The elderly primigravida : contest and complexity : a Foucauldian analysis of maternal age in relation to pregnancy and birth : a thesis presented in fulfilment of the requirements for the degree of Doctor of Philosophy in Nursing at Massey University, Palmerston North, New Zealand

Abstract

This study identifies and analyses the discourses deployed by women recalling their experiences of pregnancy and birth at the age of 35 or over, and by maternity service practitioners describing their practice in relation to women pregnant or giving birth for the first time aged 35 and over. The philosophical approach underpinning the study was derived from the works of Michel Foucault, particularly his concept of discourse and its inextricable relationship with power and subjectivity. The data for the study included texts of published medical, midwifery and women's health literature and relevant government policies. The primary source of data was the transcripts from 32 interviews with women, midwives, general practitioners and obstetricians. The analysis reveals the diversity, contest and complexity that exists amongst women and the practitioners in their ways of thinking about prenatal genetic diagnosis, birth, and maternal age in relation to pregnancy and birth. Textual analysis identified two contesting discourses regarding pregnancy and birth: the scientific medical discourse and the natural birth discourse. The scientific medical discourse demarcates the age of 35 as the time when pregnancy and birth become problematic for such women and assigns to them the label of "elderly" primigravida/primipara to signify their different status. Thus defined, "elderly primigravida/primipara" are recommended to be under the care of an obstetrician and to give birth in an obstetric hospital. The natural birth discourse opposes the construction of maternal age as an independent risk factor. Instead speakers reproducing this discourse argue that other factors are the cause of complications experienced by "elderly" primigravida/primipara, in particular the beliefs and fears perpetuated regarding these women and the interventions that occur as a consequence. Each discourse offers competing subject positions for the first time pregnant woman aged 35 or over. She is positioned in the scientific medical discourse as potentially pathological and incapable of giving birth without intervention. In contrast, the natural birth discourse positions her as not different from younger women and capable of giving birth naturally. Maternal age has the potential to further complicate pregnancy in that women aged 35 and over are compelled to consider the possibility of being mothers of a child with chromosomal abnormalities, particularly Down syndrome. Analysis of the texts showed that the participants brought numerous discursive identities into being in relation to prenatal genetic diagnosis. While most of the women and practitioners identified themselves as subjects of the medical genetic discourse, the discursive identities brought into play by the women were quite different to those deployed by the practitioners. Although the choice to undergo prenatal genetic diagnosis is a binary yes/no, the women revealed fragmentary and complex subjectivities. The study found that women assessed their capabilities to mother a disabled child drawing on multiple and contradictory discursive meanings of risk, motherhood and disability. In comparison, the practitioners positioned themselves as enforcers of informed choice, information experts and as vulnerable to discipline. I suggest that the legal discourse's subject position of vulnerable practitioner may complicate the practitioners' positioning and interests in informing women. Women's right to informed choice may compete in priority with the practitioners' desire to avoid being disciplined for the wrongful birth of a child. A further finding of the study is the strategies deployed by women, midwives and general practitioners to resist power techniques such as surveillance. Women's tactic of elusion avoids the normalising gaze of prenatal genetic diagnosis. Similarly, a strategy of opposition is used by midwives and some general practitioners to create an opportunity for "older" primigravida/primipara to keep open the possibility of giving birth without intervention.