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Article Excerpt
I am to be a mother in July.... Are there any spacil things that i should eat? If so, what? Any what kind of exercices should i take? And how often? What kind of clothes should i buy and make for the baby and my self? And how much of everything? Will you please write down everything i need? and the baby as i would not like to buy to much because i cannot afford to pay much, I would like to buy as less things as possible. and make as much as i can at home, I will be a very young mother as i am only 17 years old.... [W]ill you please tell me why i always think that eather I or the baby will die after its birth.
--Mrs. C. Carroll to Mrs. Max West, 23 March 1921
It is wise for an expectant mother to consult a physician as early in pregnancy as is possible as much trouble later on may be avoided by the care of a physician throughout pregnancy.... If you are perfectly well and strong there is no reason at all to think that either you or the baby will not live. It is much better for both you and the baby not to let such unhappy ideas find a place in your thoughts. If you take the very best care of yourself possible, there is no reason why all should not go well.
--Florence McKay, M.D., Assistant Director, Division of Hygiene, U.S. Children's Bureau to Mrs. C. Carroll, 1 April 1921
In 1921 the Sheppard-Towner Act was signed into law, thereby establishing the first federal welfare program in the United States. The objective of Sheppard-Towner was to reduce infant and maternal mortality. One pillar of this campaign was a national educational program designed to promote the use of medical prenatal care, since, when Sheppard-Towner became law, only pregnant women with severe complications were receiving medical attention prior to the onset of labor.
In 2000, 97 percent of all pregnant women in the United States received regular medical prenatal care.1As evidenced by the widespread cultural acceptance of prenatal care, pregnancy has been medicalized (come under a medical jurisdiction) during the twentieth century. Indeed, the efficacy of prenatal care is so widely accepted that the late 1980s and early 1990s, an era otherwise characterized by harsh cutbacks in welfare benefits, witnessed an expansion in eligibility for publicly-funded prenatal care. A series of "welfare reforms" recently decoupled Medicaid from other cash assistance for poor women and children formally AFDC. Consequently, low-income women who do not qualify for cash welfare benefits can still qualify for Medicaid. This expansion of eligibility contributes to the remarkably high utilization rate for prenatal care. (1)
From the passage of Sheppard-Towner in 1921 to the maternal health policy reforms of the 1990s, the federal state has equated women's maternal health needs with prenatal care. Although recent research raises questions about the efficacy of prenatal care historically and contemporarily in terms of its impact on infant and maternal mortality, I will not discuss the merits of prenatal care here. (2) Rather, I demonstrate how and why women's maternal health needs were first defined and institutionalized as medical needs and, thereby, explore the historical origins of the contemporary cultural and political acceptance of medical prenatal care.
Medicalized Maternalism: Needs Talk and Definitional Institutionalization
In Unruly Practices: Power, Discourse, and Gender in Contemporary Social Theory, Nancy Fraser argues that the struggle over defining "needs," is a central political process in shaping the welfare state. (3) Lay citizens make demands on the state for resources and services as they attempt to politicize their needs. In bringing their demands to the state, lay citizens--as groups and as individuals--encounter a form of "needs talk" that functions to respecify their needs. Experts and politicians institutionalize definitions of needs in ways that conform to their own personal and professional agendas, converting economic or political needs into matters that require legalistic, managerial, or medical intervention. This process serves the interests of professionals (who create institutional niches for their work) and, to the extent that experts harness, or depoliticize, potentially "runaway" needs claims, this process also serves the interest of the state. In other words, the political stakes of needs talk are the power to determine how problems and needs are defined as well as how the state shall meet those needs.
The empirical section of this article applies the conceptual framework advanced by Fraser to the case of the Sheppard-Towner Act. It was through the educational programs of Sheppard-Towner that most women in the United States were introduced to a medical framing of pregnancy and the concept of medical prenatal care. The programs of Sheppard-Towner, therefore, mark the introduction of a medical definition of women's maternal health needs and the institutionalization of that definition through federal social policy. By presenting the needs talk between lay women and women physicians of the U.S. Children's Bureau, I illustrate how a medical definition of women's maternal health needs was promoted via the programs of the Sheppard-Towner Act. As predicted by Fraser's model, women physicians in the Children's Bureau institutionalized a definition of women's maternal health needs that conformed to their own personal and professional agendas and ultimately served the interests of the emerging welfare state by limiting the types of claims mothers could make on the state.
However, the needs talk of women physicians must be located historically, politically, and institutionally. To that end, I situate my analysis within Theda Skocpol's framework for the rise and fall of Sheppard-Towner. (4) According to Skocpol, a particular combination of political opportunities and constraints that distinguish the early-twentieth-century United States (e.g., a weak labor movement, decentralized state, and well-organized women's club and settlement movements) made "maternalist" welfare successes like Sheppard-Towner possible. In contrast to the more familiar, paternalist welfare states in other Western nations during this period, where male bureaucrats oversaw programs directed primarily at industrial workers, female-dominated public agencies and state provisions for mothers and children characterized the nascent U.S. maternalist welfare state.
This political context, Skocpol argues, helps account for the character of Sheppard-Towner, as well as that act's subsequent institutional legacy embedded in the Social Security Act of 1935. Here I make a parallel argument with respect to definitional institutionalization. In the same way that political opportunities and constraints explain the institutional nature and legacy of Sheppard-Towner, political opportunities and constraints facing bureaucratic women also explain its definitional nature and legacy. In particular, Sheppard-Towner played a crucial role in the medicalization of pregnancy in the United States.
Birthing and Bureaucratic Women's Letters
As an example of locating needs talk within a historical context of political opportunities and constraints, I use the written correspondences between lay women and women physicians in the U.S. Children's Bureau from 1920 to 1935 from the National Archives Children's Bureau Central File. Eighty-eight letters are included in this investigation: forty-four letters from lay women to the Bureau and the corresponding forty-four responses from Bureau physicians. (5) Using the Children's Bureau Central File catalog, I traced letters indexed under pregnancy, childbirth, obstetries, gynecology, midwifery, prenatal care, Sheppard Towner, and Title V of the Social Security Act. Paired letters between lay women and Bureau women physicians cataloged under these substantive areas are included in this analysis.
Although the overwhelming majority of letters written to the Children's Bureau are cataloged along with the Bureau's written response, not all archived letters are so paired. Lay/medical pairings used in this analysis represent the most common form of exchange cataloged under the denoted topics during the time period under investigation. There are, however, several paired letters cataloged under these topics between lay women and Bureau chiefs (three pairs), and a few between lay women and Bureau clerks (two pairs). These paired letters are not included on the grounds that they do not represent the exchange between lay and medical women, and, more importantly, because they represent a much less common pattern of exchange.
Some context can be provided regarding the individual letter writers, both lay and medisal women. The letters from lay women offer some basic demographic information. Appendix A provides summary data regarding rural and urban status, geographic region, and class of the lay women letter writers. The majority lived in rural communities in the North Central and Eastern regions of the country, and, although it is not possible to determine class background in all cases, in those cases where class could be determined the majority were working class. The Bureau physicians who responded to lay women were in the Division of Hygiene (later renamed the Division of Maternal and Infant Hygiene). The staff of the division was small; in 1926 it included "three physicians, three nurses and three clerks." (6) The letters included here, written between 1920 and 1935, indicate that two or three physicians were on staff in any given year. These physician positions included the division director, associate director, and staff physician.
A few specific details about the individual women physicians whose letters appear here can be linked to what is known about the Bureau physicians generally. Anna Rude, the division's director from 1921 to 1923, was a close friend of Julia Lathrop, and like Lathrop, worked at Hull House before joining the Children's Bureau. This is in line with general claims that Bureau physicians were recruited from the ranks of the settlement movement. (7) Both Ethel Dunham and Ella Oppenheimer graduated from Bryn Mawr in 1914 and then received their medical degrees from Johns Hopkins in 1918. Johns Hopkins trained many of the Bureau's most...
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