Childbirth, Midwifery and Concepts of Time edited by Christine McCourt

BOOK REVIEWS

Nursing Contradiction: Ideals and Impro-visations in Uganda. Helle Max Martin.Copenhagen: AMB Publishers, 2009; ix +189 pp.

Karen Lucas BredaUniversity of Hartford

The Ugandan health care system is wroughtwith difficulties stemming in part from thenational political and social upheavals thattranspired during the postcolonial periodand in part from the devastating AIDS pan-demic. Severe underfunding of the educa-tion and health care sectors as well as fac-tionalism, patronage, and corruption are thebackdrop for Danish anthropologist HelleMax Martin’s fascinating study of nurs-ing in Uganda. This timely and well-writtenethnography is a welcomed addition to thefields of both medical anthropology and theanthropology of work.

Martin researched the educational prac-tices and work life of nurses in a schoolof nursing and midwifery and in health fa-cilities in the Jinja and Tororo Districts ofUganda. The purpose of the study was toexplore “nursing education and service, fo-cusing on the interface between the personand the nursing profession in Uganda to-day” (p. 5). The author provides a cogentinsider’s view of Ugandan nursing educationand practice, detailing the intricacies of thenursing school experience for students andteachers as well as the realities of hospitaland clinic nursing for practicing nurses.

Martin reviews the history and politicaleconomic developments in Uganda, specif-ically the disintegration of the country’shealth care and education systems duringthe postcolonial years and the subsequentattempts to rebuild some semblance of a

functioning health care system. She detailshow these events transpired, the progressivedegradation of the health care system, andthe present day deplorable working con-ditions of health care workers, specificallynurses.

Although nurses in many parts of theworld are trusted and revered by the gen-eral public, nurses in Uganda, or at least inMartin’s ethnographic field site, are lookedon with cynicism and, in some cases, dis-dain. The origins of the antagonistic rela-tionship between nursing and the generalpublic is complex and bound to politicaleconomic as well as sociocultural changes inthe country as a whole. To understand thedynamics of this relationship, Martin art-fully and systematically analyzes the originof this condition and describes how the se-vere underfunding of the Ugandan healthservice and nursing education systems influ-ence not only the image of nursing but alsothe practice of nursing itself. Nurses’ con-stant struggle with their roles, the unparal-leled contradictions they face, and the needto constantly create makeshift and impro-vised methods of care are part of the milieu.

The book is organized into three mainsections. After an introduction of the con-ceptual framework, Part I looks at the his-tory and organization of nursing in Ugandain the context of recent political develop-ments during the Obote and Amin years andthe consequent disintegration of all publicservices, including health and public health.Part II treats the formation and character ofthe student nurse, juxtaposing professionalnursing ideals with the reality of nursingpractice within a dismantled health care ser-vice. Part III focuses on the survival of prac-ticing nurses in the government health ser-vice hospital, concentrating specifically on

543

544 Medical Anthropology Quarterly

corruption, morality, and the contradictionsof what she calls nurses, “domestic” versus“professional” obligations.

Martin studied what it means to be anurse in the difficult environment of thegovernment health care system in Uganda.Rather than considering nursing merely as acategory of work or an occupation or pro-fession to be analyzed, Martin used a holis-tic approach in her ethnographic research.She looked at the nurse as a “whole personconceptualized through the merging of thenurse role and the social person in educa-tion and everyday practice” into what shecalls the “nurse character” (p. 158). Withinthis framework, Martin was able to morefully analyze the rationale behind nursingactions. For example, she explored why anurse might take hospital supplies to use orsell to patients at a later time. An outsider’sview might consider these actions as simplecorruption.

Martin’s insider’s analysis allowed herto look at nurses’ poor working conditions,low salaries, and dismal career opportuni-ties as one part of the equation. She also con-sidered how nurses function in a resource-poor environment to treat acute situationsand provide some semblance of care. Shepaid equal attention to the domestic do-main, that is, the nurses’ complex domesticand extended family responsibilities, such asthe unrealistic expectations made on nursesby their families to care for them in the hos-pital while they were sick, to find work fortheir unemployed relatives, and to supportthem financially. Although families had ex-tremely high expectations of nurses’ socialinfluence, power, and financial status, thepublic often scrutinized and criticized nursesand held them directly responsible for thepoor conditions in the health care facilities.Martin’s unique approach to conceptualiz-ing a profession allowed her to focus on themany contradictions present in Ugandannursing and to expand on nurses’ improvi-sations both in life and in clinical practice.

In summary, this book is rich with de-tail and offers the reader a sound basisfor understanding the extreme contradic-tions within the social relations of nurs-

ing in Uganda. It provokes the reader tothink beyond simple determinisms and tobetter understand some of the complex rela-tionships that exist in resource-poor coun-try contexts. This innovative ethnographywould be useful in both graduate andundergraduate courses focusing on medicalanthropology, medical ethics, and the an-thropology of work.

Substitute Parents: Biological and SocialPerspectives on Alloparenting in HumanSocieties. Gillian Bentley and Ruth Mace,eds. New York: Berghahn, 2009; xviii + 354pp.

Courtney L. MeehanWashington State University

Like all mammalian species, human mater-nal commitment and provisioning is essen-tial to successfully rearing offspring. Yet, anemphasis on maternal exclusivity in childrearing has historically undermined our un-derstanding of human reproduction, life his-tory, developmental psychology, and theevolution of social behavior; and it has hadprofound effects on perceptions of mother-hood. As Sarah Hrdy notes in the prologueof Substitute Parents, throughout our evolu-tionary history maternal commitment alonewould not have been successful. Human fe-males give birth to highly dependent off-spring, have relatively short interbirth in-tervals, provide for offspring long beyondweaning, and support multiple dependentchildren simultaneously. As these costs aremore than a mother could sustain on herown, women must have, and do rely on, avariety of allomothers (nonmaternal care-givers) to assist with reproduction. Thisassistance in caregiving and provisioning,which is ubiquitous in humans, classifieshumans as cooperative breeders. The evo-lutionary history and the effects of cooper-ative breeding in humans today is the focusof this recent volume.

In Substitute Parents Bentley and Macebring together current research in anthro-pology, biology, sociology, economics, andpsychology to explore the evolutionary

Book Reviews 545

significance of alloparental (nonparental)assistance, its cross-cultural variance, andwhat our cooperative breeding historymeans for caregivers, children, and cul-tures throughout the world today. The bookis broadly divided into two sections. Thefirst examines alloparental strategies, ex-ploring questions surrounding the evolutionof alloparental behavior, why alloparentsare motivated to offer care, and how andwhy cooperative caregiving varies cross-culturally. This section begins with a chap-ter by Solomon and Hayes, which presentsan overview of cooperative breeding acrossspecies and explains the evolutionary the-ories regarding the origin of alloparentalbehavior.

The second section examines the effects ofalloparenting on children, exploring ques-tions such as how children respond behav-iorally, emotionally, and physiologically totheir social environments and stress. Thechapters consider whether alloparental carepositively or negatively affects child health,behavior, and responses. However, as is ap-parent in many of the chapters, divisionsbetween alloparental strategies and allo-parental effects on children are difficult toassign as there is a constant interplay be-tween carer and child, each affecting and al-tering the behavior, physiology, and strate-gies of the other.

One of the volume’s successes lies inthose chapters that successfully integrate bi-ological and social perspectives on allopar-enting and those that highlight the vari-ability in care patterns cross-culturally. Inparticular, Sear and Mace’s chapter ex-plores demographic and cultural impactsof alloparenting from historical data ona rural Gambian population. Their exten-sive investigation explores who cares forchildren and alloparental effects on chil-dren’s anthropometric status (height andweight), hemoglobin levels, and maternalfertility (age at first birth and reproductiverate). Flinn and Leone’s chapter, based onresearch in Dominica, examines stress re-sponses in children residing in householdscomposed of one natural parent and onestepparent. They find that the presence of

alloparents can mediate stress and, poten-tially, the negative long-term effects of el-evated cortisol levels on health. Two ad-ditional chapters by Kramer and Valeggiaexamine maternal care and reproduction interms of time allocation. Kramer’s researchamong the Maya offers a detailed explo-ration of the interplay among local subsis-tence, production strategies, and childcareby mothers and allomothers. Kramer pointsout the necessity of allomothers to supportfemale reproduction and the need to exam-ine variation in production and caregivingacross the family life cycles. Valeggia’s con-tribution presents data that asserts that cul-tural change among the Toba in Argentina,and the resulting alterations in demography,nutrition, time allocation and health, havechanged the traditional patterns of alloma-ternal care. Thus, she argues that allomater-nal care is flexible and dynamic.

It is the highly flexible and social natureof allomaternal care that Gottlieb examinesamong the Beng of the Ivory Coast. In Bengsociety, children are surrounded by numer-ous allomothers, which assist mothers withheavy labor demands by creating a rich so-cial world where children are emotionallybonded to numerous caregivers. Althoughmany of the authors stress the seeminglyabundant allomaternal care in traditionalsocieties, van Blerk and Ansell describe, intheir chapter, how culture change and AIDSoften tests the limits of care networks.

Several chapters focus on nonmaternalcare, family dynamics, and social policyin Britain and the United States. Chaptersby Bensel and Belsky highlight the often-contentious scholarly debate over the ef-fects of nonmaternal care on child develop-ment, stressing the novelty of placing same-age children into a room under the super-vision of a nonrelative for hours each day.Both Hrdy and Belsky argue this is a so-cial experiment, of which we have yet tosee the full results. The task ahead of re-searchers in these fields is underscored wellby Gillian Paull, who attempts to disen-tangle economic considerations involved innonmaternal care in the West. Chapters ona school’s role and responsibility in care


(Mayall), the practice of surrogacy (Lycett),and why individuals may be motivated toadopt nonrelated children (Howe) examineboth perceptions of allomaternal care in theWest, and the motivations to offer care tononrelated children. The volume concludeswith a chapter by Robinson, Scanlan, andButler that presents children’s perspectiveon stress and their roles in divorce. Chil-dren’s voices, heard throughout the chap-ter, focus on the stress of divorce and newrelationships developed with parents as aresult of the dissolution of nuclear families.The authors discuss children’s need to seekemotional support, mostly through friends,as children often perceive that support maynot be available through their parents.

Although it is not a textbook, the vol-ume may have particular relevance for grad-uate students and scholars interested incross-cultural caregiving patterns and its ef-fects on fertility, health, child development,and social organization. In particular, somechapters (e.g., Sear and Mace, Flinn andLeone, Bensel, van Blerk and Ansell, andLycett) may be of more interest to MAQreaders than others. A couple of chaptersare, unfortunately, only distantly related toalloparental care; these focus more on chil-dren’s relationship with their parents, thanexplore current cultural or evolutionary per-spectives on alloparental motivation. How-ever, these weaknesses do not detract fromthe overall goal and successes in the volume,which brings together many of the pioneersresearching human allomaternal care. Sub-stitute Parents attempts to bridge biologi-cal and cultural domains to integrate theoryand data on allomothering throughout theworld.

One key success is in the way the bookhighlights both the need to explore allo-mothering from a cross-disciplinary per-spective, and the need to avoid assuminga universal pattern in nonmaternal care.Allomothering is embedded in complex cul-tural, biological, demographic, behavioral,and economic factors, which we are onlyjust beginning to explore. Substitute Par-ents offers a welcome addition to the re-cent interest in the evolution of coopera-

tive breeding, and the effects of allomater-nal care throughout our evolutionary his-tory and in contemporary populations.

Pursuits of Happiness: Well-Being inAnthropological Perspective. GordonMathews and Carolina Izquierdo, eds.New York: Berghahn, 2009; x + 278 pp.

Andrew RussellDurham University

This book is the first to bring togetheranthropologists working on the notion ofwell-being. There are a number of difficul-ties inherent in such an enterprise. First isthe concept of well-being itself. This, likehealth (a frequently mentioned constituentof well-being), is an extraordinarily diffi-cult concept to define. The editors drawon the straightforward American HeritageDictionary definition, “the state of beinghealthy, happy, or prosperous” (pp. 2–3),which they see as connoting “being well psy-chologically, physically, and socioeconomi-cally, and, we should add, culturally” (p. 3).One might question the wisdom of such anaddition, given that the term culture is it-self potentially problematic. Colby (authorof one of the two chapters styled “theoreti-cal background”) would argue for its inclu-sion, but given the discord that exists withinanthropology as to the meaning and evenutility of “culture” at all, others might pre-fer to exclude it. To argue that culture ismore than a context or element shaping theother components of well-being identifiedin the dictionary definition introduces con-tentious issues of objectivity and compari-son. These are chewed over by Colby andThin (the other “theoretical background”contributor), apparently to the discomfitureof the editors, who hold that “most anthro-pologists, including most of those appearingin the remaining chapters of this book, aresceptical of such efforts” (p. 9).

Thin’s chapter questions why, consider-ing the abundant interest in “well-being”among other disciplines (a point made byWeisner in his chapter later on), anthro-pologists have been so silent at the feast.

Book Reviews 547

He invokes the relativist–adaptivist bias inanthropology, which makes practitionerswary of cross-cultural evaluation or judg-ment. He rightly criticizes analysts who pur-port to be writing about (say) health butend up writing about pathology, suggestingthat most anthropologists have assumed,like Tolstoy, that well-being is too boringlyuniform to merit serious attention. He alsocriticizes the cognitivist–social construction-ist bias in anthropology, which ends upbattling with, rather than complementing,biological and evolutionary psychologicalapproaches to topics such as “emotion.”It is almost as if anthropologists too eas-ily follow the lead given by many of thepeople they work with in regarding well-being as a default setting, or something youdon’t recognize until it’s gone. Thin calls thisthe “neutral/positive” semantic nexus, butit could as well be regarded linguistically asthe unmarked–marked nexus, a point madeby Allen about “health” in the ASA volumeSocial Anthropology and Medicine back in1976.

The fact that well-being is what Math-ews and Izquierdo call an “experience far”(etic) concept in most languages and cul-tural contexts poses another problem for an-thropologists. Only in Japanese, it seems, isthere a commonly used word that starts tocapture the existential dimensions of well-being. This is ikigai, translated in the title ofan earlier book by Mathews as What MakesLife Worth Living? Mathews argues thatwhile ikigai is a term unique to Japan, it is aconcept with cross-cultural validity. It can,he suggests, be signified in one’s relationshipto work, family, dreams, or God, and he de-scribes interesting intergenerational changesin the nature and practice of “ikigai.”

One of Mathew’s concerns is the gap be-tween inner experience and outer expres-sion. He suggests that “people in tribal oragricultural societies located significance informs that we can now scarcely comprehendexcept through an effort of the imagination”(p. 168). This seems odd given that threechapters in the book deal with just such“small-scale” societies. Izquierdo’s chap-ter on well-being among the Matsigenka

of the Peruvian Amazon, which has ap-peared in an earlier version in Social Sci-ence and Medicine (2005), makes the pointthat improvements in physical health donot necessarily correlate with improvementsin psychosocial senses of well-being. Heil’swork with Australian Aboriginal people ina settlement in New South Wales (the statewith the longest history of intercultural en-counter on the continent) is a fascinating in-sight into the importance of social practiceand social integration as a prerequisite notonly for well-being but also for marginalizedcommunities confronting “an often discrim-inatory non-Indigenous ‘other’” (p. 105).Her chapter ends somewhat positively withthe suggestion that engagement with non-indigenous practice opens up “spaces fornew forms of meaning” (p. 105). This op-portunity is reflected in the geographicallyvery different experience of the Cree, dis-cussed by Adelson. The Cree, with their del-egated right to “first nation” status, are in amore confident position, culturally speak-ing, than their counterparts in Australiaor the Amazon. “Being Cree” is becomingmore open to reinvention and active engage-ment, even as some young people are losingthe ability or inclination to make the tradi-tional connections among people, land, andwell-being.

Derne reports on interviews with high-caste, middle-class men from merchant fam-ilies in Banaras, North India. He argues forthe importance of social structure in reg-ulating the cultural and psychological ori-entations concerning well-being. His chap-ter complements Jankowiak’s in its time-depth. In further interviews conducted inDehra Dun in 2001, following the mas-sive expansion and transformation in me-dia, goods, and services that India hadexperienced in the intervening 15 years,Derne found young men finding new sourcesof well-being in consumerism and reject-ing media propositions of love marriageand independence from family as “fantasy.”Jankowiak, working in northern China,explores the relationship between politi-cal structures and the cultural and psy-chological orientations emanating from the


synergetic folk system of Confucianism andDaoism. The insularity and parochialismengendered by the Cultural Revolution andits aftermath is now giving way to a muchbetter fit between Chinese philosophical andcultural values and the opportunities avail-able to people (particularly in the larger ur-ban centers), at least while economic growthpersists.

Clark offers a charming evocation ofthe pleasures of the Japanese bath in thefirst of three chapters offering “new an-thropological directions,” although it is onethat is not much discussed by the othercontributors. Perhaps this harks back toThin’s suggestion of an antihedonism orien-tation that precludes anthropologists takingpleasure seriously. The people with whomClark discusses bathing frequently commenthow rarely they normally talk about it (p.194), and questions of well-being initiatedby Izquierdo led to “blank stares.” Peopleworldwide, it seems, rarely discuss the com-ponents of well-being, perhaps for fear itcould make them aware of inadequacies intheir own situation or that doing so might“tempt fate” in some way.

The editors make a valiant effort to drawthe somewhat discordant threads of the re-spective chapters together in both an intro-duction and a “towards an anthropology ofwell-being” reprise (which includes a secondset of chapter summaries, which, with morejudicious editing, could have been incorpo-rated into the introduction). Also somewhatdistracting is the tendency of several of theauthors to berate “Western” perspectives(be they biomedical, social, or psycholog-ical) and to ignore the potential for morefine-grained, intrasocietal variation basedon gender, age, and organizational cultures,among others.

Well-being is a multifaceted concept thatclearly lends itself to more interdisciplinaryresearch. Mildred Blaxter is incorporatedas an anthropologist on page 12, some-thing she would never have called her-self, but other sociologists and psychologistswho have done interesting work in the field(e.g., d’Houtaud) are ignored. There wouldalso be potential to take up the work ofphilosophers such as Seedhouse and writers

such as Antonovsky whose concept of salu-togenesis (the factors that generate health)would add further theoretical breadth tosuch a volume. As a whole (to use an-other well-being term) the book doesn’tseem comfortable enough in its own skin tosupport the recommendation of more thanindividual chapters for student use. How-ever, in its open invitation for medical an-thropologists to consider well-being cross-culturally, this new book is to be saluted.

Reference Cited

Izquierdo, Carolina2005 When “Health” Is Not Enough:

Societal, Individual and BiomedicalAssessments of Well-Being among theMatsigenka of the Peruvian Ama-zon. Social Science and Medicine61(4):767–783.

The Wounds of Exclusion: Poverty,Women’s Health, and Social Justice.Colleen Reid. Walnut Creek, CA: Left CoastPress, 2004; viii + 277 pp.

Neil ThinUniversity of Edinburgh

Colleen Reid’s book provides a good ex-ample of a well-adapted Ph.D. dissertation,with lots of stimulating analysis and empir-ical information on the theme of the socialfactors influencing health, illness, and ac-cess to healthcare. Its empirical case stud-ies and abundant live quotes will make it auseful teaching text, although some of theanalysis of health inequalities, the causes ofill health, and policy responses are a littlenaı̈ve and would need to be complementedby more substantial theories of justice, well-being, and welfare regimes. The book is alsoinstructive for what it leaves out, particu-larly men (as factors influencing women’shealth and experiences) and positive routesto health and well-being; by focusing onultrapoor people and on their suffering,rather than their well-being, the book sitssquarely within the dominant pathologicaltraditions of the social sciences.

Book Reviews 549

The book is clear and straightforward,and, apart from a few moments of enthu-siastic declarations of postmodern antipa-thy to master narratives, it avoids the pre-tentious waffle that bedevils so many socialscience PhDs nowadays. It is a stirring por-trayal of what we can learn about social ex-clusion and health by listening to people’sown stories of how they experience socialexclusion and illness. It centers on 12 briefminiautobiographies of women on welfaresupport who were each interviewed twiceand who attended focus groups to discusstheir situation and experiences and impli-cations for policy and practice. The coreargument is that if people feel socially ex-cluded and experience relative deprivation,they are likely to suffer downward spiralsof mutually reinforcing ill health, low self-esteem, and anger. Slightly optimisticallycalled a “theory of cultural, institutional,and material exclusion” (p. 12), this analy-sis is backed up by vivid empirical evidence.

A good way of understanding suchsocially and physically pathological pro-cesses, Reid argues, is to conduct qual-itative enquiries through face-to-face in-terviews, which allow socially deprivedpeople to speak for themselves. This canbe well facilitated by a Feminist Action Re-search approach as deployed in the WomenOrganizing Activities for Women project, acollective organization in the Tri-City areaof Canada involving partnerships amongacademics, service providers, and womenon low income. Although she wanted thewomen to develop with her a sense of co-ownership of the research effort as fellowmembers of a “Research Team,” she is ad-mirably frank in acknowledging she wasoverly optimistic in that regard, becauseof group conflict and lack of interest inhow the research findings were written up(pp. 65–67, 74–75).

From the start, Reid expresses moral out-rage at the social injustice of inequitiesin health and longevity worldwide and inCanada, where she argues inequities are in-creasing because of globalization and ram-pant capitalist individualism. Arguably amore nuanced approach would accept that

some kinds of inequity have got worse whileothers have got better, and providers of wel-fare systems might reasonably take issuewith Reid’s repeated assertions that healthneeds are best met through redistribution,rather than economic growth. Reid thenproceeds with unseemly haste to the as-sumption we should worry mainly aboutwomen’s health, not just the health of thepoor or the elderly or other vulnerable cat-egories of people. This is a very seriousflaw.

Like so many texts written under a “gen-der” or a “women’s health” rubric, thisbook is bafflingly inconsistent in its appli-cation of social justice principles, and as-tonishingly gender blind. Many years afterthe “women’s health” movement belatedlybegan inspiring a complementary “men’shealth” movement, and many more years af-ter most people involved in “gender” stud-ies ceased to see gender as primarily a setof issues about women and for women, itis hard to excuse any attempts to under-stand health inequalities, or even just poorwomen’s health, without analysis of mas-culinity, femininity, and gender relations.

Notwithstanding, Reid’s provocativechallenges on social justice issues conveyboth empirically and analytically a reallystrong sense of why it matters to listen topoor people’s views on how the indignitiesand material deprivations of being welfarerecipients adversely affect their health andprevent them from effectively accessing thefull range of state benefits to which theyare theoretically entitled. These argumentsmight have been more persuasive if backedup by some plausible theoretical positionson justice and well-being, specifying howmuch well-being, of what kind, everyonein a just world might reasonably expect.If social scientists want to be taken seri-ously as advocates of justice, they mustcomplement their pathological studies withefforts to understand health, well-being,and pathways to these.

Reid clearly shares the poor women’smoral outrage at what they describe as the“two-tiered” public health system, whichis “more difficult to access for people on


low income” (p. 141). Although health ser-vices personnel may like to note that thesewomen experience their treatment of themas derogatory and prejudicial, it turns outthat their substantial complaints were thatthey envy richer people who can stay in hos-pital longer because they can afford babysit-ters or can leave work for longer, and thatthey believe that it’s wrong for them to haveto pay for any health care items (e.g., a pri-vate room in a hospital, expensive specta-cles). Reid complains that they “were unableto access the full range of options to addresstheir health” (p. 141). Policymakers need tohear such complaints but can’t be expectedto meet all demands for expensive welfareservices. It is commendable to help power-less people acquire a voice through partici-patory research, but Reid could have givenmore realistic acknowledgment of the limitsto their wisdom on policy matters.

Finally, I must comment on the dust-jacket advertising. Half of this is taken upwith a very supportive review by AllisonTom, who supervised Reid’s research. An-other selling point on the cover is that thedissertation on which the book is basedwon the 2002–03 Dissertation Award ofthe International Institute for QualitativeMethodology. I’m sure this award was wonfair and square and deservedly so, but theirweb site notes that the award is made inassociation with Left Coast Press, the pub-lishers of this book. Perhaps Reid shouldn’tbe blamed for the incestuous backslappingof the cover, but it suggests to me that sheought to venture beyond the cozy world ofmutually congratulatory feminist patholo-gists and expose her evident research talentsto more robust and varied scrutiny.

Childbirth, Midwifery and Concepts ofTime. Christine McCourt, ed. New York:Berghahn Books, 2009; xviii + 260 pp.

Barbara A. AndersonFrontier School of Midwifery and FamilyNursing

Rarely have I reviewed a more compellingand brilliantly themed work. Incorporat-

ing the wisdom and intellectual prowessof midwives, anthropologists, and midwife–anthropologists, this edited volume exploresthe relationship between concepts of timeand the management of childbirth within asocial constructivist paradigm. Using ethno-graphic methods, writers from various re-gions of the world explore birth in relationto concepts of time in hospitals, in birth cen-ters, and at home births. The central thesisis the management of childbirth within spe-cific cultural measurements of time. Author-itative knowledge, empowered by culturaltime-related norms, further reinforces thosenorms, and defines the limits of tolerance forthe amount of time allowed in giving birth.Rituals surrounding time management inthe birthing process are grounded and re-inforced by shared cultural understandingof how time is defined.

The book is organized into three sub-themes: the historical and cultural con-text of time in childbirth; time in rela-tion to birthing practices; and childbirthexperiences through the prism of timeas narrated by midwives, anthropologists,birthing women, and their families.

An overarching question raised in thebook relates to whose time is the mostvaluable. From the biomedical perspective,the writers suggest that those persons withthe most culturally accepted authoritativeknowledge, those who control and rationtime in childbirth, are the ones whose timeis considered most valuable. Grounded inclock-oriented, linear, Industrial Revolutionmeasurements of time and money, child-birth, as a lightning rod for cultural ex-pression of time, creates a hierarchy of val-ued time. It deplores any “waste” of profes-sional time as a tangible lost resource. Thebirthing women, as “cervix” and machine,and her child, as product, are subject to themanipulation of time as defined by the man-agers of time. Even the word labor denotes acultural framework and assigns the laboringwoman to her role as machine.

In contrast the book presents rich qual-itative and narrative examples of process-oriented approaches to childbirth, placingthe woman, her embodied experience of

Book Reviews 551

time in childbirth, and the birthing messagescoming from her unborn child as the cen-tral foci driving the limits of tolerance fortime in birth. Process-oriented approachesuse an action vocabulary thematically dif-ferent from the word labor. Semantic dif-ferences in childbirth words reflect conceptsof embodied time. Some examples from myexperience are: dar la luz (giving the light),a Spanish expression for giving birth; ljos-moor (mother of light), the Icelandic wordfor midwife; or barnmorska (helping themother of the child), a Swedish descriptionof the midwife. One shortfall of this other-wise stunning work was the lack of attentionto how words describe concepts of time andpower relationships in childbirth.

This book definitely stimulates debatein that it raises the question of theknown versus unknown body. From thebody-known perspective, a production-commodity paradigm arises, necessitatingthe use of externally driven systems to knowthe body (e.g., monitoring during labor),the use of hierarchal and command lan-guage (chain-of-command, in-charge, team-work), the rationing and careful use of re-sources (provider’s time), and a futuristicgoal-oriented outcome (delivery of the prod-ucts of conception, including the baby andplacenta, in a specific time frame). Thisbody-known (my phrase) perspective, theauthors suggest, is grounded in a largeunknown—a fundamental mistrust of thecapacity of the woman and her baby to haveways of knowing about the birthing process.

If, however, we take a physiologicalapproach based on complexity theory,birthing is viewed as a journey, not con-strained or propelled so much by time asby messages from the central actors—themother and her child. This view is present-oriented, allowing for becoming, ratherthan producing. The body-unknown (myphrase) will reveal its secrets in time, anassumption rooted in fundamental trust inthe woman and her child in their ways ofknowing.

As an educational tool, this work haspotential to stimulate new paradigms ofthinking among students and professors in

graduate-level anthropology, public health,nurse-midwifery, women’s health, feministstudies, or sociology courses. There is anongoing and often contentious debate be-tween biomedical interventionist care andalternative, woman-directed care. Certainly,never in my biomedical professional experi-ence have I encountered this debate framedby the prism of cultural time. Nor have Iencountered many health professionals whohave been introduced to the concept of timein childbirth through a social constructivistparadigm. Generally the debate centers onauthoritative knowledge, rituals, the role ofbeneficence by providers, maternal auton-omy, and maternal–fetal conflict of inter-est. The case study of the Inuit birth cen-ter movement in Nunavut, Quebec, as de-scribed in this book, is an excellent teachingmodel and framework for introducing thedebate.

An ongoing theme in this work is theevent of time versus the meaning of time,exposing meaning behind the metaphor oftime in childbirth—the power relationships,the distrust of the body-known that com-pels cascades of intervention, and the per-spective of the body-unknown, a constructthat trusts shared communication amongthe woman, the baby, and the one whoguards their safety and attends them on theirjourney.

Poor and Pregnant in New Delhi, India.Helen Vallianatos. Victoria: Qual InstitutePress, 2006; xiii + 247 pp.

Holly Donahue SinghUniversity of Virginia

The simply elegant title of this book,Poor and Pregnant in New Delhi, India,which is based on dissertation research con-ducted by nutritional anthropologist HelenVallianatos in 2001, belies the complexanalysis of poor women’s beliefs about andpractices of food consumption during preg-nancy that the book contains. Working incollaboration with an NGO focused on ma-ternal health in a jhuggi-jhopri commu-nity (slum or squatter settlement) of about


50,000 in New Delhi that she calls ChandaNagar, fieldworkers from the NGO withwhich Vallianatos was affiliated identified154 multiparous women to participate inthis mixed-methods study. Vallianatos as-sembles an impressive range of material.With continuing food price inflation, thebook is timely and significant in topic; italso raises important methodological ques-tions for future research.

Vallianatos uses the biocultural synthe-sis framework of Goodman and Leather-man (1998) to study the biology of inequal-ity and poverty. This approach asks “howsociocultural and political–economic pro-cesses affect human biologies, and then howcompromised biologies further threaten thesocial fabric” (p. 13; see Goodman andLeatherman 1998:5). Vallianatos locatesher work at the intersection of food, power,and gender with three major emphases:political–economic systems of food, socialenvironments of food, and the intertwine-ments of food and health. She is meticu-lous in outlining the global scene, the majorimplications for India, and how macroleveldynamics affect food consumption amongpoor women in Chanda Nagar. Ultimately,she is more successful in developing the bi-ological aspect of the biocultural synthesisthan the cultural aspect because of linguis-tic challenges and because of choices madeabout how to collect and present the datafrom Chanda Nagar.

The effort by Vallianatos throughout totranslate the technical elements of policydiscussion, methods in nutritional anthro-pology, and biomedical specifications forpregnancy for the benefit of nonspecialistreaders is evident and valuable. Her meth-ods reflect an orientation toward policyreform, and in that sense, her work re-flects sensitivity toward local conditions.Vallianatos, her research assistants, andtranslator conducted several interviews withpregnant women, collecting progressivelymore detailed and personal informationabout their food consumption and experi-ences in pregnancy. In 24-hour food recalls,they carried along a variety of utensils pur-chased in Chanda Nagar as prompts for

women to estimate how much food they hadeaten. The researchers also gathered anthro-pometric data by measuring women’s bod-ies during visits throughout their pregnan-cies. Vallianatos found that most women inthe study were chronically undernourished,(p. 170), yet she found a lower prevalenceof low-birthweight infants (18 percent) thanreported elsewhere for India (25–33 per-cent; pp. 154, 179). She notes that in India,60 percent of urban households reportedspending 60 percent of their income on food(p. 68, as per Swaminathan 2000:29–31)and suggests that babies are protected atthe cost of the mother’s health (p. 179).Biomedical pregnancy recommendationsdisregard the nutritional needs of pregnantwomen who simultaneously breastfeed anolder child. This gap in extant medical lit-erature complicated the analysis of localdata, as Vallianatos points out, becausemany women in the study were breastfeed-ing older children throughout their pregnan-cies (p. 112). The research in Chanda Nagarfacilitates critique of biomedical standardsfor pregnancy, as well as of internationalstructural adjustment programs and Indiannational food distribution programs.

In her discussion of women’s food crav-ings and avoidances, Vallianatos extends, towomen living in poverty under conditionsof structural adjustment, work by MarkNichter and Mimi Nichter, Patricia andRoger Jeffery, and Moni Nag on pregnancyin India and on hot–cold food classificationschemes, often found in humoral systems ofhealing, such as Ayurveda. Women’s actualpatterns of consumption were influenced byideologies about food’s properties, as wellas by financial constraints—but they werenot ruled by them (p. 194). For example,women sometimes recategorized foods tomake them more acceptable for consump-tion during pregnancy.

The focus on food cravings and aver-sions is fascinating here precisely for theimplications it has for thinking through is-sues of decision-making power, agency, andpoverty in pregnancy. In chapter 7, Val-lianatos argues for reconsidering the empha-sis on the infant in maternal–infant care to

Book Reviews 553

focus on maternal outcomes, while statingthat the data about aversions in pregnancyfrom Chanda Nagar generally supportthe “maternal–embryo protection” hypoth-esis of nausea and vomiting in pregnancy(p. 136). However, a variety of women inthe study reaffirm South Asian ideals aboutmothers and motherhood that center onmotherly sacrifices in the interests of thechild. These women said that the fetus de-sires particular foods, or feels disgust to-ward other foods, not the pregnant woman.For example, Yasmin reported that

In the 8th and 9th months I cravedsweets like rasgulla and laddoo, notregularly, just sometimes. I alsocraved fruit, and if good-smellingvegetables were cooking I’d eat them. . . I also craved chili pickle in all mypregnancies. It’s the baby that wantsthese foods, not the woman; it’s thechild who wants. [p. 126]

Other women echo these sentiments;Rihana argued that her baby controlled her,making her feel aversions to certain foods(p. 130). Anokha said that her baby wantedparticular foods, but that she could not al-ways get them because of financial restraints(p. 140). Many women argued that it mustbe the case that the fetus expresses food pref-erences, because their experiences changedfrom one pregnancy to another, and de-pending on the sex of the fetus (p. 127).More detailed consideration of the mean-ings of food consumption in pregnancy andexamination of women’s constructions ofagency, blame, and power in food cravingsand aversions, and their implications forthe health of birthing women and infants,would strengthen this part of the work.

The story that Vallianatos creates aboutfood, gender, and health integrates bio-logical and cultural methods to shed lighton nutrition in pregnancy, and for that itis appropriate for use in advanced under-graduate and graduate courses dealing withwomen’s health, the effects of globalizationon women living in poverty, and interna-tional food policy. The book’s movement

from the global level to the lanes of ChandaNagar is laudable, but it ultimately left mewith an unsatisfied hunger for more vividthick description of the day-to-day lives ofpregnant women in Chanda Nagar. The sto-ries from individual women that appear inthese pages are suggestive of rich experi-ences that have been half told, or left tolanguish in field journals, or perhaps savedfor future publications, in the interest of em-phasizing charts, statistical data, and talk-ing points for policy reform. Collabora-tion with a cultural anthropologist with fullcommand of the local language might helpto flesh out this dimension of the work. Itraises important methodological questionsabout whether certain types of data, such asanthropometric measurements, should andcan be collected in tandem with narrativeperspectives about embodied experiences ofpregnancy that future researchers using abiocultural approach should consider care-fully. I would argue that the repeated in-vasion of a poor pregnant woman’s homeby a team of researchers, including a trans-lator, with a clear affiliation with a lo-cal NGO, to measure her body and orallycollect her food diary, does not create anideal situation for her to freely and fully ex-press her experiences to a foreign researcher.Poor and Pregnant in New Delhi, India,does provide a fascinating contribution to-ward bringing together biological and cul-tural perspectives. It does not provide a fullyconvincing integration of those perspectivesin this single publication, but it does pointto the potential that a mixture of methodshas to generate data for a variety of publi-cations geared toward academic and policyaudiences.

References Cited

Goodman, A. H., and T. L. Leatherman1998 Traversing the Chasm between Bi-

ology and Culture: An Introduction.In Building a New Biocultural Syn-thesis: Political–Economic Perspec-tives on Human Biology. A. H.Goodman and T. L. Leatherman, eds.


Pp. 3–41. Ann Arbor: University ofMichigan Press.

Swaminathan, Madhura2000 Weakening Welfare: The Public

Distribution of Food in India. NewDelhi: LeftWord Books.

Assisting Reproduction, Testing Genes:Global Encounters with New Bio-technologies. Daphna Birenbaum-Carmeliand Marcia C. Inhorn, eds. New York:Berghahn Books, 2009. vi + 297 pp.

Marginalized Reproduction: Ethnicity,Infertility and Reproductive Technologies.Lorraine Culley, Nicky Hudson, and FloorVan Rooij, eds. London: Earthscan, 2009.xii + 207 pp.

Lara BraffUniversity of California San Diego

Since the 1970s, involuntarily childless in-dividuals and couples have increasinglyturned to assisted reproductive technolo-gies (ARTs), like in vitro fertilization (IVF),to help them have children. For anthro-pologists, these technologies have analyticutility: examining them sheds new light onperduring issues of scholarly interest, suchas kinship, gender, nature–culture, person-hood, and social difference. Regarding so-cial difference in particular, anthropologistshave suggested that ARTs exacerbate “strat-ified reproduction”—an expression coinedby Shellee Colen in the 1980s, and later ex-panded on by Faye Ginsburg and RaynaRapp—that refers to how the reproduc-tion of elites is socially privileged over,and sometimes facilitated by, marginalized“others.” “Stratified reproduction” mani-fests in various ways, from population con-trol strategies to the high cost of fertilitytreatments that make them more accessi-ble to the wealthy. It further manifests, asthese two edited volumes contend, throughthe effects of the popular misperceptionthat infertility affects Western elites morethan socially marginalized groups in theglobal North and South. Such groups arefrequently, but falsely, portrayed as “hy-

perfertile” despite evidence that they suf-fer elevated rates of infertility. In seek-ing new ways to cope with the social suf-fering that can be wrought by infertilityand with heightened pressure to reproduce,some of them are now using ARTs even de-spite material and structural obstacles. At-tending to the understudied reproductiveexperiences of ethnic minorities and non-Euroamericans, these two volumes success-fully accomplish their shared goal of in-vestigating new forms of “stratified repro-duction.” In doing so, they show that theproliferation of ARTs is not a neutral pro-cess of technology transfer. Rather, ARTs,like (in)fertility, are always shaped by cul-tural meanings and practices, social obsta-cles and inequalities, and political and ethi-cal regimes.

However, these two volumes take verydifferent approaches to studying the prob-lem of “stratified reproduction.” WhereasAssisting Reproduction, Testing Genes isa compilation of anthropological work onlocal experiences of reproductive and ge-netic technologies mostly based in non-Euroamerican sites, Marginalized Repro-duction is an interdisciplinary volume thatexamines a range of issues—from infertilityto reproductive technologies to healthcareand ethnicity—among ethnic minorities liv-ing in the West. Hence, the books not onlyhave different regional and topical foci butalso make distinct scholarly contributions.

In terms of regional foci, the chaptersin Assisting Reproduction, Testing Genesexamine experiences of infertility and re-productive technologies in a wide range ofsites: Germany, Bulgaria, Egypt, Lebanon,Ecuador, Shia Iran, Vietnam, Israel,Argentina, India, and Brazil. This geograph-ical breadth demonstrates a central aimof the book: to broaden the anthropolog-ical inquiry into reproductive and genetictechnologies by examining their receptionin non-Euroamerican sites in which repro-duction is often privileged and infertilityis often stigmatized. In contrast, Marginal-ized Reproduction focuses on South Asiansin Britain, Turkish women in London,Turkish and Moroccan groups in the

Book Reviews 555

Netherlands, Hmong women in Australia,as well as African Americans, Latino/aAmericans, and Arab Americans in theUnited States. There is an additional chap-ter on perceptions of embryos in Ireland.The editors rightly contend that studyingethnic minorities in the Western context ad-dresses a significant “research lacuna” (p.2). However, it would have been usefulfor them to explain their focus on mostlyAsian and Middle Eastern groups, ratherthan other ethnic minority groups who alsoreside in the West and whose (in)fertilityexperiences are likewise understudied andmisunderstood.

The two books also concentrate on dis-tinct topics. The focus of Assisting Repro-duction, Testing Genes is primarily on re-productive technologies, and the chaptersprogress toward what may be consideredincreasingly complex or novel technologies.In part 1, the chapters examine the local re-sponses to infertility and fertility treatmentin various sites. Part 2 extends this discus-sion to consider how gamete donation andsurrogacy are shaped by moral, legal, mar-ket, and kinship systems. Finally, the chap-ters in part 3 examine adaptations to thefusion of reproductive and genetic technolo-gies through case studies of preimplantationgenetic diagnosis (PGD), embryonic stemcells, and paternity testing.

Several chapters holistically examine thecultural circumstances that shape repro-ductive or genetic technologies and theirsocial ramifications. For example, MelissaPashigian argues that assisted reproductionregulations and the ban on surrogacy aredeveloping in Vietnam alongside politicaland economic reforms, as the nation shiftsto a market economy yet tries to main-tain traditional moral values and structures(such as the centrality of gestation in con-structs of womanhood and motherhood). Inher chapter, Kelly Raspberry contends thatPGD is spurring Argentine practitioners tonegotiate the legal and moral ambiguity sur-rounding in vitro embryos. She shows howtheir negotiations proceed in terms of con-flicting religious and scientific discourses aswell as “desperate hopes and economic in-

centives” (p. 216) as practitioners seek tostake claims to modernity and global sci-ence. Other chapters situate biotechnologieswithin “local moralities” (p. 8) by examin-ing how the reception of fertility treatmentis shaped by religion or local ethics. For in-stance, Soraya Tremayne examines how theShia Islamic religion flexibly allows religiousleaders, as well as practitioners and patients,to accommodate ARTs (incl. gamete andembryo donation) in ways that may alter thevery kinship structures that they seek to pro-tect. The implications of ARTs for genderand kinship are taken up more explicitly inseveral other chapters. For example, MarciaInhorn elucidates the understudied and stig-matized issue of male infertility and its treat-ment among Middle Eastern Muslim men,unraveling stereotypes about them while il-luminating the inadvertent consequences ofARTs for both men and women, family life,and moral order in these sites.

Marginalized Reproduction focuses rela-tively less on reproductive technologies andmore on reproduction and infertility as wellas ethnicity. One of the book’s main aimsis to examine how “ethnicity and culturemight shape the experience of infertility inthe West” (p. 4). As Arthur Greil contendsin the Foreword, the “lens of infertility”(p. xi) can help us better understand ethnicstratification and cultural pluralism; con-versely, the (in)fertility experiences of ethnicgroups deepen our understanding of repro-ductive issues. Hence, the volume serves asa corrective to the ethnocentricity of otherreproduction-related studies conducted bysocial scientists, healthcare policymakers,and others that have overlooked marginal-ized ethnic communities living in the West.Yet, the experiences of people within thesecommunities remain important: for them,fertility often carries high stakes, yet accessto fertility treatment tends to be impeded byeconomic, cultural, and linguistic barriers,as well as institutional racism.

In examining these issues, the volume isorganized into two parts. Part 1 addressessome conceptual and methodological issuespertaining to the study of infertility, cul-ture, ethnicity and, more broadly, the role of


ethnicity in health, healthcare, and socialscience research itself. Part 2 presents qual-itative and ethnographic case studies thatexamine how infertility and fertility treat-ment are experienced within several ethnicminority communities.

Across the chapters, central themes in-clude the health-related effects of institu-tional racism, the gendered constructionof infertility, the implications of culturalpronatalism, and the roles of culture andreligion in infertility and its care. For ex-ample, Pranee Liamputtong provides a nu-anced explanation of fertility beliefs andcare-seeking practices, including traditionalpractices, within a Hmong community inAustralia. In detail, she describes the dis-tinctively Hmong ways in which reproduc-tion is infused by religion, pronatalism, pa-trilineality, and notions of woman’s bodies.Other chapters attend more to how so-cial inequalities impact (in)fertility. For ex-ample, the chapter coauthored by Mar-cia Inhorn, Rosario Ceballo, and RobertNachtigall presents a theory of infertility asa “potent form of ‘health disparity’ in theU.S.” (p. 182). This theory is substantiatedby the authors’ analyses of the infertilityexperiences of African Americans, Latino/aAmericans, and Arab Americans. These areall marginalized groups within mainstreamU.S. society whose infertility is often ren-dered invisible amid currents of racism, clas-sism, and xenophobia.

Ultimately, these two books offer dis-tinct contributions to the social study ofreproduction and reproductive technolo-gies. Assisting Reproduction, Testing Genesusefully extends work on biotechnologi-cal globalization. As editors Daphna Biren-baum-Carmeli and Marcia Inhorn con-tend, “Examining such global encounterswith new biotechnologies tests taken-for-granted assumptions about biotechnolog-ical Eurocentrism, namely, as reproduc-tive and genetic technologies are widelyembraced in diverse non-Western settings,these technologies undergo sometimes pro-found forms of invention and innova-tion, occasionally leading to surprising andunprecedented legal outcomes and socio-

cultural transformations” (p. 3). Indeed,through rich ethnographic accounts, thechapters provide compelling evidence for“technological indigenization”: the pro-cesses by which “those who actually usenew reproductive and genetic technologiesimbue their practice with particular localsensibilities” (p. 3). They illustrate howperceptions and practices of reproductiveand genetic technologies are infused by,and can affect, local moralities, politics,economies, gender–kinship orders, and sub-jectivities. Further, they demonstrate howthese technologies can be either beneficialor inequitable and either culturally conser-vative or transformative as people variablycondone, condemn, resist, or adapt thesetechnologies in diverse contexts. Althoughthese issues may primarily interest anthro-pologists of reproduction and ARTs, somechapters engage broader theoretical top-ics, such as globalization or kinship, thatmay appeal to a wider scholarly audience.For instance, in showing how egg dona-tion can fortify female economic alliances inEcuador, Elizabeth Roberts challenges priortheories of kinship as constituted throughexchanges of women between men, and un-dermines bourgeois notions of the distinc-tions between love and money, public andprivate spheres, and other putative dualities.

However, readers should note that, de-spite its title, the book’s substantive em-phasis is on reproductive, not genetic, tech-nologies. In addition, the question of whatis really “new” about the amendments(third-party donors, genetic testing, etc.)to “older” ARTs (artificial insemination,IVF, etc.) remains somewhat unresolved.Nevertheless, in ethnographically address-ing questions about stratified reproductionand biotechnological globalization in non-Euroamerican sites, the volume makes a sig-nificant contribution to the existing scholar-ship.

In a different vein, Marginalized Repro-duction also contributes to the social studyof reproduction, particularly by virtue ofits interdisciplinary approach. The chap-ters are written by an international groupof scholars that include anthropologists,

Book Reviews 557

sociologists, health researchers, psycholo-gists, social work and social policy scholars,and a reproductive endocrinologist. Hence,the volume presents a range of theoreticalinterests and methodological strategies thatgive the book its broad audience appeal andpractical bent. In fact, one of the book’sgoals is to promote cultural understandingamong practitioners and policymakers. Inthis regard, several authors not only aimto elucidate the reproductive experiencesof minority ethnic groups but also to usethis knowledge pragmatically by, for exam-ple, making visible these overlooked groupsand inspiring public policy that targets theavoidable causes of infertility and disparitiesin its care.

Yet, the argument of several authors thatculture matters with respect to reproductionand fertility treatments does little to advancetheoretical work in this area. And, althoughsome of the authors reject cultural essential-ism, the volume as a whole does not presenta unified view of either culture or ethnicity—a point acknowledged by the editors them-selves. Thus, the chapters vary considerablyin their engagement with these phenomena:some take “culture” and “ethnicity” forgranted; others conflate the two; others in-terrogate them in more sophisticated ways.For instance, Karl Atkin keenly examinesthe social construction of ethnic identity bythinking through the concepts of “diversity”and “difference” in multicultural contexts,while considering the role of institutionalracism particularly in the healthcare arena.

In essence, both books are useful correc-tives to the Euroamerican focus that hasdominated social studies of infertility andreproductive technologies. They shed newlight on “stratified reproduction” and onthe use of ARTs among several understud-ied groups. Assisting Reproduction, Test-ing Genes: Global Encounters with NewBiotechnologies will likely appeal to schol-ars and students of the anthropologies ofreproduction, biotechnologies (particularly,ARTs), and globalization. Marginalized Re-production: Ethnicity, Infertility and Re-productive Technologies may interest so-cial scientists and policymakers concerned

with the role of ethnicity in reproduction,reproductive technologies, and healthcare.Select chapters from both books would beappropriate for an undergraduate or gradu-ate reader on these topics.

Nursing and Globalization in the Ameri-cas: A Critical Perspective. Karen L. Breda.Amityville: Baywood Publishing Company,2009. xi + 381pp.

Denise Saint ArnaultMichigan State University

The purpose of this book is to use criticalmedical anthropological theories and meth-ods to examine the political and economicconditions that affect and shape nursing ed-ucation and practice in selected countriesacross the Americas. This ambitious under-taking has resulted in a book that can serveas a reader for educators in internationalnursing education courses, as well as forstudents examining the way that politicsand economics affect the provision of healthcare.

The editor created a clear and organizedtemplate for contributors to use, which re-sulted in evenly analyzed and presentedchapters, each covering difficult material.The carefully crafted introduction assistsreaders and teachers to track the interac-tions and trends, but sorting through thecomplexity of the material requires diligenceand patience. Readers who do not have abackground in the intricacies of capitaliza-tion, liberalism, or even the generally inter-twined economics across the Americas willstruggle to make sense of the at times densepresentations of these multifarious interac-tions. Therefore, this volume is suited forhigher-level students who want to under-stand nursing care delivery and nursing ed-ucation in its political context.

The thrust of this book is to show how thepractices of nursing and nursing educationare situated in the broader political and eco-nomic climate of their respective countriesand the Americas as a whole. Despite thesubstantial diversity of countries spanningSouth and North America, the reader gains


an overview of the interacting and diver-gent forces that shape the provision of nurs-ing in these countries. The contributions arewell researched and contain important ref-erences and documentation. For example,there is an extensive description of the evo-lution of the Argentinian Health Care sys-tem, including information on critical healthcare reforms. Another section documentsthe entry of nursing into the academy inMexico. In regard to the northern part ofthe Americas, there is a section about U.S.nursing and the dominance of medical man-agement of disease. At times, political enti-ties are not defined, which suggests that theauthors assume that the readers are familiarwith the overarching political and economiclandscape of the Americas despite the sug-gestion in the introduction that the bookwill be suitable for the student beginningtheir study of this topic.

The emphasis on critical medical anthro-pology serves as both a strength and a limi-tation for this volume. One strength is thatthis is a highly focused collection. Becausethe authors use the same concepts and for-mula to examine diverse areas of the Amer-icas, by the end of the book, the reader cangain a very clear sense of how the conceptsand analyses can be applied across vastlydifferent areas. However, this exclusive fo-cus does not shed light on the interactionbetween nurses and the diversities of peoplethey serve. In addition, the reader does notgain a sense of the ways that these politicaland economic forces also shape the health ofthe populations within the countries of in-terest; although this was not of course a goalof the text, it is important for contextualiza-tion. One interesting exception is the sectionin the Canada chapter that documents thechallenges of Aboriginal health. One couldcertainly use critical medical anthropologyto examine issues of gender, power, and racein an analysis of nursing in these countries.This would expand the entries substantially,however, making this volume unwieldy inlength. Perhaps a second, complimentaryvolume might be added to this series.

In conclusion, students of health andnursing in any given country might use these

chapters as one of many pieces of informa-tion about health and health care deliveryfor these countries. In addition, students do-ing study abroad or providing for the healthof people in these countries might use thesechapters to gain an overview of how nursingfits in the larger political and economic land-scape of the countries, region, and other re-lated areas. For medical anthropologists inparticular, this book illuminates how polit-ical and economic issues interact to shapehealth care delivery as well as the forcesthat regulate the education of the healthcare work force, making this book useful incourses related to these topics. In addition,because this book focuses on the Americasin one volume, using the same format andconceptualizations, teachers could use thisbook to compare and contrast political andeconomic forces.

Frameworks of Choice: Predictive andGenetic Testing in Asia. Margaret Slee-boom-Faulkner, ed. Amsterdam: Amster-dam University Press, 2010. 271 pp.

Kin, Gene, Community: ReproductiveTechnologies among Jewish Israelis.Daphna Birenbaum-Carmeli and Yoram S.Carmeli, eds. New York: Berghahn Books,2010. viii + 372 pp.

Sallie HanState University of New York at Oneonta

“Assisted conception is so unprecedentedand the consequences for beliefs about re-production so uncertain that we anthropol-ogists have had our plates full as we try toconstruct theoretical frameworks with ade-quate explanatory power,” Kahn observesin Kin, Gene, Community. As the two vol-umes discussed here illustrate, reproductivetechnologies present opportunities and chal-lenges, not only for the nurses and doctors,religious and spiritual leaders, politicians,and patients who participate in or deal withthem but also for the anthropologists andother scholars who observe their uses.

One challenge in studying reproductivetechnologies is maintaining focus while also

Book Reviews 559

acknowledging the breadth of the topic.Noting the diversity within Israeli soci-ety, the focus of Kin, Gene, Communityis on Jewish Israelis. Yet, as the contrib-utors note, Jewish Israelis themselves aredivided further along lines of Ashkenazi(European) and Mizrahi (Asian andAfrican), religious and nonreligious, Ortho-dox and non-Orthodox, Israeli-born andimmigrant, and so on. There remain ques-tions, too, about others, including “ArabOthers,” in Israel. The volume considers arange of reproductive technologies, includ-ing techniques of assisted conception, suchas in vitro fertilization (IVF); as well, a num-ber of the chapters are concerned with thediagnostic tests that can be performed dur-ing pregnancy or before conception. Frame-works of Choice presents contrasting ac-counts from four Asian nations—India, SriLanka, Japan, and China. Given the dif-ferences between and within each of thecountries, four separate volumes could beproduced. What gives this collection its co-herence, however, is its focus on predictiveand genetic testing. The book is organizedaround the theme of “choice,” demonstrat-ing how and why “choice” cannot explainadequately the expectations and experiencesof individuals, families, and communities.

Taken together, the two volumes describeand discuss the particularities that condi-tion and constrain the uses of reproductivetechnologies, with perspectives from an-thropologists, sociologists, bioethicists, andphysicians. Israel is known as a “pronatal-ist” society and a nation unique in its en-thusiasm for reproductive technologies, anumber of which were pioneered there. Itis a country that provides fertility medicineservices to nearly all of its citizens free ofcharge, and boasts one of the highest ra-tios of IVF centers per capita and the high-est levels of use or consumption of IVF inthe world. Preconception screening of adultsas potential carriers of recessive disorders,prenatal testing of fetuses for chromosomalanomalies, and preimplantation genetic di-agnosis of embryos created through IVF allhave been accepted widely and almost un-questioningly.

An aim of Kin, Gene, Community, how-ever, is to reveal the tensions beneath thesurface. Remennick contrasts the enthu-siasm for assisted reproductive technolo-gies among native Jewish women with thereservations shared among native Muslimand Russian immigrant women. Goldberg’schapter on male infertility and Teman’schapter on surrogate motherhood considerthe disruptions that reproductive technolo-gies represent for Jewish family and Jewishidentity. Surrogacy in Israel is allowed, butTeman suggests that the kinds of restrictionsplaced on the practice indicate the “lim-its” of Israeli pronatalism. Ivry describes theuse of fetal ultrasound imaging in Israel asa “reproductive horror picture show” thatemphasize the potential problems with apregnancy, in contrast to the opportunityfor “bonding” and reassurance about thehealth of a fetus that some feel the scanrepresents in the United States. Ivry sug-gests that Israeli pronatalism is interestednot only in increasing fertility but also in“fetal quality control.” For the contribu-tors to this volume, “pronatalism” repre-sents not the answer but the question; theyask about how and why reproductive tech-nologies have come to be used in Israel.

In contrast to the embrace of reproduc-tive technologies in Israel, Frameworks ofChoice describes uneasy acceptance of pre-dictive and genetic testing in Asia. Not onlyis there uneven availability of the tests them-selves but also more significantly there isunequal access to the kinds of therapeu-tic interventions, services, and support thatmight make testing a meaningful “choice”in the first place. In India, unlike in Israel,patients must seek (and pay for) testing fromprivate hospitals and clinics. Not surpris-ingly, even as communities acknowledge aproblem such as sickle cell disease, Patraand Sleeboom-Faulkner note resistance toscreening, especially in rural and tribal ar-eas, where families generally cannot accessor afford treatment, which nevertheless can-not cure the disease. “Why should I aban-don my dreams and happiness,” one mantells them, “for something which has no cureand which cannot be diagnosed properly


with certainty?” In addition, preconceptionscreening of adults has led to gender-basedgenetic discrimination against women whoare found to be genetic carriers, with pro-found effects on their marital prospects andin their familial lives. In China, Sui andSleeboom-Faulkner describe discriminationand psychological distress, not to mentioneconomic hardship, suffered within the fam-ilies of boys with Duchenne muscular dys-trophy (DMD), which has no effective treat-ment. Because DMD is an X-linked geneticdisorder, a carrier’s son can be affected withDMD, and her daughter can be herself acarrier. The experience of stigma attachedto their families, however, also can lead in-dividuals to advocate for more availabilityof and access to genetic testing: “Let thisdamned illness disappear from my family.”

Reading accounts of genetic carrierscreening in Asia and in Israel proves in-structive because it reminds readers thatthe responses to reproductive technologiesmust be understood in context. In Israel,Prainsack and Gil describe the particu-lar acceptance of premarital genetic test-ing in Haredi or ultra-Orthodox communi-ties. Living separately from non-Haredim,they are regarded as special cases in Is-rael because they also observe restrictionson the uses of other modern technologies,such as cell phones and the Internet. Yet,Haredi communities encourage their mem-bers to receive free and anonymous car-rier screening and genetic counseling, whichthe state sponsors. Potential marriage part-ners then can present an identification num-ber to check on their “genetic compatibil-ity.” They are not given the results of thetest itself, which prevents the stigmatizationof individual carriers or of “carrier fami-lies.” Not only are families involved in ar-ranging marriages but also regard dissolvingmarriage plans as an option when couplesare genetically incompatible. In a sense, ge-netic carrier screening becomes a part of thematchmaking process, rather than a concernof medical care.

In Israel, Haredi couples accept screen-ing before conception (and before marriage)as an acceptable intervention because it

enables them to follow the commandmentsof the Torah to reproduce and to avoid hu-man suffering (which a genetic disease mightcause a child)—and to adhere to the Harediprohibition on abortion unless the potentialmother’s life or health are endangered. Thisalso explains the relatively limited uptakeof other forms of testing during pregnancyin Haredi communities. The acceptability ofabortion to individuals, families, and com-munities critically shapes the responses topredictive and genetic testing. “In reproduc-tive genetic testing, as it occurs in the West,there is an implicit link, widely taken forgranted, between the results of genetic test-ing and the ability to act on those resultsby way of terminating a pregnancy,” Simp-son observes in Frameworks of Choice. Asthe title of the collection suggests, “choices”are themselves products or effects, and whatought to be examined are the “frameworks”that shape them. In Sri Lanka, Simpson sug-gests the prohibition and restriction placedon abortion, in the absence of other medicalinterventions, contributes to a “therapeuticgap” that makes tests like amniocentesis un-acceptable for doctors and patients alike.Doctors express reluctance to perform testsbecause they have no options to offer theirpatients.

Both books address the unease withwhich reproductive technologies—in par-ticular, predictive and genetic testing—areviewed because of the possibilities oftheir “eugenic” uses. After all, the testscan be used to determine which couplesmight marry, which embryos ought tobe implanted, and which pregnanciesshould or should not be continued. InFrameworks of Choice, Gupta notes thatindividuals, families, and communities havean interest in “healthy birth.” His chapteron predictive and genetic testing in Indiacalls to attention “the thin line separatingindividual choice and overt or covertcoercion” that cuts across expectations andexperiences of reproduction technologies.Doring, using prenatal sex selection inChina as his example, argues against the“slippery slope” argument that predictiveand genetic testing necessarily leads to

Book Reviews 561

eugenic uses. Instead, he emphasizes theconstellation of cultural, social, economic,and political consideration—includingChina’s current one-child policy and aculturally and socially institutionalizedpreference for sons—which shapes the usesof predictive and genetic testing.

Tsuge describes the sensitivities sur-rounding disability in Japan, which resultfrom its eugenic history in the second halfof the 20th century, with laws mandat-ing the forced sterilization of disabled peo-ple. The repeal of these laws is creditedto the disability rights movement that hasemerged. Prenatal testing has been criticizedas a “eugenic” practice, and the uses of ma-ternal serum screening and amniocentesishave been limited. Kato finds that obste-tricians today offer little information aboutgenetic testing to pregnant women, in partto avoid being perceived as “eugenic prac-titioners.” In part, obstetricians also are re-sponding to the cultural conception of preg-nancy as an anxious time, which places ondoctors the obligation to relieve the suffer-ing of their patients by not discussing ge-netic “risks.” Kato suggests, however, thatthe silence on reproductive genetics pro-duces a fear of the unknown, contributingto more anxiety among pregnancy and tothe further stigmatization of disability inJapan.

Japan, like Israel, had been known histor-ically as a pronatalist society, with laws thatrestricted access to abortion. Japan, how-ever, allowed it for “eugenic” reasons, suchas a diagnosis of genetic disease. Japaneseabortion law continues to place restrictionson abortion, requiring approval from thespouse and setting a limit at 22 weeks ofpregnancy. Stripped of its eugenic language,the law now allows for abortion for healthor financial conditions. In Israel, as in Japan,the national law prohibits abortion “on de-mand,” but in fact is flexible enough to ac-commodate selective abortion, which seems

surprising in a society that is known to bepronatalist. This becomes evident in Rimon-Zarfaty and Raz’s account of Israeli hospi-tal committees that review applications forabortions. Interviews with individual com-mittee members and medical advisors tothe committees reveal support for coupleswho request abortions even for test resultsthat were inconclusive or ambiguous or forconditions that might be described as rel-atively mild. Rimon-Zarfaty and Raz sug-gest that genetic testing, even when it mightlead to selective abortion, is consistent withnotions of good mothering and responsibleparenthood, which involves meeting obliga-tions not only to individuals and familiesbut also to the Israeli nation and to Jewishtradition.

Although the strength of Frameworks ofChoice is its focus on predictive and ge-netic testing, it also attempts to cover a lotof ground, so that the comparisons acrossthe four Asian societies remain rather gen-eral. Kin, Gene, and Community maintainsits focus on Jewish Israelis and their re-sponse to a range of reproductive technolo-gies, which results in issues being repeatedor retread across chapters. What both booksaccomplish is a demonstration of the waysin which reproductive technologies are cul-tural and social technologies. The two vol-umes will be appropriate for graduate stu-dents in medical anthropology, science andtechnology studies, and public health. In ad-dition, Frameworks of Choice should in-terest medical anthropologists concernedwith “therapeutic gap” in whatever field ofstudy and practice they work. The collectionought to make its way into the hands of pro-gram planners and policymakers, and notjust in Asia. Kin, Gene, Community shouldbe read not only as a contribution to med-ical anthropology and the anthropology ofreproduction but also to area studies. Bothbooks certainly deserve attention in and outof medical anthropology.

Documents

Childbirth, Midwifery and Concepts of Time edited by Christine McCourt