Beyond Control?: Resituating Childbirth Pain in Subjectivity

Introduction

Much current childbirth discussion in developed countries focuses on ‘choice’, knowledge and information for women. Women’s choices for ‘natural’ birth, home birth or caesarean birth are supported as rights; ‘natural’ birth activists argue women’s choices are being curtailed; critics of medicalisation argue doctors are making choices on the basis of convenience. In these discussions, women preparing for childbirth are most often represented in contests for control that are best won by carefully considered processes of discernment and decision. As Schultz suggests,

Having a baby now goes well beyond the selection of a mate. Listen to a group of thirty-something  would-be mothers and the conversation is far removed from the old notion of “falling pregnant”. These women don’t fall anywhere, they make informed decisions, there are supplements to take, tests to be had, results to be analysed (2004: 9).

These discussions invoke conventional notions of a rational autonomous subject contemplating various birth options and ‘choosing’ a course of action. In this framing, the birthing body generally materializes as an entity about which choices need to be made, rather than as the place of/for birth. It seems that this often means that pain does not feature as a key issue; as in the following quote from Atul Gawande’s 2006 New Yorker article, ‘The Score: How childbirth went industrial’, pain is briefly touched on before processes, decisions and control are emphasized;

[Elizabeth Rourke] was not afraid of the pain. Having seen how too many deliveries had gone, she was mainly afraid of losing her ability to control what was done to her (Gawande, 2006: 59).

Yet, pain is integral to childbirth, fear of childbirth pain is widespread if not universal and women’s experiences of pain have been central to the processes of childbirth medicalisation. In this article, I am interested to focus on the experience of pain in childbirth, and to explore how this pain might be re-articulated through feminist theories of embodiment and pain. I am drawn to this task by a sense that the persistent invocation of rational choice in childbirth discussions depends on forms of subjectivity that have been critiqued and challenged by feminist theorists as deeply inadequate. I am interested to consider whether an underlying fear that pain cannot easily co-exist with subjectivity underpins and shapes the focus on choice and control in childbirth discourses.

Feminist scholars have long contested versions of subjectivity grounded in assumptions of the instrumentality of the body, where the mind is given preeminence and understood to act as sovereign over the body. They have argued that these hierarchised accounts of mind and body privilege models of masculine disembodied subjectivity and locate women as somehow lesser subjects due to their closer and more intricate relationship with matters of the flesh (Diprose 1994; Shildrick 1997). The birthing woman presents a particularly embedded version of this ‘feminine subjectivity’ since she materially challenges the concept of a distinct and disembodied subject. Her individuality cannot be easily established in the two-in-one corporeal entity of the birthing body, control over the body is problematic in the physical, medical and social terrains of birth and importantly here, questions of pain and consequent loss of ‘control’ haunt childbirth. In this article, I examine contemporary feminist thinking about pain beginning with Elaine Scarry’s (1985) account of pain as disassembling the self and moving towards Sara Ahmed’s (2002) argument that pain establishes boundaries of self and other. I consider Wendy Lee’s (2006) proposition that many of our accounts of pain rehearse the hierarchised Cartesian self and that this rehearsal shapes and delimits our understandings of subjectivity and pain. From these theorizations and intersections, I argue that rather than reducing subjectivity on the basis of ‘diminished’ access to rationality, pain can be understood as potentially constituitive of more complex forms of subjectivity. Relocating pain in birth may offer a way to rethink and resituate women’s subjectivity in relation to birthing.

Pain and the self

In pain, the body becomes a colossal mass of flesh that ensnares the self and the world (Fournier 2002: 63)

Elaine Scarry’s (1985) important examination of pain, The Body in Pain, locates pain as a crucial element of thinking embodiment. Scarry’s account of the impact of pain, of its unknowable and incommunicable character, its capacity to disassemble and destroy subjectivity, as well as its potential to remake, to which I return later, established new critical articulations of the relation between subjectivity and the experience of pain. Scarry argues that pain isolates the experiencing subject, since pain is radically private, creating distance between self and all others. Another’s pain cannot be felt or understood: it can only be expressed in metaphors such as ‘it cuts like a knife’. As well as isolating the self, Scarry argues that pain works to destroy subjectivity and capacity to communicate; pain ‘actively destroys [language], bringing about an immediate reversion to a state anterior to language, to the sounds and cries a human being makes before language is learned’ (1985: 4). Scarry’s account invokes the unknowable nature and the destroying power of pain and points to a reversion or retreat to a place before subjectivity, before language where sensation, unmediated, comprises the whole of the world.

More recently, Valerie Fournier (2002) has suggested a crucial role for pain in the production of gendered embodiment. She draws on the array of social, cultural and religious discourses that link women to pain, including the pain of childbirth, and argues that these critical symbolic connections reveal the processes of gendering women as innately painful and violent. For Fournier, pain threatens the possibility of ‘making ... a self’ (Fournier 2002: 60). The production of female bodies and female subjectivities is through pain inflicted and inscribed on women’s bodies, through effacement and evisceration.

Gender identity is performed (and thus has no ‘essence’) through inscriptions on the body; … these inscriptions do the work of gendering by inflicting pain’ (2002: 58)

Both Fournier and Scarry are suggesting that subjectivity may be reduced by the ‘ensnaring’ capacity of pain; pain engulfs and empties subjectivities; we become ‘nothing but a mass of hurting flesh’ (Fournier 2002: 63). These accounts of the disassembling and destroying effects of pain are helpful in understanding how pain, if it is integral to childbirth, might be understood as threatening women’s subjectivity in childbirth.

Fournier goes further, specifically linking pain and agency, as she argues that the infliction of pain is crucial to the destruction of agency and subjectivity. In the infliction of pain, agency shifts, Fournier suggests, from the experiencing body to the weapon: ‘the process of making pain visible, of re-presenting pain, lifts pain away from the human and attaches its totality, certainty and incontestable reality to something else, to the weapon that inflicts the pain’ (2002: 67). In this formulation, not only is ‘pain … utterly private and subjective … and … [the ground for] a divide between sufferer and observer’ (Whelan, 2003: 464), it acts to remove power and agency from the experiencing subject.

Lee concurs with Fournier that feminist attention must be focused on pain, gender and power as ‘women, especially women marginalized on account of account of ethnicity, culture or economy, remain exceptionally vulnerable to violent actions’ (2006: 277). But Lee is interested in reframing pain beyond the destruction of subjectivity and asks whether there might be applications of pain that work to produce rather than erase subjectivity. This possibility depends on eschewing the constraints of ‘a faint but nevertheless delimiting pulse … [of Cartesian dualism]’ (Lee 2006: 279) which undermines efforts to think beyond mind/body hierarchies and their associated political and social hierarchies. Lee argues that the infliction of pain does not involve erasure or the necessary transfer of agency – rather, pain inflicted in pursuit of power requires recognition, interpretation and understanding from the subjected body in order to take effect. Subjects are ‘not rendered mindless through the experience of pain, but rather quite mindful’ (Lee 2006: 282). Lee’s account has connections to Scarry’s iteration of pain as an embodied experience which draws out, rather than dissolves or destroys, consciousness and sentience; pain requires imagination and intention as the experience brings the body to mind in its ‘aversiveness and deprivation’ (Scarry, 1985: 165). This sense of necessary interpretation and engagement is present too in Rosalyn Diprose’s (1994) careful analysis of pain and its meaning for the biomedical body. Pain ‘tears … the fabric … of being-in-the-world’ (1994: 108) and introduces a ‘split between the self and the body, the self and the world, the self and the other’ (1994: 108). Rather than sundering mind and body, pain calls the body to consciousness, back from an ‘habitual engagement’ (1994: 108), where the body seems absent and instrumental. Lee and Diprose are proposing a more complex relationship between pain and subjectivity, where consciousness and attentiveness may be intensified rather than diminished through the experience of pain. While experiences of pain clearly disrupt conventional Cartesian forms of subjectivity (the mind understood as sovereign over the body) since the body is clearly present and potentially out of control, pain should not necessarily be understood as diminishing or destroying subjectivity. Instead, these accounts point to new possibilities for thinking subjectivity as emerging in and through the body in pain.

The potential of pain as potentially constitutive rather than destructive of subjectivity is addressed by Sara Ahmed (2002), who argues pain shapes both the subjective and the social realms. Ahmed suggests that ‘pain involves the violation or transgression of the border between inside and outside, and it is through this transgression that I feel the border in the first place’ (2002: 21, emphasis in original). Although Ahmed recognizes the isolation and unknowability in pain, she argues ‘the affectivity of pain is crucial to the forming of the body as both a material and lived entity’ (2002: 19); pain is one of the experiences that allows and informs our relation to others and the world. It has potential to connect us to others as well as isolate us from them, to produce sociality as well as isolation, so ‘while the experience of pain may be solitary, it is never truly private’ (Ahmed 2002: 23) since pain invites the witness of others and draws on complex individual and social histories. Ahmed suggests that ‘the amount and quality of pain we feel is … determined by our previous experiences and how well we remember them, by our ability to understand the cause of pain and to grasp its consequences’ (2002: 18). Pain is not before or outside subjectivity as it requires the active ‘re-constitution of bodily space’ (2002: 19, emphasis in original) and involves ‘the transformation of sensation into judgment’ (2002: 19).

Ahmed redraws the relation of pain and the material body and offers a different ground for thinking about pain and subjectivity. Like Lee, she pushes towards an account of pain that does not erase the experiencing subject, or the relational aspects of subjectivity. Ahmed argues for the potential pain has to draw us to our bodies and to others. The way we usually think about birth pain draws heavily, in my view, on the reductive, isolating and erasing power of pain; on the fear that pain will make us less than human by obliterating or dissolving subjectivity. Ahmed’s account offers a useful counterpoint as she draws out the ways in which pain establishes, rather than reduces, experience and subjectivity; she focuses on the communicative and connecting potential of pain. As Scarry suggests in the ‘making’ section of The Body in Pain, the experience of pain is a critical ground for generation, for imagining and transforming, for ‘modest acts of authoring, self-alteration and self-artifice’ (1985: 167). In the next section, I ask whether the productive potential of pain, as articulated in these feminist theorizations, can be usefully introduced to conceptions of subjectivity and pain in childbirth.

Birthing subjectivity and childbirth pain

Pain seizes me back to my body (Ahmed 2002: 21).

The oft-quoted axiom that ‘women forget childbirth pain or they’d never do it again’ points to the unknowability and incommunicability of birthing pain. But childbirth pain, and the fear of it, is central to birthing. Pain certainly haunts birthing preparation especially in Western societies; as Jacqueline Wolf observes there is a ‘terror’ of ‘unbearable pain during labour’ (2002: 366), despite likely available reductions of unbearable pain due to analgesia and some forms of intervention. Birth pain has also, as Katherine Beckett carefully records (2005), has been central to medicalisation, changes in birth practices and to feminist activism dedicated to women’s birthing autonomy, since efforts to manage and control pain have generated many interventions and changed procedures. Most research into birthing suggests that women are afraid of the pain of childbirth (Fisher et al, 2006; Simkin, 2000; Wall, 2000), even with the opportunities for analgesia that currently exist. Patrick Wall presents results from pain questionnaires and says ‘evidently, the average reported pain of childbirth ranks high in human experience’ (2000: 84, see also Niven & Murphy-Black, 2000). In some ways, the ubiquity of childbirth pain may diminish attention to its meaning and salience. But, from Diprose (1994), this point of ‘callback’ when comfortable distinctions between body and mind are challenged though the experience of pain offers an important opportunity to consider the inadequacies of conventional accounts of subjectivity and embodiment, especially for women in childbirth. I consider that pain might be more fully explored and resituated as a ground for subjectivity, knowledge and authority in childbirth.

Investigating the intersections of subjectivity, rationality and embodiment in childbirth has always presented significant challenges for feminists. Many of the discussions of control in birth focus on the movement of decision-making and authority between women, their partners and birth assistants of all types, often with adverse consequences for women (Beckett, 2005; Reiger and Dempsey, 2007). As Fox and Worts (1999) show, the critique of the medicalisation of childbirth by feminist scholars and activitists has been ‘compelling’ (1999: 327). Critical observers of contemporary childbirth (reflecting on the growth of medical technologies, interventions and socio-cultural expectations of safety and control) suggest that as women’s autonomy is compromised by medicalisation, possibilities of blaming and making women responsibility have intensified (see Crossley, 2007; Fox & Worts, 1999). There is a prevailing sense that modern forms of surveillance and technology produce decisions taken on the basis of information gathered independently of the birthing woman and that women’s subject status is consequently lessened in this context. Martin (2003) says ‘culturally, birth has become more real for those with the outsider gaze than those with the lived bodily experience of it’ (2003: 64). In this framing, women are no longer authoritative in their own births (Martin 2003, Akrich & Pasveer 2004; see also Wolf 2002 who suggests this shifting authority has a much longer history).The proposition that ‘women must wrest back control of their bodies from physicians, especially during pregnancy and birth reinforces the notion that positive birth outcomes are something women can control’ (Layne, 2003: 1888).

This desire for control and authority is vitally important in birth choice, as feminist scholars and activists contend, but has implications for how we understand the relationship between subjectivity and birthing. Childbirth conflicts between medical practitioners, or social institutions more generally, and birthing women, who, as Layne (2003) observed, are bound to try to ‘take back’ their bodies seem to centre on who is in charge of this unruly entity. An emphasis on claims for control and choice invokes a particular form of Cartesian subjectivity where the instrumentality of the body is assumed. But feminist scholars have worked to undo this Cartesian myth of embodied subjectivity and many have suggested that in childbirth any lingering assumptions about the instrumentality of the body must be finally put aside. Does this collapse of sovereignty over the body in childbirth take us towards a place where subjectivity is dissolved, as is often assumed, or does it invite attention to new and complex subjectivities that may be produced in birthing? In my view attention to the particular embodied contexts of childbirth and women’s experiences point toward the latter option.

Akrich and Pasveer (2004) examine the birthing narratives of seventy women and argue that embodiment in birthing emerges as a continuing process of negotiating and re-negotiating the relationship between embodied experience and a sense of self as “I”. As the body cannot be silenced or controlled in childbirth, birthing is an event that requires the continuous assembling, disassembling and reassembling of subject position and embodied experience. Akrich and Pasveer (2004) do not focus on one type of birth (vaginal, for example) but argue that all births (whether ‘natural’, ‘medicalised’, satisfactory or not) require on-going mediation by the birthing woman to construct and reconstruct her subjectivity in the intensely demanding physicality of birthing. Akrich and Pasveer argue that the ‘body-in-labour’ is an ‘emerging entity’ (2004: 66) which requires the attention and concentration of the birthing woman to produce. This study suggests that Diprose’s account of the ‘callback’ can be usefully applied here; birthing is a time when habitual assumptions about the mind/body relation cannot readily be maintained. Rather than producing a diminution in subjectivity, the findings of Akrich and Pasveer suggest that all birthing women need to respond, interpret and constitute the changing embodied experiences of childbirth, whatever the course of their labours and deliveries. Relationships between subject and other, subject and world, and understandings of the body as the locus of subjectivity are all emphasized and clearly in need of attention as women deliver. How might we think and understand the specific role and meaning of pain in the context of this need to actively produce subjectivity in birthing?

The pain of childbirth often evokes ideas of reversion, of return to a primal place where the ‘natural’ order reasserts itself and pushes women back into the body, where sentience and sensation come to dominate the embodied subject. The intensity of childbirth pain is often located as the reason for the loss of subjectivity in the birthing woman as agency, intelligibility and authority are threatened. The pain of childbirth pushes a birthing woman into a non-rational space where she becomes other; ‘screaming, yelling, self-centered and demanding drugs’ (Martin, 2003: 54), not ‘feminine’ as Martin suggests but also somehow less than human. The fear of childbirth pain is the fear of the bifurcating and unruly body, which threatens to engulf and dissolve subjectivity. Reasserting choice and control is an important strategy for feminist scholars and activists, but it is a strategy that may accept the premise of the birthing body as a troubling materialization of a ‘less than’ subject, as pain seems to dissolve the woman’s hold on rationality. Scarry’s idea of pain as disassembling the self is particularly useful then for thinking about cultural meanings of pain in birth and the potential threats to subjectivity. For birthing women, this Cartesian model of subjectivity with an emphasis on self-possession and the instrumentality of the body is deeply problematic, since pain, occurring, expected, feared, will always render authority in birthing as provisional and open to collapse into the ensnaring and enslaving, labouring body. If pain threatens subjectivity, then turning away from pain offers a promise of holding onto subject status against the painful materiality of the birthing experience. As Rivera-Fuentes and Birke (2001) suggest in their dialogic account of pain and torture, linking ‘emotion and rationality inevitably gives rise to dissonance’ (2001: 654), since these states/affects are understood as distinct and as emerging from different hierarchically ordered locations. Femininity, emotion and embodiment, which childbirth pain intensifies, are always already at the base of such hierarchies.

It is here that the productive constitution of pain suggested by feminist theorists such as Scarry and Ahmed can be usefully connected to the argument of Akrich and Pasveer that birthing, including pain as a defining element, requires active and ongoing reconstitution of embodied subjectivity. The intersection of these two ideas pushes us towards Scarry’s (1985) articulation of the dual important roles of pain. Pain can disassemble the subject, but pain drives experiencing subjects towards imagination and interpretation.

In isolation, pain “intends” nothing; … it is suffered rather than willed or directed… Pain only becomes an intentional state once it is brought into relation with the objectifying power of the imagination; … pain will be transformed from a wholly passive and helpless occurrence into a self-modifying and, when most successful, self-eliminating one (Scarry, 1985: 164).

Scarry argues for the transformative potential of pain as it is assumed/experienced by the subject. The integrity of the human subject is violated when the ‘body at work [is] separated from the objects of its work’ (1985: 170), when the opportunity to direct effort and exertion in pain is interrupted or disavowed. In this context, childbirth pain could only operate to violate the experiencing subject when it is not owned and authorized by that experiencing subject. This formulation of the constitutive potential of pain as it transformed through ‘work’ or labour of the experiencing subject brings together what Ahmed (2002) suggests about the meaning and impact of pain on the boundaries of self and other and what Akrich and Pasveer (2004) identify as one of the labours of birthing women as they reformulate their “I” throughout birthing. Pain here emerges as an experience which requires interpretation, imagination and transformation to produce and ground the embodied subject. Pain in childbirth may produce, rather than diminish subjectivity.

It is through this movement out into the world that the extreme privacy of the occurrence (both pain and imagining are invisible to anyone outside the boundaries of the person’s body) begins to be shareable, that sentience becomes social and thus acquires its distinctly human form’ (Scarry, 1985: 170).

Rather the acceding to the premise that pain cannot co-exist with subjectivity, that pain threatens subject status, and debating levels and forms of control over the birthing body in pain, Scarry’s account of pain as intrinsic to subjectivity reinforces the active production of self, subjectivity and experience in pain. For the birthing woman, the pain that is assumed, experienced and engaged, even when it is inflicted by medicalisation or in failures of care (Layne, 2003), is an integral part of her presence, experience and authority as the subject.

This resituation of pain offers the opportunity to recognize the specificity of childbirth pain as a crucial aspect of women’s diverse birthing subjectivities. Scarry’s argument that pain is experienced in the mobilization of imagination offers a definition of ‘pain’ beyond the physical sensations of labour (contracting uterus, pressures on the spinal column). It allows us to understand the fear of pain, the experiences of complex and difficult decisions and the management of competing expectations as aspects of the ‘pain of childbirth’. It has long been recognized that ‘labour involves intense pain’ (Niven and Murphy-Black, 2000: 244), but as Ahmed (2002) and Lee (2006) suggest, the intensity and experience of any pain is variable, shaped by context and interpretation and the embodied history of the experiencing subject. The ‘pain of childbirth’ will be shaped by context of the individual birth, each woman’s experience of care and her embodied history; it will include labour pains, but also fears, conflict over decisions and associated social and cultural experiences. Every birthing woman is likely to experience some type of pain in childbirth, whatever type of delivery she has and that pain, its intensity, its elements and its meaning, will be fully known only to that woman. Pain is inherently subjective, as it emerges in the subject, in and through her specific experience of childbirth.

A claim for a refigured form of subjectivity that engages childbirth pain and redraws the relation between pain, the body and the subject as necessarily productive might offer more opportunity for women to speak as authorities in their own birthing. As Ahmed (2002) suggested, pain is crucial in the constitution of the self, of the boundaries between self and others; pain can, as Scarry (1985) finally argues, make the self and the world as well as destroy it. Arguing that subjectivity can and should encompass pain moves us towards a fuller understanding of embodied subjectivity in general and it certainly produces a deeper understanding of agency, embodiment and subjectivity in childbirth. It offers potential for reclaiming women’s authority over their own birthing, since rather than a threat to the subject seeking control over the birthing body, pain may be a ground for claiming authority in that very birth process. I am not suggesting that ‘real labour’ must be painful in order that women can gain power through experiencing it (see Beckett (2005) for a critical evaluation of this notion). Nor am I suggesting that this is a privileged form of subjectivity for women. I am asking whether, if we understand the ‘pain of childbirth’ as encompassing the process of entering into birth, the fear of childbirth, the difficulty of decisions about birth as well as labour pains, we can then locate each woman as the authority, the authoring and knowing subject of her own birth, the only one that can know the extent and meaning of her pain, the only one that can speak in, and for, her birthing body. If pain is relocated as constituitive of birth experience, if pain is understood as encompassing all the complex, troubling and challenging aspects of birthing and asserted as an active process of interpretation and transformation, as the work of birthing, pain becomes a vital ground for knowledge and agency, rather than a potential threat. Rather than seeking control over the birthing body, as Scarry suggested, we look for ‘modest acts of self-authoring’ (1965: 187). And birthing women are the only possible authoring subjects in childbirth.

Conclusion

The body of terror, the body in pain is never sealed off from the rest of the world [even though we might when terrorized or in pain, wish that it were] (Rivera-Fuentes & Birke 2002: 654).

..a precondition for agency and critical consciousness is a lived body open to an undetermined future (Diprose, 2009: 158).

Pain, as Scarry suggested, can make and unmake the world; it simultaneously undoes the social and drives us toward the other; it can’t be truly communicated yet evokes visceral responses in others that demand action, response and engagement. Pain inflects expectations about and experiences of childbirth and pain is integral to the materialization of birthing body. It holds a central place in social, cultural and medical contests over childbirth. It is an ineluctable element of what Ruth Fletcher, following Mary O’Brien, describes as the ‘necessary sociality [of reproductive labour] and ... its integration of rational negotiation and biological process’ (2006: 31). Fletcher suggests that ‘most feminist analysis seeks to chart the various and changing ways in which reproductive practices are organized and limit or enhance women’s … and men’s … opportunities’ (2006: 28) and these opportunities are important to explore, enhance and support. Contemporary debates over childbirth ‘choices’, however, set the boundaries of the debate in the realm of the rational as the locus of power and agency, and the birthing body inevitably materialises as an entity over which control is sought. But these debates and discussions seem to disavow the affect of pain, and its meaning; they fail to acknowledge that all ‘choices’ and decisions are embedded in the pain of childbirth, and they assume a subject in pain as less than a subject.

Childbirth pain emerges in the physical pain of labour, in the pain aroused through fear, in the pain that arises in making complex and difficult decisions; it is integral to all births, whatever their particular course. If we take seriously the place of pain in constituting subjects proposed by Scarry, Diprose, Ahmed and Lee, childbirth pain might be understood as producing a very different form of embodied subjectivity in birthing, where each woman is called back to re-negotiate embodiment and subjectivity anew. And in this re-negotiation, only she can have the authority to speak in and of the pain, the fear and the tumult, to produce the particular embodied subjectivity of her childbirth. Rather than viewing pain, as the potential diminishment of subjectivity, we valorize subjectivity in pain and resituate authority with the birthing woman alone. This will not resolve questions of control and conflict in childbirth, but it would allow pain to be a productive part of these conversations and contests.

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