Women – Dr. Ruth De Souza

Providing Culturally Safe Maternal and Child Healthcare

Cite as: DeSouza, R. (2016, June 1st). Keynote address-Providing Culturally Safe Maternal and Child Healthcare, Multicultural Health Research to Practice Forum: Early Interventions in Maternal and Child Health, Program, Organised by the Multicultural Health Service, South Eastern Sydney, Local Health District, Australia. Retrieved fromhttp://www.ruthdesouza.com/2016/06/11/cultural-safety-in-maternity/

A paragraph haunts me in The Namesake, Jhumpa Lahiri’s fictional account of the Indian immigrant experience. Ashoke and Ashima Ganguli migrate from Calcutta to Cambridge, Massachusetts after their arranged wedding. While pregnant, Ashima reflects:

Nothing feels normal. it’s not so much the pain which she knows she will survive. It’s the consequence: motherhood in a foreign land. For it was one thing to be pregnant to suffer the queasy mornings in bed, the sleepless nights, the dull throbbing in her back, the countless visits to the bathroom. Throughout the experience, in spite of her growing discomfort, she’s been astonished by her body’s ability to make life, exactly as her and grandmother and all her great grandmothers had done. That it was happening so far from home, unmonitored and unobserved by those she loved, had made it more miraculous still. But she is terrified to raise a child in a country where she is related to no one, where she knows so little, where life seems so tentative and spare. The Namesake, Jhumpa Lahiri

Ashima’s account beautifully captures the universality of the physical, embodied changes of maternity, the swelling, the nausea and other changes. But what Lahiri poignantly conveys is the singular emotional and cultural upheaval of these changes, the losses they give rise to. The absence of loving, knowledgeable, nurturing witnesses, the absence of a soft place to fall.

Arrival of baby girl in Prato, Tuscany. Credit DeSouza (2006).

In 1994 I worked on a post-natal ward where I was struck by the limits of universality and how treating everybody the same was problematic. For example, ostensibly beneficial practices like the routine administration of an icepack for soothing the perineum postnatally, or the imperative to mobilise quickly or to “room in” have potentially damaging effects on women whose knowledge frameworks differed from the dominant Pakeha culture of healthcare. These practices combined with a system designed for an imagined white middle class user, where professionals had knowledge deficits and monocultural and assimilatory attitudes, led to unsafe practices such as using family members and children as interpreters (my horror when a boy child was asked to ask his mother about the amount of lochia on her pad). The sanctity of birth, requiring the special, nurturing treatment of new mothers and a welcome from a community was superseded by the factory culture of maximum efficiency. Not all mothers were created equal, not young mothers, not older mothers, not single mothers, not substance using mothers, not indigenous mothers, not culturally different mothers. The sense that I was a cog in a big machine that was inattentive to the needs of “other” mothers led me to critique the effectiveness of cultural safety in the curriculum. How was it possible that a powerful indigenous pedagogical tool for addressing health inequity was not evident in clinical practice?

Photo of me as a staff nurse back in the day.

Leaving the post-natal ward, I took up a role helping to develop a new maternal mental health service in Auckland. There too I began to question the limitations of our model of care which privileged talking therapies rather than providing practical help and support. I was also staggered at the time at the raced and classed profile of our clients who were predominantly white middle class career women. Interestingly, the longer I was involved in the service the greater the number of ethnic women accessed the service. For my Master’s thesis, I interviewed Goan women about their maternity experiences in New Zealand, where the importance of social support and rituals in the perinatal period was noted by participants.

As much as it was important to register and legitimate cultural difference, I was also aware of the importance of not falling into the cultural awareness chasm. As Gregory Philips notes in his stunning PhD, it was assumed that through teaching about other cultures, needs would be better understood as “complex, equal and valid” (Philips, 2015). However, it didn’t challenge privilege, class and power. As Joan Scott points out:

There is nothing wrong, on the face of it, with teaching individuals about how to behave decently in relation to others and about how to empathize with each other’s pain. The problem is that difficult analyses of how history and social standing, privilege, and subordination are involved in personal behavior entirely drop out (Scott, 1992, p.9).

The problem with culturalism is that the notion of “learning about” groups of people with a common ethnicity assumes that groups of people are homogenous, unchanging and can be known. Their cultural differences are then viewed as the problem, juxtaposed against an implicit dominant white middle class cultural norm. This became evident in my PhD analysis of interviews with Korean mothers who’d birthed in New Zealand. In Australia and the US, cultural competence has superseded cultural awareness as a mechanism for correcting the limitations of universalism, by drawing attention to organisational and systemic mechanisms that can be measured but as a strategy for individual and interpersonal action, several authors draw attention to competence as being part of the “problem”:

The concept of multicultural competence is flawed… I question the notion that one could become “competent” at the culture of another. I would instead propose a model in which maintaining an awareness of one’s lack of competence is the goal rather than the establishment of competence. With “lack of competence” as the focus, a different view of practicing across cultures emerges. The client is the “expert” and the clinician is in a position of seeking knowledge and trying to understand what life is like for the client. There is no thought of competence—instead one thinks of gaining understanding (always partial) of a phenomenon that is evolving and changing (Dean, 2001, p.624).

In Wellness for all: the possibilities of cultural safety and cultural competence in New Zealand, I advocated for a combination of cultural competence and cultural safety. Cultural safety was developed by Indigenous nurses in Aotearoa New Zealand as a mechanism for considering and equalizing power relationships between client and practitioner. It is an ethical framework for practice derived from postcolonial and critical theory. Cultural safety proposes that practitioners reflect on how their status as culture bearers impacts on care, with care being deemed culturally safe by the consumer or recipient of care. In my PhD I wrote about the inadequacy of the liberal foundations of nursing and midwifery discourses for meeting the health needs of diverse maternal groups. My thesis advocated for the extension of the theory and practice of cultural safety to critique nursing’s Anglo-European knowledge base in order to extend the discipline’s intellectual and political mandate with the aim of providing effective support to diverse groups of mothers. In Australia, cultural responsiveness, cultural security and cultural respect are also used, you can read more about this on my post on Minding the Gap.

So let’s look at culturally safe maternity care. My experience as a clinician and researcher reveal a gap between how birth is viewed. In contemporary settler nations like New Zealand, midwifery discourses position birth as natural and the maternal subject as physically capable of caring for her baby from the moment it is born, requiring minimal intervention and protection. The maternal body is represented as strong and capable for taking on the tasks of motherhood. In contrast, many cultures view birth as a process that makes the body vulnerable, requiring careful surveillance and monitoring and a period of rest and nurturing before the new mother can take on new or additional responsibilities. The maternal body is seen as a body at risk (Mahjouri, 2008), and vulnerable requiring special care through rituals and support. Therefore, practices based on a dominant discourse of birth as a normal physiological event and neoliberal discourses of productive subjectivity create a gap between what migrant women expect in the care they expect from maternal services. These practices also constitute modes of governing which are intended to be empowering and normalizing, but are experienced as disempowering because they don’t take into account other views of birth. Consequently there is no recognition on the part of maternity services that for a short time, there is a temporary role change, where the new mother transitions into a caregiver by being cared for. This social transition where the mother is mothered is sanctioned in order to safeguard the new mother, a demonstration to value and protect both future capacity for mothering and long term well being, in contrast with dominant discourses of responsibilisation and intensive motherhood. Thus, instead of a few days of celebration or a baby shower, extended post-partum practices are enacted which can include the following (Note that these will vary depending on in group differences, urbanisation, working mothers, migration):

Organised support- where family members (eg mother, mother-in-law, and other female relatives) care for the new mother and infant. Other women may also be involved eg birth attendants.
Rest period and restricted practices- where women have a prescribed rest periods of between 21 days and five weeks, sometimes called “Doing the month”. Activities including sexual activity, physical and intellectual work are reduced.
Diet- Special foods are prepared that promote healing/restore health or have a rebalancing function for example because the postpartum period is seen as a time when the body is cold, hot food (protein rich) chicken soup, ginger and seaweed, milk, ghee, nuts, jaggery might be consumed. Special soups and tonics with a cleansing or activating function are consumed eg to help the body expel lochia, to increase breastmilk. These foods might be consumed at different stages of the perinatal period and some food might be prohibited while breastfeeding.
Hygiene and warmth- particular practices might be adhered to including purification/bathing practices eg warm baths, immersion. Others might include not washing hair.
Infant care and breastfeeding- Diverse beliefs about colostrum, other members of family may take more responsibility while mother recovers and has a temporarily peripheral role. Breastfeeding instigation and duration may differ.
Other practices include: binding, infant massage, maternal massage, care of the placenta.

If women are confronted with an unfamiliar health system with little support and understanding, they can experience stress, insecurity, loneliness, isolation, powerlessness, hopelessness. This combined with communication gaps and isolation, poor information provision, different norms, feeling misunderstood and feeling stigmatized. What could be a special time is perceived as a lack of care. Fortunately in Australia there are some excellent resources, for example this research based chapter on Cultural dimensions of pregnancy, birth and post-natal care produced by Victoria Team, Katie Vasey and Lenore Manderson, proposes useful questions for perinatal assessment which I have summarised below:

Are you comfortable with both male and female health care providers?
Are there any cultural practices that we need to be aware of in caring for you during your pregnancy, giving birth and postnatal period? – For example, requirements with the placenta, female circumcision or infant feeding method.
In your culture, do fathers usually attend births? Does your partner want to attend the birth of his child? If not, is there another close family member you would like to be present? Would you like us to speak to them about your care?
Are there any foods that are appropriate or inappropriate for you according to your religion or customs during pregnancy, birth and the postpartum period?
Are there any beliefs or customs prohibiting physical activity during pregnancy, birth and the postpartum period? Do you plan to observe these? – For example, a confinement period.
What is the culturally acceptable way for you to express pain during childbirth? – For example, screaming or trying to keep silent.
Are there any precautions with infant care?
How many visitors do you expect while you are in the hospital?
Do you have anyone in your family or community who can help you in practical ways when you get home?

Negotiating between cultural practices, values and norms, religious beliefs and views, beliefs about perinatal care is a starting point. It is also important to consider language proficiency, health literacy, quality of written materials, and level of acculturation. For further information on health literacy see the Centre for Culture, Ethnicity & Health (CEH) resources including: What is health literacy?, Social determinants of health and health literacy. Using professional interpreters improves communication, clinical outcomes, patient satisfaction and quality of care, and reduces medical testing, errors, costs and risk of hospitalisation. Lack of appropriate interpreter service use is associated with adverse health outcomes. Centre for Culture,Ethnicity & Health (CEH) has excellent resources in this regard: Interpreters: an introduction, Assessing the need for an interpreter, Booking and briefing an interpreter, Communicating via an interpreter, Debriefing with an interpreter, Developing a comprehensive language services response, Language services guide Managing bilingual staff, Planning for translation, Recruiting bilingual staff.

Assessment should also consider:

Genetics and pregnancy: women’s age, parity, planning and acceptance of pregnancy, pregnancy related health behaviour and perceived health during pregnancy.
Migration: women’s knowledge of/familiarity with the prenatal care services/system, experiences and expectations with prenatal care use in their country of origin, pregnancy status on arrival in the new industrialized western country.
Culture: women’s cultural practices, values and norms, acculturation, religious beliefs and views, language proficiency, beliefs about pregnancy and prenatal care.
Position in the host country: women’s education level, women’s pregnancy-related knowledge, household arrangement, financial resources and income.
Social network: size and degree of contact with social network, information and support from social network.
Accessibility: transport, opening hours, booking appointments, direct and indirect discrimination by the prenatal care providers.
Expertise: prenatal care tailored to patients’ needs and preferences.
Treatment and communication: communication from prenatal care providers to women, personal treatment of women by prenatal care providers, availability of health promotion/information material, use of alternative means of communication.
Professionally defined need: referral by general practitioners and other healthcare providers to prenatal care providers

A review by Small, Roth et al., (2014) found that what immigrant and non-immigrant women want from maternity care is similar: safe, high quality, attentive and individualised care, with adequate information and support. Generally immigrant women were less positive about care than non-immigrant women, in part due to communication issues, lack of familiarity with care systems, perceptions of discriminatory care which was not kind or respectful. The challenge for health systems is to address the barriers immigrant women face by improving communication, increasing women’s understanding of care provision and reducing discrimination. Clinical skills including—introspection, self-awareness, respectful questioning, attentive listening, curiosity, interest, and caring.

Also:

Facilitating trust, control
Delivering quality, safe care, communicating, being caring, providing choices
Facilitating access to interpreters and choice of gender of care provider,
Considering cultural practices, preferences and needs/different expectations for care
Engendering positive interactions, being empathetic, kind, caring and supportive.
Taking concerns seriously
Preserving dignity and privacy
Seeing a person both as an individual, a family member and a community member
Developing composure managing verbal and non-verbal expressions of disgust and surprise
Paradoxical combination of two ideas— being “informed” and “not knowing” simultaneously.

In that sense, our knowledge is always partial and we are always operating from a position of incompletion or lack of competence. Our goal is not so much to achieve competence but to participate in the ongoing processes of seeking understanding and building relationships. This understanding needs to be directed toward ourselves and not just our clients. As we question ourselves we gradually wear away our own resistance and bias. It is not that we need to agree with our clients’ practices and beliefs; we need to understand them and under-stand the contexts and history in which they develop (Dean, 2001, p.628).

Conclusion

In this presentation I have invited you to examine your own values and beliefs about the perinatal period and how they might impact on the care you might provide. I have asked you to consider both the similarities and differences between how women from culturally diverse communities experience maternity and those from the dominant culture. Together, we have scrutinised a range of strategies for enhancing trust, engagement and perinatal outcomes for all women. Drawing on my own clinical practice and research, I have asked you to consider an alternative conceptualisation of the maternal body when caring for some women, that is the maternal body as vulnerable, which requires a period of rest and nurturing. This framing requires a temporary role change for the new mother to transition into being a caregiver, by being cared for, so that her future capacity for mothering and long term well being are enhanced. I have asked you to reflect on how supposedly empowering practices can be experienced as disempowering because they don’t take into account this view of birth. In the context of differing conceptualisations of birth and the maternal body I have drawn special attention to: negotiating between health beliefs; having cultural humility; considering ways in which your own knowledge is always partial; and recommended a range of resources that can be utilised to ensure positive outcomes for women and their families. As health services in Australia grapple with changing societal demographics including cultural diversity, changing consumer demands and expectations; resource constraints; the limitations in traditional health care delivery; greater emphasis on transparency, accountability, evidence- based practice (EBP) and clinical governance (Davidson et al., 2006), questions of how to provide effective universal health care can be enhanced by considering how differing views can be incorporated as they hold potential benefits for all.

Selected references

Boerleider, A. W., Wiegers, T. A., Manniën, J., Francke, A. L., & Devillé, W. L. (2013). Factors affecting the use of prenatal care by non-western women in industrialized western countries: A systematic review. BMC Pregnancy and Childbirth, 13(1), 8.
Dennis, C. L., Fung, K., Grigoriadis, S., Robinson, G. E., Romans, S., & Ross, L. (2007). Traditional postpartum practices and rituals: A qualitative systematic review. Women’s Health (London, England), 3(4), 487-502. doi:10.2217/17455057.3.4.487.
Mander, S., & Miller, Y. D. (2016). Perceived safety, quality and cultural competency of maternity care for culturally and linguistically diverse women in queensland. Journal of Racial and Ethnic Health Disparities, 3(1), 83-98. doi:10.1007/s40615-015-0118.
Small, R., Roth, C., Raval, M., Shafiei, T., Korfker, D., Heaman, M. Gagnon, A. (2014). Immigrant and non-immigrant womens experiences of maternity care: A systematic and comparative review of studies in five countries. BMC Pregnancy and Childbirth, 14(1).

Additional web resources

The Victorian Refugee Health Network has maternity resources.
Opportunities to improve maternal health literacy through antenatal education: an exploratory study, article by Susan Renkert and Don Nutbeam

“I had to keep my options open”: White mothers and neoliberal maternity

Unpublished manuscript that never found an appropriate institutional home, but sharing for those who might be interested. Cite as: DeSouza, R., & Butt, D. (2016, June 11). “I had to keep my options open”: White mothers and neoliberal maternity. [Web log post]. Retrieved from: http://www.ruthdesouza.com/2016/06/11/i-had-to-keep-my-options-open-white-mothers-and-neoliberal-maternity/

Where patriarchal healthcare institutions saw birth as a process controlled by male doctors and supported by female nurses, contemporary midwifery draws from liberal feminism the concept of “choice” as the marker of maternal agency. However, critiques of neoliberalism locate “informed choice”, “empowerment” and “partnership” as discursive markers of specific capitalist subjectivities that are unevenly distributed among class, race, and sex. The ideology of reproduction as choice aligns with Foucault’s notion of “governmentality”, where the managerial state promotes middle-class discourses of responsibilisation, transformation and empowerment to regulate and maximise the efforts of individuals within the social body. Previous research has shown how maternal care nurses and midwives are instrumental in reproducing these discourses, reflecting white middle-class ideals of the individual service user. This study explored these themes through a secondary discourse analysis on focus groups with white migrant mothers in Aotearoa New Zealand. While migrant mothers noted differences between the New Zealand context and their home nation, unlike ‘other’ migrant mothers they generally adhered to neoliberal requirements to make choices aligned with the expectations of the state. The mothers espoused ideals of natural birth that sat in tension with their notions of informed consumption, reflecting technoscientific discourses that have informationalised the maternal body and interpellated mothers into neoliberal ideologies. The paper argues that attention to the restricted discourses of choice as empowerment illuminates how settler-colonial maternal healthcare systems are limited in their universality, failing to escape cultural and class-based assumptions that empower some mothers at the expense of others. The paper concludes that critical healthcare analysis and methodologies such as cultural safety provide tools for the transformation of these discourses.

Keywords  Maternity, whiteness, neoliberalism, Foucault, cultural safety.

Introduction

Midwifery discourses have advanced a feminist vision of women’s empowerment where women usurp patriarchal control of maternity institutions and increase their own power by becoming informed. However, the intrapersonal strategies of information accumulation and behaviour modification can leave structures of power intact and fulfil neoliberal ends. Facilitating a non-authoritarian, woman-centred ethic of care through liberal feminist values (such as individual choice and autonomy) allows mothers to choose to be healthy and productive, while also leading to a reduction in demands on the state as women govern themselves and each other (Collins, 2009). Although midwifery has positioned itself outside dominant norms as an anti-authoritarian discourse, these ‘choices’ are made within a neoliberal consumerist context of health care (Spoel, 2007). Midwifery is simultaneously constructed by these norms and reproduces them, masking new forms of social regulation shaping health care delivery in the process (Skinner, 1999; Spoel, 2006; O’Connell and Downe 2009). Consequently, the emancipatory promise of liberal feminism has disturbingly converged with the economic ‘freedoms’ of neoliberalism, in a discursive formation structured by whiteness. Where previous work established this formation in the discourses of maternal and child health nurses, this paper diagnoses neoliberal discourses employed by white informed consumers.
The dominance of whiteness in Western healthcare systems has been well established (see e.g. Allen, 2006). The liberal theoretical paradigm is deeply embedded in nursing, where those employed in care are rarely able to see how it structures their professional culture, in turn making it difficult to understand how adherence to seemingly neutral and egalitarian values (to white norms) can be oppressive. Whiteness here does not refer only to the visible phenotype of individuals, but to “a cultural disposition and ideology held in place by speciﬁc political, social, moral, aesthetic, epistemic, metaphysical, economic, legal, and historical conditions, crafted to preserve white identity and relations of white supremacy” (Bailey & Zita, 2007: vii). Although it is a scientific and cultural fiction like other racial identities, it has a real social impact on the distribution of resources due to a “possessive investment in whiteness” among white individuals (Lipsitz, 2006). A combination of public policy and private prejudice operate simultaneously to create this investment and perpetuate racialised hierarchies that structure access to resources, power and opportunity. Lipsitz contends that white supremacy is less a direct expression of contempt (as usually described by whites who distance themselves from the term), and more a system that protects white privilege and prevents communities of colour from accumulating assets and upward mobility. Complicating any direct identitarianism, Lipsitz contends that non-white people can become agents of white supremacy as well as passive consumers in its hierarchies— not all white people are equally complicit with white supremacy. White dominance and neoliberalism are two powerful and interrelated concepts that describe the systemic and structural forms that produce and reproduce ideal subjectivities. It is this relationship between subjective experience and institutional rationality that this paper seeks to illuminate.
Liberalism and neoliberal maternity
The revalorisation of liberal precepts into the global structures of institutional power termed neoliberalism has been most thoroughly documented by Michel Foucault. Foucault’s analysis of governmentality as “both a political discourse about the nature of rule and a set of practices that facilitate the governing of individuals from a distance” (Larner, 2006: 6) has particular resonance in health and in maternity. The birth of a future citizen is an event with great emotional, biological, cultural and social significance; and consequently the rites and routines that organize birth reflect core cultural values (Fox & Worts, 1999; Reiger, 2008). Maternal and infant public health has been shaped by state concern about the quantity and quality of population in the context of imperial rivalry, both in the centre of empire and the outer edge of white settlement (Lewis, 1988). The “health of the race” and infant health have been a central focus for doctors and politicians, with babies viewed as valuable assets in the struggle for imperial supremacy (Lewis, 1988). While such explicitly racial discourses are today less prevalent, maternity discourses and practices still reflect and reproduce historical and cultural visions of what it is to be a citizen (Georges, 2008). Good mothering and good governing are intimately linked. Foucauldian analysis in health has shown how institutions produce subjects as citizens, where health professionals are not simply individual agents constrained by institutions but develop their values, beliefs and skills within parameters guided (but not fully determined by) those institutions. Healthcare professionals such as nurses and midwives manage key processes through which hegemonic social subjects are reproduced, and thus reflect transformations in ideologies of the public and the citizenry (Fox & Worts, 1999). Maternal health is therefore a rich site to track shifts in public health from a sovereign technique of population management to a global industry in a neoliberal economic system.

Foucault’s analysis in The Birth of Biopolitics identified neoliberalism as the development of a “general regulation of society by the market” (Foucault, 2008: 145). It involves the enforcement of competition (rather than exchange) as the principle of the market in a game which one is not allowed to drop out of, “a sort of inverted social-contract” (Foucault, 2008: 201). Neoliberal economics becomes “no longer the analysis of the historical logic of processes; it is the analysis of the internal rationality, the strategic programming of individuals’ activity” (Foucault, 2008: 222). In this game, economics is redefined as a behavioural science governed by the “relationship between ends and scarce means which have mutually exclusive uses” (Foucault, 2008: 222). This “competitive ratio” is naturalised, and the neoliberal subject “accepts reality” by responding to “systematic modifications artificially introduced into the environment” — becoming “eminently governable” (Foucault, 2008: 270). Through the extension of market values to all institutions and social action, good neoliberal citizens are constructed as choice-making subjects, who take responsibility for maximising their healthy productivity and minimising risks to their health, reducing collective health demands upon the state.
Historically, women’s freedom during pregnancy was constrained by structural or physical factors to ensure the safety of mother and foetus. Improvements in health have led to the emergence of more subtle kinds of governmental regulation, where normalising strategies focussing on individual ‘lifestyle’ have developed in tandem with the new public health and risk discourses (Petersen & Lupton, 1996). Self-regulation through the internalisation of scientific knowledges and medical technologies and the corresponding modification of behaviour have become central to a type of ideal neoliberal subjectivity variously identified as the healthy citizen (Petersen & Lupton, 1996), the active consumer (Fox, Heffernan, & Nicolson, 2009) and the reflexive project of the self (Giddens, 1991).

Mothers are incited to take up the advice and guidance of experts; are incorporated into relations of surveillance and discipline; and are required to monitor and adapt their behaviour against normative discourses. Ideal neoliberal maternal subjects are scientifically literate, meet normative standards, and consume specialty objects and expert advice (Avishai, 2007). They invest in “intensive motherhood”, a pervasive ideology in Western culture that is: “child-centered, expert-guided, emotionally absorbing, labour intensive, financially expensive” Hays (1998: 46).
As Simon and Dippo (1986: 198) note, a historical and material perspective is required to understand the “nonarbitrary specificity” of power relations in the present, “for while the production and reproduction of social forms is a result of what people do, it can never be understood in terms of what they intend.” To that end, contemporary maternal speech must be linked to the historical conditions of its emergence. The history of midwifery development provides structural clues to the emergence of dominant discursive formations of maternity in New Zealand that enable, constrain and contest the narrated experience of migrant mothers.
Midwifery in New Zealand: erosion, erasure and re-emergence

Midwifery’s emergence as an autonomous feminist profession in New Zealand has been shaped by the desire for professional recognition among midwives and feminist aspirations for the control of birth to be returned to women, (Stojanovic, 2008). Midwifery training began in 1904 with the advent of the Midwives Act, prior to which trained midwives were imported from Britain. Free midwifery services became available to all women from 1938, either in their homes or in maternity hospitals (Pairman, 2006). The trends of medicalisation, hospitalisation and nursification eroded the autonomy of midwifery between 1904 and the 1970s (Stojanovic, 2008). For Māori, the Tohunga Suppression Act (General Assembly of New Zealand, 1907) curtailed the active involvement of tohunga (traditional knowledge specialists) in childbirth, and the expertise of Māori birth attendants or tāpuhi remained suppressed as midwives were trained in New Zealand. With fewer tāpuhi assisting birthing women in their homes, childbirth became relocated into state-owned maternity hospitals, which in the colonial view were thought to be safer and cleaner than Māori homes (Simmonds, 2011), even though Māori maternal mortality rose to three times that of non-Māori by the 1960s. Interventions to reduce infant mortality coupled with demands from women for pain-free childbirth increased the medicalisation of birth, leading to doctors supervising midwifery births and holding legal responsibility (Pairman, 2006). Nursification saw the merging of midwifery into nursing, the erasure of the word ‘midwife’ from legislation and the redefinition of the scope of midwifery practice within nursing (Stojanovic, 2008).
Autonomous midwifery practice (differentiated in scope from nursing) re-emerged through mutually beneficial political lobbying by consumers and midwives forcing legislative changes in the late 1980s. Spurred by decades of feminist struggle, maternity consumer activists saw autonomous midwifery practice as a mechanism for gaining increased control over their own birthing (Pairman, 2006). This pressure eventually led to the passing of the Nurses Amendment Act in 1990 which provided New Zealand women with the option of a caregiver (Lead Maternity Carer or LMC) who could either co-ordinate or provide the care they required from early pregnancy to six weeks postpartum (Pairman, 2006). Consequently, 75.3% of New Zealand women were registered with a midwife to provide lead maternity care in 2007 (Ministry of Health, 2007). Hence, partnership with women became a central tenet of New Zealand midwifery and to its claim as protector of the health of women from an intervening medical corpus (Reiger, 2008). The discourse of ‘partnership’ positions women as ‘naturally’ equipped and capable of carrying and delivering babies without physician monitoring or intervention in hospitals (Macdonald, 2006). The social model of this discourse locates risk not within the female body as under the medical model, but from power relations in the social world including poor support for women. In response, midwives have the capacity to nurture and empower the autonomous woman so that she is capable of birth without intervention (Lane, 2012). The study discussed here consisted of focus groups with mothers and maternal care professionals to evaluate the effects of these discourses and institutional arrangements on different groups of migrant women.
Study Design

The focus groups for this project were undertaken with the assistance of The Royal New Zealand Plunket Society (Plunket), and consisted of focus groups with five ethno-cultural groupings of new migrant mothers (including white mothers) about their maternity experiences (DeSouza, 2006; DeSouza, 2011). Ten first time mothers aged between 29-40 years, who had been living in New Zealand for between two and ten years took part in the white focus group. The women self-identified as ‘white’ and had migrated from South Africa (Jane and Charlotte), England (Nancy, Annette, Olive, Sarah, Carol), the US (Joan and Mary) and Scotland (Georgina). Four had post-graduate qualifications; four had under-graduate qualifications and one a trade certificate. Their occupations included: teacher, scientist, project manager, account manager, project manager, lecturer. Reasons for migrating included the New Zealand lifestyle and their husband’s careers. The group are not intended to be representative of all white female migrants, although the demographic bias of white migrants to New Zealand skews toward the upper-middle class. Of interest here are the range of available subject positions in the discourses represented and what implications those subject positions hold. Discourse analysis can aid understanding of the relationship between “subjectification (the condition of being a subject) and subjectivity (the lived experience of being a subject)” (Walkerdine, 2001: 20). In this case, the focus is on discourses of knowledgeable consumption, natural birth, and intensive motherhood.
Knowledgeable antenatal consumers

Mary invokes liberal feminist/woman centred tenets of choice, freedom and autonomy when she speaks about becoming pregnant through assisted reproductive technologies:

Mary: Artificial insemination… was something that was incredibly easy in New Zealand whereas in the States it would’ve been a lot more difficult and more expensive. For us moving to New Zealand was partly a life-style choice, we had a known donor and we found that we went to a fertility class and it was just incredible how helpful and inclusive they are and everything was really easy to do… more information is always good for us and we found that there was plenty of information for us. It’s like I said before we’ve been planning this for over five years so that was, their resources were there for us.

Mary’s excerpt reflects the liberal feminist ideal of a planned pregnancy and the control of reproductive processes (even in the context of assisted fertility), to which the democratisation of knowledge, its acquisition and demystification are fundamental. Mary positions herself as a responsible health consumer who makes choices (including migrating), within a caring and available system. She actively searches for and chooses the appropriate information, products and services from a saturated global market. Migration is a space where she can realise possibilities for mobility and self-actualisation, imbricating maternity in local and global patterns of consumption. Annette also positions herself as a knowledgeable and responsible consumer, who can both evaluate and challenge expert knowledges:

Annette: Although our doctor suggested certain paths that we could take I wasn’t necessarily in total agreement with what he wanted so I was trying to combine his knowledge with the information that I was reading as well.

Annette’s capacity to act and make choices is evident in her avoidance of informal and embodied knowledge in favour of formal knowledge:

Annette: When I found that I was pregnant the first thing I did was I bought a book named New Zealand Pregnancy Guide… although we have a lot of friends here I didn’t feel that I was in a position where I wanted to talk to anybody about the pregnancy because it was so early and I felt that the more people that I talked to and asked for their advice then if I did miscarry I’d have to tell everybody that I’d miscarried. So I was in that situation of having to try and discover a lot of information out by myself initially and I found that was a little bit overwhelming at times. But that book was particularly useful and then I phoned I think the Ministry of Health and got a list of midwives. And then to be quite honest it was absolutely useless, because I just looked at this list and I’m going, ‘well where do I start’? So you are in this catch 22 thinking ‘do I phone this person? Would they come to me because we’re on the other side of town?’ I didn’t have any recommendations. It was literally a list and it meant nothing to me.

Annette’s preference for purchasing a book of expert knowledge about pregnancy in New Zealand—rather than seeing her networks and friends as primary resources—is emblematic of her desire to produce herself as an autonomous, composed, and rational individual, avoiding public judgement upon her possible failure to reproduce. Her unwillingness to expose her pregnancy and potentially complicate social relationships means that she loses out on possible social support, information and referrals, which could enable the transition to parenthood.
Natural birth
The rewards of antenatal preparation are realised when women describe feeling informed and in control of their birth experiences, aligning with midwifery discourses of natural birth (Brubaker & Dillaway, 2009).

Mary: Well I thought we were going to have a very sort of natural birth with no drugs although I was hoping to take drugs if I was in pain. I found the antenatal explanation of how what happens in a C-section very useful as I ended up having a C-section. And the fact that they explained, ‘ok all of these people are going to be there and it’s going to be a person on your right is going to be your doctor and the person with the baby’, and all of that… I had a really negative reaction to all the drugs and when she explained again who was going to be in the room it was exactly the same as what the antenatal person had said.

Mary’s antenatal preparation equips her for an unintended Caesarean, but instead of feeling cheated by the requirement for medical intervention, she surfaces the woman-centred natural birth discourse of feeling in control and informed. Thus birth can be considered ‘natural’ despite medical intervention, as long as the labouring mother chose the intervention (Macdonald, 2006).
Charlotte’s narrative also captures the two competing discourses of birth that Mary situates herself in. On the one hand, Charlotte values having self-control (through being informed and behaving accordingly) and on the other is willing to surrender control—the choice to rescind action is also a choice (Lupton, 1994):

Charlotte: I just have to say to myself you know we’ve even had to go with the flow, and then also those booklets that you receive on feeding, those pamphlets. I did a lot of reading and my midwife gave me a lot of information. The information from those pamphlets helped me a lot and so I felt comfortable, like I’m on the right track now so everything is going well. So I was trying to speak to myself and keep calm (speaks quietly). I was in labour for since the Saturday and I gave birth on Monday morning so (laughter) I had to keep my options open as well about taking drugs so you know things like that.

Charlotte presents herself as a self-efficacious middle class maternal subject, able to internalise information and adapt her behaviour accordingly through self-discipline, self-denial and will power. Disciplining herself by subsuming her own distress and fear, aligns with the needs of the institution for calm consumers, who are more compliant and require less time and support than distraught ones.
Being given the right information at the right time made Charlotte feel supported:

Charlotte: The midwife that delivered my baby is actually from New Zealand but she worked in Cape Town for three years so that was good, that connection. She told me, step by step where and what stage I’m at. I think that’s the biggest support that you really need in the delivery room is to tell you at what stage you are at and what’s happening.

It is significant that Charlotte constructs her midwife as the person who delivers her baby rather than facilitates Charlotte’s ability to birth her baby. She discursively positions her midwife as a translator, who can link what is happening in her body to an identified physiological process. This positioning challenges midwifery discourses of the mother as ‘expert’ as the midwife’s role as a translator reinforces a hierarchy reminiscent of biomedicine.

Jane actively and discursively resists biomedical discourses, until she acquiesces to Entonox:

Jane: I was trying to still keep my energy up by eating and drinking as much water as possible. My choice was that I wanted to stay at home as long as possible, I didn’t want to be in the hospital for too long because when I start thinking of all the other options, and I wanted a natural childbirth, no assistant and also no pain relief. At the end for about 2 ½ hours before baby was delivered I chose Entonox with the gas and that helped. As the pamphlets also say I actually felt distance from the actual experience so if I think back I would’ve actually chosen nothing but I just felt at that stage I needed something and I chose that. So fortunately baby was in the right position, in a good position so I didn’t have to have a Caesarean. I was more scared of the Caesarean than the pain and I wanted a natural childbirth.

Jane positions herself within midwifery discourses of natural birth, disciplining her body so that she avoids hospital as much as she can, and engaging in deliberate bodily maintenance so she can maximise the efficiency of her body and have the energy to labour. She constructs a natural birth as one where she uses pain relief as a last resort.

Nancy disciplines her body through specific breathing techniques learned outside the health system:

Nancy: Yes. At the beginning of my pregnancy I was kind of really worried about actually giving birth. But what really helped me was I went to do yoga in pregnancy and through that they talked a lot about it and they did sort of breathing and just general exercises to help you kind of keep calm and focused. And at the end of it I really wasn’t worried about it at all and I thought I might even be able to get through this without drugs but I didn’t in the end, I gave in, in the last couple of hours.

Nancy positions herself as a good mother to be, taking control and acting to promote her own health and wellbeing through natural breathing. Nancy’s expectation that her body would be able to cope with birth naturally and without medical intervention reflects her incorporation in woman centred/natural birth discourses. Her acceptance of a biomedical intervention in the form of pain relief in the last few hours is presented as a capitulation, and reflects her perception of the control she had in the process and her failure to accomplish a natural process.
Intensive motherhood
The post-partum period is characterised by the demands of intensive mothering. Producing oneself in the discourses of the “good mother” requires taking sole responsibility for the well-being of the infant while being isolated and having minimal support. The post-natal ward represents a space where the rude transition from women-centred discourses to intensive mothering begins. There is a glaring shift from one-to-one attention from midwives, to competition for support and assistance with other new mothers:

Olive: I mean the actual labour and delivering – fantastic. I couldn’t fault them and the staff was superb, the midwife was just brilliant, the obstetrician fantastic. When I got on the ward I found it really hot, I felt really overwhelmed. I was right next to this buzzer and it just went buzzing all the time because everybody wanted help, I found that really quite distressing and I was absolutely knackered.

The clamour of the buzzer and interruptions signal a consequence of being returned to the factory model of maternity. Olive experiences a shift from care described in superlative terms to feeling overwhelmed, distressed and tired. Meanwhile, Nancy recognises that her expectations were primarily oriented to the birth event with no real preparation for the post-partum period:

Nancy: I just want to say in terms of thinking after the birth, and how it was compared to expectations, I didn’t really have any expectations of after the birth, everything was concentrated about the labour and, ‘oh God, it’s going to feel terrible’ and after the birth it just hit me like that and it was hell for six weeks more or less it was just hell… Yes and I wished somebody had actually told me that it was going to be that hard.

Nancy assumes that if she had been given the information, this post-partum period would have been easier for her, reflecting the notion of autonomous rational personhood that with planning and control of one’s circumstances, future success can be ensured (Wall, 2010).

Interviewer: What was the “hell”?

Nancy: Mainly lack of sleep, lack of sleep and just coping with a crying baby, and I had my Mum and I was lucky she was there for the first three weeks and she did the housework, the cooking and stuff. [Group laughter]
Jane: I also think you also just feel like a robot, cleaning the bottles, making a bottle, breast-feeding, in a little corner all the time, just you and the baby.

The mothers in the group identify a conspiracy of sorts. Much of their preparation for the world of parenthood revolved around knowledge acquisition, maintaining good health during their pregnancies and having control during their labour, none of which help in the postnatal period.
In the quotes that follow, the limitations of expert knowledge and self-sufficiency are identified and Nancy identifies the difference support might make for her.

Nancy: It would’ve been different in that I would’ve had a lot more support and for me a lot of my anxieties around that was I didn’t have anyone to talk to, and particularly (baby crying). And yes OK you meet people at your antenatal group but at that time they’re not your closest friends that you can say anything too. And having said that I did, you know… But I think that was it for me was thinking, ‘oh my God, I just need some adult conversation’. And that’s what I struggled with most probably.

Emotional support and having a confidant require time and energy, and an investment, which can be drawn on. The friendships Nancy has made cannot be drawn on for the kind of support she needs. For Georgina, the absence is emotional as well as practical—in the form of having ‘time out’ for errands or for ‘couple time’:

Georgina: Yes you do miss the support network, friends as well. I’ve got a lot of friends back home who have got kids and I think you miss that as well… Not just family but friends who would maybe be a bit more candour than you might take from them or what you feel than you take from close family and things. So I definitely miss that and also, we were just back home and it was just so nice…you know tight as you are, what simple things, like I needed to go out and do couple of things and I knew I was only going to be half an hour or so and to actually have somewhere to leave him and it would take me half the time.

Discussion and Conclusion

Women who identified as ‘white’ in this study constructed themselves within liberal feminist and neoliberal discourses as consumers who were rational unified actors. They were interpellated as competent selectors and consumers of maternity services, and moral value was attached to their ability to engage in self-reliant behaviours. They embraced the neoliberal psychological imperative to improve and transformed themselves, responding positively even in the most difficult of situations (Baker, 2009). These practices reflect women’s engagement in ‘techniques of the self’ that are constitutive of neoliberal subjectivity. The white mothers conform to the ideal of the good mother (to be) by discursively positioning themselves as taking appropriate individual care and responsibility for their pregnancies and maternal care.
The speech of the women reflects three specific discourses of liberal feminist maternity that form the basis of normative midwifery ideologies.
Firstly, the women routinely position themselves as knowledgeable consumers of authoritative maternity information provided by the health system. Critically interrogating the authority of biomedicine by coordinating and evaluating diverse sources of information is central to woman-centred discourses, where acquiring authoritative knowledge both bypasses medical control and is a way to claim empowerment, subjectivity and agency (Edwards, Davies, & Edwards, 2009). Her ‘preparation’ for motherhood through the acquisition of knowledge valorises scientific/professional knowledge rather than the informal and personalised information or social and emotional support that friends and extended family can provide (Marshall & Woollett, 2000). Authoritative professionals transmit information to individual women whose embodied, enculturated understandings and experiences are discounted or devalued. Yet individual women are expected to engage in reflexive techniques and /or practices of subjectification, to be accountable for the choices that are made, and to account for their behaviours to those who are tasked with monitoring and validated for monitoring them (Stapleton & Keenan, 2009). Thus regulatory technologies “construct an autonomous subject whose choices and desires are aligned with the objectives of the state and other social authorities and institutions” (Petersen & Lupton, 1996: 64).
Secondly, natural birth is positioned as a goal, suppressing technical and industrial discourses associated with medicalisation, except as far as they are in control of the mother. The women articulate being informed and having control, autonomy or authority despite experiencing various degrees of obstetric intervention. As middle-class women are more likely to receive the birth and/or medical treatments they desire, pregnancy and childbirth can be framed as contributing to their personal growth (Brubaker, 2007). In this paradigm of actualisation, it is assumed that intentional actions, self-discipline, self-denial and will power will achieve the ‘right’ kind of birth, and that intervention from a public health system is not a default practice but a considered choice of the mother based on information. In other words, a ‘natural birth’ does not happen naturally, but is chosen as an expression of the knowledgeable consumption discussed above.

Finally, the excerpts on intensive motherhood highlight how this responsibility for maternal self-expression and knowledge is a critical instrument of women’s control in the post-partum period. The mother’s needs are marginalised, as mothers take on most of the responsibility for nurturing and developing the sacred child. Pregnant women and their partners are subject to discipline, given that they are held responsible for maximising their own health and that of their foetus‘ and then infant’s body (Collins, 2009). Intensive mothering is intertwined with a neoliberal rationality, where individual responsibility and self-management are fore-grounded and social support is reduced compared with earlier in the perinatal period (Wall, 2001). Neoliberal discourses place individual responsibility for parenting on mothers, shifting the costs and the burden of work from public resources to household resources. The gendered aspects of these discourses are visible in the assumptions of reproductive heteronormativity, where market production separates the private and public spheres with women taking responsibility for childrearing. These discourses assume that households are based on a nuclear family; that caring labour is divided on the basis of gender, and that this labour is elastic and must expand to fit demand. In turn, the domain of the private is subject to surveillance and regulation to account for responsibilisation, or the ways in which public tasks become the responsibility of individuals, the private sector and community (Schinkel & Van Houdt, 2010; Clarke, 2004). In the postpartum, women note that they are treated like a “normal person”, a labouring, productive figure rather than the choice-making perinatal consumer. The responsibilities for infant care and repetitive ‘robotic’ household tasks seem overwhelming, and there is a sense of failure and disillusionment with the system and with providers that cannot be displaced through their well-developed information gathering strategies.
The interplay of the three discourses has significant implications for maternal mental health, as they locate the “specialness” of birth in decisions which are seen to be under the mother’s individual control, when in fact broader class positions are strongly determinant of what services and support are available. The incentives to locate maternal knowledge in an individual relationship with an authoritative caregiver produce dependence on a system that shifts risk and responsiblity onto the individual. These assumptions come to structure the professional habitus of nursing and midwifery professionals, who adopt regulatory behaviours that fail to support women who do not subscribe to white middle-class ideals. Governing occurs through the aspirations of mothers, and while the state appears to be protecting the interests of infants and parents, little in the way of actual resources are provided. These neoliberal discourses of individual responsibility constructed through dependence on knowledge also disempower women who do subscribe to these ideals, as the institutional withdrawal of support in postnatal care cannot be addressed by the skills the knowledgeable consumer has developed.
Conclusion
In recent decades the capacity of liberal feminist frameworks to provide effective support to non-Western women has been questioned, and midwifery has not been exempt. In New Zealand, the discursive emphasis of being ‘with woman’ implied in the etymology of the word midwife is central to indigenous critiques of Pākeha (white/European) midwifery (Kenney, 2011). Kenney notes that the Pākeha liberal feminist agenda privileges the individual while neglecting the familial context of pregnancy and birth. In contrast, the Māori word for midwife ‘kaiwhakawhānau’ emphasises the facilitation, creation and development of whānau (family). This discursive contrast between Māori models of midwifery has heightened significance in the context of the under-representation of Māori midwives (6.4%) when Māori births comprise approximately 28% of total births and in the context of and inequalities in birth outcomes between Māori and non-Māori (New Zealand Health Information Service 2010 cited in Kenney 2011; Ratima& Crengle, 2012). Midwifery as a profession has attempted to redress these injustices by incorporating Māori cultural principles and values (Ngā Turanga Kaupapa) in midwifery practice competencies (Kenney, 2011), and the development of cultural safety has become a central, if contested tenet of nursing education in New Zealand (Ramsden 1997; DeSouza 2008).
A consistent aim of cultural safety training in nursing has been to deconstruct the implicit racism of the healthcare system, by asking practitioners to reflect on one’s practice, values and cultural assumptions (Browne et al., 2009). In other words, it asks all of us involved in the health system to understand our own position as culture-bearers. Yet, the assumptions of white culture are hard to identify as the norms and commitments of whiteness are naturalised by their ubiquity and dominance. This culture not only shapes practitioner values but also shapes the dominant voices of those consumers who receive and evaluate care, while marginalising women outside these cultural assumptions. Operationalising critical feminist and postcolonial critiques through cultural safety can help nurses understand how the discourses they use are shaped by wider social discourses, which can then be critically interrogated (Browne, 2005). This analysis has aimed to contribute to this project by identifying three norms of white maternity that are normalised in alignment with neoliberal principles: the knowledgeable consumer, natural birth and intensive motherhood. These norms contrast to the discourses that have been identified in the literature on migrant maternity, which generally reflect less of an individualised focus on choosing the experience of birth and more on the presence or exclusion of wider family and social supports. Given the shock and isolation many women experience in the transition from impending mother to intensive mothering, critically advocating for those diverse structures of support can potentially benefit all mothers.
References
Allen DG (2006) Whiteness and difference in nursing. Nursing Philosophy 7(2): 65–78.
Avishai O (2007) Managing the lactating body: The breast-feeding project and privileged motherhood. Qualitative Sociology 30(2): 135-152.
Baker J (2009) Young mothers in late modernity: Sacrifice, respectability and the transformative neo-liberal subject. Journal of Youth Studies 12(3): 275–288.
Browne AJ (2005) Discourses influencing nurses’ perceptions of First Nations patients. Canadian Journal of Nursing Research 37(4): 62–87.
Browne AJ, Varcoe C, Smye V, Reimer-Kirkham S, Lynam M, and Wong S (2009) Cultural safety and the challenges of translating critically oriented knowledge in practice. Nursing Philosophy 10(3): 167–179.
Brubaker SJ and Dillaway HE (2009) Medicalization, natural childbirth and birthing experiences. Sociology Compass 3(1): 31–48.
Clarke J (2004) Dissolving the public realm?: The logics and limits of neo-liberalism. Journal of Social Policy 33(1): 27–48.
Collins EA (2009) Governing partners: responsibilization in pregnancy advice literature for men. Unpublished doctoral thesis. Victoria: University of Victoria.
DeSouza R (2006) New spaces and possibilities: The adjustment to parenthood for new migrant mothers. Wellington: Families Commission.
DeSouza R (2008) Wellness for all: the possibilities of cultural safety and cultural competence in New Zealand. Journal of Research in Nursing 13(2): 125–135.
DeSouza R (2013) Regulating migrant maternity: Nursing and midwifery’s emancipatory aims and assimilatory practices. Nursing Inquiry 20(4): 293-304.
Edwards M, Davies M and Edwards A (2009) What are the external influences on information exchange and shared decision-making in healthcare consultations: A meta-synthesis of the literature. Patient Education and Counseling 75(1): 37–52.
Foucault M (2008) The Birth of Biopolitics: Lectures at the Collège de France 1978-1979. Basingstoke: Palgrave Macmillan.
Fox B and Worts D (1999) Revisiting the critique of medicalized childbirth: A contribution to the sociology of birth. Gender and Society 13: 326-346.
Fox R, Heffernan K and Nicolson P (2009) “I don’t think it was such an issue back then”: Changing experiences of pregnancy across two generations of women in South-East England. Gender, Place & Culture 16(5): 553–568.
Frankenberg R (1993) White women, race matters: The social construction of whiteness. Minneapolis: University of Minnesota Press.
Freda MC (2001) If given the choice. MCN: The American Journal of Maternal/Child Nursing 26(3): 117.
General Assembly of New Zealand (1907) An Act to suppress Tohunga. Statute No: 13. Wellington: Government Print.
Georges E (2008) Bodies of knowledge: The medicalization of reproduction in Greece. Nashville: Vanderbilt University Press.
Giddens A (1991) Modernity and self-identity: Self and society in the late modern age. Stanford: Stanford University Press.
Harvey D (2005) A brief history of neoliberalism. Oxford: Oxford University Press.
Hays S (1998) The cultural contradictions of motherhood. New Haven: Yale University Press.
Hunn JK (1961) Report on the Department of Maori Affairs, with Statistical Supplement, 24 August 1960. Appendices to the Journal of the House of Representatives, G.10. Government Printer, Wellington.
Kenney C (2011) Midwives, women and their families: a Maori gaze. Towards partnerships for maternity care in Aotearoa New Zealand. AlterNative: An International Journal of Indigenous Peoples 7(2).
Lane DK (2012) Dreaming the impossible dream: ordering risks in Australian maternity care policies. Health Sociology Review 21(1): 23–35.
Larner W (2006) Brokering citizenship claims: Neo-liberalism, biculturalism and multiculturalism in Aotearoa. In: E Tastsoglou and AZ Dobrowolsky (eds) Women, migration, and citizenship: Making local, national, and transnational connections. Hampshire: Ashgate, pp. 131–148.
Lewis M (1988) The ‘health of the race’ and infant health in New South Wales: Perspectives on medicine and empire. In: RM MacLeod and MJ Lewis (eds) Disease, medicine, and empire: perspectives on Western medicine and the experience of European expansion. London: Routledge, pp. 301–315.
Lupton D (1994) Medicine as culture: Illness, disease and the body in western societies. London: Sage.
Macdonald M (2006) Gender expectations: Natural bodies and natural births in the new midwifery in Canada. Medical Anthropology Quarterly 20(2): 235–256.
Marshall H and Woollett A (2000) Fit to reproduce? The regulative role of pregnancy texts. Feminism and Psychology 10(3): 351–367.
Ministry of Health (2007) Notice Pursuant to Section 88 of the New Zealand Public Health and Disability Act 2000. Wellington: Ministry of Health.
Mookherjee M (2005) Affective citizenship: Feminism, postcolonialism and the politics of recognition. Critical Review of International Social and Political Philosophy 8(1): 31–50.
Nairn RGR (2003) Madness, media & mental illness: A social constructionist approach. Unpublished doctoral thesis. Auckland: University of Auckland.
O’Connell R and Downe S (2009) A metasynthesis of midwives’ experience of hospital practice in publicly funded settings: compliance, resistance and authenticity. Health (London) 13(6): 589—609.
Pairman S (2006) Midwifery partnership: Working with women. In: L Page and R McCandlish (eds) The new midwifery: Science and sensitivity in practice (2nd ed.). Philadelphia: Elsevier/Churchill Livingstone, pp. 73–97.
Petersen AR and Lupton, D (1996) The new public health: Health and self in the age of risk. St Leonards, NSW: Allen & Unwin.
Powers P (2001) The methodology of discourse analysis. Mississauga, Ontario: Jones & Bartlett Publishers.
Ratima M and Crengle S (2012) Antenatal, labour, and delivery care for Maori: Experiences, location within a lifecourse approach, and knowledge gaps. Pimatisiwin: A Journal of Aboriginal & Indigenous Community Health 10(3): 353–366.
Reiger K (2008) Domination or mutual recognition? Professional subjectivity in Midwifery and Obstetrics. Social Theory & Health 6(2): 132–147.
Schinkel W and Van Houdt F (2010) The double helix of cultural assimilationism and neoliberalism: Citizenship in contemporary governmentality. The British Journal of Sociology 61(4): 696–715.
Simmonds N (2011) Mana wahine: Decolonising politics. Womens Studies Journal 25(2): 11–25.
Simon RI and Dippo D (1986) On Critical Ethnography Work. Anthropology & Education Quarterly 17: 195–202.
Skinner J (1999) Midwifery partnership: individualism contractualism or feminist praxis? New Zealand College of Midwives Journal 21: 14–17.
Spoel P (2007) A feminist rhetorical perspective on informed choice in midwifery. Rhetor: Journal of the Canadian Society for the Study of Rhetoric 2: 1–25.
Stapleton H and Keenan J (2009) Bodies in the making: Reflections on women’s consumption practices in pregnancy. In: F Dykes and VH Moran (eds) Infant and young child feeding: Challenges to implementing a global strategy. Ames, Iowa: Blackwell, pp. 119–127.
Stojanovic J (2008) Midwifery in New Zealand 1904-1971. Contemporary Nurse 30(2): 156–167.
Wall G (2001) Moral constructions of motherhood in breastfeeding discourses. Gender and society 15(4): 592–610.

Acknowledgements

Many thanks to Debbie Payne, David Allen, Ray Nairn and Tim McCreanor for their helpful conversations and feedback.

“Kiwi food is okay for Kiwis, but it isn’t okay for us”: Special food in the perinatal period for migrant mothers

I attended the 5th International Conference on Nutrition and Nurture in Infancy and Childhood: Relational, Bio-cultural and Spatial Perspectives from Wednesday, 5 November 2014 – Friday, 7 November 2014.

Those who know me or follow my work will know that I am deeply interested in eating and thinking about food. I’m interested in how food structures our days and our lives,it nourishes and sustains us, reminds us of people, events, history, all in a mouthful.

Birthday cake — A special birthday cake, made for a surfer on his special birthday.

I’ve written elsewhere about how migrants perform identity through food preparation and consumption. I’ve also written about consumptive multiculturalism. I’m also interested in the provision of food in (monocultural) institutional contexts such as health where people are racialised by the foods that they eat and how the processes of hospitalisation strip people of their cultural and social identities and often lead people into being unable to access culturally appropriate food. This presentation brings those ideas together.

Abstract

Food, its preparation and ingestion, constitutes a source of physical, emotional, spiritual and cultural nourishment. Food structures both daily life and major life transitions, including the transition to parenthood, where food is prepared and consumed that recognises the unique status of the mother. However, the reductive focus of hospitals where efficiency, economy and a focus on nutrients dominate and where birth is viewed as a normal event can mean that there is a mismatch between the cultural and religious dietary needs of migrant mothers with the food that is available from Western instititutional environments. In this paper I outline a research study, which examined the transition to parenthood among new migrant groups in New Zealand. Based on a number of focus groups with mothers and fathers, the data were analysed using a postcolonial feminist lens and drew upon Foucauldian concepts to examine the transition to parenthood. The findings show that Asian new migrant parents construct the postnatal body as vulnerable, requiring specific kinds of foods to facilitate recovery from the trials of pregnancy and delivery and optimize long term recovery from pregnancy. This discourse of risk contrasts with the dominant discourse of birth as normal, and signals the limitations of a universal diet for all postnatal mothers, where consuming the wrong food can pose a threat to good maternal health. Paying attention to what nutrition and nurturing might mean for different cultural groups during the perinatal period can contribute to long term maternal well-being and cultural safety. Health practitioners need to understand the meanings and significance attached to specific foods and eating practices in the perinatal period. I propose that institutional arrangements become responsive to dietary needs and practices by providing facilities and resources to facilitate food preparation.

I’m hoping that the written form of the paper becomes part of an edited book about mothers and food. Fingers crossed, it’s under review at the moment.

Happy Mothers’ Day

I’ve written a lot about maternity, an interest derived from my clinical nursing practice and an interest in the intellectual and political ways in which women’s bodies have been mobilised in nationalist state interests. My interest in ‘maternity’ (the initial life-changing journey of being pregnant, giving birth and nurturing and the corporeal processes of the transition to motherhood) is supplemented with an interest in ‘mothering’ (the work of meeting the needs of and being responsible for dependent children) and ‘motherhood’ (the context where mothering occurs). All of which are shaped by the historical, the cultural, the political, the social and the moral.

Mother’s day is one of mixed emotions for many. It brings sadness for those who have lost their mothers, mothers who were never there and for mothers who were present yet absent, who didn’t fulfil the sentimental fantasy. It’s also a day when particular idealised mothers are invoked while others are made invisible as Ali Smith points out in her collection of 40 portraits of mothers in the act of mothering, Momma Love:

I am sick to death of the blandness of the “family mystique.” We all know that every family has cracks in it, and that some of those are profound. Silence, secrecy, disillusionment, lies, in my experience, are the most poisonous ingredients in any family and can exist in traditionally picture perfect households too.

I can’t stomach the lack of diversity in pop culture. I can’t stomach one more TV show that has a single character “of color” on it being considered ethnically diverse. I can’t stomach another public discourse about whether or not members of the LGBT community are complete human beings who deserve the same human rights as straight white men. I can’t stomach these things and so, I chose not to participate in them. I went the other way. I portrayed the world I see, which includes challenges and love in a variety of situations.

The ironies of celebrating this day are also pointed out in Ann Lamott‘s powerful essay about how mothers are simultaneously exalted and vilified. Her critique of mother’s day extends to the ways in which women who mother are viewed as superior and more evolved for having ‘chosen’ a more challenging path. More importantly she points out how the focus on individual mothers means that the sociality of mothering is forgotten:

But my main gripe about Mother’s Day is that it feels incomplete and imprecise. The main thing that ever helped mothers was other people mothering them; a chain of mothering that keeps the whole shebang afloat. I am the woman I grew to be partly in spite of my mother, and partly because of the extraordinary love of her best friends, and my own best friends’ mothers, and from surrogates, many of whom were not women at all but gay men. I have loved them my entire life, even after their passing.

So with these two beautiful pieces in mind, I thought I would acknowledge the gaps and silences in the pop culture version of mothering and acknowledge those who mother on the margins, without acknowledgement, without the support of the State or who mother while vilified by the State.

I dedicate this day to those who have birthed and brought into being projects and works that were a labour of love into the world in forms other than flesh. I acknowledge those who grieve for their mothers, for those whose mothering is painful, for those who can’t be mothers but contribute to their communities and families. I acknowledge fathers, extended family, grandparents and “other” mothers that mother. I pay tribute to those mothers who mother against the odds, who mother while in detention, under occupation, in war, in poverty, in prison, in marginalised spaces and places. I salute the mothers whose mothering knowledges have been marginalised by colonisation, by assimilation, by racism, by the medicalisation of the body. I bless the animal mothers we share this earth with, I give thanks to our Earth mother who nourishes and sustains us all. Let us all acknowledge those who create and bring to life, those who nurture and sustain life and those who plant seeds, care for and protect.

Dedication: This blog is dedicated to both my grandmothers who died in May 1965 and who I never met, but whose presences have been with me. For Joyce and Kadogo Ayagwe, always in my heart.

Acknowledgements: Thanks to Rosemarie North for reminding me of the plural, to Alison Barrett for reminding me of Anne Lamott’s great piece and to Danny Butt for sharing the Momma Love link.

Korean migrant mothers on giving birth in Aotearoa New Zealand

Cite as: DeSouza, Ruth. (2014). One woman’s empowerment is another’s oppression: Korean migrant mothers on giving birth in Aotearoa New Zealand. Journal of Transcultural Nursing. doi: 10.1177/1043659614523472. Download pdf (262KB) DeSouza J Transcult Nurs-2014.

Published online before print on February 28, 2014.

Abstract

Purpose: To critically analyze the power relations underpinning New Zealand maternity, through analysis of discourses used by Korean migrant mothers. Design: Data from a focus group with Korean new mothers was subjected to a secondary analysis using a discourse analysis drawing on postcolonial feminist and Foucauldian theoretical ideas. Results: Korean mothers in the study framed the maternal body as an at-risk body, which meant that they struggled to fit into the local discursive landscape of maternity as empowering. They described feeling silenced, unrecognized, and uncared for. Discussion and Conclusions: The Korean mothers’ culturally different beliefs and practices were not incorporated into their care. They were interpellated into understanding themselves as problematic and othered, evidenced in their take up of marginalized discourses. Implications for practice: Providing culturally safe services in maternity requires considering their affects on culturally different women and expanding the discourses that are available.

Keywords: focus group interview, cultural safety, Korean women, maternal, postcolonial, Foucault.

Introduction

A feature of contemporary maternity is the notion that birth can be empowering for women if they take charge of the experience by being informed consumers. However, maternity is not necessarily empowering for all mothers. In this article, I suggest that the discourses of the Pākehā maternity system discipline and normalize culturally different women by rendering their mothering practices as deviant and patho- logical. Using the example of Korean migrant mothers, I begin the article by contextualizing maternity care in New Zealand and outlining Korean migration to New Zealand. The research project is then detailed, followed by the findings, which show the ways in which Korean mothers are interpellated as others in maternity services in New Zealand. I conclude the article with a brief discussion on the implications for nursing and midwifery with a particular focus on cultural safety.

You can read the rest at: Journal of Transcultural Nursing or download DeSouza TCN proof.

I wish we cared about every new baby, the way we care about the Royal baby.

As a child I was enchanted by the idea of princesses and fairy godmothers and obsessed with the story of Sleeping Beauty. I even directed classmates in a play version of it in the playground of my Nairobi primary school. In case you aren’t familiar with the story, three good fairies arrive to bless the infant princess. Using their magic wands, one gives her the gift of beauty and the second the gift of song, but before the third can give her blessing, an evil fairy appears and curses the princess because she wasn’t invited to the christening ceremony. The curse is that the princess will die when she touches a spinning wheel’s spindle before sunset on her sixteenth birthday. Luckily the third fairy who was interrupted from her wish making uses her blessing to weaken the curse so that instead of death, the princess will fall into a deep sleep until she is awakened by a kiss.

Since the Royal baby was born, there has been a lot of fanfare with landmarks in London and all over the world lit up to celebrate the birth of the Royal baby. Many in both red and blue leading up to the birth and then blue upon confirmation of the baby’s gender. Former colonies have also got in on the act with almost 40 buildings in New Zealand partaking in the lighting frenzy. This baby has certainly had the Royal treatment in the media:

Led to creative gestures like this one from the crew of the HMS Lancaster based in the Caribbean:

I’ve loved the idea of being able to bestow wishes, fancying myself as a fairy godmother even if I haven’t had a magic wand. Working on a postnatal ward in the 90s, I would wish every infant and their family a wonderful new life. The birth of the Royal baby has rekindled my desire for godmothership, so this is what I wish for every infant, mother, and family:

I wish the arrival of every infant in the world was greeted with the same sense of anticipation and enthusiasm as the Royal arrival.
I wish every mother, infant and family could receive the same “care” as the Royals will.
I wish “we” cared as much about maternal and infant mortality around the world.
I wish “we” cared as much about “other” mothers who aren’t supported in their mothering and against whom active measures are taken to regulate and surveil their bodies merely because of the accident of their own circumstances.
I wish we could remember the resources that have been extracted globally to maintain the Royal Family in the lifestyle they are accustomed to and that these could be redistributed.

However, all babies are not created equal and neither are all mothers. Regulating the reproduction of those considered to be a burden on society has been a way to secure and control the well-being of the population, leading to the surveillance and management of women’s bodies. The quality and quantity of the populations been an enduring concern of governments, a concern which has seen two kinds of policies, the ones that encourage some mothers to procreate (pronatalist) and others that discourage or even coerce other mothers from reproducing (antinatalist).

Our recent colonial history is emblematic of these concerns, reflecting a shift from Malthusian anxiety about over-population and the inability of the environment to support growth to a concern with the quality of the population. In white settler nations pronatalist movements often had nationalist overtones, equating international prominence with demographic strength, requiring both productive and reproductive capacity. For example in the United States, Republican motherhood was a site of civic virtue, demonstrated through bearing arms if you were a man and producing and rearing sons if you were a woman. These sons would embody republican virtues, even if as a woman you were excluded from citizenship.

1789 Charles Willson Peale 1741-1827 Mary Gibson (Mrs. Richard Tilghman) & sons. Maryland Historical Society. — 18th-Century American Mothers & Their Children By Charles Willson Peale

Fears of ‘race suicide’ arose in early 20th Century Australia, New Zealand and the United States and made motherhood a political duty for white women in the interests of the nation and the health of the race. Reproducing white citizens in the colonies was a patriotic duty for women superseding involvement in public affairs. The concern about ‘race suicide’ was attributed to middle class women neglecting their duties by not having children while ‘other’ women (migrant, indigenous or working class) had too many in white settler societies. Anglo-Saxon middle class’ individualised mothering contrasted with shared child rearing that was more common in other societies. This resulted in women from those communities, for example immigrant and indigenous women, being labelled as bad mothers. Evolutionary theory played a role in demarcating good and bad mothering: Anglo-Saxon and Northern European women were positioned on the top of the hierarchy of the ‘races’ and were the only women capable of being good mothers irrespective of what other mothers did. Such women bore the responsibility for ensuring the well-being of their families, the future of the nation and the progress of the race. Anglo-Saxon mothers were thus both exalted and pressured.

Market Court, Kensington High Street, London

It has always been easier to focus on the management of mothers rather than politically challenging public health issues. Schemes to address maternal malpractice such as health visitors (whose job it was to keep surveillance and intervene to educate women) were initiated to ensure that the British working class mother was subjected to the imperatives of the infant welfare movement and became a ‘responsible’ mother. A proliferation of organisations to promote public health and domestic hygiene among the working class thrived, assisted by upper or middle class women. This class-based maternalism in Europe and North America reflected a race-based maternalism in the colonies, where Europeans challenged and transformed indigenous mothering in the name of “civilisation, modernity and scientific medicine” (Jolly, 1998, p.1). Similarly, in colonised countries the ‘cleaning up’ of birth was achieved through both surveillance and improved hygiene and sanitation. Sadly, interventions have involved the removal of children, most notably in the Stolen Generation in Australia, where Aboriginal – and some Torres Strait Islander – children were forcibly removed from their families by Australian Federal, State and Territory government agencies, and church missions, from the late 1800s to the 1970s and children sent either to institutions or adopted by non-Indigenous families.

A grassroots campaign calling for a national apology led to the first national Sorry Day on 26 May 1998 marked by ceremonies, rallies and meetings. Sadly, Australian Greens leader Bob Brown’s move to amend the sorry motion by offering “just compensation to all those who suffered loss” – was voted out by all the non-Green Australian Senators.

Australia Day 2008. The ‘Sorry’ writing was commissioned by a private person. Photo: Michael Davies, Flickr

Forced sterilisations without consent occurred as recently as between 2006 and 2010 where prison doctors sterilized 150 California women. The targets of Golden State prisons were people with a mental illness or who were poor. The practice was eventually banned in 1979, but even by 1933, California had subjected more people to forceful sterilization than all other U.S. states combined. This eugenic programme spread to Nazi Germany where extreme anti-natal racial hygiene doctrines were implemented against ‘unfit mothers’. Anti-natalist ideologies have often occurred concurrently with pronatalist ones. Women with mental or physical impairments or ethnically ‘other’ women such as Jews, Gypsies and Slavs were forcibly sterilised and abortions conducted, while Hitler simultaneously supported initiatives for the growth of a strong German Nazi Volk through a virtuous German motherhood. Breastfeeding in Nazi Germany was obligatory and women were awarded the Mutterkreuz medal (Honour of the German Mother (Ehrenkreuz der deutschen Mutter) for rearing four or more children.

So how will the other children born in the UK on 22 July 2013 fare? Emily Harle in The new Prince and his 2,000 birthday buddies paints a bleak picture. To summarise, 226 children of the 2,000 will live in overcrowded, temporary or run down housing, 11 will be homeless. 540 children will live in poverty. 8 children will die before their first birthdays and poor housing and low quality healthcare will be contributing factors.13 children will be taken into care during their childhood and have around five different sets of carers and nine of them will leave school with no qualifications. 120 will have a disability and 40 will have difficulty accessing services, support and activities that their able-bodied friends can. 25 of the 2,000 will be young carers who look after ill or disabled family members. Eleven of the children born on the same day will suffer from severe depression during their childhood, and 500 will experience mental illness during their lives, half of whom will have reported that the problem began before they were 18.

Seumas Milne contends that the monarchy embodies inequality and fosters a “phonily apolitical conservatism”. The hypocrisy at the heart of the celebration of the monarchy is seen in the British government’s preaching of democracy globally, whilst supporting an undemocratic system at home through an unelected head of state and an appointed second chamber giving the monarchy significant unaccountable powers and influence aside from the more visible deferential culture and invented traditions.

The festivities to mark the Royal baby’s arrival are likely to continue for some time but let’s not forget the ‘other’ mothers, infants and families for whom there are no celebrations and for whom there will never be. Let us not forget that not all lives are equal, there are those whose lives are valued and those who aren’t. Most of all, let’s do something about it.

Niagara lit blue — Niagara Falls turns blue to celebrate the arrival of the royal baby.

Regulating migrant maternity: Nursing and midwifery’s emancipatory aims and assimilatory practices

I’ve just had the first paper from my PhD published: DeSouza, R. (2013), Regulating migrant maternity: Nursing and midwifery’s emancipatory aims and assimilatory practices. Nursing Inquiry. doi: 10.1111/nin.12020

In contemporary Western societies, birthing is framed as transformative for mothers; however, it is also a site for the regulation of women and the exercise of power relations by health professionals. Nursing scholarship often frames migrant mothers as a problem, yet nurses are imbricated within systems of scrutiny and regulation that are unevenly imposed on ‘other’ mothers. Discourses deployed by New Zealand Plunket nurses (who provide a universal ‘well child’ health service) to frame their understandings of migrant mothers were analysed using discourse analysis and concepts of power drawn from the work of French philosopher Michel Foucault, read through a postcolonial feminist perspective. This research shows how Plunket nurses draw on liberal feminist discourses, which have emancipatory aims but reflect assimilatory practices, paradoxically disempowering women who do not subscribe to ideals of individual autonomy. Consequently, the migrant mother, her family and new baby are brought into a neoliberal project of maternal improvement through surveillance. This project – enacted differentially but consistently among nurses – attempts to alter maternal and familial relationships by ‘improving’ mothering. Feminist critiques of patriarchy in maternity must be supplemented by a critique of the implicitly western subject of maternity to make empowerment a possibility for all mothers.

Refugee women in New Zealand: Findings and recommendations

Today on International Women’s Day, it seems apt to share this article that I wrote on behalf of our research team for the Women’s Health Action Update, volume 16, Number 43, December 2012. Women’s Health Action is a charitable trust, that works to “provide women with high quality information and education services to enable them to maintain their health and make informed choices about their health care”. Their focus is on health promotion and disease prevention and they are particularly supportive of breastfeeding and screening. Their vision is ‘Well women empowered in a healthy world’.

More than 80 per cent of the world’s refugees are women and their dependent children. Often women of refugee backgrounds [1]are constructed within deficit frames as having high needs. This representation is problematic as it deflects attention from considering broader historical, social, systemic and political factors and the adequacy of resettlement support.

Little is known about the experiences of women who enter New Zealand through the Women at Risk category identified by The Office of the United Nations High Commissioner for Refugees (UNHCR). This category constitutes up to 75 places (10%) of New Zealand’s annual refugee quota of 750. Refugee Services worked with AUT University and the three Strengthening Refugee Voices Groups in Auckland, Wellington and Christchurch to undertake a project to examine the resettlement experiences of women who enter New Zealand through this category or become sole heads of households as a consequence of their resettlement experiences. This project was funded by the Lotteries Community Sector Research Fund.

The project was important not only for its findings but also for the research process, which focused on strengths, social justice, community development and transformative research. This transformative agenda aimed to enhance the wellbeing of refugee background women by focussing on the roots of inequality in the structures and processes of society rather than in personal or community pathology (Ledwith, 2011). Within this frame we were committed to constructing refugee women as an asset rather than deploying a deficit model of refugee women as a burden for the receiving society (Butler, 2005).

Focus groups were held in 2009 and 2010 with women who entered New Zealand as refugees under the formal category ‘Women at Risk’ or became women who were sole heads of households once they arrived in New Zealand. Women that took part had lived in New Zealand from between five months to sixteen years. Lengthy consultations were held with the three Strengthening Refugee Voices groups in Auckland, Wellington and Christchurch prior to undertaking data collection, in order to scope and refine the research focus and process. These groups were subsequently contracted to provide services and support.

Key findings

Although support needs are similar to all refugees arriving in New Zealand, there were unique and exacerbated gender issues. Refugee background women experienced a double burden of stress with half the support, especially as they parented on their own. This is despite the tremendous unpaid and voluntary support provided by faith and ethnic community members. Women frequently postponed their own aspirations in order to assure the future of their children. When they were ready to take up further education (including English language classes) or employment, limited assistance was then available (given the focus on early resettlement) leading to women feel disadvantaged.

We have made several recommendations based around several specific themes. More broadly we recommended that:

More intensive and longer term instititutional support be made available from agencies such as Refugee Services.
Subsidised practical help be made available.
Assistance to broaden sources of support and networks is goven.
Subsidised English language lessons and childcare are available.
That a one stop shop/holistic support from culturally and linguistically skilled refugee community insiders be provided.

Parenting

Raising children in New Zealand brought new stresses. These included concern about the loss of culture, values and language and losing their children to less palatable values including the consumption of alcohol and drugs, gender mixing and loss of respect for elders. Women addressed these issues in a range of ways that included trying different less hierarchical styles of parenting, attempting to spend more time with their children, engaging them in broader supports eg mosque. However, a few women had the experience of losing their children through the intervention of CYFS and felt disempowered in their interactions with CYFS and with schools.

Programme for parenting for Refugee women, particularly around issues such as discipline, inter-generational gender issues
Programmes for young people.
Cultural competence training for CYFS.

Family reunification

Living in New Zealand is difficult for women who are conscious of their own comfort while other family members struggle. However, the cost of bringing family members over is prohibitive and the costs involved in providing support in the form of phone calls and remittances add a burden to already stretched lives of the women. The importance of extended family is highlighted for women on their own and the kinds of help that could be provided by family members. Additional stresses are the requirement that refugee women are able to support their families once they arrive in New Zealand. The process is also made difficult by the lack of transparency in the immigration process.

Prioritise the reunification with family for women who are here on their own.
Provide financial support to women.
Increase transparency of the processes and decisions that are made.

Health system

Women encountered a different health system that at times was difficult to navigate. Many women felt that their health concerns were not taken seriously and that the health system created new problems. In terms of some health beliefs and stigma there was value in having more culturally appropriate services available. The surfeit of refugee background health professionals was a potential resource that was not being used.

Train and employ a more ethnically, religiously, and linguistically diverse health workforce at all levels
Develop culturally responsive services.
Examine the affordability of services.
Develop cultural competence of staff working in health services.

Education

The cost and availability of day care for Refugee women on their own is prohibitive in some cases consuming the lion’s share of their income/benefit. Taking up loans in order to finance their own educations is also a problem. This prevents women from achieving their own goals such as learning English, driving or further education, which would assist them in the long term with employment and independence. Women generally considered their own advancement as secondary to their children. If women were resourced financially to gain an education this would assist them to also be a resource for their children. Having long-term support to enter the workforce would also be of benefit.

Subsidised day care for women on their own.
Mentoring.
Scholarships for further education.

Employment

Women were concerned that their children were not getting employed despite tertiary qualifications. Barriers to employment included: ‘lack’ of New Zealand experience, language barriers, their perceived difference (clothing, culture, skin colour) and paucity of appropriate childcare, poor public transport. The impacts of unemployment included losing their dignity, health impacts of taking inappropriate jobs, boredom

Subsidised driving lessons, support with transport
More work with employers to destigmatise refugee workers
Work mentoring/brokering services
Support for family members who come into New Zealand through the reunification category to obtain further education

Racism

Refugee women and their families experienced a range of racism related harms that were instititutional and interpersonal taking physical and verbal forms. Their clothes and accent marked them out, and verbal altercations saw stereotypes being invoked particularly around Islamophobia and discourses of war on terror. Women deployed a range of strategies to cope with racism including minimising the racism and helping their children to cope with it.

Social marketing campaigns
Community education
Addressing structural racism
National conversation on racism
National campaign against racism

The research team hope that this research provides a snapshot of the role and value of various sectors in enabling or constraining the resettlement of refugee background women. This could contribute to better informing theory, practice and policy in order that the self-determination and resilience of refugee background women and their communities is supported.

[1] Note that terms like ‘refugee background women’ and ‘communities’ refer to highly diverse groups of people (Butler, 2005). In capturing the experiences of refugee women as sole heads of households, we were mindful of the potential that using a category could imply a “single, essential, transhistorical refugee condition” (Malkki, 1995, p.511).

How can we better support new mothers to sing?

I am a member of the Perinatal Mental Health New Zealand Trust (PMHNZ) whose vision is to : “improve outcomes for families and whanau affected by mental illness related to pregnancy, childbirth and early parenthood”. They produce a quarterly newsletter that includes information about research, training, workshops and courses, innovative projects and services, topics for discussion and stories. It was a privilege to share my research with other members in the February newsletter (pdf) and on this Women’s day it seems apt to share it with a broader audience.

One of my favourite stories that I would tell when we ran workshops in the nineties about postnatal depression was by Jack Kornfield. I would share this story and half the room would be in tears.

“There is a tribe in East Africa in which the art of true intimacy is fostered even before birth. In this tribe, the birth date of a child is not counted from the day of its physical birth nor even the day of conception as in other village cultures. For this tribe the birth date comes the first time the child is a thought in its mother’s mind. Aware of her intention to conceive a child with a particular father, the mother then goes off to sit alone under a tree. There she sits and listens until she can hear the song of the child that she hopes to conceive. Once she has heard it, she returns to her village and teaches it to the father so that they can sing it together as they make love, inviting the child to join them. After the child is conceived, she sings it to the baby in her womb. Then she teaches it to the old women and midwives of the village, so that throughout the labor and at the miraculous moment of birth itself, the child is greeted with its song. After the birth all the villagers learn the song of their new member and sing it to the child when it falls or hurts itself. It is sung in times of triumph, or in rituals and initiations. This song becomes a part of the marriage ceremony when the child is grown, and at the end of life, his or her loved ones will gather around the deathbed and sing this song for the last time.” A Path with Heart (1993, p. 334).

For me the message in this story reflects the importance of love, being loved by a community and the importance of acknowledgement. Painfully, however, it highlights the ways in which women’s experiences of maternity can be just the opposite. That is, they can feel isolated, disrespected and invisible. As a clinician, I’ve learned that there are ways in which we, and the system that we work in can make this most magnificent, sacred and profound time in a woman and her family’s life also one that is painful, one that leaves long lasting scars. Health professionals can cause harm even especially when we think we are doing good. As an academic for 13 years prior to which I worked as a clinician for 10 years, I am deeply interested in the issue of power and how professional frameworks of care can undermine women’s personal experiences.

This song has been the background soundtrack to my recently completed PhD. I used data from a study funded by the Families Commission and assisted by Plunket, where I talked to 40 migrant women about their experiences of becoming mothers in New Zealand. I also talked to Plunket nurses about their experiences of caring for women from ethnic migrant backgrounds.

My motivation for doing research was prompted by my clinical experiences. Several years ago I decided to make a move from working in mental health to working in maternity. As someone who had worked as a community mental health nurse I took a lot of concepts about my work in mental health into this new setting, for example, I believed that care should be client centred and driven, that services should fit around consumers of services and that taking time to be with people was important. What I found in the institutionalised setting of hospital maternity care and later community care was that some of the routine procedures that are administered in hospitals and in the community with good intentions had negative impacts and were oppressive especially for women who did not tidily fit into the mould for the factory style model that was in place then. The conveyor belt metaphor is apt given that women who were the wrong fit were viewed as a problem, as only a single way of becoming a mother was acceptable. I saw that staff were frustrated at the extra demands or complexity of working with ‘diverse’ women, they lacked resources like time and knowledge. In turn, I could see that women who valued particular kinds of social support, acknowledgement and rituals were not getting their needs met. It seemed like a situation where no one was a winner.

What I found out in my research was that there was a big gap in satisfaction among women who were familiar with the structure of maternity services in the west and women whose lives had been shaped by growing up in other cultural contexts. Fundamentally there was a schism in the ways in which birth was understood. To be simplistic, western modes of being a mother valued independence, autonomy, taking up expert knowledge and using it and being an active consumer. By that I mean the individualising of responsibility for maternity on the mother, to take up scientific knowledge through reading self help books and for the role of the partner to be a birth coach and the goal of birth to be “natural”.

This dominant Pakeha middle class model of being a mother clashed with other understandings of motherhood, where responsibility was more collectivised, so that embodied knowledge from cultural authority figures (mother and mothers in law) protected mothers and where a range of rituals and supports were available for the mother (including some which were also not necessarily helpful). Women who became mothers in New Zealand had to negotiate these two different models of maternity and come to terms with what they negotiated. However, in the context of an assimilatory maternal health system it was very difficult for women to maintain traditions that were important to them. For example many women were not supported if they wanted to bring in traditional foods with them or have support from grandmothers. Many of these encounters left migrant mothers feeling disempowered. Another important clash was the different philosophies and roles of professionals and mother in the context of midwifery models and medical models. Some women viewed birth as a risky process and wanted the reassurance of visualising technologies. The view of birth as a risky process clashed with midwifery models of birth as a natural process that women are physically prepared for but need encouragement and support with.

Conclusion How can we support all kinds of women with different values, beliefs and rituals around birth, to feel loved, nurtured, safe and supported? How can we give women who might be separated from their loved ones, support to access those values, beliefs and that will allow them to manage the transition into motherhood? Returning to the metaphor of singing, and the power of connection it engenders, how can we connect and support people who are singing different kinds of songs? Can we adjust our tone so that we can harmonise? Can new songs and rhythms infuse the songs we already know with new energy and possibility?

Having a baby in New Zealand without your support base http://www.mentalhealth.org.nz/kaixinxingdong/page/486- resources+dragon-babies+parents-stories

Migrant support for Idle No More

When my parents were considering migrating from East Africa, their focus was on the white settler contexts of Australia, New Zealand, Canada and the United States. For a bunch of reasons I won’t go into here, they settled on Aotearoa New Zealand. A part of me always felt like my life would have been better if we’d moved to Canada or the United States, because there would have been a bigger Goan community and more support for my family. I reasoned I might have felt more culturally confident, more capable at speaking Konkani. My visit to Canada in October helped me accept the gift that my parents had given me in migrating to Aotearoa New Zealand. By not being wrapped in the comforting cocoon of an insular diasporic community, I had to figure out my own relationship with my personal and cultural history but also what Ghassan Hage terms, an ethical relationship with colonisation and living on colonised land. Visiting Canada and meeting terrific indigenous people and migrant scholars allowed me to see the contrast between Canada’s genocidal history and its self-representation as a benign, civilised and benevolent nation. The parallels between Aotearoa and Canada of a colonial history supplemented by exploited migrant labour to meet settler ends mirrored the clearly unfair outcomes in measures of health, well-being and prosperity for indigenous peoples that I see in Aotearoa New Zealand as a health professional. For the first time I began to see how the issues I’d been grappling with as a migrant were replicated across seemingly disparate white settler contexts.

Image courtesy: Aaron Paquette

The Idle No More movement which began on Great Turtle Island on December 10, 2012 was initiated by four women Nina Wilson, Sylvia McAdam, Jessica Gordon & Sheelah McLean in response to legislation (Bill C-45) affecting First Nations people and gained momentum with the hunger strike by Attawapiskat First Nation Chief Theresa Spence. Impressively the United Church of Canada has acknowledged it’s complicity in colonization, inequality and abuse, through being one of the bodies that ran Indian Residential Schools. In 1986 they apologized to Aboriginal peoples for confusing “Western ways and culture with the depth and breadth and length and height of the gospel of Christ.” Apologizing to former residential schools students in 1998. Their response to the Idle No More movement has been to fully support Chief Spence’s statement that “Canada is violating the right of Aboriginal peoples to be self-determining and continues to ignore (their) constitutionally protected Aboriginal and treaty rights in their lands, waters, and resources.”

Other activists have also taken note of the commonalities of the struggle, noting how how what is particular, has universal relevance. Naomi Klein notes that

During this season of light and magic, something truly magical is spreading. There are round dances by the dollar stores. There are drums drowning out muzak in shopping malls. There are eagle feathers upstaging the fake Santas. The people whose land our founders stole and whose culture they tried to stamp out are rising up, hungry for justice. Canada’s roots are showing. And these roots will make us all stand stronger.

International support has come from the occupied lands of Palestine and indigenous communities around the globe. In Aotearoa New Zealand a Facebook page has been developed called Aotearoa in Support of Idle No More: Maori women’s group Te Wharepora Hou, a collective of wāhine based in Tāmaki Makaurau Auckland with a commitment to ensure a stronger voice for wāhine have also pledged support. As a migrant occupying a disquieting position in a country working through issues of biculturalism and mutliculturalism in a monocultural context. Diasporic migrant communities and organisations have also backed the Idle No More movement, with South Asian activists and BAYAN-Canada, an alliance of progressive Filipino organizations noting the similarities between migrant experiences and indigenous struggles.

Immigrants in Support of Indigenous Rights via Harsha WaliaPhoto credit: Cameron Bode — Immigrants in Support of Indigenous Rights via Harsha Walia
Photo credit: Cameron Bode

How do we do engage with an indigenous struggle when we do and don’t belong at the same time? Himani Bannerji notes in a Canadian context (but one that readily resonates through various white settler contexts):

So if we problematize the notion of ‘Canada’ through the introjection of the idea of belonging, we are left with the paradox of belonging and non-belonging simultaneously. As a population, we non-whites and women (in particular, non-white women) are living in a specific territory. We are part of its economy, subject to its laws, and members of its civil society. Yet we are not part of its self-definition as ‘Canada’ because we are not ‘Canadians.’ We are pasted over with labels that give us identities that are extraneous to us. And these labels originate in the ideology of the nation, in the Canadian state apparatus, in the media, in the education system, and in the commonsense world of common parlance. We ourselves use them. They are familiar, naturalized names: minorities, immigrants, newcomers, refugees, aliens, illegals, people of color, multicultural communities, and so on. We are sexed into immigrant women, women of color, visible minority women, black/South Asian/Chinese women, ESL (English as a second language) speakers, and many more. The names keep proliferating, as though there were a seething reality, unmanageable and uncontainable in any one name. Concomitant with this mania for naming of ‘others’ is one for the naming of that which is ‘Canadian.’ This ‘Canadian’ core community is defined through the same process that others us. We, with our named and ascribed otherness, face an undifferentiated notion of the ‘Canadian’ as the unwavering beacon of our assimilation.

The experiences of marginalisation that Bannerji elucidates can guide our responses to the Idle No More movement. Gurpreet Singh from Vancouver, notes that South Asian seniors have always referred to the indigenous peoples as Taae Ke (family of elderly uncle). If we see a familiar connection between what we ourselves experience as migrants and extend that empathy to the struggles of indigenous people who have experienced an inter-generational slow genocide, we might be able to see beyond our own oppression and our view that we are too far outside the structures of power to claim a space. Privileged in some ways, disadvantaged in others, our futures are tightly imbricated in this indigenous struggle. Our presence has sometimes diffused indigenous claims and we must consider our complicity in the continuing colonisation of indigenous people. We must put pressure on governments to recognise the rights of indigenous people and their unique place as guardians of the lands we stand upon, our futures depend on it.