Damned if you do-Damned if you don't: Or does it even matter? (our birth story)

It's unbelievable that it's been a month (ok, six weeks now; 2 weeks since we started writing this post!) since Annabelle was born! That it has taken us this long to write this post about her birth is a testament to the realities of life as new parents doing field work. In our case, it's also a testament to the complicated emotions surrounding the birth itself.

Whether the birth would've gone differently had we been living in the United States is unclear, and that in itself is quite interesting from the perspective of a medical anthropologist. Living in India, Jo had a late-term ultrasound at 37 weeks. This late stage ultrasound is not routinely done in the United States, and we aren't quite sure as to why it's not done at that stage here. The ultrasound showed that the umbilical cord was wrapped twice around Annabelle's neck. When the ultrasound tech told us this in a matter-of-fact sort of way, we were kind of in shock..."What does this mean"..."What will this mean for the birth, for the birthing options, for our unborn child?". There were so many questions. While Jo's next doctor's appointment wasn't for several days, we did know immediately that this information was going to what we had envisioned to be the birthing process.

Upon returning home, we did did what any obsessive and anxiety ridden parents-to-be would do (but shouldn't): we consulted the Pandora's box that is the Internet. For the next several hours, we uncovered countless contradictory accounts of how the cord wrapped around the neck doesn't matter, as opposed to those that claimed it caused a child's death or serious impairment. This conflicting information was quickly compounded by the conversations we had with our friends and relatives, who have very different perspectives on medical culture.

After two days of stewing in information and misinformation we went to see Jo's OB. She told us, whether or not this is true, that there was a 95% chance that Jo would require an emergency c-section if she tried to go for a natural delivery. In short, she strongly, strongly recommended "electing" to have a c-section as opposed to a normal delivery. With this advice, what we had envisioned about the birth (natural, quiet, and most importantly, not characterized by medical intervention) evaporated. As Jo was only 37 weeks along, the doctor said we had a few days to decide, but that she would like to do the "procedure" in the next week if we "decided" to go that route.

Over the next few days, I think we walked around the little park in our neighborhood enough times to wear a track in the cement. As academics, we couldn't help but see this decision as being fraught with incredibly complicated epistemological issues. At a first glance, this seemed like the embodiment (pun not intended) of the classic Foucauldian knowledge/power couplet. To paraphrase, Foucault wrote that knowledge is indeed power, but power allows those in control to determine what counts as knowledge. The knowledge/power complex dictates what can be said, and by whom, and through cultural institutions becomes embodied in our everyday lives through action, interaction, and social structure. Foucault wrote about these concepts extensively in The Birth of the Clinic. What counts as knowledge in this situation? Was the "information" we found on the Internet "credible"? Was it sanctioned by the medical establishment? No. And was it credible? Even if they cited peer-reviewed journal articles, many of the accounts we read were on online bulletin boards, and thus seemed devoid of power because they weren't from a medical authority figure. On the other hand, the information dispensed by our OB and medically-trained family members felt official, sanctioned, and wielded a lot of power.

This was a first-hand introduction to the ways in which questions of knowledge and power dovetail with the new responsibilities of parenting. This wasn't an abstract academic exercise for us; it was very real and soon to become embodied in Jo's own body based upon which decision we made. We have a relative who is pretty severely disabled with cerebral palsy, a result of...well, it depends who you talk to, but a cord being wrapped around his neck, oxygen deprivation, and a difficult birth. And that was without a late-term ultrasound to indicate that a difficult labor would be a strong possibility.

So after much ruminating, the "decision" boiled down to the age-old axiom, "You're damned if you do, damned if you don't". "You're damned if you do" amounting to the fact that going with the c-section meant that we were "caving in" (or so it felt) to the medical establishment and its interventionist ethos. "You're damned if you don't" amounting to the life-long guilt we'd feel if we went forward with a natural birth and something went wrong (however unlikely that scenario might be). I've been writing "decision" in quotations because from the moment we had the information about the cord, we felt to a large extent that the decision had been made for us by the biomedical establishment.

In the end, we chose to go through with the c-section. Looking back now, it hardly seems important, but at the time it felt like a life-and-death decision. We'll never know if it actually was life-and-death, but we ended up with a healthy and happy little girl, and an even happier set of new parents.

Welcome Annabelle Winifred Meek, born August 18th, 2011

Sex Determination and Cultural Constraints

Blue or pink...or taupe?

Depending on where one is conducting fieldwork, learning the biological sex of one's baby before it is born can be illegal. This has been the case for us here in India. Our baby is set to arrive next week, but we still have no idea if it's a boy or a girl. Although once a source of major frustration for us--as we were curious to learn all we could about our little one--now that the birth is imminent it doesn't seem like such a big deal. Still, it's an important social and political issue, so this post is devoted to our experiences with sex determination in India.


Why is prenatal sex determination illegal in some places? The basic reason is that in some populations, males are preferentially desired over female children, and as a result females may be selectively aborted before birth, or neglected and/or killed thereafter. Although this sounds grisly and improbable, in some cases, the numbers are quite staggering. The secondary sex ratio, which is the ratio between sexes at birth (as opposed to at the time of conception) and is the statistic most frequently cited to talk about population sex ratios, should be around 105 boys to 100 girls in a "natural" (i.e., un-tampered-with) situation. In some places, this ratio is highly skewed, with numbers as high as 130 boys to 100 girls.


Why is sex selection considered a problem? Sex selection is a problem not just because it creates population imbalances that have significant social, economic, and reproductive consequences. More importantly, it is a symptom of systematic social inequalities that constitute a violation of women's human rights. Rarely, if ever, does sex selection work in the opposite direction (in favor of girls) at a population-level scale.

This year (2011), India's new census data were released. Since the previous census in 2001, sex ratios have worsened in many parts of the country, especially in the more prosperous and educated states. This is somewhat surprising because typically, as populations become more educated, women's social equality increases. At the same time, India's 2011 census shows that the country's overall infant mortality rate--the number of infant deaths per 1,000 live births--has decreased 30% in the past 10 years. Population growth has also decelerated. The fact that the sex ratio is getting worse in the face of these otherwise positive population trends is alarming. Even among Indian diasporas living in the US and the UK (two countries where prenatal sex determination is legal), the sex ratio is significantly skewed toward males.

To me, this information suggests that it's not India's within-country conditions (such as climate, geography, other demographic trends) that are causing girl babies to die more frequently than boys; it's a sociocultural reason. The pressure to have a boy in India is so intense that, according to recent newspaper reports we've been reading, people who can afford to do so will fly to Dubai and get a sex determination ultrasound or amniocentesis. Some even go so far as to have the sex of their baby surgically altered shortly after birth. Now, of course, there are bright spots--villages or towns with remarkably healthy sex ratios in the midst of a larger region of unfavorable ones, or entire states where the sex ratio resembles what one would expect--but the problem doesn't seem to be going away for India.

India's pervasive sex selection in favor of boys becomes more understandable when one considers the dominant social structure and its concomitant social pressures. In fact, I've spoken with so many women about it that while I can't sympathize, I can certainly empathize. First of all, India's dominant social systems are highly male-biased. Men in most households are still the primary breadwinners. When a woman marries, she moves into her husband's family's household, often bringing along a significant dowry which is usually negotiated in advance as part of the marriage arrangement. Even if no dowry is there (it is technically illegal), the bride's parents transfer a lot of wealth to the groom's family by paying for a lavish multi-day wedding ceremony and gifting their daughter gold jewelry. Because of social pressures to communicate status by displaying wealth (something we Americans also do a lot of, too), parents feel compelled to host ceremonies that stretch the limits of their means. They often save money for years and/or go into serious debt to pay for these ceremonies, much as American parents save and take out loans for their children's college expenses. This means that daughters constitute a financial liability, and this is one reason why a family might not be thrilled about the birth of a daughter, especially if she's not the first daughter.

On the other hand, sons are, in many ways, a form of social and financial security for their parents, at least in the traditional systems. A son brings a bride into the household, who takes over her mother-in-law's domestic responsibilities and allows her to retire. Likewise, good sons traditionally contribute most of their earnings to the family, lessening the financial responsibility of the father and allowing him to retire as well. India has no social security system and very few older-age homes, so this kind of in-built family support continues to be important for aging parents even in urban, wealthy families with access to good health care. Although many scholars claim that the joint family is dying out in India, just a little over half of the women I work with on a regular basis live in joint families, and I find that it's still the pervasive ideal communicated in popular media like blockbuster Bollywood films. This trend may be changing, but it's not gone yet.

Because boys are so important to the integrity of family structure, married women are often pressured by their in-laws to bear sons. If they fail to do so, they may be abused or threatened. In many cases of female infanticide, it's not the birth mother but another family member who kills the baby. Naturally, under this kind of pressure, women want to have sons. I would, too, if I lived with and worked for my mother-in-law and she was always breathing down my neck and punishing me and making my home-bound life miserable. In this way, the woman-oppressive system gets perpetuated by women.

Since starting my research, I've met several women who have something like 6 or 7 daughters and one son (he's usually the youngest of the bunch). I've met others who have 6 or 7 daughters and no sons. These women are always financially very strained and emotionally very stressed. Women's number-one stressor across the board, at least in my research, is getting their daughters married. Wealthy or not, this is a big social responsibility for a parent, and other family members will exert significant pressure on him or her to get the daughter settled and married earlier rather than later. This means that in many cases, women don't complete a high-school level education. And we all know that less education means less empowerment means less capability to stand up for one's rights in oppressive scenarios. Once again, the family perpetuates the system.

So given this context, for us the choice was pretty clear.

No choice--in terms of knowing that is.

Well, no legal choice. As the above discussion should illustrate, plenty of people choose to pursue illegal means of sex determination through bribing technicians or traveling to countries where it remains legal. But laws are there for a reason.