological methods of pain relief and draws on the language of self-empowerment and individual choice regarding the management of labour pain.

Today, the dominant approach to pain in childbirth in the United States is to treat labour pain as a medical phenomenon managed largely by pharmacological means. In this respect, medical professionals are guided to consider a labouring patient’s request as the only necessary indication for providing pain relief. Epidural anaesthesia is regarded by pain management professionals as the standard for providing pain relief during labour (Gibson, 2014). In this view, pain is considered a pathology that requires medical intervention, typically the use of drugs to eliminate the sensation of pain either locally, in the case of epidural anaesthesia, or less frequently, general anaesthesia. Access to non-pharmacological methods of pain relief through the US hospital system is uneven.

By contrast, an alternative, ‘midwifery’ model to pain relief in the US context articulates an approach to pain that regards it as ‘normal, necessary, and possibly empowering for the birthing woman’ (Gibson, 2014: 186). Pain is viewed as the physical experience of unpleasant sensations, but Erica Gibson (2014) and other commentators draw a distinction in the midwifery model of pain management between pain and suffering, where suffering is an indicator of the ability to draw on resources of social support or preparation for the pain of labour. Some activists and midwives also describe this as the difference between pain and distress. A woman giving birth without pain medication may experience pain, but she may or may not suffer, and she may or may not experience distress.

Studies of the discourses used by women to articulate the experience of giving birth draw on expressions of splitting, losing control, disintegration and tearing: the ‘end of me’ as one participant in a study of women’s discourses of birth described (Lupton and Schmied, 2013). These narratives, and the analysis of them in the phenomenological and sociological literatures on birth, situate the expressivity of the body in pain as a feminist project of reasserting the primacy of the birthing woman’s experience of childbirth, where ‘birth stories circulate as forms or currency of maternal…power’ (Pollock, 1999: 263, n. 10). They also articulate the disorientation of women experiencing heavily medicated or anaesthetised birth in social contexts where the ability to recount a birth story is considered an important part of expectations surrounding motherhood.

In addition to the disciplinary regimes pregnant women are expected to follow to ensure the health of their fetus (Lupton, 2012), what these varying accounts of pain in labour suggest is that women are also made maternal subjects by the expectation that they will articulate a narrative situating their experience of labour and birth – whether empowering or disempowering – as central to becoming a mother. The production of a birth narrative recounts how one experienced, controlled, was overwhelmed by or sought to embrace the pain of labour and has become one of the ways in which maternal subjectivity is structured: ‘the promotion of birth stories, which stress the body’s natural capacity for birth, are presented as key to enabling most women to have good birth experiences’ (Hallam et al., 2019: 336). Social expectations around maternal subjects as self-aware and conscious of their own feelings and bodily sensations invite women to recount the pain of labour as central to their narrative of birth. Della Pollock (1999) refers to the power of these birth stories to ‘bring pain into an open field of representation – and let it loose’ (p. 183), to give pain a new language that multiplies its potential to make and unmake the maternal subject.

The acute physical pain of childbirth, described as a momentary disintegration of the body and the self, and the reconnection through the expression of pain experienced as transformative, has generated an entire genre of texts devoted to how the experience of the acute and often all-encompassing pain of labour is transformed into a ‘rite of passage’ (Davis-Floyd, 1992). Narrating the pain of birth has become part of a set of social expectations surrounding motherhood:

women who undergo a Caesarean section may find it even more difficult, at least immediately following birth, to come to terms with their birthing experience than do women who have delivered vaginally. Unlike the women who had gone through the process of vaginal birth and were able to see and feel what was happening as the infant emerged, these women needed to construct or reconstruct the experience via other witnesses or participants. They did not experience the intensity and for some, the extreme pain and violence of birth: the opening, stretching, tearing and ripping described so vividly by the other women… Rather the experience was so disembodied as to seem unreal, disconnected from the women’s reality of embodiment. For these women, both their own bodies-in-labour and the body-being-born were largely experienced as absent, distant from and foreign to their embodied selves. (Lupton and Schmied, 2013: 838–839)

This disconnection between the body-in-pain and the body-being-born may be experienced as alienation. So too can the experience of being unable to connect one’s body with one’s embodied self. As Madeleine Akrich and Bernike Pasveer (2004: 79) write, this disconnect between body and self through labour pain ‘causes the perceived world and the ability to act, to shrink’. In this context, the inability to produce a narrative and language around one’s own labour pain may be experienced as a loss. Not remembering the pain of labour – not remembering anything at all – can be profoundly desubjectifying. In this light, without a memory of the fundamentally subject-forming experience of ‘becoming mother’ at birth, where pain marks that experience as ‘having happened to me’, dislocation and loss rather than the fullness of becoming a maternal subject may characterise the experience of birth. Feeling pain and not being to talk about it in relation to one’s birth experience because of surgical or other intervention is experienced as a loss of the ability to make legible one’s maternal subjectivity when ‘feeling is correlative with living, with experiencing childbirth’ (p. 80).

This self-constituting dimension of the pain of labour runs counter to the characterization of pain and its definition in Scarry’s work as primarily an aversive sensation: pain in labour in some birthing narratives is both redefined as ‘intensity’, ‘rushes’, and thereby distanced from other kinds of pain, but also conceived as a means of resisting the medical management of birth in which labour pain is deemed pathological and therefore in need of intervention. Conceptions of pain within this perspective also affirm that pain has a positive and beneficial function. The body’s capacity to respond to the high levels of stress hormones generated by painful contractions of the uterus is viewed as adaptive and purposeful. As one pregnancy manual asserts: ‘Your body is designed to be able to cope with pain. If the conditions are right, your brain will secrete endorphins – hormones which are natural painkillers and relaxants’ (Balaskas and Gordon, 1989: 150–151). The authors continue to describe the variety of ways to increase these painkilling and relaxing hormones: deep breathing, expressing sounds, moving, rocking and rotating the hips, walking, immersion in water and visualizing fluid images of water or waves, as well as ‘relaxing stiff muscles and joints through exercise, resolving any fears, anxieties or problems in your relationships with your loved ones, and cultivating the art of relaxation and meditation’ (pp. 151–152). The maternal subjectivity envisioned here embraces the pain of labour without pharmacological means.

Pain and the Maternal Subject

Regardless of the method chosen to encounter labour pain, the centrality of pain as a problem that must be resolved or addressed by the birthing woman characterises contemporary forms of maternal subjectivity and the making of maternal subjects. The pain of labour is given expression in the many manuals and guidebooks aimed at pregnant women and through the collections of birth narratives in which pain appears as one of the central forces at work in the process of birth. This pain is also, for some, a form of political power, in which ‘reclaiming’ the pain of labour as non-pathological permits alternative renderings of the birthing subject’s relationship to medical institutions and technologies. In birth stories and narratives of labour, pain is invited to speak, to become expressible and made into a vehicle for one’s agency. Sara Cohen Shabot (2017: 132) expresses this approach to pain as ‘positive’: pain ‘may be one of the most powerful tools available to women for defying authority, for recovering agency over an experience that was originally loud but has been silenced by the medical powers-that-be through painkillers and interventions’. In Shabot’s account, the suffering, enduring, overcoming and expressing of pain in childbirth marks the coming into being of a new kind of (resistant) maternal subject.

The literature on the biopolitics of reproduction asserts that the choice for or against pain relief during labour is part of broader exhortations to ‘choose wisely’ during pregnancy and birth (Fannin, 2012; Samerski, 2009; Weir, 1996). These choices are part of the making of a maternal subject who is encouraged to consider all aspects of pregnancy and birth as expressions of the self, whether this is as a consumer of high-technology interventions, such as elective caesarean births, or in seeking out the right environment and practitioner to avoid particular kinds of medical interventions. The expectation to choose how to manage one’s pain and to articulate these choices in one’s narrative of birth is coherent with other modes of maternal self-fashioning that emphasise the assertion of individuality and self-empowerment as central to being and becoming a mother.

Yet birth narratives don’t always cohere with normative expectations surrounding a ‘good mother’ or a ‘good birth’. Birth stories may also articulate one’s disappointment, sense of failure or lack of control over pain (see Pollock, 1999). Regardless, birth stories of the labouring body in pain and the discourses surrounding how labour pain is a problem for contemporary maternal subjects are shaped by a social expectation that there is a story to tell, and that one’s personal experience of birth takes shape around one’s own pain and the way one navigates and narrates it.

Reflections on the embodied and immanent experiences of pain during birth described by historians, sociologists and activists can thus be brought into productive conversation with work on the self-constituting and politicised dimensions of pain. In contrast to Scarry’s characterization of ‘pain as inherently resistant to language’ (Morris, 1991: 3), the novel ways in which pain is now measured, classified and gains legibility through the medium of the pain chart, the pain scale and other devices demonstrate the effort to give a language to pain and to enable a subject to speak about his or her pain. More recent scholarship on the political history of pain considers how pain, compassion and relief can be read as foundational elements of political debate (Wailoo, 2014). Inspired by Scarry’s exploration of the meanings of pain, reflections on chronic pain and its management now present pain as a mode of philosophizing (Honkasalo, 1998). In the field of birth and labour pain specifically, Sheila Lintott (2012) considers how the pain of birth offers a feminist conception of the sublime to counter Enlightenment philosophical reflections in which the sublime is characterised as the experience of a transcendent self in relation to external dangers. Expanding the philosophical examination of the feminist sublime through pregnancy and birth, Lintott argues, offers ways to interrogate and explore aspects of the sublime that are dangerous and painful: ‘exploring gestation and birth for sublime potential allows inquiry into relatively “wanted,” ”chosen,” or “accepted” maternal experiences, but also to those that are definitely not wanted, not chosen or not fully accepted’ (Lintott, 2012: 248). Lintott’s attention to pregnancy and birth seeks to counter the tendency of philosophical reflection on the sublime to focus only on those ‘external’ phenomena that invite introspection rather than attending to the embodied and the immanent.

Scarry’s valuable contribution to thinking on pain therefore makes it possible to explore how pain operates as a political instrument in the field of birth and as a means of understanding the relationship between the maternal body and self and between maternal self and world. Maternal pain, in the narratives described above, is presented as both a challenge to the understanding of pain as wholly ‘aversive’ and a reconfiguration of pain as both world-shattering and, through its overcoming or enduring, world-creating. Labour pain is considered inextricable from the event of birth that makes a maternal subject and in this way, however, differs from Scarry’s account of pain as unshareable. Shared through birth narratives, labour pain is made to ‘speak’. By articulating how one chooses to manage or endure labour pain in relation to the many technologies and techniques available, this pain has also become part of how birth is now considered a ‘personal investment’ (Akrich and Pasveer, 2004: 79). Critiques of the medical management of pain speak of reclaiming labour pain through a new language, but one that coheres, like other dimensions of late 20th-century motherhood, with an individualist account of the subject and self.

However, pain’s history as a political object and locus of social movement activism suggests that accounts of labour pain as constitutive of maternal subjects tend to obscure how natural childbirth advocacy for reclaiming pain is most often a concern of White, middle-class and aspirational women. In the following section, I consider alternative readings of pain in relation to agency, where the social dimensions of pain are foregrounded in ways that suggest possibilities for reconfiguring the relationship of pain to social transformation. Pamela E. Klassen’s research on home birth and Talal Asad’s reflections on maternal agency provide deeply social, rather than individualistic, accounts of labour pain. These social accounts of labour pain suggest an analytical frame through which to examine the efforts to demonstrate the racialised hierarchies shaping the expressivity of labour pain in the contemporary United States. I conclude with an exploration of the possibilities of a ‘natal politics’ of pain in the light of these readings of pain as social, relational and differentiated: how might other stories of labour pain circulate and what form would they take?

Revisiting Pain and Agency

Pamela E. Klassen’s (2001) ethnography of the efforts by religious and conservative women to experience unmedicated births at home surveys the divergent views on pain in labour, from feminist scholars decrying the association between Christian notions of suffering and women’s willingness to undergo labour pain as instances of women’s subordination, to natural childbirth advocates who see in the pain of labour the possibility of achieving ecstatic and powerful, even spiritual, states of consciousness. What these women share is a conviction that their own birth is an important dimension of becoming a mother. Klassen writes: ‘Women seeking unmedicated birth today…have often proclaimed their pain as an act of defiance to medical protocol’ (2001: 208). Despite differences between home and natural birth advocates’ views relative to women’s other reproductive rights (e.g. the right to terminate a pregnancy), Klassen suggests that the pain of childbirth is primarily not understood as a material reality to be avoided, but rather as ‘visionary pain’, where birthing without drugs is seen to invert the dualism of patriarchal cultures in which women are seen as passive and weak: ‘birthing without drugs revalues a form of women’s power denigrated in the wider society’ (p. 211). Klassen cites historian Carolyn Walker Bynum’s provocation that what is valued in the concerted effort to experience the pain of labour rather than to avoid it is the seemingly paradoxical dynamic in which pain and creation (or ‘generativity and suffering’ in Bynum’s terms) can be coupled together rather than opposed to each other.

In Klassen’s reading, contemporary public cultures of the body envision pain as something to be avoided at great cost. Citing Talal Asad’s writings on interpretations of the religious martyr’s pain as deeply estranging, she writes that pain in public culture is now deemed ‘scandalous’ (Klassen, 2001: 176, citing Asad, 1997). This has the effect of making the efforts by natural childbirth advocates to experience and embrace the pain of childbirth into a strange and seemingly anachronistic practice. Yet despite this context, the participants in Klassen’s study sought to revalue and remake pain into a meaningful experience, to create a ‘newfound sense of self’ and to form new ways of relating to others. Home birthing women articulated a diverse array of reasons for desiring to give birth without drugs and in pain. They suggested that pain was something they needed to endure for their child, something that could approach pleasure but was also ‘often invested with the power to grant women understanding of their gods, their intimate relationships and themselves’ (p. 182). For Klassen, this construction of an alternative form of agency through pain suggests different women’s ways of re-embodying their senses of self as women. It was, in Klassen’s terms, a form of agency that they sought, and a rebuttal to the disavowal of their bodies as mediums for their agential power in the world.

The relationship between this liberal form of agency as self-authoring and self-constructing and the ‘destructive’ force of pain leads Talal Asad in his own reflections on pain and agency to conclude that pain is a source of agency, but not precisely in the way depicted by Klassen. If pain is, as Scarry so powerfully suggests, a sensation that negates the possibility of narrating one’s self coherently, if pain is so completely unshareable with others, how, Asad asks, does the infliction of pain upon others continue to operate as an exercise of ‘power?’ How does pain become power, in this reading? More generally, Asad takes up the problem of agency in relationship to pain to show how the presumption of an essentially self-conscious human subject underwrites anthropological and sociological concepts of ‘agency’. Asad’s analysis presents the limits of these readings of agency that allow no spectrum between passive victim and self-empowered master.

Asad (2000: 43) writes: ‘Pain, one might venture, is neither a brute reality undermining thought nor an interpretation. It is an active, practical relationship’. Asad’s reading of Klassen’s ethnography of pain at birth is not aimed at identifying the ways that pain becomes a mode of empowerment against the late 20th-century medical emphasis on removing pain and one’s experience of pain from the body. Instead, pain ‘creates a new situation for the mother herself and for others’ (p. 48, emphasis in original). Pain, in Asad's reading, is not an individualised experience in which only the mother is involved, privately and in isolation. The agency of women seeking natural childbirth is, he suggests, not found in the effort to constitute oneself as an ‘empowered’ and autonomous subject. Rather, their efforts to shape the conditions for their embodied experience of pain are

quite simply, the activity that reproduces and sustains human relationships…For the act of birthing doesn’t merely produce another living body, it also helps to reproduce and extend a distinctive set of kinship relationships. The mother is an agent as a consequence of what she has done in a particular social situation – after the event, as it were – and not because of her desire or intention. (p. 48)

Asad’s criticism of the ‘agency’ reading of feminist accounts of pain in labour, and of liberal readings of agency more generally, is that they discount how pain is a deeply social rather than individual phenomena. His emphasis on the relational and social aspects of pain offers a different reading of labour pain from that of social movements that focus on the reconfiguration of the mother as a self-empowered actor ‘taking control’ of her body. These efforts can arguably leave unrealised the potential for pain to fundamentally reconfigure the social relations surrounding childbirth. The mother is an agent at birth, Asad asserts, not because of what she has willed or intended, but neither is she completely passive. The pain of childbirth could thus be a paradigmatic example of how pain is agency itself: the living body’s ‘ability to suffer, to respond perceptually and emotionally to external and internal causes, to use its pain in particular ways in particular social relationships, makes it active’ (Asad, 2000: 49).

This relational account of pain is also explored in Elly Teman’s ethnography of surrogacy relations in Israel. Intended mothers describe accompanying surrogates in birth and seeking and being encouraged to vicariously experience the pain of labour. As one participant in Teman’s study recounts: ‘When she had contractions I felt it. I felt horrible….When they induced, you know, she feels pain. I looked at her, and I also felt pain’ (Teman, 2010: 174). For Teman, these enactments of couvade, a term more often used to describe the identification of men with their partner’s pregnancy through bodily and behavioural changes, are part of how intended mothers and surrogates supplement the well-established legal and contractual arrangements of surrogacy by drawing on a ‘premodern script for establishing kinship and paternity’ (p. 178). The accounts of intended mothers’ accompanying surrogates in birth suggest that vicariously experiencing or sharing the pain of birth is an effort to distribute the agency of labour pain: ‘the intended mother’s vicarious embodiment of the pregnancy can be read as an expression of her desire to be socially recognised as the mother’ (p. 177).

Pain Speaks for Whom? Collective Pain and Reproductive Justice

Talal Asad’s understanding of pain as social and collective suggests a fruitful way to consider how labour pain became politicised and a matter of concern for feminist and maternal health activists. As Asad notes, the tendency is to ascribe this politicization of pain to a sovereign self. Movements for reproductive justice in the United States, however, take maternal pain and suffering as the grounds for making political claims and work to reconfigure labour pain as a social question. Inequities between women’s access to pain relief and the ability to receive pain relief are well-documented, and in the United States, these discrepancies suggest that the unknowability of another’s pain is not just, as Scarry suggests, the deep structure of pain itself, but rather is a particularity of how pain, when it becomes legible and intelligible, does so in specific and situated ways.

In the United States, social movements for reproductive justice have critiqued the overweening emphasis of reproductive rights feminism on abortion law and access to abortion (Smith, 2005). Landmark scholarly texts including Dorothy Roberts’ Killing the Black Body argue that the historical alignment of practices to liberate White women’s reproductive experiences (e.g. contraception, abortion) from state control were simultaneously directed at controlling and limiting Black women’s capacities to act (Roberts, 1997; Solinger, 2001). The framing of reproductive politics in the United States from the 1970s primarily around access to abortion, and the marginalization of reproductive concerns from civil rights movements, has meant that a commitment to ending Black women’s oppression in American society – for feminists and civil rights activists alike – must address the ways women’s experiences of pregnancy, birth and parenting are shaped by racist health and welfare practice and policy.

Black women’s ability to exercise choice surrounding pregnancy and birth is constrained by racist legacies of the mythologies surrounding Black womanhood, and by the class-stratified US health-care system. Calling for an approach to reproduction from a social justice rather than individual liberty perspective, Roberts’ work laid the groundwork for greater scholarly and activist attention to the limits of reproductive rights activism, and to the efforts by activists within civil rights and radical political social movements to make Black women’s experiences of fertility, pregnancy, birth and parenting central to anti-racist politics. These include addressing the criminalization of reproduction, particularly the increased likelihood that Black women who are drug users will be subject to greater medical surveillance that White women and are more likely to face criminal charges in which their drug use is considered a form of foetal or child endangerment (Luna and Luker, 2013; Silliman and Bhatacharjee, 2002). Black women are also more likely to experience coercion relating to their care during pregnancy and birth, including a greater likelihood of experiencing unnecessary medical interventions.

As Simon Strick argues, pain in labour was historically understood as a relay point between the constructions of two figures from 18th- and 19th-century medicine and science: ‘the “overcivilized” white woman, who experiences birthpain as pathology; and the primitive, sexualized African woman, lacking sensitivity to pain’ (Strick, 2014: 76). The efforts by obstetricians in the antebellum United States to develop methods to anaesthetise birthing women were directed at alleviating the pain of White women, while Black women were imagined as experiencing birth as relatively painless and to be therefore less sensitive – and also less compassionate – to the pain of others (p. 91). This differential sensitivity marked White women as bearers of the capacity to reproduce civilization, and prominent figures in the efforts to develop the use of anaesthesia in childbirth drew analogies between the pain and suffering endured by women in labour and the agonies experienced by slaves at the hands of slaveowners. This analogy between the suffering endured by slaves and that endured by White women in labour worked to create what Strick calls a comparative ‘dolorology’ or study of pain that constructed capacities for feeling pain as racialised truths in scientific and public discourse.

In the contemporary United States, the legacies of racialised hierarchies of labour pain remain: devaluing the experiences of Black birth givers’ pain and requests for pain relief is one of the ways in which the maintenance of racial inequality is enacted in the US medical system. The disparities between Black and White birth givers’ experiences of pain point to how the expressivity of pain and access to pain relief are means through which racial discrimination is perpetuated. More profoundly, these disparities suggest that the historical context in which Black bodies are deemed indifferent to pain continues to shape contemporary medical practice and social norms: ‘if this pain has been largely unspoken and unrecognized, it is due to the sheer denial of black sentience rather than the inexpressibility of pain’ (Hartman, 1997: 51).

The continued practice of shackling labouring women prisoners and evidence of disparities between Black and White women’s experiences of adequate pain medication at birth suggests that Scarry’s thesis on the inexpressibility of pain – and its relationship to the seemingly grander structures of political violence and conflict – brings the limits of individual investments in expressing labour pain into stark relief. Racialised responses to the pain and suffering of Black birth givers highlight the extent to which the denial of Black social life, or how ‘black life is lived alongside – or even within – spaces of death’, is enacted at birth (Nash, 2019: 21). As Talal Asad suggests in his writings on childbirth pain and agency, efforts to manage pain at birth are part of a broader set of social practices that enable and sustain the birth giver’s relationship to others, despite the framing of pain as the property of an individual subject. Pain and suffering at birth, and their mobilization as individual rather than as relational and collective experiences, are thus essential to understanding the dynamics of race and gender in the contemporary US.

Labour Pain for a New ‘Natal’ Politics

This essay considered how maternal subjects are made through and by embracing pain, controlling pain and making pain into an object of politicization. In contemporary medical and ‘natural’ childbirth approaches to labour pain, giving birth requires assuming responsibility for controlling or enduring one’s pain, articulating an approach to the pain of childbirth coherent with one’s sense of self. Pain management, in this view, requires the technical expertise of others but cannot be left to them; rather, managing the painful experience of childbirth must be assumed as a responsibility and obligation for the individual birth giver. Pain relief makes worlds, but so too does embracing the pain of labour – it ‘makes’ a mother, as the many citations to the apocryphal references to biblical pain attest.

Despite the emphasis in this essay on the expressivity of maternal pain in labour, maternal pain in labour and childbirth itself have often occupied the spaces of what Julia Kristeva and others describe as ‘abject’. The visceral and liminal dimensions of labour and birth, the expulsion of what was inside the body to the outside, and childbirth’s fluid materiality have meant, until recently, that visual representations of childbirth in public culture are often sanitised and bear little resemblance to the experiences of many birth givers. I conclude this essay by considering recent efforts to call for a revision of the cultural presumption that birth, and by extension, birth pain, remains invisible and abject.

Drawing from Hannah Arendt’s efforts to think politics in relation to birth or ‘natality’ as the inauguration of new beginnings, Imogen Tyler and Lisa Baraitser (2013) examine how the public cultures of television and social media now make childbirth visible in new ways. They situate the visual proliferation of images of labour and birth as efforts to reinsert the mother’s body back into visual cultures of pregnancy after decades of attention to representations of the fetus, both in popular culture and in critical feminist scholarship (Petchesky, 1987). Tyler and Baraitser write that if the 1980s were the era in which the subject of ‘foetal personhood’ was generated, the era of the 1990s and early 2000s brought childbirth into cultural visibility in new ways. In contrast to the opprobrium and censure surrounding images of pregnancy two decades ago, the visibility of the pregnant body in public is no longer considered unacceptable or shameful.

The increasing visibility of the mother’s body thus heralds a new kind of ‘natal thinking’ in public culture. Birth is increasingly visually depicted in ways that seek to ‘restage women’s reproductive autonomy’ (Tyler and Baraitser, 2013: 22). Childbirth has shifted from ‘“the great unseen” of European culture’ to a newly visible part of Euro-American public cultures through the diverse representations of birth on television and the circulation through social media of birth videos posted by mothers (p. 1). Despite this proliferation of representations, Tyler and Baraitser note that images of the moment of crowning and of birth presented as both ecstatic and painful sensation remain less frequently dramatised or reproduced. Extending their reading to the contemporary art world, they suggest that by examining the work of artists generating work on fertility, pregnancy and birth, one can see alternative possibilities for thinking through birth, as Arendt suggests we must, as a mode of politics. They write:

a natal politics would insist on natality as not just an experience we have in common, but a metaphor for a mode of sharing words and deeds in public space that allows for the appearance of transformational beginnings. This, we would suggest, takes us towards an articulation of a ‘maternal commons’ (Tyler, 2013) where recognising what we share, what we have in common, is also a political act. (p. 23)

Tyler and Baraitser’s articulation of a ‘natal politics’ suggests ways to consider how the pain of labour and birth might be the locus for imagining new kinds of ‘political acts’. It does so by considering how the experience of pain has been politicised, made expressive and shared with others.

Indeed, what is striking about several of the visual representations of birth Tyler and Baraitser examine is the way they present women’s faces and bodies during labour. If, as Tyler and Baraitser suggest, visual evidence of women’s ecstatic sensations during the crowning of the foetal/child head remains one of the aspects of birth still shrouded by social prohibition or censorship, what is also being hidden is the possibility of sharing socially in the moment of labour pain. The moment of crowning is so compelling visually because it presents the oscillating potentiality and liminality between the status of the fetus versus its coming into being as a child. The moment of crowning is also, visibly, ecstatic and painful. The effort to express this pain, to make it speak and to make it render and bring forth something new to be shared opens up intriguing questions about the centrality of pain at birth in a new natal politics.

Conclusion

The social movements for reproductive justice that make visible how pain during labour is deployed alongside or as punishment consider labour pain as a social or collective question, ‘decentering…many of the goals that more privileged childbirth activists in North America have defined as primary, such as freedom from medical intervention’ (Basile, 2012: 197). In this sense, considering who suffers and who is alleviated of their suffering is a necessary supplement to Tyler and Baraitser’s appeal to ‘natal thinking’. Tyler and Baraitser’s natal politics envisions the thinking of creation in new ways, where out of the newfound visibility of the birthing body comes the possibility of new political imaginaries. But what of the invisibility of the pain of racism at birth, alongside the hypervisibility of the Black body as indifferent to pain? The possibilities of a new natal politics that explores the pain of labour and its making and unmaking of maternal subjects would seek to make central the problem, as Saidiya V. Hartman writes, of the invisibility of Black sentience and the material effects in injury and death that this entails. The new possibilities of natal thinking Tyler and Baraitser anticipate could thus interrogate, following Hartman, how the visibility of the labouring body in pain is differentiated by conceptions of humanity and sentience.

The discourse and rhetoric of pain as ‘normal’ and even ‘desirable’ in activist literature on childbirth challenges one of Scarry’s most oft-cited statements in The Body in Pain. Pain, Scarry argues, is impossible to describe and is that which we do not want; pain is aversive and unwanted. Efforts to give expression to the pain of labour, and from this expression to generate new possibilities for self-creation, complicate Scarry’s emphasis on the self-destructive and world-destroying dimensions of pain. Phenomenological dimensions of pain as ‘the impossibility of language’, extended in the second half of The Body in Pain, telescope out from the body’s aversiveness to painful sensation to establish relief from bodily suffering as the originary moment of all creation. What would this mean in the context of labour pain, where pain is purposeful and its expression central to becoming a maternal subject?

This essay suggests that a natal politics of collective labour pain and its relief would respond to calls within the reproductive justice movement to redress the racism of maternal health care and feminist movements for reproductive autonomy. While labour pain is not explicitly the focus of Tyler and Baraitser’s articulation of a new natal politics, labour pain could be made newly political in order to redress the denial of Black maternal pain, ‘relieving the pained body through alternative configurations of the self and the redemption of the body as human flesh’ (Hartman, 1997: 77). The pain of labour and its relief would then be configured as more than a problem of maternal self-fashioning: the labouring body in pain could instead figure into a natal politics attentive to embodied forms of racism and the possibilities for new forms of sociality that redress reproductive injustice. The building of worlds in this context would require first and most importantly acknowledging another’s capacity for experiencing pain and the politics of hearing or not hearing another’s expressions of pain.

Like Scarry’s analysis of how physical pain is ultimately at the origins and foundations of the geopolitics of war – despite the elaborate efforts to distance war’s purpose from that of wounding and causing pain – the pain of childbirth can also be viewed in part as a form of suffering exacerbated by living in a racist society. Activists in the contemporary US reproductive justice movement articulate pain in labour as a political question and problem shaped by how pain is imagined in relationship to categories of difference: the extent to which women and men are reported to experience pain differently and be treated for pain unequally (Hoffmann and Tarzian, 2001), and the extent to which White women in the United States receive more sensitive treatment of their labour pain than Black women. Redressing reproductive injustice would require reworking Scarry’s emphasis on the individuality of the body in pain to reveal the social dimensions of labour pain, and in doing so, seeking to transform the differential suffering and pain of labouring bodies into new kinds of collective natal politics.

Footnotes

ORCID iD

Maria Fannin

Notes

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