GOVERNING RISK, EXERCISING CAUTION: WESTERN MEDICAL KNOWLEDGE, PHYSICAL ACTIVITY AND PREGNANCY by SHANNON JETTE B.Sc, Simon Fraser University, 1998 M.A., The University of British Columbia, 2004 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Human Kinetics) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) July 2009 © Shannon Jette, 2009 Abstract In contemporary Western society, the messages regarding exercise during pregnancy are conflicting and confusing. Long-standing cautions about the dangers of over-exertion intermingle with entreaties to engage in moderate physical activity in order to have a healthier baby with a reduced risk of developing various chronic diseases. These medical messages then co-mingle with advice from family and friends as well as with images of the fit, pregnant 'yummy mummy' circulating in popular culture. The purpose of this dissertation is to trace history, untangle meanings and demonstrate shifting 'truth' claims about the active pregnant body, also considering how the various messages in circulation might be experienced as simultaneously empowering and oppressive by their intended audience, the pregnant woman. With these goals in mind, I draw upon the Foucauldian tools of archaeological and genealogical analysis to examine how knowledge regarding exercise during pregnancy has been produced over the past century, and how the messages put forth by the medical profession (and circulating within consumer culture) have functioned to regulate the activities of pregnant women. I also enlist the analytical tool of 'governmentality' (Foucault, 2003; O'Malley, 2008) to examine the place of exercise during pregnancy within the larger governmental apparatus of Western society over the past century. This approach provides a key insight as to why the ideas and messages about physical activity and pregnancy are so confusing: since the late nineteenth century, exercise during pregnancy has been framed as both a problem and a solution to the larger biopolitical aims of governance, aims which themselves have changed from a concern with the collective strength of the nation-state to a (neo-liberal) concern with the cost of unhealthy bodies. By situating maternal exercise within the larger governmental complex and closely examining the 'rules of formation' that allow particular statements (at certain times) to be accepted as 'truth' or 'knowledge' as well as showing how these 'truths' turn into a form of practicing power, my project illustrates the contingency of ideas regarding maternal exercise and troubles taken-for-granted ways of thinking about the active, pregnant body. n Table of Contents Abstract ii Table of Contents hi List of Tables v Acknowledgements vi Dedication vii Chapter One: Introduction 1 Chapter Two: Literature Review 12 Theoretical Literature 13 Substantive Literature 62 Chapter Three: Methodology 76 Methodological Framework 76 Fields or Sites of Communication 82 Analysis of Data 101 Chapter Four: Building a Healthy Nation-State 109 The Female Body and Exercise Advice in the Late Nineteenth Century 110 Governing the Pregnant Body: The Rise of the Prenatal Movement 126 Physical Activity During Pregnancy: Problem and Solution 141 Conclusion 152 Chapter Five: Resistance and Counter Discourses? 156 Training for Childbirth: Childbirth as an Athletic Feat 158 Athletics and Pregnancy: Sporting Moms 171 Conclusion 189 Chapter Six: The Rationalization of'Pregnancy and Exercise' Science 192 Contextualizing the Active, Pregnant Body: Change and Uncertainty 193 The Emerging Field of Exercise and Pregnancy Science 200 Professional Power Struggles and Epistemological Debates 211 Creating 'Better' Knowledge Through 'Better' Research 221 Creating the Canadian Guidelines 229 'Important Gaps Remain' 237 Into the Twenty-first Century: A Shift in Risk Discourse 239 Conclusion 243 Chapter Seven: Fit For Two? 248 Fit For Two: 'Sweat For Your Baby's Sake' 253 in The Danger of Exercising: Responsible Exercise is Moderate Exercise 267 The Yummy Mummy: Risk of'Baby Fat' 277 Conclusion: The Vortex of...Risk 287 Chapter Eight: 'Doctor Talk' 290 Physician Knowledge About Exercise During Pregnancy 293 Exercise Advice: Setting the Limits 298 Physicians' Perceptions of the Importance of Exercise During Pregnancy..312 Conclusion 325 Chapter Nine: Conclusion 329 Future Directions 337 Bibliography 341 Appendices 379 A: Index Medicus Search Terms 379 B: Explanation of Data Collection - Scientific Articles (1950-Present) 380 Bl: Results from PubMed Search (1950-1979) 382 B2: Results from PubMed Search (1980-1990) 385 C: Results from Readers' Abstract Retrospective Search (1890-1982) 388 D: Results from Readers' Guide Abstract Search (1983 - Present) 390 E: Shape Fit Pregnancy Online Search 396 F: Government Texts Reviewed 397 G: Popular Exercise and Pregnancy Texts Reviewed (1970s and 1980s) ....398 H: Letter of Introduction (Request for Interview) 399 I: Interview Guides 400 II: Physicians 400 12: Fitness Instructor 402 J: UBC Behavioural Research Ethics Board: Certificate of Approval 404 K: Information Sheet and Consent Form 405 L: Seven Aims of Archaeological Research 407 M: Explanation of Data Analysis: Organizing and Coding Data 408 iv List of Tables Table 1 Biographical Data - Physicians 98 Table 2 Shape Fit Pregnancy Online Search 396 v Acknowledgements I offer my gratitude to my co-supervisors, Brian Wilson and Patricia Vertinsky, for their encouragement and support over the past several years. Particular thanks is owed to Patricia for inspiring me to undertake this project and guiding me along the way, and to Brian for always lending an ear and providing sound advice. I also owe thanks to Laura Hurd Clarke who has also been a wonderful mentor during this process. Special thanks are owed to my parents for their unwavering love and support, as well as to my brothers and sisters. vi Dedication To my mom Vll CHAPTER ONE Introduction About a year ago I received a phone call from one of my friends who was approximately three months pregnant with her first child. She was aware of the topic of my dissertation research - exercise and pregnancy - and wanted my advice about weightlifting: was it alright to perform overhead presses and how much could/should she lift? It seems that she was getting a variety of advice from different sources and she was confused and anxious. Her mother told her not to exercise, a few of her friends expressed surprise that she was planning to exercise throughout her pregnancy and when they were at the gym together her husband chastised her for lifting weights that he deemed too heavy. Meanwhile, her physician told her to listen to her body and do what felt right for her. Adding to her confusion was the mountain of popular health and fitness literature encouraging her to exercise (in moderation) to have a healthy baby. My friend also bemoaned the fact that after only the first few months of pregnancy she could not fit into her work clothes and explained that she wanted to exercise so that she could continue to feel good about (or at least not hate) her growing body. Why did exercise, something that is potentially pleasurable and empowering, give rise to such feelings of confusion and anxiety? The aim of this dissertation is to explore, expose and begin to untangle some of the meanings which have been attached to exercise during pregnancy in Western society by examining their construction over the past century and, by extension, the subject positions offered to women. The project is based on the premise that medicine and culture are inextricably linked. Medicine - as a central social institution in Western societies since the nineteenth 1 century - plays a key role in shaping how we understand ourselves, our bodies, the world we live in and the way we act in it. Alternatively, culture shapes medical (and scientific) views and opinions, influencing the questions that are asked, the research that is carried out in the medical context and to a certain extent, the answers that are 'discovered.' That is to say, medicine is not an objective and neutral endeavor but is informed by social issues and concerns. Feminist scholars, for instance, have illustrated the ways in which, from the late nineteenth century onwards, members of the medical profession expressed anxiety about the potential ill effects of vigorous exercise (and particular sporting pursuits) on female reproductive organs, suggesting that women restrict their physical fitness practices to ensure that they may fulfill their 'natural' roles as mothers (Verbrugge, 2002; Vertinsky, 1988; 1994). In this view, it is important to analyze medical discourse about health and physical fitness practices (and how this knowledge is taken up within society) because such knowledge is inextricably linked to networks of power, shaping women's reproductive experiences and overall state of health (both physical and mental). While the discursive field of exercise and pregnancy throughout the past century is the primary focus of this project, the starting point for my examination is the late nineteenth century. This was a crucial moment in the development of Western medicine, a time when the Enlightenment ethos of reason as the primary source of authority had firmly taken root. As 'rational' or 'scientific' thought became the dominant way to view the world (including the notion of the 'body as machine'), the male medical profession gained credibility and legitimacy over alternative approaches to health and the body, allowing them to claim expertise in solving many of society's problems (Arney, 1982; 2 Mitchinson, 1991; Vertinsky, 1994). As Vertinsky (1994) cogently articulates in her investigation of doctors' exercise advice to women in the late nineteenth century: What physicians, from their perspective as experts and rightful knowers, had to say about women, health and physical activity had an important impact upon the lives and outlook of middle-class women and provided a legacy which has had a lasting effect throughout the twentieth century, (pp. 7-8) To be sure, late nineteenth century medical statements were "precursors to and analogues o f (Arney, 1982, p. 21) many of the ideas about exercise during pregnancy that circulate today (for example, the notion of 'training for childbirth,' being 'fit for two' and vigorous exercise as dangerous). At the same time, however, the landscape of prenatal exercise has changed over the twentieth century, shaped by shifting social norms and emerging cultural issues. The prenatal movement, the natural childbirth (or 'training for childbirth') movement, the women's movement of the late 1960s, the health and fitness boom of the 1970s and contemporary fears of an 'obesity epidemic' are just some of the social factors that have shaped ways of viewing the issue of physical activity during pregnancy and the advice provided - or withheld. In her cultural history of pregnancy, Hanson (2004) similarly suggests that social history is imprinted on the pregnant body, explaining that the pregnant body is doubly mutable: "It is mutable in the obvious sense that it undergoes continuous physiological (and sometimes pathological) change, and mutable culturally, in that it is viewed through constantly shifting interpretive frameworks" (p. 3). Despite changes in the way that we have come to understand the pregnant body, one constant has remained throughout the time period of my investigation: societal anxiety about the reproductive body and the need to delimit proper physical activity (along with numerous other lifestyle behaviours) to ensure the health of the mother and fetus. And by the latter half of the twentieth century, the focus of advice around exercise 3 had, in many ways, shifted to the fetus. On one level, then, this project is about exercise and pregnancy, but at the root it is about the anxieties and concerns regarding the reproductive female body - especially the pregnant body - that pervade Western society. Indeed, "as the mechanism by which society reproduces itself, pregnancy is by no means a private matter, but is peculiarly susceptible to social intervention and control" (Hanson, 2004, p. 6). From the late nineteenth century onwards (and in varying degrees), reproduction has been viewed as crucial to the health and strength of the nation-state - although in contemporary culture the focus has shifted from the collective strength of the 'nation-state' to a concern with the economic cost of unhealthy bodies (Rose, 2001). It was in 1901 that British physician J. W. Ballantyne published an influential paper in the British Medical Journal that introduced a new way of thinking about prenatal care - 'antenatal therapeutics.' That is, the idea that the fetus could be treated through the mother. This way of thinking gained such influence over the course of the twentieth century that many feminist scholars argue that in contemporary Western society, the fetus is now the patient and the pregnant woman merely the carrying case, an obstacle to physicians' efforts to treat the 'real' patient (Lee & Jackson, 2002; Wetterberg, 2004). They suggest that we live in an era of 'intensive motherhood' where the pregnant woman is under ever-increasing pressure to regulate her behaviours and avoid numerous pregnancy risks so that she will not only have a healthy baby, but a better, smarter one (Lee, 2008; Lupton, 1999; Ruhl, 1999). She is required to be 'fit for two.' Despite this growing body of literature that draws critical awareness to the shifting web of power relations that entwine the pregnant body (and the prominence of medicine and science in this web), there is a striking lack of attention to the interplay of 4 medical knowledge, exercise and pregnancy. While feminist researchers in the sociology of sport have examined how, from the late nineteenth century and into the twenty-first, medical knowledge about the female body has been used to justify the restriction of women's physical fitness opportunities (Verbrugge, 2002, Vertinsky, 1988; 1994; 1998), there has been little focus on the production and application of medical knowledge about prenatal exercise. Similarly, while there is a vast amount of feminist research on the manner in which, throughout the twentieth century, the pregnancy experience has been increasingly medicalized (Arnup, 1994; Lee & Jackson, 2002; Wetterberg, 2004) and commodified (Marshall & Woollett, 2000; Taylor, 2000; Taylor, 2004), there has been virtually no investigation of physical fitness practices in these processes. In particular, there is a lack of research focusing on exercise prescriptions in the Canadian context. A close examination of the production of medical knowledge about exercise and the pregnant body is crucial for, given the symbiotic relationship of medicine and culture, such knowledge potentially shapes the ways that pregnant women understand their changing bodies, the activities they engage in during pregnancy, as well as the enjoyment that they derive from them, thus impacting their physical and emotional well-being. The aim of this project is to begin to untangle the knot of statements about physical activity and pregnancy, and in doing so, also pick apart some of the 'truth' claims about the active pregnant body, illustrating how what is considered 'common sense' at a certain point in time could have been otherwise. By demonstrating the contingency of knowledge and the power relations at play in its creation, I hope to bring to light alternative ways of knowing about physical activity during pregnancy, and increase women's enjoyment of exercise during pregnancy. 5 It is with these goals in mind that the following research questions are pursued: What have been the discursive constructions of exercise and pregnancy and by extension, fit motherhood over the past century and into the present? How have these constructions or ideas been arrived at? (i.e., what are the rules of formation?) How does the larger cultural context factor into medical advice about physical activity during pregnancy? (i.e., how do medicine and culture intersect?) How are the discourses surrounding exercise during pregnancy put to use in the operation of power? How does exercise fit into the governmental apparatus created to manage the risk of the pregnant body and the unborn child? In an attempt to answer these questions, I combine the methodological tools of archaeological and genealogical analysis. I explain the theoretical underpinnings of these concepts in the following two chapters, but briefly, an archaeological analysis aids the researcher in 'excavating' the 'rules of formation' that allow some statements (at certain times in certain cultures) to be accepted as 'truth' or 'knowledge' and others to be marginalized. A genealogical analysis facilitates an exploration of how these 'truths' or this knowledge turns into a form of practicing power that disciplines individual bodies and regulates the social body. Because archaeology and genealogy are more 'methodology' than 'method,' I also use the following research techniques to further examine the truth claims and power relations regarding exercise and the pregnant body: 1) textual analysis of academic medical literature, government publications (specific to Canada), and popular texts that focus on prenatal exercise advice for women (and were published from the beginning of the twentieth century to present); and (2) interviews with 6 individuals who transmit or translate this knowledge to pregnant women (i.e., medical doctors and a leading fitness trainer). The structure of the dissertation is as follows. It begins with a review of the literature in which I discuss theoretical work regarding power, the body and risk, with a particular focus on the ideas of Michel Foucault and his concept of governmentality. This is followed by a review of the substantive literature on exercise during pregnancy and a discussion of the project's substantive, theoretical and methodological contributions. In the next chapter I further describe the methodological approach used to answer the research questions, namely archaeology and genealogy, and then outline the 'nuts and bolts' of the project: the texts and statements that I examined (and why) and how I went about analyzing the data. With this theoretical and methodological background, I then share my research findings which are presented in five chapters. In the first results chapter I examine the production of medical knowledge about exercise during pregnancy from the early twentieth century until the years following the Second World War (the late 1940s/early 1950s). My aim is to 'excavate' the 'rules of formation' that helped to produce and regulate what was to be accepted as knowledge about the female (reproductive) body, and ultimately, shaped the exercise prescriptions given to pregnant women. This entails examining the wider social conditions that influenced the ways of thinking about and understanding the pregnant body, delimiting what was 'sayable' about its physical capabilities. A central focus of the chapter is how/if the prenatal movement that emerged in the first decades of the twentieth century - and began to shift the meanings and social practices surrounding the pregnant body and prenatal care - influenced medical ideas regarding appropriate physical activity and 7 exercise practices for women. Thus, a central focus of this chapter is on the development of professional power in the government of the pregnant body. In the following chapter I examine two groups of 'alternative' views pertaining to pregnancy and exercise which emerged in the first several decades of the twentieth century: 'training for childbirth' and 'sporting moms.' I focus on the relation of these discourses to the mainstream (or 'traditional') medical statements discussed in the previous chapter, and in particular I consider the extent to which they acted as 'points of resistance' to traditional ways of thinking about the pregnant body and its physical capabilities. I therefore use this chapter as a case study to examine and build upon Foucault's ideas regarding power and resistance. In the 1970s there was a significant change within the discursive field of physical activity and pregnancy: the view of the pregnant body as incongruous with anything more than gentle exercise was increasingly questioned within both the medical and lay community and, in conjunction with the rise of second wave feminism and the fitness boom, the meanings attached to and practices of the pregnant body began to shift. In the third results chapter I examine how this initial shift in the discursive field of exercise during pregnancy was met within the medical and scientific community and, more specifically, the debates that arose - particularly in the 1980s - as medical experts strove to determine the limits of safe exercise for expectant women. I assert that the disagreements about 'how much and how far' were rooted in epistemological differences regarding proper 'ways of knowing' about physical activity and pregnancy. Issues around professional power reemerge in this chapter as I explore the process by which 'pregnancy 8 and exercise' became a specialized or rationalized area of study throughout the closing decades of the century and into the next. In the fourth results chapter, I shift the focus from the field of science and medicine to the field of popular culture. I examine the various discourses concerning exercise during pregnancy that are in circulation in contemporary consumer culture and more to the point, how they are put to use in the regulation of the pregnant body. I discuss the types of knowledge or 'ways of knowing' that dominate the popular literature and identify three main concepts or themes, illustrating how they come together to form a group of statements that may be placed under the rubric of 'risk.' The focus of the chapter is on how this 'discourse of risk' fits within the promotional logic of contemporary society, more generally. While popular literature is an important source of health knowledge in our mass mediated society, physicians continue to play a central role in prenatal care. Therefore, in the final results chapter I examine 'doctor talk' about exercise during pregnancy - that is, the way doctors talk about and construct the issue in their daily practices and their encounters with patients. I explore physicians' knowledge about physical activity during pregnancy, their attitudes towards maternal exercise as well as how they present this information to pregnant women in the course of prenatal care. This chapter builds upon our understanding of the messages that women receive about pregnancy and exercise in contemporary neo-liberal society, allowing for a consideration of how these messages compare to/interact with those circulating in the popular literature. As such, this chapter provides insight into the role that physicians play in the regulation of the active pregnant 9 body and how 'doctor talk' about maternal exercise fits into the context of neo-liberal society, more generally. This project is designed to makes a significant contribution to our understandings of medical knowledge, fitness practices and the pregnant body. To date, the discourse of physical activity and pregnancy has been a fractured one, examined by professionals in varying fields or disciplines such as exercise science, obstetrics and sports medicine, and disseminated to women by health care practitioners. What has been lacking, however, is a detailed discussion of the topic which brings together ideas and knowledge from these various realms and examines them through a critical lens of social science, troubling taken-for-granted ways of thinking about the active, pregnant body. In addition to this broad contribution to our understanding of the production of medical knowledge about prenatal exercise (and the power relations involved in this process), the proposed research will contribute to the sociology of health and illness and the sociology of consumer culture by examining the interactions between the realm of medicine and the health and fitness industry. Although some scholars have explored the appropriation of medical discourse by marketers in consumer culture to 'sell' fitness and health to women (MacNeill, 1999; Madden & Chamberlain, 2004; Markula, 2001), there has been a lack of focus on how medical knowledge is used to encourage pregnant women to exercise in order to be 'fit for two.' My exploration of the links between consumer culture and medical discourse is designed to address this limitation. This research study also has practical implications. A critical analysis of the symbolic meanings attached to exercise and pregnancy in the realms of science, medical practice and consumer culture promises to aid in the creation of more effective messages 10 and communication techniques. Considering the central role that medicine plays in most women's pregnancy experience in Western society, the production of more positive and effective prenatal health messages may improve women's subjective experience of pregnancy and the ways they view their bodies. Similarly, examining representations of prenatal fitness circulating in the commercial media may allow for the identification of discursive practices that objectify and/or disempower women, and provide the basis for challenging media producers - with the ultimate aim of constructing alternative (more positive) subject positions for women. Finally, the interdisciplinary nature of this project means that it will be of interest to a number of different groups - exercise scientists, obstetricians, general practitioners, feminist scholars and sociologists of the body, to name a few. My hope is to open up a dialogue between these various groups, offering a differing perspective to individuals in disciplines that might not consider the issue through an historical/social constructionist lens and also sharing medical and scientific perspectives with scholars of the body and feminist theory, more generally. 11 CHAPTER TWO Literature Review This review of literature begins with a general discussion of key theoretical approaches to medicine, power and the body, with particular attention to the approach that I privilege as my theoretical framework: social constructionism. With this background, I then outline the work of Michel Foucault and more specifically, his ideas regarding discourse, truth and knowledge, and his concept of power and its relation to the body. Incorporated into this review is a discussion of how these ideas have been taken up by feminist scholars. Following this, I provide an overview of Foucault's notion of 'governmentality' and how it may be used as an analytical tool to deconstruct the working of power - more specifically by analyzing the inter-dependencies between political rationalities (e.g., welfarism, neo-liberalism) and technologies of government (i.e., the techniques, tools and means through which 'problems' identified under a political rationality are 'solved'). I provide a brief overview of welfarism and neo- liberalism, the two dominant political rationalities to emerge during the timeframe of my project, and then move into a discussion of theories of 'risk' and 'bodywork,' both of which have been identified as technologies of neo-liberal government. With this theoretical background, I then provide an overview of substantive work in the area of pregnancy and exercise, identifying gaps in the literature as well as the contributions that my project will make on a theoretical and methodological level. 12 Theoretical Literature Theoretical Perspectives of Medicine and Society In her book Medicine as Culture, Lupton (2003) identifies three dominant theoretical perspectives in the history of medical sociology1: functionalism,2 the political economic approach and a social constructionist approach (p. 6). She notes that while variants of all three approaches are in evidence in medical sociology scholarship - and, indeed, that the divisions she draws between the perspectives have blurred in recent years - the social constructionist approach has gained ascendancy over the past two decades in line with the poststructuralist turn more generally. While I incorporate some of the concerns of the political economy perspective into my research, it is the social constructionist approach that I privilege. Thus, I will first offer a brief overview of the political economy perspective (along with a few critiques and limitations) before discussing the central tenets of the social constructionist approach. The political economy perspective of medicine is rooted in the view that the economy is the basis of society and follows a Marxist critique of the social inequalities produced by the capitalist economic system. From this perspective, notes Lupton (2003): the institution of medicine exists to attempt to ensure that the population remains healthy enough to contribute to the economic system as workers and consumers, but is unwilling to devote resources for those who do not respond to treatment and are unable to return to the labour market. Medicine thus serves to perpetuate social Medical sociology is also termed the 'sociology of health and illness.' The former is the commonly used term in the United States while the latter is the preferred term in Britain and Australia (Lupton, 2003, p. 6). 2 The maintenance of social order is the basis of functionalist theorizing on the nature of illness and the medical encounter, with medicine perceived to be an important mechanism to control the potentially disruptive nature of illness. Talcott Parson's explanation of the demands and functions of the 'sick role' and its implications for the physician-patient relationship were particularly influential to medical sociology in the 1950s and 1960s (Lupton, 2003, Turner, 1999). 3 While Lupton suggests that the sociological tradition of social constructionism is typically privileged in the study of medicine, she also recognizes the importance of the perspectives of anthropology, cultural studies and history. She also notes that the divisions that she draws between perspectives and paradigms have become blurred in recent years, but that she maintains these divisions for the sake of clarity. 13 inequalities, the divide between the privileged and the underprivileged, rather than ameloriate them. (p. 9) Similar to the functionalist view of medicine, political economists see medicine as a moral exercise used to define 'normality' and maintain social order; however, political economists tend to take a negative view of this power dynamic and feel the medical profession is abusing its power. Proponents of the political economy perspective in the realm of medicine also tend to take up what Lupton (1997) calls the 'orthodox medicalization critique' which asserts that medicine, as practiced in Western societies, has increasingly amassed power and influence over the twentieth century - despite its alleged lack of efficiency in treating a range of conditions and its negative side-effects - so that social life and social problems have become increasingly 'medicalized' (see Ehrenreich & English, 1978; Illich, 1975; Zola, 1972). In this view, individuals are rational independent human subjects whose autonomy is being constrained by the more powerful medical profession that medicalizes everyday life and in doing so dictates how others should behave. The increasing power of scientific medicine, it is argued, results in the further marginalization of disempowered groups by reframing issues of social inequality as medical issues that are better treated by drugs/medical therapies rather than by making wider structural changes to society. The medicalization critique has been taken up by feminists who view the medical profession as a patriarchal institution that uses medical discourse to maintain the inequality of women by drawing attention to the weakness inherent to the female body and that fails to recognize realities of women's lives (structural inequalities perpetuated by class, race and gender divisions), instead 'blaming women' for not changing their individual behaviours. Thus, feminists recognize the capitalist system as a key component underlying class 14 inequality in the realm of medicine but view patriarchy as a pernicious ideology that maintains gender inequality (see Ehrenreich & English, 1978; Oakley, 1984; 1989).4 The political economy perspective is important for it draws attention to the social structural reasons underlying health disparities across populations, with the goal of challenging these disparities. As Lupton (2003) notes "continuing problems of access to health care and the larger environmental and political issues surrounding the question of why certain social groups are more prone to ill health remain important points of discussion for the political economy approach" (p. 11). However, there are several critiques of the political economy perspective, a central one being its overly simplistic view of power as something that is possessed by a group or institution, wielded from above by those in possession of economic power. Moreover, while proponents of the political economy perspective (and medicalization critique) question the value of biomedicine and highlight it as an institution of social control that reinforces racism, patriarchy and social class inequalities, it tends to accept the neutrality and objective validity of medical knowledge itself. In short, the production (or philosophy) of knowledge is not problematized - which stands in contrast to a social constructionist approach. Plainly stated, social constructionists question the existence of essential truths, instead viewing what is asserted to be 'truth' as a product of power relations, never neutral but always in the interest of an individual or social group (Burr, 2003). 4 Health promotion scholars have taken up the political economy perspective, arguing that health promotion efforts often fail to address the consequences of capitalism on public health, consequences such as social inequalities, poverty and pollution to name a few (see Crawford, 1977; Nettleton & Bunton, 1995). As I will discuss in more detail below, scholars taking a social constructionist approach generally have a different view of power, recognizing a multiplicity of interests and sites of power. As Lupton notes (2003), the view that "medicine acts as an important institution of social control has remained but the emphasis has moved from examining medical power as an oppressive, highly visible, sovereign-based power, to a conceptualization of medicine as producing knowledges which change in time and space" (p. 13). 15 Knowledge is not independent of reality but produced through human interactions and social relations and therefore subject to change. In this view, knowledge is not a linear progression, producing increasingly refined knowledge, but is "a series of relative constructions which are dependent upon the socio-historical setting in which they occur and are constantly renegotiated" (Lupton, 2003, p. 12). Early proponents of this viewpoint were Berger and Luckmann (1967) who questioned the notion that the 'truth' about the world (or social phenomenon) can be revealed by identifying and analyzing the hidden structures shaping reality, instead asserting that human beings create and then sustain all social life through social practices. According to Burr (2003, p. 13), the anti-essentialist account of social life offered by Berger and Luckmann shows "how the world can be socially constructed by the social practices of people but at the same time experienced by them as if the nature of the world is pre-given and fixed" (p. 13). The social constructionist approach has gained popularity in the last few decades with the growing popularity of poststructuralist theory which questions the humanist notion of a conscious, unified and rational subject and views reality as 'constructed' through language and cultural practices (Burr, 2003; Rail, 2002; Weedon, 1997). As Lupton (2003) explains, post-structuralism brings to social constructionism a consideration of power relations at the macro-level, thus incorporating some of the concerns of the political economy perspective - previously neglected in the more 'micro' symbolic interactionist analyses (p. 12). From a poststructuralist perspective, human identity (or subjectivity) is not an innate feature of an individual, but socially produced and therefore shifting and open to change (Burr, 2003). Moreover, proponents of this perspective reject the (structuralist) notion that the 'truth' about the world (or social phenomenon) can be revealed by identifying and analyzing the hidden structures shaping reality such as the economy. Marx, for example, explained the social world in terms of an underlying economic structure, his theory constituting a meta-narrative in that it understands the social world in terms of one all-embracing principle - class relations (see Burr, 2003, p. 11). Post-structuralism emphasizes the co-existence of "a multiplicity and variety of situation-dependent ways of life" (p. 12), or pluralism. 16 Recognizing medical knowledge as inextricably linked with culture and social practices allows for alternative ways of thinking about the 'truth' claims of biomedicine and health promotion. It illustrates, notes Haraway (2004), that the commonsense ideas that we currently hold are often not objective 'facts,' but socially constructed. Scholars following this tradition have undertaken 'science studies,' demonstrating that science is not purely objective, but rather driven by the politics of culture (see for instance Fleck, 1979; Latour, 1987; Latour & Woolgar, 1986; Price & Shildrick, 1999; Pronger, 2002; Vertinsky, 1994). Fleck (1979, originally published 1935) offered one of the earliest examinations of the socially constructed nature of scientific 'facts,' arguing that every scientific concept and theory is culturally conditioned and the product of 'thought collectives' - a certain way of viewing or thinking about a concept or issue at a certain point in history. An examination of the construction of a scientific 'fact' entails tracing an issue back to its roots (i.e., before it was accepted as fact or knowledge) in order to get a sense of how certain ideas take on the status of 'truth' (Latour, 1987). In doing so, one may see the political and social nature of the decisions made in studies that (on the surface) often appear 'neutral' and 'objective.' As Latour (1987) explains, one must examine 'science in action' in order to trouble 'ready made science.' Feminist scholars have led the way in deconstructing medical and scientific knowledge, and in particular have critiqued the 'biology as destiny' ideology taken up in the medical context and used to deny women participation in the public sphere (see for instance, Schiebinger, 1987; Vertinsky, 1994). Indeed, while earlier feminist work tended to understand the body as a 'given' and accepted male categories and claims about the body, feminists taking a social constructionist approach re-conceptualize the ways they 17 think about the female body by deconstructing 'truths' and producing alternative forms of knowledge that challenge truth claims of biomedicine and science (Price & Shildrick, 1999).7 In a similar manner, I aim to trace back medical discourse around exercise and pregnancy in the hope of gaining a better understanding of the taken-for-granted features of the present and the workings of power. A central critique of a social constructivist approach is that it lapses into relativism - that is, if there are no ultimate 'truths' then all perspectives are equally valid, robbing the perspective of any political edge (Burr, 2003; Lupton, 2003). However, following feminist scholars who use this approach, I argue that it allows the researcher to present a different version of the way things could be and this deconstruction itself is a political stance. As Lupton asserts: "social constructionism is not nihilistic if it is recognized that exposing the social bases of medicine, health and illness states renders these phenomena amenable to change, negotiation and resistance" (p. 14).8 Foucault: Discourse, Power and Knowledge An influential figure in the rise in prominence of the social constructionist approach within the study of medicine has been Michel Foucault. His historical analyses of how networks of power produce medical knowledge and experience, along with his complex and nuanced understanding of the relationship between power, discourse and the body changed the way that scholars approach the study of medicine (Lupton, 2003). See also Lock & Kaufert (1998) for a compilation of feminist essays which are concerned with taken-for- granted knowledge as it manifests itself in the practices of medicine and public health. Social constructionists have also been critiqued for ignoring the material reality of embodiment in favour of a focus on the discursive construction of health and disease (see Howson, 2005; Williams & Bedelow, 1998). In response to this critique, Lupton argues that "very rarely is it claimed by those adopting the constructionist perspective that fleshly experiences are simply 'social constructs' without a reality based in physical experience. Most social constructionists acknowledge that experiences such as illness, disease and pain exist as biological realities, but also emphasize that such experiences are always inevitably given meaning and therefore understood and experienced through cultural and social processes" (p. 14). 18 Foucault's primary research objective was to understand the different ways in our culture that humans develop knowledge about themselves, and how this knowledge has shaped the way that individuals make sense of and act in the world (i.e., the effects of knowledge) (Foucault, 2003d; Markula & Pringle, 2006, p. 24). He conducted a range of historical studies of the development of the human sciences (psychiatry and medicine) as well as the prison system and sexuality, focusing on the "rules of formation" around "what is to be done" and "what is to be known" in social institutions, and the effect of these discourses (or regimes of practice) on individual bodies and the social body (population) (Foucault, 2003c, p. 248). In other words, he was interested in the material conditions and social structures that produce certain forms of knowledge, and how these knowledges or discourses in turn shaped social practices.9 Discourse is central to the work of Foucault. In his early investigations of the human sciences (his archaeological studies) he was concerned with the discursive rules and structures that produced scientific knowledge. More to the point, he aimed to reveal the set of rules that allow for a discourse to construct its field in particular ways and not others (Locke, 2004). In his book, Archaeology of Knowledge (2002, original English translation 1972), he expanded on his concept of discourse, explaining that he tended to use it in three different ways10: as a general domain of all statements, an individualizable group of statements and as a regulated practice that accounts for a number of statements. Because of the centrality of 'discourse' to Foucault's project - and my own - 1 briefly 9 He was concerned with 'deconstructing' the discourses or texts that construct our experiences, taking them apart to show how they "work to present us with a particular vision of the world, and thus enabling us to challenge it" (Burr, 2003, p. 18). 10 As Mills (2004, p. 55) explains, there is an important distinction to be made in Foucault's work between discourse as a whole, which is the set of rules and procedures for the production of particular discourses, and discourses or groups of statements themselves. His archaeological technique was a method for 'unpicking' these rules of formation. 19 discuss the three uses of discourse to which he refers - although they can be (and typically are) subsumed under a more general definition: a system of thoughts composed of ideas, courses of action, beliefs and practices that shape the way individuals understand and act in the world. In the first definition (the broadest of the three), discourse is concerned with the statements that join together within specific social contexts and that have a particular meaning and in turn an effect in the 'real' world (Markula & Pringle, 2006, p. 29; Mills, 2004, p. 6). The discursive effect refers to the production of objects, subjects or conceptual understandings. For example, the discursive effect could produce our conceptual understanding of 'motherhood,' the nuclear family (with mother, father and two children), as well as a set of rules for how a mother should act (both unofficial rules disseminated in popular magazines and official rules in the form of laws and policies). Discursive meanings and effects are not 'set in stone' and are viewed as transitory and always open to change. The second instance - discourse as an individualizable group of statements - refers to statements that apply to the same phenomenon (for example, a discourse of motherhood). They seem to be regulated in some way and to have a common force to them (Mills, 2004). Markula and Pringle (2006) remind us that while some discourses appear to refer to the same phenomenon they should not be viewed as necessarily unified. A discourse of motherhood, for instance, can be related to sets of statements concerned Foucault stressed that the complex workings of discourse shaped the construction of subjects. In his view, the discourse of motherhood would not automatically shape a woman as a mother but rather she would be subject to multiple (shifting) discourses shaping her identity. Foucault's notion of discourse attempted to decentre the individual as a rational, conscious entity (that acts in the world), instead presenting the formation of individuals (and human identity) as a changing fragmented process (acted upon by the world). 20 with mothers but can construct mothering in differing/divergent ways. For instance, in some popular advertisements mothers are constructed as harried women racing after their kids and in others as sexy women (i.e., the yummy mummy). Motherhood is not merely spoken into existence but is constructed through various social practices and social policies. As such, discourse should not be considered as "a simple translation between reality and language but as practices that shape perceptions of reality" (Markula & Pringle, 2006, p. 31). In the third usage of discourse - a regulated practice that accounts for a certain number of statements - Foucault was referring to the unwritten rules that guide social practices and shape the way we make sense of the world (e.g., what statements are accepted as truth and what statements are dismissed as unimportant or false). Mills (2004) explains that in this third usage "he is interested less in the actual utterances/texts that are produced than in the rules and structures which produce particular utterances and texts" (p. 6). In my examination, for instance, I illustrate how viewing exercise and pregnancy through a lens of 'objective' or positivist science has led to the creation of certain types of exercise prescriptions, excluding other ways of knowing. While Foucault's early focus on discursive structures and knowledge production has been termed 'structuralist' in nature (see Dumas & Turner, 2006), he is often associated with the poststructuralist movement, largely due to his rejection of the humanist or Enlightenment view of the subject as a rational individual whose consciousness is unique, coherent and unchanging (Burr, 2003).I2 Instead, he viewed human identity as unfixed and malleable, and shaped by discourse. As he explained: 12 Foucault disliked being labeled and resisted being positioned in either 'camp' (see Markula & Pringle, 2006; Olssen, 2003). 21 "nothing has any meaning outside of discourse" (Foucault, 1972 cited in Hall, 2001, p. 73) which is not to say that objects or a 'real world' do not exist, but that discourse is what gives them meaning.13 Markula and Pringle (2006) explain that while Foucault was critical of the way that humanism placed the individual at the centre of research focus and positioned the individual as "free, rational, unitary and fully coherent" his main concern was the way that humanism "had not necessarily acted to free or liberate humans, but had served as a conceptual tool of domination that resulted in more constrained modes of human behaviour" (p. 28). Foucault also argued that the knowledge generated in different epistemes (the set of discursive structures as a whole within which a culture formulates its ideas, allowing certain ideas to be accepted as 'true' while obscuring others - see Mills, 2004), was not necessarily superior or inferior to previous knowledge but rather was the effect of the discursive conditions in which they were produced. This allowed him, explain Markula and Pringle (2006), to question the modernist notion that scientific knowledge "accumulates in a unilinear fashion and contributes to human advancement" (p. 27).14 Tied to this, he also questioned the positivist assertion that knowledge is objective in nature - and indeed, a central aim of his work was to trouble the 'truth claims' of science. Rail explains that his assertion that "knowledge was always subject to certain epistemic conditions and that truth, accordingly, was always a partial, localized version of reality" (2002, pp. 183-4) is in line with the postmodernist viewpoint. For example, in History of Sexuality, Volume 1 (1990), he discusses how discourse around sexuality constructed individual's understandings of it, and in fact, actually produced individuals as sexual subjects. According to Foucault, sexuality is not an innate quality of the body, but socially constructed - the effect of power. Markula and Pringle (2006) further note that his focus on ruptures in the episteme allowed him to decentre the subject and deemphasize the role of human consciousness (p. 28). 22 The concepts of 'knowledge' and 'power' are also central to the work of Foucault, and closely link to his ideas around discourse in what Carabine (2001) calls the discourse/power/knowledge triad. While there can be competing or contradictory knowledges within a discursive field, those knowledges accepted as the 'truth,' 'natural' or 'just the way it is' are imbricated with relations of power as they can then be put to practice in the regulation of social conduct and, more specifically, the regulation of bodies (Hall, 2001). According to Hall (2001), the application and effectiveness of this power/knowledge concept was, in Foucault's opinion, more important than whether or not the knowledge was actually 'true.' He further explains, "knowledge linked to power, not only assumes the authority of 'the truth' but has the power to make itself true. All knowledge, once applied to the real world, has real effects and in that sense, at least, 'becomes true'" (p. 76). With this emphasis on the importance of discourse and the close relationship between truth and knowledge, Foucault introduced a new concept of power. His model is not a top-down one in which power is possessed by a dominant group and used to oppress another group, but instead, power is seen as dispersed throughout society in a network of power relations. The power relations running throughout society produce forms of subjectivity and behaviour rather than just repressing them and in effect, constitute the subject (Mills, 2004, p. 18). Bodies are invested with power in the form of 'knowledges' (medical advice to pregnant women, for instance), producing certain forms of behaviour and limiting others.15 This is not to say that Foucault did not recognize the importance of the state in regulating society and/or the possibility of power asymmetries and even 15 Stated in a slightly different manner, power is productive because it is people's daily and ongoing relationships with each other that ultimately produce subjectivities (Markula & Pringle, 2006). 23 domination (for example, in the prison system).16 At the same time, however, he did not wish to reduce power to the state, economy or large institutions in a determinate cause and effect relationship, for he viewed these structures as ultimately rooted in the micro- practices of everyday life. Indeed, he suggested that the state (with its prohibitions) can only "take hold and secure its footing where it is rooted in a whole series of multiple and indefinite power relations" that invest "the body, sexuality, the family, kinship, 1 7 knowledge, technology" (Foucault, 2003g, p. 309). 'Resistance' is central to Foucault's concept of power. He viewed power and resistance as mutually constitutive, as evidenced in his oft-cited assertion that: "where there is power, there is resistance, and yet, or rather consequently, this resistance is never in a position of exteriority in relation to power" (1990, p. 95). In his view, the relational nature of power as a dense web passing through various institutions and apparatus in society depends on multiple points of resistance to reinforce it, to "play the role of adversary, target, support, or handle in power relations" (p. 95).18 According to Foucault, these points of resistance are present everywhere in the power network, and as a result there "is no single locus of great Refusal, no soul of revolt, source of all rebellions, or pure law of the revolutionary. Instead there is a plurality of resistances, each of them a special case" (p. 95-6). Thus, one cannot account for resistance through a grand theory Foucault discusses 'states of domination' in more detail in his essay entitled The Ethics of the Concern of the Self (2003e). His ideas around the possibility for complete liberation underscore this point. Foucault asserts that even if a state of domination is reversed, this does not mean an individual or group is completely liberated and free of relations of power. He views power as produced through relations between individuals and groups of individuals as they implement tactics and strategies to carry out their various objectives, objectives which are sometimes complementary, sometimes contradictory. These tactics become connected to one another, "attracting and propagating one another, but finding their base of support and their condition elsewhere, end by forming comprehensive systems" with clear aims - yet "it is often the case that no one is there to have invented them, and few who can be said to have formulated them" (Foucault, 1990, p. 95). 24 but instead must examine the strategic field of power relations surrounding the issue of interest, recognizing that power relations change and shift before one's eyes: the points, knots, or focuses of resistance are spread over time and space at varying densities, at times mobilizing groups or individuals in a definitive way, inflaming certain points of the body, certain moments in life, certain types of behaviour, (p. 96) Similar to the manner in which the network of power relations are not rooted in one location but weave throughout society, "so too the swarm of points of resistance traverses social stratifications and individual unities" (p. 96). Revolution is possible but through the "strategic codification of these points of resistance" - somewhat similar to the way in which the state relies on the institutional integration of power relationships (ibid.). Feminism and Foucault Feminists disagree about the usefulness of Foucault's work for feminist theory and practice. In her book, Feminism, Foucault and Embodied Subjectivity, McLaren (2002) explains that "some feminists advocate a Foucauldian feminism while others argue that the underlying assumptions of feminism are antithetical to Foucault's theoretical framework" (p. 1). McLaren points to three major points of tension for feminist scholars who reject Foucault, the first being his own rejection of a normative framework which underpins such concepts as 'justice,' 'equality' and 'freedom.' This rejection, when combined with the view that truth and knowledge are never free of power relations, has led some feminists to claim that his work slips into relativism and nihilism, undermining the emancipatory (political) aim of feminism. The second sticking point is his view of subjectivity as produced solely within and in relation to discourse which has been critiqued for negating agency and/or resistance by women (see also McNay, 1991). Finally, it has been asserted that his concept of 'power as everywhere' leaves no way to 25 distinguish the difference in power between the dominated and the dominator. This is viewed as particularly problematic, notes McLaren as, "a conception of power that can account for the asymmetry of gendered power relations is essential for feminism" (p. 2.) Despite these critiques, other feminists find Foucault's ideas about the body and power relations to be particularly useful. McLaren (2002) explains that, ironically, it is the very ideas that some feminists find problematic that others - notably poststructuralist feminists - embrace.19 She further observes that: some feminist supporters of Foucault see his anti-humanism, his rejection of metanarratives and universal norms, and his challenge to the notion of a unified subjectivity as necessary steps toward a politics of diversity and inclusion. And many feminists find Foucault's conception of power as a network, and as operating through discourses, institutions and practices beneficial for understanding the ways that power operates locally, on the body, and through particular practices, (p. 2) Indeed, Weedon (1999) notes that his approach enables feminists to recognize both the repressive and productive aspects of power relations, including those which are patriarchal but "none the less offer women forms of subjectivity that are experienced as pleasurable" (p. 119). Bordo (1993b), for instance, draws on Foucault's relational concept of power to better understand eating disorders as encouraging practices that train the body to comply with cultural norms, while at the same time being experienced in terms of power and control. More specific to my focus on pregnancy is the work of Sawicki (1991), recognized as one of the first Foucauldian feminist accounts of obstetrics and new reproductive technologies (NRT). In Disciplining Mothers, Sawicki questions the radical feminist view that obstetrical practices and NRTs are modern technologies that work as a form of social control and domination over the female body and reproductive capacities (akin to Marcuse's notion of'technological rationality') - in essence, a form of violence The 'Foucault debate' is symbolic of the debate about the compatibility of a poststructuralist approach with emancipatory politics, more generally. 26 against the female body. She offers a Foucauldian account of the history of women's procreative bodies, a history that recognizes "multiple centres of power, multiple innovations, with no discrete or unified origin" (p. 80). Her book is an excellent early example of the application of Foucauldian theory to the history of female reproduction. She presents a nuanced account of how power works through the techniques of surveillance and the creation of 'norms,' and how women may experience NRTs as enabling (instead of repressive) in that they offer possible solutions to the problems women face. Her work also serves as a useful reminder that: a Foucauldian feminist does not assume a priori that the new reproductive technologies are the product of a long standing male 'desire' to control women's bodies or to usurp procreation. This does not mean that such motives do not play a role in this history of medicalization, but it does deny that they direct the historical process overall, (p. 80) In recent years, a growing number of feminist scholars have recognized the usefulness of a Foucauldian perspective in the examination of the various political, social and cultural aspects of pregnancy (for instance, Lee & Jackson, 2002; Wetterberg, 2004; Weir, 1996; 2006). I share this position and add to this growing body of literature with my own project. I will now turn to a more detailed discussion of Foucault's notion of the body and power, discussing how feminists have taken up his ideas and how I plan to make use of them in my own research. The Body and Power It was in his genealogies of the prison system (Discipline and Punish) and sexuality (History of Sexuality, Volume 1) that Foucault more fully fleshed out his ideas around the working of power by examining ruptures in the episteme (or ways of thinking) in the shift from traditional to modern society. Through his genealogical work he 27 explored the body as a site of the operation and exercise of power and one of his main concerns was the way that social norms operate on the body (something shared by feminists who problematize the working of norms - especially patriarchal norms on the female body). The working of disciplinary power was the focus of Discipline and Punish (1977) which sketched the practice of imprisonment, illustrating how beginning in the seventeenth century there was a decrease in violent public punishment. By the nineteenth century, it had almost disappeared in favour of a much more subtle form of power which operated largely by investing the body and mind with knowledge within the enclosed space of the prison. In an attempt to produce a disciplined, "docile" body the prisoner was subjected to "habits, rules, orders, and authority.. .exercised continually around him and upon him, and which he must allow to function automatically in him" (p. 128-129). Foucault suggested that the success of disciplinary power derives from the use of the instruments of surveillance (both by others and by instilling individuals with the habit of self-surveillance) and normalizing judgments which impose homogeneity at the same time that they individualize (or make it possible to compare oneself to others) (p. 192).20 For Foucault (1977), the architectural structure of Jeremy Bentham's panopticon encapsulated the workings of disciplinary power in that it maximized the efficient workings of power. It consisted of a guard tower at its center that looked out at a surrounding building divided into separate cells. Each cell had a window into which the prison guard could gaze - but without the inmate knowing if he/she were being observed. The primary effect of the panopticon (and the omnipresent gaze) was to discipline the He further explained that the collection of personal knowledge about the subject is also required for the production of disciplined bodies; personal knowledge is collected through the use of three instruments: hierarchical observation (i.e., surveillance), normalizing judgment and their combination in a procedure that is specific to it, the examination. These three techniques help to transform individuals into 'objects of knowledge' (Pringle & Markula, 2006, p. 41). 28 inmates to survey and monitor their own behaviours. According to Foucault (1977), panopticism also worked on a broader societal scale as the mechanisms of surveillance and discipline expanded (throughout the eighteenth and nineteenth century) into such institutions as schools, factories and hospitals. Indeed, these disciplinary techniques were conducive to "controlling the location of individuals and the production of work - via manipulation of space or architecture, the organization of time (e.g., rigid timetables) and the use of graduated, repetitive and systematized 'exercises' - to help produce docile but productive bodies" (Markula & Pringle, 2006, p. 41). In this view, power 'works from below,' regulating society not through physical restraint and coercion, but through individual surveillance and self-correction to norms, and the body is the ultimate site of this regulation (Bordo, 1993b). Thus, although disciplinary power was regarded by Foucault as a 'technology of dominance,' it can be characterized as a more positive or productive form of power (versus sovereign/juridical •y i power which is more negative or coercive). To provide a contemporary example of the working of disciplinary power, feminist researchers in the area of sport sociology have drawn upon Foucault's notion of disciplinary power to examine how women's fitness magazines (with their glossy photos of toned bodies and 'success stories') expose women to a panoptic gaze that encourages them to self-regulate and monitor their bodies to attain feminine bodily norms (Duncan, 1994; Markula, 1995). Similarly, it may also be applied to a woman's experience of pregnancy in contemporary Western society. Since the rise of the prenatal movement in the 1920s, for instance, there has been a proliferation of educational material for pregnant women, advising that they engage in a number of 21 Foucault's ideas on the workings of panoptic power rest on the assumption that individuals are free - and this relative freedom related to the efficiency of the panopticon as individuals could assume some of the burden of regulatory function formerly taken on by the state (see Markula & Pringle, 2006, p. 44). 29 'normalizing practices' (follow proper nutrition and exercise guidelines, undergo routine medical examinations) thus encouraging women to monitor and regulate their bodies. Such disciplinary practices may be simultaneously constraining and empowering as women struggle (physically and emotionally) to achieve certain norms yet feel satisfied/empowered when/if they are able to do so. In the History of Sexuality, Volume I (1990, French original 1976), Foucault further elaborated on the workings of power, introducing the notion of 'biopower,' a form of power that circulates throughout society, regulating both individual bodies and the collective social body. He suggests that the demographic upswing in the eighteenth century created the problem of 'population' and more specifically, the need to control the population. Biopolitical techniques such as demographics and the calculation of available resources for citizens emerged to aid in the administration of the collective social body. Knowledge about the population was produced through the use of the techniques of statistics, demography and epidemiology and by experts in such fields as psychiatry, medicine and criminology. Thus, "power over life," Foucault contends, developed around two opposite yet complementary poles: the disciplined, individual body (inscribed with social norms) and the species body (population control, public health and genetics) (p. 139). In short, "there was an explosion of numerous and diverse techniques for achieving the subjugation of bodies and the control of populations, marking the beginning of an era of 'biopower'" (p. 140). Significantly, Foucault observed that biopolitical mechanisms (which apply to the population) and disciplinary mechanisms (which apply to the individual body) connect through the norm, acting together to constitute power over life (bios) or biopower (Foucault, 2003; Harwood, 2009). 30 Foucault identified women's reproductive health as a key dimension of the history of biopower, asserting that in the nineteenth century a "thorough medicalization" of the female body and their sex "was carried out in the name of the responsibility they owed to the health of their children, the solidity of the family institution, and the safeguarding of society" (Foucault, 1990, pp. 146-147). Although never completed, Foucault had intended to "locate the processes through which women's bodies were controlled through a set of discourses and practices governing both the individual body and the health, education and welfare of the population, namely, the discourses and practices of 'biopower'" (Sawicki, 1991, p. 67). Building upon Foucault's notion of women's health as a form of biopower, Sawicki (1991) observes that: [i]f, as Foucault claimed, biopower was an indispensible element in the development of capitalism insofar as it made possible a 'controlled insertion of bodies into the machinery of production,' then it must also have been indispensable to patriarchal power insofar as it provided instruments for the insertion of women's bodies into the machinery of reproduction, (p. 68) As the quote by Sawicki suggests, feminists have usefully taken up the notion of women's health as a form of biopower in their examinations of the way that the individual female body has been disciplined through the use of medical knowledge, monitoring, practices of surveillance and technological advances (e.g., NRTs) which construct 'norms' to which women must conform, with the corollary aim of maximizing the health of the population (see Jette, 2006; Sawicki, 1991; Weir, 2006). Foucault's ideas regarding the working of power are especially relevant to my research, for the pregnant body is, essentially, the perfect site for the administration of biopower. The disciplining of the individual pregnant body results in the simultaneous regulation or management of the social body. Thus, discourses (or 'truth claims') that 31 work to construct 'norms' regarding the actions that pregnant women must undertake to have a healthy baby encapsulate the workings of biopower. Such teachings or directions on how to live, how to eat, how to move, how to look have been termed bio-pedagogies, part of the apparatus of governmentality that focuses upon regulating life (Harwood, 2009; Rail & Dumas, 2008; Wright, Rail, MacDonald, MacNeill & Evans, 2006).22 As I will discuss in more detail in the methodology section, in my dissertation I focus on three sites of communication and knowledge exchange, with the aim of interrogating the concealed pedagogical practices of biopower as they relate to exercise during pregnancy.23 Governmentality Biopower, as one form of power (a technology of domination), is part of a larger complex of power relations that Foucault later termed 'governmentality,' "an ensemble formed by institutions, procedures, analyses, and reflections, the calculations and tactics" (2003a, p. 244) that aims to regulate the population not through coercive means but by providing guidance on how individuals should conduct themselves. He therefore used the concept of government to help explicate the close link between power relations and the process by which individuals are made into subjects (subjectification) (Lemke, 2001). In his famous essay entitled Governmentality (Foucault, 2003a), Foucault described how, from the mid-sixteenth to the end of the eighteenth century, there was a shift in political writings from treatises presented as 'advice to the prince' about how best to secure the 22 Harwood (2009) suggests that a consideration of the workings of truth, power and modes of subjectification "take shape as analytic tools for interrogating biopower's pedagogies of life" (p. 19). 23 Before moving on, however, I should note that while I take up Foucault's notion that power is relational (i.e., power is everywhere in the micro-practices of everyday life), I recognize that power asymmetries do exist in the form of the capitalist system (economy) and patriarchy, for example. As Bordo (1993a) so succinctly states, "no one may control the rules of the game, but not all players on the field are equal" (p. 191). Thus, as researchers we must attend to specific, local contexts and situations, but also move beyond the local, individual level to analyze power relations at the level of large scale social structures. 32 acceptance and respect of his subjects to a concern with the 'art of governance' or "how to be ruled, how strictly, by whom, to what end, by what methods, and so on" (p. 229). He defined government as 'the conduct of conduct,' a term which ranges from 'governing the self to 'governing others.' As Lemke (2001) explains, "All in all, in his history of governmentality, Foucault endeavours to show how the modern sovereign state and the modern autonomous individual co-determine each other's emergence" (p. 191). In his Governmentality essay, Foucault (2003a) identified a shift in the mentality of government in seventeenth century Europe towards the view that the population, the market and individuals (three of the main entities to be 'discovered' during this time) were actually self-governing, with their own intrinsic mechanisms of self regulation (O'Malley, 2008, p. 55; Rose, 1993, p. 289). The central aim of government became to foster these self-organizing capacities without disrupting their natural rhythm or internal logic. This produced a series of problems about how to govern individuals, families and the market without destroying their existence and autonomy - or in other words how to strike a balance between governing too much and too little. Thus, the emerging political rationality of the time (liberalism) sought to limit the scope of political authority in favour of emphasizing individual freedom, and led to the formation of a whole series of governmental apparatuses and the development of a whole complex of knowledges in order to 'know' and govern the population (Foucault, 2003a, p. 244). Experts and the knowledge they produced, especially in relation to the modern In his genealogy of the art of governance, Foucault traced "the concern with government from its initial usage in relation to the management of the family, to its concern with territory, to its concern with the category of population, to its concern with civic society" (Olssen, 2003, p. 197). Foucault suggests that while the notion and theory of the art of governance were put forth in the sixteenth and seventeenth century, they were implemented to a limited extent due to military, political and economic tensions that 'afflicted' the seventeenth century from beginning to end. He also suggests that the centrality of sovereignty as the primary political institution (in the seventeenth century) impeded the implantation of the art of governance. 33 professions (such as medicine, public health, psychiatry and criminology) were central to govemmentality - allowing the state to 'govern at a distance' (Lupton, 1995; Rose, 1993) as individuals were 'produced' through the knowledge that was created, governing themselves. By linking itself with the authority of expertise, liberal governance was not arbitrary but based upon knowledge and intelligence concerning those whose well-being it was mandated to enhance (Rose, 1993, p. 290). As Rose and Miller (1992) argue: government is intrinsically linked to the activities of expertise, whose role is not one of weaving an all-pervasive web of 'social control', but of enacting assorted attempts at the calculated administration of diverse aspects of conduct through countless, often competing, local tactics of education, persuasion, inducement, management, incitement, motivation and encouragement, (p. 175) Thus, while the State was important as part of the structure of power relations, so too were the numerous institutions, sites, social groups and interconnections at the local level, whose concerns and activities could support, as well as conflict with, the imperatives of the state (Lupton, 1995, p. 9). It is important to note that in Foucault's view, sovereign and disciplinary power did not disappear but a governmental order became pre-eminent - a more tactical approach was taken in which risk was to become a central technology (as I address in more detail below). His intent was to dispense with forms of epochal analysis, as evidenced by his suggestion that: we need to see things not in terms of the replacement of a society of sovereignty by a disciplinary society and the subsequent replacement of a disciplinary society by a society of government; in reality one has a triangle, sovereignty-discipline- government, which has as its primary target the population and as its essential mechanism the apparatuses of security. (2003a, p. 243)25 Notably, he viewed 'govemmentality' as capturing the encounter between the technologies of domination of others and technologies of the self, as he expressed a few years after writing his original Govemmentality essay (Foucault, 2003d, p. 147). Foucault also differentiated between positive (or productive) forms of power such as disciplinary power and security/governance and negative forms such as sovereign power. 34 With his writings about Governmentality, Foucault extended his discussion about the influence of the State over populations to focus more on the links between micro- and macro-workings of power (Foucault, 2003). As Markula and Pringle (2006, p. 20) explain, he illustrated how his earlier theorizations concerning the working of power at local levels could be similarly used to understand the broader workings of power associated with State governments. His concept of Governmentality, however, was not intended to serve as a grand or systematic theory of power, but instead "stress was to be placed on the multiplicity of power relations, and the diversity of their origins, workings, and effects" (O'Malley, 2008, p. 53). He introduced the concept as he saw existing theories of power during that time - which set up a dichotomy between public/private, state/civil society, political/non-political and viewed power as emanating from a single, central source - as unable to comprehend the complex working of power in modern societies.26 In this sense, governmentality (small 'g') was intended as an analytical tool to be used to help understand (deconstruct) the workings of power or 'Governmentality' (O'Malley, 2008, p. 54) - although Foucault's colleagues have been credited with further developing the 'governmental analytic' (p. 57). According to Rose and Miller (1992), the problematics of government may be analyzed in terms of their political rationalities (the broad discursive frame of reference through which political problems and solutions are identified and considered, and which determine the focus and objects of governance) and in terms of the technologies of government (which pertain to the level of Instead, his notion of biopower and governmentality allowed recognition of "the complex dependencies between the forces and institutions deemed 'political' and instances, sites and apparatuses which shape and manage individual and collective conduct in relation to norms and objectives, but yet are constituted as 'non-political'" (Rose, 1993, p. 286). 35 operationalization and involves a consideration of the techniques, tools and means through which practical policies are devised and inserted) (see also Olssen, 2003, p. 197; Rose, 1993). It is through an analysis of the intricate inter-dependencies between political rationalities and governmental technologies, note Rose and Miller (1992), that we can begin to understand the multiple and delicate networks (or the various technologies) that "connect the lives of individuals, groups and organizations to the aspirations of authorities" (p. 175-6). His analytic of govemmentality also had a political aim, namely to provide a tool that would help destablilize and question the present by revealing its contingent formation. As O'Malley (2008) explains: In govemmentality, emphasis would be on how that which appears as necessary is to be understood as assembled together out of available materials, ideas, practices, and so on, in response to a specific understanding of the nature of problems to be solved.. .as the arbitrariness of many taken-for- granted categories in the present is made visible, possibilities for change emerge - the analytic gives rise to insights into how things might have been otherwise, and thus how they could be different in the future, (p. 54) Thus, this analytic tool is in line with the poststructuralist feminist goal of deconstructing the present and creating alternative ways of knowing. Welfarism and Neo-liberalism: Political Rationalities of Governance Foucault traced the genealogy of Govemmentality from the days of Classic Greek and Rome (via Christian pastoral power) through to post-WWII forms of neo-liberalism, but his most well known governmental writings focused on the exercise of power in modem societies characterized by classical liberal values (discussed above). However, his analytical technique of govemmentality has been taken up by scholars examining 27 Or, as Olssen (2003) explains, "it is the conceptual coupling of political rationality with specific technologies of governance which enables one to understand the link between discursive systems and material realities and, thus, which are essential to conceptualizing liberal and neo-liberal forms of state reason" (p. 197, my emphasis). 36 power relations in Western society from the nineteenth century to present, with an intense interest in neo-liberal forms of governance (see for instance, Lupton, 1995; Olssen, 2003; O'Malley, 2008; Osbourne, 1993; Rose & Miller, 1992; Rose, 1993). Because I aim to examine power relations with respect to exercise and pregnancy across the twentieth century and into present, these previous analyses, which sketch out the shifts in political reason and technologies of governance over this time (including the changing role of experts and expert knowledge as well as shifts in models of risk management), provide a useful backdrop for my own investigation. In what follows, I provide a brief overview of this literature, drawing largely upon two much-cited genealogies of liberal governance, that of Rose (1992) and Rose and Miller (1993). Rose and Miller (1992) explain that the welfare state (or welfarism) was programmatically elaborated in relation to a number of specific problems that nineteenth century liberalism was thought to be responsible for and/or failed to address (including low birth rates, social fragmentation and the individualization of modern society as evidenced by high rates of suicide and crime, delinquency and the recognition that ill health had negative social consequences). It was thus structured by the wish to encourage national growth and well-being through the promotion of social responsibility and the sharing of social risk (Rose & Miller, 1992, p. 192). As a political rationality, it subscribed to the key principles of community, rational planning and institutional design. Rose and Miller (1992) note that a key innovation of welfarism lay in its attempt to link the "fiscal, calculative and bureaucratic capacities of the apparatus of state to the government of social life" (p. 192-3). In other words, it sought to better organize the 'tangle' of machinery for the surveillance and regulation of the social, familial and 37 personal conduct of the problematic sectors of the population (i.e., the courts, reformatories, schools, clinics) that had emerged out of classical liberalism. The prominence of experts (and expert knowledge) as a technique of governance remained, but an attempt was made to make it more centralized. As Rose (1993) notes, the authority of expertise became inextricably linked to formal political apparatus of rule with the aim of re-establishing solidarity in a social form (p. 285). The goal was to transform the state into a centre that could programme (shape, guide, and control) events and persons distant from it - not directly but through society (i.e., form a centre from which welfare apparatus could be governed). This was to be done by acting upon persons and events in relation to a social norm and constituting their experiences and evaluations in a social form. It is important to note that the state of welfare still sought to keep distance between the knowledges and allegiances of experts and the calculations of politicians. As Rose explains: The truth claims of expertise were highly significant here: through the powers of truth, distant events and persons could be governed 'at arms length': political rule would not itself set out the norms of individual conduct, but would install and empower a variety of 'professionals' who would, investing them with authority to act as experts in the devices of social rule. (p. 285) Social insurance was one technique of government to emerge which exemplified the collectivist desire of welfarism to encourage national growth and well-being through the promotion of social responsibility and the mutuality of social risk (Rose, 1993, p. 293). As a government sponsored insurance programme, it provided protection against socially recognized conditions (i.e., aging, disability, unemployment) and was funded through premiums or taxes paid by or on behalf of participants. Thus, risk was still spread 38 across the population but through taxation. The other exemplary technique of government to emerge was social work which Rose (1993) describes as both individualizing and responsiblizing. Social work does not act upon communities as a whole but rather on specific problematic cases. With respect to the prenatal movement, for example, nurses identified individual mothers who were not following social norms (i.e., who were judged as pathological in relation to social norms and therefore 'at risk') and then visited their homes with the aim of educating and 'responsibilizing' them. Rachel Turner (2008) asserts that the rise of neo-liberalism was not a mere revival of classical liberal doctrines (advocating free trade and minimal state intervention) but rather that it originated (in the late 1940s) as a counter-movement to the coUectivist threat (i.e., welfarism) that it saw sweeping throughout the Western world. These various formulations of collectivism, comments Turner, "not only formed the context in which neo-liberalism arose, but also provided one if its key distinguishing arguments: that all forms of collectivism, even milder rationalist liberal forms, lead to dictatorship and economic catastrophe" (p. 75). Thus, the political rationality of neo-liberalism was in large part the solution to the political 'problem' of welfarism and since the 1970s, contends Harvey (2005), "there has everywhere been an emphatic turn towards neo- liberalism in political-economic practices and thinking" (p. 2). That is to say, de- regulation, privatization and withdrawal of the state from collective social provisions Rose explains that social insurance is both inclusive and solidaristic as it "incarnates social solidarity, collectivizing the management of the individual and collective dangers posed by the economic riskiness of a capricious system of wage labour and the corporeal riskiness of a body subject to sickness and injury, under the stewardship of a 'social' state" (p. 293). It therefore established new connections between 'public' norms and procedures and the fate of individuals in their 'private' economic and personal conduct (one of an assortment of ways in which, at the start of the twentieth century, the 'privacy' of the spheres of family and factory were attenuated). 39 have become the reality of neo-liberal political reason (p. 3). It is proposed that the individual citizen is best served (i.e., best able to exercise his or her freedom and skills) within an institutional framework characterized by private property rights, free trade and free markets (Harvey, 2005, p. 2). Gone is the collectivist desire of welfarism to encourage national growth and well-being through the promotion of social responsibility and the mutuality of social risk. The notion of the autonomous individual is central to the success ofneo- liberalism. Rose (1993) notes - somewhat ironically - that while neo-liberalism arose out of critiques of welfarism and its alleged failing, it was also made possible through a range of new devices for governing the conduct of individuals that have their origins in the 'success' of welfare (p. 285). He contends that welfarism and its associated experts had been successful in implanting the norms of health and education into citizens. The result is the disciplined, rational, autonomous and choosing individual - the calculating entrepreneur that is central to the success of neo-liberalism. As Rose notes, we see the reversibility of the relations of authority- what starts off as a norm to be implanted into citizens can be repossessed as a demand which citizens can make of authorities. In addition to the shift away from governing through society towards governing through the regulated choices of individuals, Rose explains that neo-liberal rule articulates experts into the apparatus of rule differently. That is, it seeks to "detach the substantive authority of expertise from the apparatuses of political rule, relocating experts within a market 29 Turner (2008) observes that there is no pure 'neo-liberalism' for it is composed of different strands that make it complex and difficult to define. She suggests, however, that three core principles can be identified: the importance of the market order as an indispensable mechanism for allocating resources and ensuring individual freedom; minimal state intervention (the state is afforded the primary responsibilities of securing law and order, providing public goods and preserving the rules that safeguard the market order, but the centralized political apparatus of welfarism is eschewed); the privileging of private property rights. 40 governed by the rationalities of competition, accountability and consumer demand" (Rose, 1993, p. 285). With respect to the medical profession, for instance, the calculative regimes of positive knowledge of human conduct were replaced by the calculative regimes of accounting and financial management (Osbourne, 1993). In my work, I illustrate how expert medical knowledge has been taken up (profitably) by entrepreneurs in the health and fitness industry, becoming part of the apparatus in the governance of society (see Jette, 2006, plus Chapter Seven of this document). A common theme to arise in genealogies of liberal governance, notes O'Malley, 2008, p. 69) has been that of 'risk' and more specifically, changes in the manner in which risk (as a technology of governance) has been constituted and deployed under differing political rationalities of rule, particularly in the change from welfarism to neo-liberalism which witnessed a shift from spreading risk across society (social insurance) to personal responsibility for risk (prudentialism).30 I discuss this body of literature in more detail in what follows. Socio-Cultural Theories of Risk 'Risk' has arguably become one of the defining cultural characteristics of Western society (Beck, 1992; Douglas, 1990; Giddens, 1991; Lupton, 1999).31 Indeed, we live in a society that has become more and more aware of risk, especially those caused by technology and lifestyle habits (Lupton, 1993). On a daily basis one hears about some Foucauldian scholars view 'risk' as a central technology of governance because it works at the level of the population. That is to say, risk is a statistical and probabilistic technique in which large numbers of events are sorted into a distribution. The distribution can then be used as a way of making probabilistic predictions that can be used to manage the population in an efficient manner (based on how they compare to the normal distribution of the population). Rather than attempting to learn about an individual case in detail (the focus of disciplinary technologies), only certain recurring characteristics (i.e., risk factors) are attended to (O'Malley, 2008). As Robertson (2001) explains, "risk has become a common construct around which health in western society is described, organized and practiced, both personally and professionally" (p. 293). 41 sort of risk or another: of global warming due to the depletion of the ozone layer; of cancer due to drinking out of plastic water bottles; of a long term global recession due to inappropriate banking and lending practices; of lung cancer by smoking and by inhaling second and even third-hand smoke. Lupton (1993) emphasizes the prevalence of health risks in the late twentieth century, explaining that they: seem to loom around every corner, posing a constant threat to the public. They constantly make headlines in the news media and are increasingly the subject of public communication strategies. Risk assessment and risk communication have become growth industries. In short, the work 'risk' itself has acquired new prominence in western society, becoming a central cultural construct, (p. 425) To be sure, 'risk' is a central discourse of contemporary pregnancy - it has become a common construct around which pregnancy is described, organized and practiced in both the popular and medical realm (Lee & Jackson, 2002; Lupton, 1999; Ruhl, 1999; Weir, 1996; 2006; Wetterberg, 2004). Significantly, there are numerous definitions and understandings of'risk,' depending on who is using the term - making it a complex and confusing concept (Garland, 2003; Lupton, 1993). Lupton (1993) explains that in its original usage, 'risk' is neutral and refers to probability or the mathematical chance of an event occurring; the risk of an event occurring could relate to either a positive or a negative outcome. However, within contemporary culture, 'risk' is often understood as a danger, an idea that is perpetuated by the growth of the field of risk assessment of environmental hazards, the rise of epidemiology in the realm of health and the pervasive media coverage (and politicization) of risk more generally (Lupton, 1999; see also Douglas, 1990)32. Ruhl Douglas notes that risk has entered politics in contemporary society and in doing so "has weakened its old connection with technical calculations of probability" (p. 2). She further asserts that the risk concept has come to the fore in politics because in the transition to modern industrial society "probabilistic thinking is pervasive in industry, modern science and philosophy...however, the risk that is a central concept for our 42 (1999) provides the further insight that in today's 'risk society,' the two meanings of risk (risk as probability and risk as danger) have been conflated so that "risk implies the probability of threat or danger" (p. 101) with the underlying assumption that risk is pervasive and ubiquitous. Risk discourse in the realm of health, observes Lupton (1993), can be loosely separated into two perspectives, that of external risk and internal risk. The first views risk as a health danger to populations that is posed by environmental hazards such as pollution and nuclear waste. In this context, the health threat is viewed as an external hazard, out of the control of the individual. The second approach to health risk (internal risk) views it as a consequence of the 'lifestyle' choices made by individuals, and thus places emphasis on self-control. Lupton (1993) observes that in today's secular society, the notion of 'sin' can be relocated to the realm of risk. In the context of external risk, the 'at risk' individual is 'sinned against' (for example by environmental hazards perpetuated by large industry); in regards to internal risk, the risky individual is the 'sinner' making inappropriate lifestyle decisions and engaging in risky behaviour. It is the latter form of 'risk' that is the main focus of public health and more specifically, prenatal care advice. Given the centrality of risk in contemporary society, it has received a growing amount of attention within the professional and academic realm (both natural and social sciences) over the past thirty years and there are a number of different approaches to analyzing risk. One common approach (especially within natural sciences and in industrial risk assessment) is the 'technico-scientific' approach (Lupton, 1999) in which risk is viewed as an objective phenomenon that can be measured through quantitative risk policy debates has not got much to do with probability calculations. The original connection is only indicated by arm waving in the direction of possible science: the work risk now means danger; high risk means a lot of danger" (emphasis in original, p. 2-3). 43 assessment techniques (e.g., determines the probability of a hazardous event and tries to control for this). In contrast to this approach, the sociocultural approach takes into account the broader social and cultural (and sometimes historical) contexts in which 'risk' as a concept derives its meaning and resonance (i.e., asks why we view an event as risky in the first place). In her book, Risk and Sociocultural Theory, Lupton (1999) suggests that three major theoretical perspectives on risk have emerged since the early 1980s and gained prominence during the 1990s: the work of Mary Douglas which takes a cultural anthropological approach to risk (i.e., focuses on the cultural construction of purity and the transgression of social borders); Beck's (1992) theory of 'risk society' which focuses largely on the globalization of risk (i.e., an examination of the macro- structural factors that have led to an intensification of concern about risk in late modern societies); and the governmental perspective of risk which views 'risk' as a governmental strategy of power by which populations and individuals are monitored and managed. The latter is especially relevant to my work because it facilitates an examination of health risks considered to be the responsibility of individuals (i.e., pregnant women) to control through appropriate lifestyle behaviours. However, before turning to a discussion of this literature, I will provide a brief overview of Beck's 'risk society' with attention to how it might be useful to my project. According to Beck (1992) and other proponents of 'risk society' (most notably Giddens, 1991; 1998), the growth of science and technology in late modern societies has led to an increase in manufactured (external) risk - such as pollution, nuclear warfare, chemical residue. In other words, the risks produced under the conditions of late modernity have increased in magnitude and become globalized and are therefore more 44 difficult than in past eras to calculate and manage or avoid. As such, we live in a risk society.33 What is fruitful about the theory of 'risk society' for my project is the centrality assigned to experts and media in mediating public understandings of risk. Because manufactured risks often are incalculable risks (i.e., manufactured risk leads to manufactured uncertainty), the public is increasingly dependent on expert knowledge and media coverage to help them to define/understand risk. Thus, while Beck (especially in his early work) tends to view risks as objective phenomenon that are proliferating out of control, he also draws attention to their mediation through social and cultural processes and it is the latter point which is useful to my own analysis.34 Moreover, regardless of his epistemological position on the nature of risk, the key point is that we live in a society where we perceive that we are facing more and more risks. Feminist scholars (Lupton, 1999; Ruhl, 1999) have drawn on Beck's notion of risk society to make the point that in contemporary society, risk is central to pregnancy - it is ubiquitous and pervasive. Noting that medical professionals have added 'growing risk' to the existing categories of 'high risk' and 'low risk,' Ruhl (1999) explains that "there is no 'no risk' category. Threat is everywhere" (p. 101). Risk: A Technology of Governance Viewed through a Foucauldian lens, 'risk' is one of the "heterogeneous governmental strategies of... power by which populations and individuals are monitored 33 As Beck famously argued, early modern industrial society (in the eighteenth and nineteenth century) produced 'goods' but contemporary industrial society produces 'bads.' As such, we are now in a stage of reflexive modernization or a critique of the processes of modernity. Dean (1999) suggests that modernity finds itself in a state of self-confrontation with the effects of risk society, effects that cannot be assimilated in the system of industrial society. 34 In his original book, Beck was critiqued for moving ambivalently between two positions (realist and social constructionist) and in later work (Beck, 1995) he aimed to develop a position between the two. Lupton (1999) explains of his later work: "he puts forward the idea that 'real risks' exist and can be objectively measured through science but also supports the notion that what are considered to be 'risks' are conceptualized differently in different historical and cultural contexts" (p. 5). 45 and managed so as to best meet the goals of democratic humanism" (Lupton, 1999, p. 4). Much of the early writing around risk and governmentality focused on insurance as one of the many strategies of government that operates in the space between the individual and state (Defert, 1991; Ewald, 1991; Rose, 1993; for discussions of governmental perspectives of risk see Baker & Simon, 2002; O'Malley, 2008).35 Ewald (1991) wrote a landmark paper on the development of governmental approaches to risk in which he traced the emergence of risk as a dominant way of knowing and intervening in the world, beginning in the nineteenth century with a focus on the rise of social insurance as a means of 'spreading risk' throughout the population. For Ewald, "risk is the product of insurance technologies that bring probabilistic methods to bear on aggregated data, producing actuarial representations of risk as an object that can be known and distributed" (c.f. Baker & Simon, 2002, p. 17). Thus, risk was not seen as intrinsically 'real' but rather as a certain way that problems are viewed (or imagined) and dealt with (O'Malley, 2008).36 Rose (1993; see also Rose & Miller, 1992) also contributed to the development of a governmental approach to risk as he explored the breakdown of the social logic of governance (social insurance or 'risk spreading' discussed by Ewald (1991)) and the emergence of a prudential insurance approach that emphasizes individual responsibility. Actuarialism (which emerged in the seventeenth century but became increasingly prevalent in the nineteenth and twentieth century) entails evaluating the likelihood of events and quantifying the possible outcomes with the aim of minimizing losses (both financial and emotional) associated with uncertain and undesirable events. Insurance is a central form of actuarial risk management used to hedge against the 'risk' of loss through the practice of'risk spreading' (O'Malley, 1996). By placing events and/or individuals in the context of population, that which on its own might appear random can be treated as predictable and calculable. Through the use of mathematical and statistical calculations, an individual's risk can be determined based on the group or cohort that they belong to. Ewald reminds us that notions of risk in insurance are linked with chance, probability and randomness instead of danger and peril (Ewald, 1991, p. 199) - although others provide a counter-argument to this, suggesting that in contemporary society, risk has entered into the political realm and weakened its old connection with technical calculations of probability (see Douglas, 1990; Lupton, 1993). 46 This shift in risk management strategies is in line with the previously noted emphasis on personal responsibility and individualism that is central to neo-liberalism. As O'Malley (2008) explains, "risk management.. .changed from a social or collectivized model to one focused much more on management by individuals on their own behalf, frequently in the name of 'freedom of choice' (p. 71). Thus, new self-governing entities are created through shifts in unemployment insurance (subjects are no longer 'beneficiaries' of social insurance, but 'active citizens' making themselves 'job ready') and changes in crime prevention (individuals are admonished not to make it easy for criminals and to seek the help of government and the police to manage their own crime risks). Moreover, social work (an innovation of the welfare state characterized by professionals seeking out individuals to share expert knowledge and produce responsible citizens) has been replaced by the private counselor or self-help manual as "practices whereby each individual binds themselves to expert advice as a matter of their own freedom" (Rose, 1993, p. 196). A number of scholars have discussed how the neo-liberal emphasis on personal responsibility and individual risk management has become increasingly evident in health care systems and health promotion strategies in Western societies since the late 1970s (see Bunton, 1997; Castel, 1991; Lupton, 1995; MacNeill, 1999; McDermott, 2007; O'Malley, 1996; Petersen, 1997; Vertinsky, 1998; Wheatley, 2005; White, Young & Gillett, 1995). Good health and risk avoidance are viewed as lifestyle choices that are within the realm of personal control, and an individual not engaging in such behaviour is stigmatized as immoral and irresponsible. This mentality, termed the ideology of 'healthism' (Crawford, 1980), promotes the idea that involvement in health promoting 47 activities is a moral obligation, and according to Petersen (1997), is a manifestation of the "individual as enterprise" (p. 197) mindset which is characteristic of neo-liberal governance.37 Indeed, the rhetoric of lifestyle management, the urging to avoid or eliminate risky behaviour and the ascendancy of an ethos of prevention were viewed as possible solutions to a fiscal crisis in health care (namely escalating health care costs and the notion that access to health care is a right) (Ingham, 1985; MacNeill, 1999; Wheatley, 2005). Scholars have pointed out how, in contemporary society, the subject of health care is viewed more as a client or consumer of health than a patient (see for instance, Bunton & Burrows, 1995; Henderson & Petersen, 2002, p. 2-3; Lupton, 1995; Rose, 2001). The health consumer is entreated to lessen his/her dependence on public health care services (through actual policy changes whereby health care is privatized or where publicly subsidized programmes are downscaled), at the same time that a disciplinary regime of the body is promoted with respect to care of the body - based on the assumption that "subjects of risk will opt to participate in a self-imposed programme of health and fitness" (O'Malley, 1996, p. 199). Two closely related images recur: the responsible (moral) and the rational (calculating) individual, notes O'Malley (1996, p. 199). He goes on to explain: Guided by actuarial data on risks (e.g., on smoking and lung cancer; bowel cancer and diet, etc.) and on the delivery of relevant services (e.g., relative costs and benefits of public and private medicine), the rational and responsible individual will take prudent risk-managing measures. Within such prudential strategies, then, calculative self-interest is articulated with actuarialism to generate risk management 37 A critique of healthism or the 'lifestyle' philosophy, note Petersen and Lupton (1996, p. 16), has centered on its failure to acknowledge the impacts of such factors as class, gender and ethnicity both on life chances and on those individual decisions predisposing to 'unhealthy lifestyles,' and on the consequent tendency to 'blame the victim' for what are seen as structurally induced problems (see Crawford, 1977). 48 as an everyday practice of the self. This is backed up by a moral responsibility, or duty to the self. (p. 200) Ironically, explain Henderson and Petersen (2002), the consumer-oriented model of health care is often presented in terms of personal empowerment, but "behind the rhetoric of 'freedom of choice,' 'right to know' and 'entitlement to participate' .. .lie compulsions surrounding the exercise of choice and an array of predefined and limited options for action" (p. 3). The 'good consumer' is compelled to make certain (rational) choices, exhibit appropriate information-seeking behaviour and behave in prescribed ways (i.e., consult certain experts, take the 'right' medicine) and a number of scholars of the sociology of health and illness have questioned the extent to which this ideal of rational consumer behaviour meshes with the reality of people's everyday lives (Henderson & Petersen, 2002; Lupton, 1995; Lupton & Petersen, 1996). In my own analysis I draw on this previous literature to examine the manner in which the practice of pregnancy and exercise (and the pregnant exerciser) has been constructed in medical and health promotion literature. While insurance as a form of risk technology has been a central focus of writings around risk and governance, there is also a growing body of literature focusing on the deployment of risk technologies in relation to health and medicine, particularly the rise of 'risk factor' epidemiology in the latter half of the twentieth century. Epidemiology entails the study of disease and illness as they occur within a defined population as opposed to individuals (see Armstrong, 1995; Castel, 1991; Gifford, 1986; Lupton, 1995; Rose, 2001; Susser & Susser, 1996). Within epidemiology, 'risk' is conceptualized in terms of 'risk factors' which are not direct causes of a disease but instead are characteristics that appear to be related to the occurrence of a disease in some way (i.e., 'risk' expresses a 49 statistical measure of the degree of association between a characteristic and a disease) (Gifford, 1986). Attention to risk factors intensified in the late 1950s in accordance with the creation of a new object of study for epidemiology: chronic disease. Scholars assert that with declining rates of infectious disease in advanced capitalist societies (and the widespread availability of penicillin) in the years following World War II, infectious diseases had seemingly been 'conquered' and there was a turn towards identifying the risk factors of chronic disease which required more sophisticated models of multiple causation as opposed to identifying a single pathological or social cause (Armstrong, 1995; Gifford, 1986; Susser & Susser, 1996; Weir, 2006). Rose (2001) explains that with the rise of 'risk factors,' the "binary distinctions of normal and pathological, which were central to earlier biopolitical analyses" are now organized within a variety of strategies that try to "identify, treat, manage or administer those individuals, groups or localities where risk is seen to be high" (p. 7).38 Castel's (1991) essay, From Dangerousness to Risk, was one of the earliest to examine risk technologies in relation to health and the implications of the application of this risk technology in how we are to be governed. In short, he mapped out the transition within the health profession from privileging clinical risk knowledge (based upon the characteristics of individual case studies observed by experts) to privileging epidemiological risk knowledge (calculated through the observation of patterns in anonymous populations of disease and the identification of associated risk factors). More specifically, Castel discussed the shift in psychiatric diagnoses over the twentieth century, Binary distinctions are still used as a risk strategy but are now part of a wider variety of strategies organized at a number of levels, including epidemiological strategies that seek to reduce aggregate levels of risk across a population, strategies for the management of high-risk groups and strategies based on the identification of, and preventive intervention for, risky individuals. 50 suggesting that there has been a move from diagnosing dangerousness (based on the manifestation of concrete symptoms) towards diagnosing 'risk' (based on the presence of characteristics identified as risk factors). He characterized the former as a disciplinary technology whereby the individual patient is examined (in a clinical environment), diagnosed as having an existing condition and then treated/restrained to govern the possibility of harm, and the latter as an actuarial practice in which the individual case is represented as part of a larger sub-population with known 'objective' statistical properties (O'Malley, 2008, p. 60).39 Castel explains that with the emergence of risk in psychiatry, or more specifically, by making the notion of risk autonomous from the notion of danger, the practice of psychiatry came to be seen as more 'objective.' Similar to insurance, rather than attempting to learn about a case in detail, a risk diagnosis identifies the presence of a risk factor and consigns the individual to a risk pool. Because aggregate 'objective' characteristics can be represented with statistical precision, they became regarded as real rather than simply hypothetical diagnoses of individuals based on medical opinion. Castel problematized this process as it masks the socially constructed nature of risk factors, explaining that "prevention, in effect, promotes suspicion to the dignified scientific rank of a calculus of probabilities" (p. 288). The result was the creation and justification of preventative strategies aimed at entire categories of people to 'reduce' risk (O'Malley, 2008, p. 60-61). Both types of risk knowledge (clinical and epidemiological) aim to render risks calculable and governable and are therefore normalizing - albeit the former are based on the characteristics of case studies of individuals and the latter calculated through the observation of patterns in anonymous populations of disease and the identification of associated risk factors (Lupton, 1999, p. 63). 51 Sociologists have extended Castel's (1991) examination of 'risk factors' and epidemiology in relation to the discourse of health and the body (see Lupton, 1995; Dean, 1999; Petersen and Lupton, 1996; McDermott, 2007; Gard & Wright, 2005; Ruhl, 1999; Weir, 1996; 2006). Petersen and Lupton (1996), for instance, note that epidemiology has become increasingly prevalent in contemporary health care regimes (i.e., the new public health) which follow a neo-liberal model of risk organization. Indeed, epidemiology as a risk technique helps to mobilize neo-liberal values of personal responsibility and minimal government intervention. Through statistical analysis, epidemiological risk factors are identified and subsequently used to encourage individuals to engage in appropriate (self- regulatory) lifestyle choices. Risk assessment (through the science of epidemiology) therefore facilitates 'government at a distance' in such a way that health promoters are not clearly seen to be directly intervening, coercing or punishing. They instead view themselves as working through the efforts of others, particularly by forging collaborative ventures and promoting community action (empowerment) (Petersen & Lupton, p. 19). In their efforts to identify and control the factors of risk, note Petersen and Lupton, health promoters have taken on the roles of expert administrators, programme coordinators and 'community developers.' The 'factors of risk' they identify are distributed throughout the social body to the extent that (responsible) individuals at every turn face the task of having to monitor, regulate and change (that is, refashion) themselves to avoid, modify, control and eliminate behaviours and situations deemed as 'risky' (p. 20).40 In her article, "The Meaning of Lumps: A Case Study of the Ambiguity of Risk," Sandra Gifford (1986) examines the difficulties that arise as risk-related knowledge about 40 In their examination of the construction of epidemiological 'fact,' Petersen and Lupton (1996) question the apparent neutrality and objectivity of this practice, noting that what is routinely glossed over in the official accounts of epidemiological research.. .is the socially constructed nature of the findings" (p. 33). 52 breast cancer is translated from epidemiological findings to clinical knowledge and practice. She asserts that confusion about how to translate concepts of epidemiological risk into the clinical context arises because contextual differences in the meaning and use of the concept are not fully recognized. In epidemiology, risk from an exposure (i.e., the presence of a risk factor) is a quantitative concept that is calculable over a study population whereas in the clinical context, risk from an exposure to an individual patient cannot be calculated (see Weir, 2006, p. 65). There is therefore always an element of intrinsic uncertainty in the practice of clinical medicine because the doctor must translate generalized knowledge to the treatment of a specific individual, deciding if an epidemiological risk factor is clinically relevant - or in other words, if a statistic should be transformed into a physical entity.41 Gifford argues that when epidemiological knowledge is inserted into the clinical setting, risk factors are often read as equivalent to "objective clinical signs of disease" (p. 222) and patients are treated (sometimes through invasive procedures) for risk factors on the assumption that eliminating them will improve their health (and prognosis) (see also Weir, 2006, p. 67). Feminist scholars (Lupton, 1999; Weir, 1996; 2006) have also examined the mobilization of both clinical risk and epidemiological risk in the governance of pregnancy. Lupton (1999), for example, explains that both of these approaches serve to render the risks attendant upon pregnancy as "calculable and governable, thus bringing them into being as problems that require action" (p. 63). Both types of risk knowledge, For the clinician, "there is always a certain amount of uncertainty which cannot be measured. Risk then, for the clinician, takes on the added dimension of unmeasured uncertainty" - as opposed to the measured uncertainty of the epidemiologist who has the laws of probability at his or her disposal (Gifford, 1986, p. 220). 53 she asserts, are normalizing, locating the individual woman within a framework of comparisons to many other women: The collective results of diagnostic tests on populations establish a norm against which a particular pregnant woman's health and the development and growth of her fetus may be compared. Any major deviation from the norm is defined as 'abnormal', evidence of 'high risk' that requires further medical intervention, (p. 63) Similar to Gifford (1986), Weir (2006) points to the difficulties that arise when epidemiological risk factors are simply folded into the clinical context, constructing 'clinical risk.' She illustrates how, beginning in the 1950s, risk techniques were attached to pregnancy and childcare creating a form of risk-based prenatal care that bound together categories of epidemiological risk with diagnostic information, test results and patient histories; the result was to make standardized prenatal risk assessment into a "higgedly- piggedly concatenation of epidemiological and clinical reasoning as risk came to invade the space of patient management, treated as equivalent to any clinical intervention" (pp. 3-4). She argues that clinical risk conjoins two conceptually distinct forms of health judgment: the judgment of risk (from epidemiological reasoning) and the judgment of the normal and the pathological (diagnostics).42 According to Weir, the aggregation of heterogeneous and incommensurable forms of health reasoning makes clinical risk "analytically incoherent and intrinsically unstable" and she explains that although this incoherence has been "recognized and repeatedly contested within medicine and the Referring to the Ontario Antenatal Record (a standardized form used to assess pregnancy risk), Weir (2006) illustrates how diagnostic categories appear as risk factors (e.g., diabetes, renal disease without hypertension) with no clear demarcation between risk and diagnostics. With this elision, she argues, risk factors proliferate and the state of health becomes elusive, a condition of 'no predictable risk' - or, in other words, uncertainty (p. 67). Thus, risk encroaches upon the meaning of health and almost displaces it, exemplified by the fact that a Risk Level A in the form is a 'healthy pregnancy' with 'no predictable risk.' Health is defined in risk language, placed within a risk hierarchy. 54 allied health professions, uses of risk reasoning in clinical practice persist, the internal critique constantly forgotten" (p. 65). In later chapters I examine how knowledge based on epidemiological data has been translated into exercise guidelines and assessment tools to be used in the clinical context. I also illustrate how, in the context of the epidemic of obesity in contemporary Western society, physical inactivity itself has been identified as a risk factor in the development of'maternal-fetal' disease and a discourse of epidemiological risk mobilized to urge pregnant women to be physically active. The Body as a Project In a society where risk and uncertainty are so prominent, social theorists argue that the body has taken on a new importance, becoming the target of many new health risk- management strategies (Giddens, 1991; Shilling, 2003). Williams and Bendelow (1998) explain: as the macro-social, economic and global environment becomes ever more unstable and uncertain, then new systems of surveillance and government are put into place in order to regulate and control the social and natural environment, including the body itself. Seen in these terms, the discipline, surveillance and control of bodies may effect an albeit precarious 'resolution' of the more global threats and dangers we face at the turn of the century - one in which the current bodily preoccupation with health and fitness in consumer culture play no small part. (pp. 72-3) In this section, I outline the work of theorists who view the body as a project. This literature facilitates an examination of how pregnant women are positioned as 'at risk' and in need of managing this risk through 'bodywork.' I also provide a brief overview of Weir (2006) explains that the inclusion of diagnostic elements within prenatal risk assessment has been contested on the grounds that it simply records what would already be in a patient's chart, inflates the reliability of the risk tool, and initiates a course of care that would have occurred without the assessment tool (p. 67). 55 scholarly work examining the role that the consumer culture industry has played in perpetuating the preoccupation with the body in contemporary society. The centrality of the body in 'risk society' has been the focus of prominent social theorists such as Anthony Giddens (1991) and Chris Shilling (2003) who view the body as a project to be worked at as part of an individual's self identity (see also Featherstone, 1991; Williams & Bendelow, 1998). Giddens (1991) elaborates on this process, suggesting that the decline in traditional knowledge and customs (especially religion) in the late twentieth century (what he terms 'high' modernity) has been replaced by an insistence that all knowledge is tentative, always open to contestation and change. In his view, the growth of science and technology has not achieved "certitude of rational knowledge" (p. 2-3) but rather has led to an increase in doubt.44 There has been a proliferation of expert knowledge or "systems of accumulated expertise" that represent "multiple sources of authority, frequently internally contested and divergent in their implications" (p. 3). Thus, even the authorities who provide sound 'objective' knowledge can only be trusted until the next study is published. Similar to Beck (1991), Giddens points to a change in the nature of risk in contemporary society. He asserts that while there has been a reduction in the overall riskiness of certain areas and modes of life, there has at the same time been an introduction of "new risk parameters largely or completely unknown to previous era" (p. 4), including such things as nuclear weapons and the risk of nuclear warfare; ecological catastrophes due to technological/manufacturing sectors; collapse of global economic system. These changes then combine with the increasingly mediated nature of experiences, creating a cultural milieu of risk and uncertainty. It is in Doubt, he explains, is a "pervasive feature of modern critical reason [that] permeates into everyday life as well as philosophical consciousness, and forms a general existential dimension of the contemporary social world" (p. 3). 56 this atmosphere, he argues, that the construction of self identity takes on new importance, allowing the individual to gain a sense of control by making lifestyle choices and working on his/her body. Building on the work of Giddens (1991), Shilling (2003) provides a more explicit explanation of the role of the body (and bodywork) in this reflexive project of the self: For those who have lost their faith in religious authorities and grand political narratives, and are no longer provided with a clear world view or self-identity by these trans-personal meaning structures, at least the body initially appears to provide a firm foundation on which to reconstruct a reliable sense of self in the modern world. Indeed, the increasingly reflexive ways in which people are relating to their bodies can be seen as one of the defining features of high modernity, (p. 2) Recognizing that the body has become a project for many 'modern' persons, explains Shilling (2003), entails accepting that its appearance, size, shape and even its contents are potentially "open to reconstruction in line with the designs of its owner" (p. 4). It also involves a practical recognition of the significance of bodies as both personal resources and as social symbols which tell a story about a person's self-identity. While Foucault did not use the term 'the body as a project,' his writings around 'technologies of the self resonate with the idea of bodywork as a means of constructing oneself within power relations. Late in his career, Foucault shifted his focus from technologies of domination and power (characterized by the techniques of panopticism and biopower) towards technologies of individual domination or technologies of the self (see Foucault, 2003d).45 He defined technologies of the self as those practices which permit individuals: to effect by their own means, or with the help of others, a certain number of operations on their own bodies and souls, thoughts, conduct, and way of being, so Foucault explained that in his work, he had always attempted a history of the organization of knowledge with respect to both domination and self, but that "perhaps I've insisted too much on the technology of domination and power" (2003d, p. 147). 57 as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection, or immortality, (p. 146) This is not to say that Foucault no longer viewed disciplinary power as relevant - he viewed 'governmentality,' for instance, as capturing the encounter between the technologies of domination and technologies of the self. In these later years, however, he attempted to flesh out more fully how individuals begin to understand themselves as subjects within power relations. Rose (2001) has extended Foucault's concept of technology of the self, explaining that while "the original biopolitical thesis implied a separation between those who calculated and exercise power and those who were its subjects" (p. 17), throughout the twentieth century "biopolitics was democratized" as an alliance formed between "political aspirations for a healthy population and personal aspirations to be well" (ibid.). And in the twenty-first century, he states, "selfhood has become intrinsically somatic" - the body is a key site for work on the self (p. 18). He goes on to explain: From official discourses of health promotion through narratives of the experience of disease and suffering in the mass media, to popular discourses on dieting and exercise, we see an increasing stress on personal reconstruction through acting on the body in the name of a fitness that is simultaneously corporeal and psychological, (p. 18)46 Of particular interest to Rose - and Foucault - is the ethics of bodywork.47 In putting forth the concept of technologies of the self, Foucault was interested in exploring how an individual takes an active role in constructing the self as a moral subject within He terms the use of the body as a site of experiments with subjectivity (i.e., body work), "somatic individuality" (p. 18). Foucault's primary interest was in how practices of the self (often through work on the body) might serve as practices of freedom, free of power relations of modern society (Foucault, 2003e). 58 power relations, calling this the practice of ethics. Rose (2001) introduces the concept of 'ethopolitics,' the politics of life itself and how it should be lived. He further explains that: in ethopolitics, life itself, as it is lived in its everyday manifestations, is the object of adjudication. If discipline individualizes and normalizes, and biopower collectivizes and socializes, ethopolitics concerns itself with the self-techniques by which human beings should judge themselves and act upon themselves to make themselves better than they are. (p. 18) Rose asserts that in the twenty-first century, there has been a merging of biopolitics with ethopolitics, where the "ethos of human existence.. .have come to provide the 'medium' within which the self-government of the autonomous individual can be connected with the imperatives of good government" (p. 18). In this context, bodywork is a central ethopolitical strategy a
UBC Theses and Dissertations
Governing risk, exercising caution : western medical knowledge, physical activity and pregnancy Jette, Shannon 2009
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