Soc. Sci. Med. Vol. 47, No. 8, pp.

1067±1076, 1998
# 1998 Elsevier Science Ltd. All rights reserved
PII: S0277-9536(98)00155-5 Printed in Great Britain
0277-9536/98 $19.00 + 0.00

A SHIP UPON A STORMY SEA: THE MEDICALIZATION

OF PREGNANCY
K. K. BARKER*
Department of Sociology and Anthropology, Lin®eld College, 900 S. Baker, McMinnville, OR 97128,
U.S.A.

AbstractÐThis is an empirical illustration of the role of biomedical rhetoric in the rise of medicine's
cultural authority. Using the case of pregnancy in the United States I delineate how biomedical rhetoric
was key in the historical process of medicalization. The ®rst systematic attempt to introduce women to
a medical interpretation of pregnancy was the public health campaign of the United States Children's
Bureau in the early twentieth century. A cornerstone of the Children's Bureau campaign was its publi-
cation ``Prenatal Care,'' ®rst published in 1913 and distributed to well over twenty-two million women
by the mid-thirties. Prenatal Care represents the biomedical interpretation of pregnancy as it was ®rst
introduced to women. Through an analysis of this document I demonstrate the discursive mechanisms
through which biomedicine reconceptualized pregnancy as medically problematic rather than as experi-
entially and organically demanding. Prenatal Care demonstrates the ways in which the ``universal''
claims of biomedicine can advance a particular class and racial/ethnic composite of woman. # 1998
Elsevier Science Ltd. All rights reserved

Key wordsÐpregnancy, medicalization, history of prenatal care

INTRODUCTION alone, but on the ability to reconceptualize a

The pregnant woman is like a ship upon a stormy sea full
of white-caps, and the good pilot who is in charge must
guide her with prudence if he is to avoid a shipwreck.
(``Maladris des Femmes Grosses'', Mauriceau (1668),
quoted in Taussig (1937)).
Medical sociologists, anthropologists and histor-
ians have produced myriad accounts of Western
medicine's successful penetration into our everyday
lives. These scholars have skillfully detailed the mul-
tiple arenas in which our experiences have come to
be understood medically, and the corresponding
cultural centrality of medical metaphors (Dubos,
1968; Szasz, 1970; Zola, 1972, 1975; Sontag, 1978,
1989; Starr, 1982; Oakley, 1984; Martin, 1987;
Oudshoorn, 1994). They have demonstrated our
acceptance of biomedical interpretations and treat-
ments for human behaviors once seen as moral fail-
ures, legal violations or organic experiences
(Foucault, 1966, 1975, 1980; Ehrenreich and
English, 1973; Illich, 1976; Wertz and Wertz, 1977;
Leavitt, 1986; Conrad and Schneider, 1992). In
short, these scholars have documented the medicali-
zation of our lives and the cultural authority we
have bestowed scienti®c medicine.
Importantly, this tradition of scholarship has
made evident that histories of medicalization are
not histories of scienti®c triumph per se. Medicine's
cultural authority is not dependent on ecacy
*Author for correspondence.
1067
phenomenon as ``medical'' and an acceptance of
that conceptualization by the public (Foucault,
1975; Starr, 1982; Martin, 1987; Tesh, 1988; Rodin,
1992; Irvine, 1994; Oudshoorn, 1994). In this paper
I delineate the historical sequencing in the reconcep-
tualization of pregnancy as medical. In particular, I
highlight the rhetoric of the early twentieth-century
public health campaign as revealed in the United
States Children's Bureau publication Prenatal Care.
Prenatal Care, ®rst published in 1913, represents
the widespread introduction of a reconceptualized
pregnancy as medically problematic rather than as
experientially and organically demanding. Through
an analysis of this document I demonstrate the
importance of biomedical rhetoric in the rise of
medicine's cultural authority. Additionally, I
demonstrate the ways in which biomedical in-
terpretations often carry (and can come to consti-
tute) a particular socio±political agenda. Beyond
o€ering a reconceptualization of pregnancy as
medical, Prenatal Care advanced a particular class
and ethnic composite of woman under the guise of
scienti®c universalism.
THE CASE OF PREGNANCY
It was not until well into the twentieth century
that the notion of medically monitored pregnancy
evolved, even among obstetricians. Medical texts of
the nineteenth and early twentieth centuries did not
include substantive material concerning the supervi-
sion of ``normal'' pregnancy. Correspondingly,
1068 K. K. Barker
medical prenatal care did not exist at the turn of
the century (Speert, 1980). By 1900 50% of all
women in the US had physician-attended births
(Leavitt, 1986) but only women experiencing severe
complications saw their physician prior to the onset
of labor (Speert, 1980). Little data exists concerning
the rates of prenatal care utilization in the early
century. In fact, national statistics were not col-
lected until 1972 and even then only thirty-eight
states and the District of Columbia were included.
This lack of data is in part illustrative of prenatal
care's lack of historical salience. Piecing state, re-
gional and local data together, I estimate that less
than ®ve percent of pregnant women in the United
States had any contact with a physician prior to
delivery in the ®rst two decades of the century.
Even fewer yet received routine prenatal care
(Woodbury, 1926; Barker, 1993). As late as the
1940's most pregnant women received no medical
prenatal care. In startling contrast, ninety-six per-
cent of pregnant women in the United States
received some regular medical prenatal care in 1994
(US Department of Health and Human Services,
1996). Undeniably, the nine-month period of preg-
nancy became medicalized during the twentieth cen-
tury. While almost no women saw physicians prior
to delivery in the early century, almost all pregnant
women receive such care today.
Of course, one explanation for the medicalization
of pregnancy is that at some point during the twen-
tieth century biomedical prenatal care began to
o€er real ways of reducing the infant and maternal
mortality rates. Historically plotting these mortality
rates against the introduction of prenatal care
reveals the inability to attribute their reductions to
medical intervention. Not only did the signi®cant
fall in maternal mortality in the twentieth century
pre-date the widespread use of prenatal care, but
even the modest fall in mortality since the 1950's
has not been convincingly linked to prenatal care.
Twentieth-century reductions in maternal mortality
are almost entirely attributable to the elimination of
postpartum infection and hence related to delivery
practices (speci®cally the increased use of aseptic
and antiseptic techniques), not prenatal care.
Similarly, historical sequencing reveals the limi-
tations of attributing reductions in infant morality
*The author nervously recognizes the political implications
of such claims. I unambiguously assert that too few
medical resources are allocated to poor women and
women of color. This project is not an argument for
further reduction in the already meager state and fed-
eral health programs. Rather, this project calls into
question the allocation of funds in areas were they
o€er little evidence of ecacy. Moreover, and most
importantly, this project (like many others) highlights
the ways in which racism and poverty have health
e€ects which can not be addressed via health policy
but require movement toward social, economic and
political justice.
to prenatal care. As with maternal mortality, the
fall in infant mortality precedes the widespread use
of prenatal intervention. Moreover, even a focused
investigation on the speci®c reductions in the last
twenty years reveals they are not attributable to
prenatal care. A ¯urry of recent articles/editorials in
some of the nation's leading medical and public
health journals raise doubts about the long assumed
relationship between prenatal care and the reduced
likelihood of low birth weight, currently the best
predictor of infant mortality (Huntington and
Connell, 1994; Alexander and Korenbrot, 1995).
Epidemiological evidence demonstrates that during
those periods in which there have been increases in
the percentage of women receiving medical prenatal
care (including the most recent increase during the
1970's), there have not been signi®cant correspond-
ing reductions in the percentages of low birth-
weight babies (Lantz and Partin, 1995). This has
been consistently and disturbingly true for African
American rates. The rate of low birth weight infants
born to African American women has proven resist-
ant to reduction in spite of successful public health
e€orts leading to increased utilization of prenatal
care*.
Though current prenatal care utilization rates
make evident that a biomedical understanding of
pregnancy has become hegemonic in the twentieth
century, the ecacy of medical prenatal care
remains in question. It is my assertion that to
understand the cultural authority of medical prena-
tal care one must explore the process through
which an interpretation of pregnancy as biomedical
was introduced to expectant women.
PRENATAL CARE: THE DOCUMENT AS DATA
Many historical accounts of prenatal care recog-
nize the educational campaign of the United States
Children's Bureau in the early twentieth century as
the ®rst widespread attempt to introduce women to
a biomedical conception of pregnancy (Woodbury,
1926; Wertz and Wertz, 1977; Speert, 1980; Ladd-
Taylor, 1986; Muncy, 1991). Through educational
health clinics, home visits and public health litera-
ture the Bureau set out to save women and chil-
dren. One of the most systematic and sweeping
aspects of the Bureau's campaign was Prenatal
Care, distributed to well over twenty-two million
pregnant women in the ®rst three decades of the
twentieth century (Speert, 1980, p. 144).
Prenatal Care was ®rst issued in 1913 authored
by policy researcher Mrs. West. Published by The
Government Printing Oce, West's version of the
document was distributed by the Children's Bureau
until 1930 at which time a male physician, De
Normandie, revised it. The document was intended
to serve as a handbook for women to consult
regarding their pregnancy and upcoming childbirth.
It outlined decisions they would need to make con-
 Medicalization of pregnancy
cerning their con®nement, guidelines for pregnancy
hygiene, and warnings about the complications and
disorders of pregnancy. Principally, as implied by
the title, Prenatal Care stressed the fundamental im-
portance of medical supervision throughout the
period of pregnancy.
As data, Prenatal Care embodies biomedical
rhetoric about pregnancy as it was ®rst introduced
to women. For the purpose of this paper I use
Prenatal Care by West (1924), and De Normandie's
(De Normandie, 1935) edition. Each year the
Bureau reissued Prenatal Care with a brief intro-
duction authored by the Bureau's Chief. With the
exception of these short introductions the pamphlet
contents remain unaltered during the periods of
1913±1929 and 1930±1935 respectively. My data are
the substantive content of both versions of Prenatal
Care.
TEXTUAL/RHETORICAL ANALYSIS
The use of text as data is common in many aca-
demic disciplines. Historians look to the documents
of a period as evidence of the historical context in
which those documents were produced. Likewise,
anthropologists and sociologists explore the ways in
which a society's texts (as cultural artifacts) provide
a glimpse into that society's composition. Not only
is there considerable precedence for the use of texts
in social scienti®c analysis generally, but textual
explorations have become a widely used technique
among scholars exploring the constructed nature of
biomedical knowledge (Foucault, 1966, 1975;
Oakley, 1984; Martin, 1987; Eyer, 1992; Rodin,
1992). In my analysis I employ a deconstructionist
approach (Brown, 1995) to reveal the cultural
meaning embedded in biomedicine.
Deconstructionism maintains that representations
of knowledge disclose the assumptions of knowl-
edge. Looking at Prenatal Care I focus on what
biomedical information was given to women about
their pregnancy, how that information was pre-
sented to them, and what information was suspi-
ciously absent.
PRENATAL CARE: THE POWER OF BIOMEDICAL
RHETORIC AND THE MEDICALIZATION OF PREGNANCY
Both West's and De Normandie's version of
Prenatal reveal the implicit power embedded in bio-
medical discourse as a mechanism facilitating the
medicalization of pregnancy. However, di€erences
between the two texts illustrate a substantive trans-
formation in the popular treatise about pregnancy
in the early twentieth century. While West's version
introduced a medical conceptualization of preg-
nancy to the general public on a massive scale, De
Normandie's version conceptually isolates preg-
nancy within medical topography. First I outline
the power of biomedical rhetoric introduced by
1069
West (and reiterated by De Normandie) that facili-
tated the rise of medical authority over pregnancy.
Second, I present the salient di€erences between the
texts denoting the institutionalization of an exclu-
sively biomedical conceptualization of pregnancy.
The ®rst page of the body of West's Prenatal
Care (1924) reads:
The ®rst and most natural question which occurs to the
prospective mother is how pregnancy manifests itself. The
presumptive signs of pregnancy are these: (1) cessation of
menstruation, (2) changes in the breasts, (3) morning sick-
ness, (4) disturbances in urination... One of the more sig-
ni®cant signs of pregnancy is the movement of the child in
the uterus. This is commonly called the ``quickening'', and
is usually felt by the mother about the sixteenth or eight-
eenth week. After this there can scarcely be room for
doubt that pregnancy exists, although there are other signs
upon which physicians rely, and only a physician can
make a positive diagnosis' (Prenatal Care, 1924, p. 7).
In this quote four important assumptions
embedded in medical rhetoric about pregnancy are
revealed. First, a biomedical articulation of preg-
nancy is positioned within a disease model requiring
``diagnosis''. Second, physicians alone possess the
sucient means by which to ``diagnose''. Third, a
biomedical articulation delegitimates experiential
knowledge about pregnancy. Though a woman may
stop menstruating and concurrently experience the
enlargement of her breasts, morning sickness,
increased frequency of urination and fetal move-
ment, she can not ``know'' if she is pregnant.
Fourth, a biomedical account of pregnancy is based
on standardizations that come to bracket the nor-
mal from the abnormal. For example, quickening
``is usually felt by the mother about the sixteenth or
eighteenth week...'' thereby making problematic
quickening which falls outside of this range. I will
now look at how each of these assumptions implicit
in the biomedical representation of pregnancy facili-
tated and continue to facilitate our cultural accep-
tance of prenatal care.
Disease-model
Both versions of Prenatal Care brie¯y state that
pregnancy and childbirth are natural events.
Paradoxically, however, both documents are domi-
nated by language and content that repeatedly cast
all pregnancies as potentially pathological Ð poten-
tially disease-like. Unquestioningly, taken in their
entirety both documents are composites of the po-
tential pathological ``nature'' of pregnancy and the
ways of best avoiding that potentiality.
A common mechanism through which Prenatal
Care advances a disease-like conceptualization of
pregnancy is through the application of host±para-
site metaphors (Rothman, 1991). In spite of the
obvious organic nature of the relationship between
woman and fetus, biomedicine's model for the dyad
is analogous to a host±parasite relationship
(Rothman, 1991). Examples of the host±parasite
analogy are numerous in both versions.
1070 K. K. Barker
The mother supplies the building materials in the form of
nourishment that passes through the placenta (afterbirth)
to the growing baby. Therefore her diet must have in it
the foods which contain the proper kinds of building ma-
terials... If the baby can not get what he needs from the
mother's food, he will take it from her body (Prenatal
Care, 1935, p. 6).
Similarly:
The substances needed to build teeth are mineral salts
(lime and phosphorus) and certain vitamins. The baby will
take them from his mother's body if he does not get them
through her food... (Prenatal Care, 1935, p. 18).
The ability to simultaneously represent pregnancy
as natural and disease-like through such devices as
the host±parasite metaphor also establishes a dis-
cursive means by which to move pregnancy under
the rubric of medical control. There are frequent
examples in both versions of Prenatal Care that
demonstrate the link between naturalness, precar-
iousness and medical supervision. The following
appears in a section devoted to childbirth:
This act is a natural one and, though it is painful and tir-
ing, it should end normally with a healthy mother and a
healthy baby. It probably will have this happy ending if
the mother has had proper care during her pregnancy...
(Prenatal Care, 1935, p. 35; 1924, p. 26 with minor word
changes).
As is evident, one of the most obvious impli-
cations of postulating pregnancy as disease-like is
that it requires medical supervision to avert disaster.
From the ®rst page of Prenatal Care (1935):
More important than anything else in planning the best
possible care for mother and child is that the mother
should go to a doctor for examination and advice just as
soon as she thinks she is pregnant and should remain
under his constant care until the baby is born (Prenatal
Care, 1935, p. 1).
Even more dramatically from 1924:
Many a case of life-long invalidism has resulted from the
lack of suitable and sucient attention from the doctor...
the extra dollars spent then may save a greater and poss-
ibly futile expenditure later (Prenatal Care, 1924, p. 21).
This intersected with the real fears of millions of
women who read this document in an era character-
*Letter from B. S., New York, September 28, 1926.
{Response to B. S. from Russell Anderson, Division of
Maternal and Infant Hygiene, October 1926.
{These letters are from the US Children's Bureau
Central File at the National Archives in Washington,
DC. They are the primary data base for a related
research project I am currently conducting (1997). My
total sample includes 131 letters selected from the
Central File written between 1920 and 1936. The limi-
tations of the Children's Bureau Central File system
made random sampling of letters impossible (See
Ladd-Taylor's discussion on primary sources). Using
the Bureau Central File Catalog I traced all women's
letters cataloged under pregnancy, childbirth, obste-
trics, gynecology, midwifery, prenatal care, Sheppard-
Towner and Title V of the Social Security Act. The
sample includes all letters cataloged under these sub-
stantive areas.
ized by high maternal and infant mortality rates.
Yet what the document advocated, medical prenatal
care, had no demonstrable impact on maternal and/
or infant mortality rates. Even the Children's
Bureau's own research failed to support the ecacy
of medical prenatal care (Woodbury, 1926). Still,
Prenatal Care represented pregnancy as ``naturally''
disease-like thereby situating pregnancy under medi-
cal jurisdiction.
As seen in the above quotes, casting pregnancy as
disease-like meant casting the pregnant woman as
patient. In Foucauldian terms, the ``gaze'' or focus
on the subject as patient comes to create the subjec-
tive sense of patient (Foucault, 1975, p. 90). ``New
objects were to present themselves to the medical
gaze in the sense that, and at the same time as, the
knowing subject reorganizes himself, changes him-
self, and beginnings to function in a new way''
(Foucault, 1975, p. 90). Whereas the pregnant
women in pre-medical terms organized her experi-
ence around the notion of pregnancy as organically
dicult, in medical terms her pregnancy would
come to be de®ned around her identity as patient.
Certainly the appearance of medical rhetoric
about pregnancy alone was insucient to constitute
patient subjectivities on the part of pregnant
women in the early twentieth century. For decades
a tension would exist between pre-medical and
medical understandings of pregnancy. One woman
who received Prenatal Care wrote the Children's
Bureau in 1926 about feeling moody and uncomfor-
table in the later stages of her pregnancy
(Children's Bureau Letter 66*). Explaining that she
was too poor to go out and see a movie or hear
music, she asked if the Bureau might suggested
some novels she could read to keep her spirits high.
She received a letter from a woman physician sta€
member at the Bureau who, disregarding this
request completely, instructed her to see a doctor at
least once a month and to follow all his directions
carefully (Children's Bureau Letter 67{). This
exchange and hundreds of similar exchanges
between pregnant women and the Children's
Bureau sta€ illustrate the competing ways of mak-
ing sense of pregnancy in the early century{.
Pregnant women were encouraged by medical
experts to see their condition as medical and them-
selves as patients in spite of their own non-medical
conception of their pregnancies. This tension would
play itself out during the ®rst half of the century at
di€erent rates among women of di€erent social
classes, race and ethnic groups, and geographical
regions. Ultimately the hegemonic interpretation of
pregnancy would become the natural yet precarious
medical interpretation with which we remain fam-
iliar.
Physicians and technological diagnosis
Physicians' increasing reliance on scienti®c instru-
mentation in their therapeutic environments in the
 Medicalization of pregnancy
early twentieth century would become key in the
rise of medical authority generally, and over preg-
nancy speci®cally. A biomedical articulation of
pregnancy as outlined in the document Prenatal
Care makes evident that the application of scienti®c
instruments to the pregnant body produced infor-
mation/knowledge the patient could not accumulate
on her own. For example, Prenatal Care outlines
the importance of a urine test by a physician to
detect abnormalities in kidney functioning associ-
ated with toxemia:
The patient herself can draw no conclusions from the
appearance of the urine. Albumin and sugar, the two most
signi®cant abnormal elements, give no clue to their pre-
sence save in response to speci®c chemical tests (Prenatal
Care, 1924, p. 14).
Likewise, complications emerging from elevated
blood pressure, while undetectable to the woman
herself, require surveillance via the application of
scienti®c instrumentation.
My claim is not that scienti®c instrumentation
and measurements were (or are) bad or that the
body they measure was (or is) constituted only
through them. Without scienti®c tools one cannot
see most chemicals in one's urine nor measure one's
blood pressure. Without denying the ontological
body I assert that these tests and instruments chan-
ged the understanding and experience of pregnancy
in the twentieth century. A picture appears in the
1935 monograph providing a visual representation
of the technological monitoring of pregnancy. The
woman in the picture de¯ects her eyes from the
instrumentation that provides the physician with
new knowledge about her body. The technological
monitoring of pregnancy advocated in Prenatal
Care Ð urinalysis, the stethoscope, and blood
pressure screening Ð gave physicians information
that was unobtainable, unseeable, and unintelligible
to the patient. Moreover, technological surveillance
reduced a physician's reliance on a patient's descrip-
tions of symptoms, consequently expanding the
asymmetry of power between the two parties
(Reiser, 1978). According to Starr (1982) ``... from
the patients' standpoint, these detached technologies
added a highly persuasive rhetoric to the authority
of medicine'' (p. 137).
Alternative modes of knowledge
The biomedical rhetoric of pregnancy eroded the
basis of pre-scienti®c understandings of pregnancies;
in essence, it moved pregnancy out of its pre-medi-
cal discursive space and pulled it into medical
space. Already seen was the dismissal of a woman's
reliance on signs from her own body as indicators
of pregnancy. Also evident in Prenatal Care are
examples of dispelling traditional ``folk wisdom''.
The following are but two instances:
One of the common sayings regarding pregnancy is that
the prospective mother must ``eat for two''. But since it is
an established fact that the child gains nine-tenths of its
1071
weight and substance after the ®fth month of pregnancy,
it is manifest that before that time there can be little need
for any addition to the mother's diet... (Prenatal Care,
1924, p. 9).
There is no truth to the old saying that a ``sick pregnancy
is a safe one'', and it should be entirely disregarded
(Prenatal Care, 1924, p. 17, 1935, p. 31).
The biomedical rhetoric of pregnancy dismissed
the merit of folk wisdom by de®ning it as back-
ward, ignorant, and in fact, dangerous. I am not
making the simplistic or universal assertion that
``folk-wisdom'' is good and/or biomedical knowl-
edge is bad. Rather I am asserting that biomedical
rhetoric in Prenatal Care undermined non-scienti®c
information about pregnancy. While perhaps only
coincidental, the above two quotes are examples of
the factual distortions of biomedical science and (at
least in part) the accuracy of folk-wisdom. In the
®rst quote the critique of ``eating for two'' ignores
that there is necessary weight gain beyond that of
fetal weight during the early stages of pregnancy
(including placenta weight). Moreover, there are
nutritional needs early in pregnancies that require
dietary additions Ð most notably, folic acid. The
second quote condemns the folk saying ``a sick
pregnancy is a safe one'' which I assert highlights
the non-pathological nature of physical discomfort
during pregnancy. For example, given that an over-
whelming majority of women experience ``morning
sickness'' during their pregnancies, identifying this
discomfort as normal may provide women with
solace.
Importantly, with the delegitimation of non-scien-
ti®c knowledge about pregnancy comes a shift in
who is seen as expert. No longer is experiencing
childbirth itself necessary training. Experiential
knowledge is replaced by scienti®c knowledge and
the physician replaces the mother (Mrs. West) and
midwife. One of the most interesting observations
in both versions of Prenatal Care is the total
absence of material on midwifery. In fact, the word
``midwife'' appears only once in the entire docu-
ment and it is on the enclosed copy of a birth regis-
tration form. The document itself does not mention
midwifery. This is peculiar given that well over
40% of all women still had midwife-attended deliv-
eries when the document was ®rst published and
among rural and racial/ethnic minority women,
those rates were as high as 75% (Woodbury, 1926).
By 1935 only 20% of all women had midwife-deliv-
eries but failure to mention the ``midwife'' in a 62-
page text seems oddly strategic. By making no
reference to midwives in spite of their widespread
use, Prenatal Care literally pulls them out of the
rhetoric of maternal health. The only possible in-
terpretation for the total neglect of midwifery in
Prenatal Care is a deliberate attempt to remove the
midwife entirely from the public discourse around
and understanding of pregnancy and childbirth. By
keeping midwives out of a public health document
1072 K. K. Barker
outlining how to have a healthy pregnancy and
childbirth, Prenatal Care represented a strategic
and powerful rhetorical attempt to reconceptualize
women's maternal health needs.
Again these examples reveal the discrepancy
between the rhetoric of Prenatal Care and the ma-
terial experiences of pregnant and birthing women
in the early twentieth century. Merely writing folk-
wisdom and midwives out of the public health dis-
course on pregnancy and childbirth did not remove
them materially. Medical and pre-medical under-
standings of pregnancy co-existed for several dec-
ades as they overlapped and intersected with one
another. With the weight of scienti®c expertise
behind it, Prenatal Care brought a new, modern
representation of pregnancy into the homes of
millions of women. ``Prenatal Care's'' silence on the
issue of midwifery foreshadowed the eventual tri-
umph of the modern biomedical interpretation over
its traditional predecessors.
Rationalism, standards, and bio-power
The biomedical model is based on the principle
of rationalism Ð the establishment of scienti®cally
determined standards generated through the ac-
cumulation of data (Warner, 1986; Good, 1994).
Facts about the physical body generated through
this paradigm create what is assumed to be a uni-
versal (normal) composite of the body from which
deviations are recognized as abnormal. This nor-
mal±abnormal binary legitimates diagnoses, treat-
ments and/or medically prescribed behavioral
changes. Foucault (1975) identi®ed this form of
power/knowledge as bio-power.
There are many examples of bio-power in
Prenatal Care. Two obvious examples from the
texts surround the issues of mental hygiene and
restrictions on work and mobility. Both of these
examples attempt to limit and control pregnant
women through presumably objective, universal cri-
teria that best ensure a healthy pregnancy outcome.
Moreover, through these criteria a rigid composite
of Anglo, bourgeois mother as universal ``woman''
is advanced. Consequently Prenatal Care reveals the
ways in which the bio-power of scienti®c discourse
is in part, grounded in its class, race and ethnic
assumptions and agendas.
Mental hygiene. Both the 1924 and 1935 version
of Prenatal Care outline the importance of happi-
ness and mental poise for a healthy pregnancy out-
come. Through this material, a representation of
mother as bourgeois woman situated within a bour-
geois, romantic marriage is advanced. From 1935:
Con®dence, contentment, a happy anticipation of the new
life that will be hers to guide, and a cheerful acceptance of
this responsibility Ð these are the signs of mental poise.
The mother will keep this poise much more easily if she
and her husband are working together to make their home
world a happy place for the baby to be born into. The
prospective father can help by showing that he wants to
help. Then he can speak gently and not claim the privilege
of being cross because he has come in tired from his day's
work. Pregnancy is not a disease, but it is ``nature under a
strain''; and the strain may show itself in overwrought
nerves if there is jangling instead of peace in the family
(Prenatal Care, 1935, pp. 20±21).
Also from 1935:
The mother should have pleasant exercise, out-of-door
life, pleasure, cheerful society, and should be surrounded
as far as possible with things that interest her (Prenatal
Care, 1935, p. 48).
The ways in which the objective prescriptions for
a healthy pregnancy are prescriptions for bourgeois
womanhood are obvious. In other words, the pre-
scriptive bio-power in these documents are examples
of the intersection of popular medical and class
rhetoric.
Restrictions on work and mobility. There are
many examples in Prenatal Care where class
assumptions about women's time and work are evi-
dent. ``Prenatal Care's'' medical advice for a healthy
pregnancy outcome describes the bourgeois house-
wife with all her privileges and concurrent restric-
tions. Both documents stress the need to avoid
fatigue in ways that clearly prohibit an average
workload either in or out of the home. Frequent
naps, easy walks in fresh air, and other pleasant
and relaxing activities are outlined in detail.
Spend at least two hours of each day in the open air, and
as much more as possible... Easy gardening work is a
good form of exercise and diverts the mind agreeably, but
it must be merely an amusement, not a compelling task
(Prenatal Care, 1924, p. 11).
The wording changes slightly in 1935 noting that
gardening ``... should not be a task that must be ®n-
ished, but a diversion that may be stopped at will''
(Prenatal Care, 1935, p. 13). Work that is identi®ed
as necessary should be avoided. This biomedical
advice centers on bourgeois notions of womanhood
in which activities are disentangled from tasks; the
former is permitted and the latter discouraged. The
advice is given as if bourgeois class privilege could
be extended to all women. As a biomedical de®-
nition of pregnancy is advanced, ideal womanhood
is also constituted through the con¯ation of medi-
cal, gender and class rhetoric.
The other side of female bourgeois privilege Ð
restriction Ð is also evident in Prenatal Care.
Again, these are examples where gender, class and
biomedical rhetoric become con¯ated. The de®-
nitions of a precarious pregnancy and the bourgeois
housewife come to constitute one another in ways
that discursively limit women's mobility and per-
sonal freedom.
Motoring over rough roads or for long distances should
be avoided if possible. Driving an automobile involves an
additional risk and should be done moderately and cau-
tiously. A long railroad trip or a long sea trip may cause a
miscarriage or a premature delivery; journeys should be
avoided unless absolutely necessary (Prenatal Care, 1935,
p. 14).
 Medicalization of pregnancy
Perhaps the best example of the class-laden,
restrictive nature of biomedical rhetoric in Prenatal
Care is found in the text outlining the ``lying-in''
period (that time immediately after delivery).
Most women are able to sit up in a chair for an hour on
the tenth day; they may be walking about the room
usually after two weeks and the end of the month be able
to go up and down stairs, but in all cases it is well for the
mother to refrain from full activity for six weeks (Prenatal
Care, 1924, p. 31; 1935, p. 42, minor wording changes).
As in earlier examples, the bio-power of medical
prescription is grounded in its gender and class
agendas. The universal medical advice about preg-
nancy and childbirth in Prenatal Care is also a dis-
course that constitutes the pregnant and birthing
woman in clearly class-based ways in spite of its
presumed class neutrality.
Of course historical accounts of women's lives
defy such medical advice. Though extreme in com-
parison, scholarship on the experiences of pregnant
and birthing women on the Oregon Trail highlight
the gap between prescribed and possible mobility
(Butruille, 1993). On a much more general level, the
work obligations of early twentieth century women
both in and out of their homes would have been at
complete odds with such restrictive advice (Kessler-
Harris, 1982, 1990). The inability of women of all
but the most privileged class to conform to such
advice again demonstrates the gap between the new
interpretation of pregnancy and the material experi-
ences of women. Merely writing childbirth into this
precarious state did not result in women's adoption
of this rhetoric. Biomedical prescriptions stood well
outside the abilities of nearly all women. Still, the
rhetoric o€ered a conceptualization of pregnancy to
the general public that would gain cultural auth-
ority over the next several decades. As is evident in
the rhetorical shift between the 1924 and 1935
monograph, the campaign embedded in Prenatal
Care would continue the movement toward the
medicalization of pregnancy in the early decades of
the twentieth century.
PRENATAL CARE: THE INSTITUTIONALIZATION OF
MEDICALIZATION
While the unifying themes in both versions of
Prenatal Care reveal their common embeddedness
in the biomedical model, important di€erences exist
between the monographs. Compared to the 1924,
Prenatal Care 1935 moves sharply away from the
focus on what women could do for themselves to
ensure their safety and the safety of their children
to the elemental need to defer to a physician. There
is a shift away from hygiene to a focus on medical
supervision; a shift away from preventive remedies
to a focus on medical therapeutics; and an increas-
ing emphasis on the need to monitor all pregnancies
using technology. As made evident in the changing
authorship from 1924 to 1935 there is a shift in
1073
who can be an expert. The educated woman refor-
mer who is herself a mother comes to be replaced
by the scienti®cally trained male physician.
The 1924 heading ``Complications of Pregnancy
and How to Avoid Them'' is replaced by
``Common Disorders of Pregnancy'' in 1935. While
they contain information regarding the same ``com-
plications'' or ``disorders'' (nausea and vomiting,
heartburn, varicose veins, etc.), the spotlight on pre-
vention in 1924 is replaced with the need to defer to
a physician in 1935. In 1924 West advises that per-
sistent symptoms be brought to the attention of a
physician if home remedies fail to bring relief. In
1935 if a woman experiences heartburn or vomiting
``the doctor must be told at once so that he may
direct appropriate treatment'' (Prenatal Care, 1935,
p. 29). Between 1924 and 1935 the complications,
now disorders, are no longer matters that can be
controlled by women through hygienic practices,
but rather must be medically ``managed''. The
articulation of pregnancy as an increasingly severe,
chaotic predicament necessitating medical expertise
crystallized between these two versions of Prenatal
Care.
All of these examples clearly illustrate the deliber-
ate discursive subordination of hygiene to medical
therapeutics. Concurrently, control and authority
over pregnancy was removed from pregnant women
and placed in the hands of scienti®cally trained
physicians. Perhaps the single most telling contrast
between the 1924 and 1935 version is found in the
content of their lists of the rules of pregnancy
(Table 1).
The increased medicalization in 1935 is unmistak-
able. In 1924 the ®rst seven points are hygienic in
focus and only two of the ten points spotlight
women's medical needs. The ®rst four items in the
1935 list emphasize women's medical needs and
stand in sharp contrast to the hygienic focus of
1924. The material on hygiene is present in the 1935
list and the text more generally yet its relevance has
become secondary, subsumed under the increasingly
medical-centered articulation of pregnancy. This
shift is evident in countless comparisons between
the 1924 and 1935 version. The location, forceful-
ness, and centrality of the material about continual
medical supervision throughout the course of preg-
nancy makes evident the shift away from self-care
and personal hygiene central in the 1924 mono-
graph, to deference to physicians and medical thera-
peutics in 1935.
In Medical Nemesis, Illich (1976) asserts that the
penetration of the medical model into new terrain
restricts and often destroys an individual's ability to
deal with her or his own health. The opening quote
from this paper illustrates the positioning of women
in early medical rhetoric. In his 1937 presidential
address at the annual meeting of the American
Association of Obstetrics and Gynecology, Taussig,
quoted from Mauriceau's obscure seventeenth cen-
1074
Table 1. Rules for pregnancy, Prenatal Care, 1924 and 1935
Prenatal Care 1924
(1) Guard scrupulously against continued constipation.
(2) Avoid and excessive quantity of meat.
(3) Drink a liberal amount of water.
(4) Take plenty of out-door exercise and keep all the rooms of the
house well ventilated day and night.
(5) Bathe every day.
(6) Wear light but suitably warm and comfortable clothing.
(7) Sleep at least 8 hours out of 24, and do not become overtired at (7) Drink eight glasses of water a day.
any time.
(8) Have the urine examined at stated intervals.
(9) Strive to be happy, seek self-control, and do not worry.
(10) Consult the doctor when symptoms of illness persist.
(Prenatal Care 1924: 17).
tury text Maladris des Femmes Grosses. Mauriceau
equated the pregnant woman to a ship upon a
stormy sea and the physician to ``the good pilot''.
According to Taussig (1937), Mauriceau's notion of
prenatal care entered the modern era with scienti®c
discoveries making possible the detection of eclamp-
sia and toxemia through the presence of albumin in
the urine (1843) and increased systolic blood press-
ure (1894), respectively. In Mauriceau's metaphor
retold by Taussig in 1937, the woman is to be
guided ``with prudence if he is to avoid a ship-
wreck''. Strangely, the woman becomes object, the
physician the subject. Between the ®rst printing of
Prenatal Care in 1913 and its revision in 1930,
Mauriceau's ``woman as object'' had culturally soli-
di®ed in the biomedical conception of pregnancy.
The pregnant woman's ability to know her own
body through experience and exercise self-hygienic
techniques to ensure her health had become essen-
tially super¯uous in contrast to her new, primary
patient status. Her status necessitated technological
monitoring, abstracted her body, and created an
inequitable distribution of power between the new
patient and physician.
CONCLUSION
The pregnant woman in early twentieth-century
United States found a representation of herself as
patient in the text Prenatal Care. The extent to
which this textual portrait gave composition to her
expectations and experiences would have largely
been determined by forces that the document denied
(class, race, ethnicity and geographical location).
During the course of the twentieth century, a bio-
medical representation of pregnancy would increas-
ingly come to structure viable understandings and
experiences. While there were other competing pre-
K. K. Barker
Prenatal Care 1935
(1) Place herself under the care of a competent physician
(2) Consult him regularly, at least once a month during the ®rst six
months, then every two weeks or oftener, preferably everey week in
the last four weeks of pregnancy.
(3) Have her blood pressure taken regularly.
(4) Have her urine examined at the visit to the doctor.
(5) Guard carefully against constipation.
(6) Avoid a large amount of meat and any other form of overeating
and all extra salt.
(8) Exercise daily out of doors but not to the point of fatigue.
(9) Keep all the rooms of the house well ventilated day and night.
(10) Bathe every day.
(11) Wear light but suitably warm and comfortable clothing.
(12) Sleep at least 8 hours out of 24, rest during the day, and not get
overtired.
(13) Report to the doctor all acute illnesses, especially colds, sore
throat, or persistent cough.
(14) Go to the dentist early in pregnancy.
(15) Report any unfavorable symptom, remembering that she must
at all times be well.
(Prenatal Care 1935: 31).
medical understandings of pregnancy in the early
century, the medical understanding would become
(and remains) hegemonic. The changes between
West's and De Normandie's version of Prenatal
Care highlight this outcome.
Obstetrical prenatal care did not gain nor does it
keep cultural authority among women in the
United States because it o€ered and/or continues to
o€er them maternal health advantages. Rather, the
medicalization of pregnancy during the twentieth
century was the result of a reconceptualization of
pregnancy as biomedical and ultimately an accep-
tance of that conceptualization by women. The
1913 version of Prenatal Care represents biomedical
rhetoric about pregnancy as it was ®rst introduced
to the general public. Though insucient alone,
medical rhetoric as revealed in Prenatal Care facili-
tated the medicalization of pregnancy by constitut-
ing it as disease-like, constructing the pregnant
women as patient, and (thereby) pulling pregnancy
into the domain of medicine. Moreover, the rep-
resentation of pregnancy as biomedical gave phys-
icians a monopoly over the ``knowing'' and
therapeutics of pregnancy and concurrently under-
mined existing ways of knowing (experiential/folk
wisdom). Additionally, a medical construction of
pregnancy constituted bio-power through scienti®-
cally determined prescriptions for best ensuring a
healthy pregnancy outcome. Such ``objective''
advice created the basis for the legitimate control
over the medically constituted human subject; a
control that would always already carry gender,
class and racial/ethnic assumptions and agendas.
Each of these powerful aspects of biomedical rheto-
ric was important in accounting for the medicaliza-
tion of pregnancy.
One must understand the complicated US histori-
cal matrix that made the medicalization of preg-
 Medicalization of pregnancy
nancy in the twentieth century possible. I also have
not addressed the extent to which these processes
were similar or di€erent from those shaping the tra-
jectory of pregnancy outside of the United States
during this time period. I have completely ignored
these complexities in this paper. I have done so to
assert that one must also look at the importance of
medical rhetoric itself in the rise of medical auth-
ority. Though pregnancy cannot be reduced to its
textual representations alone, the representations of
pregnancy in medical rhetoric like those in Prenatal
Care were mechanisms in the medicalization pro-
cess. Medical claims about the materiality of preg-
nancy intersected with and in¯uenced future
experiences of pregnancy; the relationship between
essence and representation is dialectical. Prenatal
Care provides an example of how the rhetoric of
modern biomedicine (based on scienti®c rational-
ism) constructs that which it is presuming to know.
In spite of a lack of demonstrated ecacy, medical
rationalism is the basis for physicians' continued
therapeutic oversight over the nine months of preg-
nancy. Foucault reminds us: ``It is extremely
dangerous to say that Reason is the enemy that
should be eliminated, it is just as dangerous to say
that any critical questioning risks sending us into
irrationality'' (Foucault, 1984, p. 249).
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