Transaction~ �9 I I | oc, oclezy AND MODERN

(Volume 43, Number 6)

Medicalizing Motherhood Ellie Lee

F rank Furedi's contribution to the discussion of

medicalization" resonated strongly with find- ings from my own research about contemporary

representations of women's emotional experiences. It is indeed the case that compared to the 1970s there is very little contest and debate about the increasing use of illness labels to account for these experiences. To the contrary, there is now wide acceptance of the idea that the most positive development that can take place for women is for more of them to be diagnosed as ill. It is also the case that, as part of this, women's lives are subject to the "unprecedented medicalization of social experience" through the "construction of new psychological conditions" to which Furedi refers.

What is striking about this development is the di- versity of claims-makers associated with this process. The vanguard associated with the medicalization of women consists not (or certainly not only) of main- stream medicine, but rather is made up of therapists, psychologists, advocacy organizations, and feminists. One area where these developments are especially clear is women's experience of pregnancy, childbirth, and early motherhood. Take the following examples:

Postnatal Stress Disorder: Understandings of the ex- perience of childbirth have been strongly influenced by the more general rapid expansion of the domain of Post Traumatic Stress Disorder (PTSD) that has occurred in recent years. The range of experiences considered sufficiently traumatic to result in PTSD has widened considerably, generating what has been termed a "post traumatic culture," and this has influenced accounts of childbirth. For example, feminist childbirth "guru" Sheila Kitzinger has linked childbirth with other ex- periences considered to be PTSD "stressors": "After the Vietnam War soldiers on both sides who had not suffered any physical injury often became distressed .... The same thing can happen after a birth .... [A woman] may feel as if she has been raped .... This can happen even with so-called 'normal' birth," she claims. It has

been suggested by psychologists that one in 20 women in Britain develop PTSD as a result of giving birth. It has been argued by counselor Janet Menage that it would help women if there were a special sub-category of PTSD included in the DSM (Diagnostic and Statisti- cal Manual) and the ICD (International Classification of Diseases) and then used by relevant health profes- sionals, a claim echoed by others including Ralph and Alexander, midwife and tutor for the mothers' group, the National Childbirth Trust. Post-childbirth counsel- ing or "de-briefing" is usually proposed as the best response to women that develop this new illness.

Tokophobia: This is a mental illness first named by psychiatrists in Birmingham, UK, in 1999. Tokophobia is considered by its proponents to be "an unreason- able fear of childbirth" that makes its sufferers unable to face the prospect of pregnancy and motherhood in the first place. Some suggest that this illness may be sufficiently widespread that it can help account for the trend towards women delaying having children or having fewer of them than in the past.

Maternal Anxiety and Mood Imbalance (MAMI): This is the newest addition to the list of illnesses as- sociated with motherhood. It was proposed in 2006 by psychologists from Glasgow, and is defined as a spe- cific category of illness that "bridges the gap between Baby Blues and PND." Its key symptom is anxiety and 63 percent of mothers are afflicted by it. It is argued by its proponents that the medical profession needs to "acknowledge how anxiety can be a key 'stepping stone' that could develop into PND" and this experience merits "its own definition--MAMI."

Postnatal Depression (PND): PND, first named by the psychiatrist Brice Pitt in 1968, is a more long-stand- ing category of mental illness than those listed above. A significant development of the 1990s onwards has been the emergence of a trend to normalize PND. A variety of organizations and commentators have come to deem PND a "silent epidemic," afflicting many more

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women than has previously been considered the case. According to a recent survey by Prima Baby magazine, one in five new mothers have the condition. Netmums, the online support group for mothers, argues there is a "clear upward trend in rates of Postnatal depression" compared to the 1970s, with almost 1 in 3 now victims of the illness. There is advocacy for new definitions of what PND is. Feminist writer Kate Figes, author of Life After Birth, thus states, "PND is a sliding scale, starting with the 'baby blues' affecting 80 percent of women, and ending with puerperal psychosis .... The vast ma- jority of women sit somewhere on this scale." Siobahn Curham, author of Antenatal and Postnatal Depression, goes further, claiming most mothers experience PND since, "as many as 90 percent of new mothers experi- ence some feelings of depression after the birth."

Antenatal Depression: Since the mid-1990s, it has been argued increasingly that research suggests many, if not more women are depressed during pregnancy than post-pregnancy. This incidence of "antenatal de- pression" has been deemed an unrecognized problem, and it is claimed that maternal depression needs to be thought of as on a spectrum with a variety of causes (not only childbirth and early motherhood). As a result, much literature now uses the category "Antenatal and Postnatal Depression."

Male PND: Postnatal depression has broadened as a category of illness in another way since it has crossed the sex divide. In 2003, for example, a new mental health scheme was launched in Basildon, Essex, UK. Called "Fathers Matter, In Tune With Dads," the scheme provides counseling to men who are suffering from Postnatal Depression (PND). Male PND has in fact been discussed in popular and specialist literature in the UK since the early 1990s. In 1992, counselor Zelda West-Meads stated in one of the first articles on this subject that in marriage guidance counseling sessions men were "admitting to a kind of post-natal depression" caused by difficulties in their marriages following the birth of a baby. Subsequent claims made about this illness include those concerning the numbers of men affected. The lowest reported estimates are that 4 percent of fathers have PND, a figure based on a 1999 survey of the public carried out by the polling agency NOP (National Opinion Poll) for Bella magazine. Other reports have put the figure affected at 7 percent and 10 percent. In 2000, it was reported that 15 percent of new fathers have PND, on the basis of estimates from Australian psychiatrist John Condo, and a recent report

has suggested that "as many as one in four new dads suffer from post-natal depression."

How might this trend towards pathologizing moth- erhood (and fatherhood) be accounted for? One point common to much advocacy of these illness labels is that it is helpful for mothers (and now fathers) to come to think of their experiences this way. In its discussion of the usefulness of the label PND, the Royal College of Psychiatrists thus suggests it "helps many a mother to be told 'You've got PND.' At least she knows her enemy. She can be reassured that she is not a freak or a bad mother and that many others are in the same boat."

T here is truth to this argument insofar as in some circumstances the illness label can provide a means through which a woman can externalize

her feelings, fight against them, gain medical treatment to help her do so, and move on. The trend I have noticed, however, is that the idea that it is helpful to be diag- nosed as ill has become adopted very promiscuously. The typifying feature of approach taken by the wide range of claims-makers now engaged in promoting the idea that parenthood makes people ill, is to urge fluid and diffuse illness definitions.

"Raising awareness" of the possibility of women becoming ill if they have a baby has, for example, come to be seen as a very valuable activity. There is now a self-conscious attempt being made to persuade more and more women (and men) to think of themselves as "at risk" from illness, and therefore to seek help at the first opportunity. The psychologists who advocate the category MAMI thus argue that women's problem is that "many mothers dismiss their emotional distur- bances as Baby Blues .... Thus they will not seek early and possibly preventative support and treatment." The concept of MAMI can be resolved thus by labeling their experience "in a much warmer way" than PND, and therefore affording women the ability to consider themselves ill and seek preventative treatment for PND that they may later develop.

Discussion of the disparity between women's own perceptions of what is wrong with them, and the need to diagnose their feelings and behavior as symptoms of illness, also exemplifies this trend. For Netmums, the biggest barrier to women being treated for PND is "the mother herself" since for various reasons she rejects the label PND, and therefore fails to consider her experiences to be symptoms of illness. Similarly, the problem according to a recent article in the British

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Journal of General Practice is that only one-third of women who were identified by researchers as having PND believed themselves to be suffering from it, and over 80 percent had not reported their symptoms to any health professional. Fathers Matter has developed its own "screening tool," a series of questions to be asked of new dads to identify those at risk from PND, entitled the "Vulnerability Index." It is suggested that this will enable men to realize they are in fact ill, when they might have explained their experiences another way. "There is nothing weak or effeminate about realizing as a man, and a father, that you have thoughts and feelings you do not understand," explains the leaflet. Encouraging men to come to realize that these feelings are, in truth, symptoms of illness, is the objective of this program.

It seems to have become widely accepted that the way we show we care for other people and have concern for them is by taking seriously--indeed, positively searching for--their traumatic and depressing experi- ences associated with pregnancy and parenthood and giving them a medical label. There is now a fairly widespread sensibility that there is much to gain, and little to lose, by creating a culture of awareness or heightened recognition through which as many parents as possible, and mothers in particular, can be encour- aged to interpret emotional problems and difficulties this way, and as a result seek help.

Notable as an aspect of this trend towards encourag- ing illness identity is the tendency for some contempo- rary feminist writers to advocate medicalization, a trend exemplified in works including Naomi Wolf's Miscon- ceptions, Truth, Lies and the Unexpected on the Journey to Motherhood, Kate Figes' Life After Birth, and Susan Maushart's The Mask of Motherhood. In these cases, a particular sort of demand is made for a shift in culture to generate a public discourse that has the emotional dif- ficulties of the experience of motherhood at its center. For Maushart, therefore, "At least part of the problem is that our society propagates a ridiculously positive myth of pregnancy." The strongest forces that constrain women, she argues, are those that "minimize the difficulties we face, insisting that motherhood is no big deal after all." Wolf writes scathingly of books that present mother- hood in positive terms and that, in her view, do not talk enough about women's negative feelings.

Medical labels now seem to appeal to those com- mitted to this project of shifting the culture, because they give legitimacy and weight to claims that negative emotions feature centrally in women's experiences

as mothers. In this sense, PND and Postnatal Stress Disorder as they are now increasingly defined by such feminists are not really about mental ill health as pre- viously understood. These terms form part of a larger argument that says becoming a mother needs to be viewed as an ordeal that victimizes women. It is strik- ing, however, that previous concerns about the effect of medicalization strongly held by feminists--centrally the disempowering effects of giving over the power to define experience to others--has disappeared. As a re- sult, feminists, too, advocate much greater recognition, diagnosis, and treatment of mental illness in women who have given birth and postnatally.

What might we make of this development? Women (and men), there is no doubt, can experience emotional and psychological distress and difficulty associated with pregnancy, childbirth, and parenthood. Moth- erhood has certainly never been easy. While some changes (e.g., the advent of disposable diapers) have made life with babies much easier, other developments introduce new strains. Changes often highlighted in the literature as important, include people being less close to family members--geographically and maybe emotionally--and the major shift of women into the workforce. Objections need to be raised, however, about a culture that has become so determined to medicalize the effects of these developments. The as- sumption that there is meri t - -or at least no harm to be done-- in encouraging more and more of us to interpret experiences as illness needs to be questioned.

One problem is that the effect of this culture seems to be quite the opposite to that of enabling people to "move on" and quickly put their episode of "illness" behind them. Rather, through objectifying distressful emotional experiences through illness labels, a process has been unleashed in which people become more pas- sive and less able to act in relation to their problems and their lives, and remain "ill." Illness labels as they are currently applied tend to give a permanence to these feelings, which are likely temporary, transitory states that will be replaced by other feelings and emotions as time moves on and therefore forgotten (in fact, a true description of parental experience for many).

Whether it is Postnatal Stress Disorder, MAMI, or PND, the range of emotions and experiences now characterized (very deliberately) as illness symptoms are broad and inclusive. An unforeseen consequence of this relentless promotion to women of the need to consider themselves potential victims of illness if

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they experience any of the wide range of feelings now pathologized may be mothers' increased preoccupa- tion with their state of mind. They come to live with the preoccupation that what they are feeling--guilt, anxiety, sadness, worry, anger, and so on, feelings all now categorized as illness symptoms- -may be the beginning of a serious illness state.

There is no doubt that the current context of illness labels is giving rise to a situation where the experience of negative emotions has become a key part of some moth- ers' identities either in a permanent or semi-permanent way. The last two decades have seen a burgeoning lit- erature published in which women "survivors" of PND or difficult childbirth recount their experiences in an effort to promote the need for more recognition and diagnosis of the illness. They live with the illness experience as a factor in their lives for the long tenn. In addition, more mothers are becoming involved in the "lay wing" of the campaign for awareness raising to inform other women of the need for diagnosis, which suggests that the current approach has clearly failed to help these women "move on" and consider their illness temporary and transitory.

In tandem with the sensibility that awareness about illness risk needs to be raised, comes the advocacy of the need for "support," usually in the form of counsel- ing of some kind. It is now widely accepted that what new parents lack more than anything else is profes- sional support and counseling. The implications of this aspect of the contemporary parenting culture also need to be exan~ined.

Claims that health professionals need to become more pro-active in identifying PND, for example, are frequently made. Articles published in medical journals have argued that family doctors should do more about identifying and treating PND, and have criticized them for constantly failing to identify PND, or recognize it for what it is. Identification of PND has become more and more prominent in discussions on the role of the UK health aide, in particular. New initiatives and services have been developed in many areas funded through UK government programs, which aim to improve maternal mental health and advance the need for health assistants to do more to identify women "at risk" from PND and ensure they are offered "listen- ing visits" postnatally, or psychological counseling. "Becoming a father can have a huge impact on a man and yet all the attention seems to be focused on the woman," argues one advocate to bring attention to the need for such psychological screening of new fathers

to find those with male PND, indicating that paternal mental health is coming increasingly into the orbit of professional intervention.

The rise in the assumption that new mothers cannot cope without professional support reflects the percep- tion that they should not be expected to ably find ways to manage their emotions and negotiate themselves through the new relationships and experiences that pregnancy and parenthood bring. Rather, someone else, a health professional, needs to support them in their attempts to do this. This persistent drive to make parents turn to professionals when they face emotional difficulties needs to be addressed. The issue suggests a low expectation of people and their capacity to be- have in an adult and mature manner. As a result, it is possible that the effect of this will be that parents will come to experience the normal disruption that parent- hood brings with it as highly disabling, and find that they are less able to manage than if they were left to their own devices. As former midwife Brid Hehir has argued, the current approach to encourage reliance on professionals may "prolong and intensify [a mother's] problems, and deter women from building their own support network, in the way mothers always have done." Society, this suggests, would do better to trust that most new parents can, as they always have, cope alone with their feelings.

From a sociological point of view, what is distinct about the current phase of medicalization, as Furedi suggests, is that it is no longer medical imperialism, but rather a much wider cultural sensibility that impels the process. In regard to its effects, whatever the intentions that lie behind the advocacy of support, advice, and treatment, it is important to ask if it will, in fact, make people "better." The wish to ask questions about this aspect of medicalization does not spring from hostility to professional help and expertise in the abstract, and certainly does not constitute an argument against the need for more well-conducted research about psychiat- ric illnesses and for the provision of treatment for those who are ill. But it is important to consider the nature and effects of the expanding place of professional sup- port that contemporary societies have built upon the expansion of psychological illness.

Ellie Lee is senior lecturer in the School of Social Policy, Sociology and Social Research at the University of Kent, UK. She is author of Abortion, Motherhood and Mental Health: Medicalizing Reproduction in the United States and Great Britain published by Transaction Publishers.

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