(De)politicising pregnancy-related risk: gender and power in media reporting of a maternity ward closure

Abstract

Following a restructuring of Swedish healthcare in the 1990s – moving from a welfare model to one inspired by New Public Management – maternity care in Sweden is increasingly centralised to bigger towns. This has led to several units being relocated or forced to close, and to a bigger distance to maternity care for women living in smaller towns and rural areas. In the present article, I analyse the media reporting on the recent closure of the maternity ward in Sollefteå, a small town in Sweden’s northern region. Using intersectional risk theory, I explore how pregnancy-related risks are articulated in Swedish newspapers, and how such articulations relate to power and ideology. Articles from three Swedish newspapers, published during a 4-month period, have been analysed using critical discourse analysis. I conclude that the newspaper articles were most likely to stress the family as the main ‘risk victim’, while the pregnant woman was rarely the focus of risk articulations. When she was, risks were described as ‘worry’ or ‘unworthiness’, and never in medical terms. When such articulations appeared within an individualist ideological discourse, they were naturalised and as such, disconnected from the political decision to close the maternity ward. My contention is that a feminist perspective is largely missing in the media articles and that a bigger focus on the effect that maternity ward closures have for women living outside urban centres is needed.

Keywords:

• pregnancy
• maternity care
• risk
• gender
• intersectionality

Introduction

This article explores articulations of health-related risks in media reporting of a maternity ward closure in Sollefteå, a town of 8,000 inhabitants in northern Sweden. A theoretical perspective that combines a critical approach to risk with an intersectional perspective is used to explore the Swedish news media’s approach to ‘doing risk’ when reporting on the closure – a process that relates closely to the doing of gender, class and heteronormativity. The article further explores how the mutual doing of risk, gender, class and heteronormativity works to either fuel or alter normative discourses around motherhood, family and the countryside or smaller towns.

Although Swedish maternity care is known for its high quality and relatively equal distribution (Tejerina, Perugorria, Benski, & Langman, 2013), the closure of maternity wards around the country has sparked public debate in recent years on the ‘crisis’ in Swedish maternity care. The closures can in part be traced to a reorganisation of Swedish healthcare in the 1990s, moving from a welfare model to one inspired by New Public Management (NPM). Although NPM is not a static term, some characteristics are commonly used to define NPM as a concept, including greater competitiveness among healthcare distributors, private alternatives, clearly defined standards, and a more restrictive use of resources (Hood, 1991). Several European countries, as well as Australia, New Zealand, and Canada, have undergone similar changes in the government of healthcare; an ideological transition that has increased centralisation of healthcare units to bigger towns, and resulted in closures of smaller maternity units. Especially for people living in the countryside or smaller towns in the inland, the closure of a local maternity unit often means that maternity care becomes more distant (e.g. Barclay & Kornelsen, 2016; Evans, Veitch, Hays, Clark, & Larkis, 2011; Kornelsen & Grzybowski, 2006). In the case of BB Sollefteå,¹ the maternity ward that is in focus for the study, the closure forces people living in the area to travel 100–200 km to get to the closest ward. The town’s inhabitants protested against the decision by occupying the ward. That occupation (which is still active) has generated significant media attention, and the closure has attained symbolic status in the debate about Sweden’s maternity care, bringing several movements together. Women’s rights organisations have criticised the Swedish government – which has proclaimed itself the world’s first feminist government – for focusing more on its ‘feminist image’ than on actually prioritising women’s health and maternity care services. Similarly, organisations campaigning for the countryside’s survival have accused the government of neglecting the needs of smaller towns and rural areas.

The case raises questions about risk and (in)equality. The way that risks are articulated in relation to gendered, classed and heteronormative power structures contributes to whether or not a closure can be legitimised. The article’s focus on how risk is done, therefore, contributes to knowledge about certain processes that inform articulations of health-related risk. It also contributes to knowledge about how (normative) discourses on pregnancy and motherhood fuel the individualisation and naturalisation of women’s risks, and how this can be used as a tool for political decision-making.

Context for this research

In Sweden, maternity care has a long history of institutionalisation; almost all women give birth at a hospital and attend regulatory check-ups before and after giving birth (DeVries, Benoit, van Teijlingen & Wrede, 2001). In a recent study of how women assess risks when deciding where to give birth, one Scandinavian woman was quoted as saying that giving birth in a hospital is as much given as having surgery in a hospital (Coxon, Sandall, & Fulop, 2014). As in all Nordic welfare states, maternity care in Sweden is characterised by extensive medical expertise and involvement in expectant parents’ lives (Leppo, 2012). In the 1990s, however, Sweden’s approach to maternity care changed when the healthcare system was restructured. An NPM-inspired model replaced the welfare model (Larsson Taghizadeh & Lindbom, 2013) widely recognised as Sweden’s political hallmark, and cost efficiency and purchaser-provider models came increasingly to the fore (Giritli Nygren & Nyhlén, 2015). This has led to increased centralisation, and units outside urban centres have been relocated to larger towns or have been forced to close (Brommels & Vintmyr, 2015). In other words, the reorganisation has made maternity care more ‘distant’, both by prolonging travel and discursively, as the conditions have changed. In studying discourses on pregnancy and risk in Finland, where healthcare has also been restructured, Anna Leppo (2012) noted how welfare ideals are mixed with neoliberal ideological discourses to create a discourse in which responsibility for pregnancy-related risks is increasingly individualised, and pregnant women are themselves expected to navigate those risks, as midwives now focus less on intervention and more on providing information about risks.

Feminist studies of risk and pregnancy have commonly been concerned with how pregnancy-related risk is articulated and how boundaries are set for the pregnant body. While women’s health advocates in the global South have often addressed the lack of medical support for pregnant women, feminist researchers and activists in the global North have been concerned to explore how medicalisation affects perceptions of the pregnant body and the foetus (Rudrum, 2017). Researchers have acknowledged a transition in the discourse on pregnancy and risk from seeing pregnancy as potentially ‘risky’ for women to a perspective that constructs women as a ‘risk’ to the foetus. This discursive change can be traced to technological and ideological changes, in which ultrasound scans and an increasing focus on expertise have redefined the foetus as an independent individual with agency (Lupton, 2012; Rothman, 2014). Lorna Weir (2006) stressed that the pregnant body is discursively constructed as risky, and the pregnant woman is expected to acknowledge and navigate risks on an everyday basis to ensure the foetus’ health – a requirement that Lealle Ruhl (1999) has characterised as ‘individualised risk’. To conform to public recommendations, pregnant women are expected to make choices linked to food, drugs and exercise that will minimise the risk of foetal damage. In her investigations of Finnish discourse on pregnancy and risk, focusing specifically on how health policies relate to pregnant women abusing alcohol or drugs, Leppo (2012) noted an on-going tension between technologies of domination (in which care interventions reflected an unwillingness to accept any risk that might impact negatively on the foetus) and women’s agency over their own bodies. Similarly, Kate Holland, Kerry McCallum and Alexandra Walton’s (2016) study of how Australian women adapt to guidelines on risk and alcohol found that women internalise discourses around ‘the good mother’ while struggling to reconcile such ideals and their own beliefs.

Exploring discourses on pregnancy and risk in Sweden from a feminist perspective has become especially interesting because Swedish maternity care is undergoing such extensive changes. In a new ideological context where maternity care is becoming less institutionalised and exposure to different forms of media increases, women can be expected to combine information about risk obtained from medical workers and from newspapers and other media. The present study contributes to new feminist insights on the formation of pregnancy-related discourses in this changing ideological, organisational and communicative context, and illuminates the political and discursive implications of certain risk articulations for expectant parents in general and for the pregnant woman in particular.

A critical feminist approach to risk and discourse

Grounded in feminist theory, the present study follows the advice of Cynthia Enloe (2014) to always look for the women in a given issue and to pay attention to the role that gender plays. Furthermore, I combine an intersectional approach to risk with discourse analysis, focusing on how normalising processes and the interaction between power structures inform newspaper articulations of risks. The theoretical framing is inspired by Fairclough’s (2013) critical discourse analysis (CDA), which views discourse as existing on three levels: a micro-level (e.g. social events and texts); a meso-level (e.g. social practices and communication) and a macro-level (e.g. structures that relate to language and ideology). These levels support a stepwise approach to the research material and analysis of risk discourses in terms of ideology and practices as well as linguistics. As such, I present the theories in three blocks. In the first block, I describe how risk is analysed at the micro-level, attending to the words used when risks are targeted. In the second block, I elaborate how such risk descriptions are done in relation to power structures, and in the third, I consider how these doings of risk relate to ideology and governance.

At the micro-level, I draw on Douglas (2002) sociocultural approach to risk which has informed my attention to how risks appear in the newspaper articles, and what actors are linked to certain risk descriptions. Douglas stresses that risk estimations entail interpretations about what is considered as a risk, how risky it is and what should be done to minimise it. For present purposes, I have added the question ‘For whom is it risky?’ to give space to the actors, which is common at the first level of CDA (Janks, 1997). These questions aid analysis of how morals, values and culture contribute to our understanding of risk. From this view, risks are not simply seen as actual dangers but also as social constructions that tell something about society and its norms. How we frame risks and prioritise some risks over others reveals things about how certain bodies and places are prioritised in society (Douglas, 2002). This understanding of risk as cultural informs my analysis, along with Åsa Boholm’s (2003) concept of ‘situated risk’, which facilitates my considerations of how risks are contextualised and how collective ideas, memories and discourses make sense for different ways of interpreting risk. In the case of BB Sollefteå, risk can be understood as situated in terms of geographical place and ideology; aspects that should be observed in light of the 1990s reorganisation of the Swedish healthcare system. The analysis of how risks are described is further augmented by contextualisation as a tool for making visible how risk links to culture and power, and what bodies or objects are described as being at risk.

At the meso-level, the theory of ‘doing risk’ has been used to analyse risks as practices from an intersectional perspective (Giritli Nygren, Öhman, & Olofsson, 2017). Intersectional feminist theory was developed by black and post-colonial feminists in the late 1980s, and has since been used to analyse oppression and privilege as the result of multiple overlapping power structures. Intersectional feminists argue that it is impossible to thoroughly study power simply by ‘adding’ categories such as gender, class and race to each other; instead, we need to pay attention to how such categories interact and complicate one another (e.g. Crenshaw, 1989; McCall, 2005; Yuval-Davis, 2006). In intersectional risk studies, power structures are understood as intersecting both with each other and with concepts of risk. That said risk can only be understood by simultaneously exploring how multiple power structures influence articulations of risk, and how the ways we do risk reproduce those structures.

The concept of doing risk builds on West and Zimmerman (1987) theorisation of gender as constantly done through practices and actions, and West and Fenstermaker (1995) later adjustment of the same theory to also address how the everyday doing of gender, class and race intersect. Just like the mentioned categories, concepts of risk are understood as done through everyday practises (Giritli Nygren et al., 2017). In the present article, ‘doing risk’ is used to understand risk discourses at the meso-level – that is, at the discursive level of understanding practices. Risk articulations are, thus, seen as a form of practices that do something to discourses, and the concept of ‘doing risk’ is used to mediate between performative theories and theories using a constructionist approach. I have focused on how the doing of risk intersects with the doing of classed and heteronormative femininity and motherhood, as well as the countryside and smaller communities as place.

At the macro-level, a Foucauldian approach has been adopted to consider ideology, normalcy and governmentality. According to Michel Foucault (2008), risk can be seen as a new order of power that is closely related to what he calls the ‘biopolitics’ of the population – that is, the control of reproduction, birth, mortality, domestic hygiene and so on. In Nordic countries, the welfare state has previously possessed strong legitimacy in regulating family life and reproduction. When mixed with neoliberalism, however, ‘choosing’ is increasingly emphasised (cf. Leppo, 2012). Pregnancy falls within the normalisation apparatus of biopolitics, where women’s behaviour is both self-policed and policed by ‘expert’ advice (Lupton, 2012). Very often, women perform a sense of self-conduct through the construction of ‘normal’ pregnancies and ‘good’ motherhood (Mulinari, 2011; Ruhl, 1999). Ruhl (1999) noted that this is the most common way in which governance over the pregnant body is performed; pregnant women are informed about risks in newspaper articles and at maternity centres and are expected to act rationally by weighing up possible risks and benefits with the goal of minimise risks. In a more recent study on how pregnant women consider risks associated with medical drugs, Widness and Schjøtt (2016) concluded that pregnant women tended to overestimate risks, something that could be explained by the influence of media and a tendency to report risks rather than benefits. As use of different media and sources of information becomes more common, governance is often also performed through media, which promotes self-regulation (Löfmarck, 2014). Enloe (2014) further noted that presenting something as normal or natural is often used as a political strategy, causing an issue to appear unproblematic and unconnected to decision-making. She stressed that this strategy often appears in conjunction with the feminisation of certain issues and practices; as these are labelled as ‘natural’ for women, they can be profited from.

The theoretical framework as outlined supports a fuller understanding of the risk discourses at work in the case of BB Sollefteå and how they affect the pregnant women who must navigate risk in this new situation. It should also contribute to further understanding of how discourses around pregnancy and risk affect us all in reproducing (or challenging) norms of motherhood, family and the countryside as place.

Methods

The research material comprised newspaper articles published in three Swedish newspapers: Dagens Nyheter (DN), which is nationally distributed and has its head office in Stockholm; Sundsvalls Tidning (ST), which is distributed in Sundsvall, the biggest town in Västernorrland’s county (the county where Sollefteå is located); and Örnsköldsviks Allehanda, which is locally distributed in one of the smaller towns in the county. The newspapers were selected to facilitate analysis of how geographic setting influences the portrayal of risk in reporting of the maternity ward’s closure. Sweden’s biggest newspaper – DN – has a broad coverage and is read all over Sweden. However, Sweden’s national media has often been accused for focusing disproportionately on bigger cities, while ignoring Sweden’s countryside and smaller towns. The two local newspapers are each distributed in one of the towns where the hospitals closest to Sollefteå are located, yet they can be expected to display different views regarding the closure of BB Sollefteå. Sundsvall, being the county’s biggest town, is often associated with (and blamed for) the urbanisation process in the county, while Örnsköldsvik is – similar to Sollefteå – facing the opposite trend. In the activist groups formed after the closure, there have been speculations about that the hospital in Örnsköldsvik will follow the fate of BB Sollefteå, and many in Örnsköldsvik have expressed solidarity with Sollefteå’s inhabitants. Together, the three newspapers provide a national, as well as a regional perspective on the closure of the maternity ward.

In my analysis, I drew on a sample of articles published in a 4 month period; from 1 November (a few days after the decision to close the maternity ward was made) to 1 March 2017 (1 month after the maternity ward closed). During this period, 163 articles concerning BB Sollefteå were published in the three newspapers (seven in DN, 53 in ST and 103 in Allehanda), and from these, a sample of 62 articles – all addressing health-related risks – was selected. Articles focusing on other risks (e.g. economic or political risks), and articles reporting on the closure without addressing risks, were excluded. I decided to maintain a focus on medical risks rather than more abstract risks. In news reporting on the closure of BB Sollefteå, a few events stood out. The first of these was the occupation of the hospital entrance area on January 30; the second was the Workers Educational Association (WEA) course for expectant parents on how to act if they had to deliver the baby in the car. WEA was founded by the Social Democratic Party and two trade unions in 1912 and is Sweden’s biggest educational association, arranging a big number of seminars, workshops and study circles around the country. The car-delivery course started on February 1, the day after BB Sollefteå closed, and soon after, on February 24, a woman did not make it to the hospital in time and gave birth to a baby girl in her car. These events generated many articles and were highly visible in the material.

I analysed the material following a CDA approach, employing a model informed by Fairclough’s (2013) three-step manual on analysing discourses in texts. The analytical process included a descriptive phase, a processing phase and an explaining phase. In the first (descriptive) phase, the main ‘themes’ in the risk framings were identified, focusing primarily on what was described as risky, and for whom. I also explored what was identified as the cause of risk. I coded all articles using this basic, rough form of coding. In the second phase (processing), I considered intertextuality in interpreting how context and interests influenced articulations of risk. Here, using intersectionality as an analytical tool, the risk articulations identified in phase one were analysed in terms of how they linked to gender, class and heteronormativity. Finally, in the third (explaining) phase, I analysed the risk articulations from the perspective of how they linked to specific ideologies and governmentality. I paid particular attention to what was not being expressed in the texts, and to what was taken for granted. The articles were all written in Swedish, and the quotes that are presented to exemplify the findings have been translated for the purpose of the article.

Findings

The closure of BB sollefteå: media portrayals of health-related risks

Below I present the analysis in three sections, structured on the basis of the ideological discourses that I identified in the material: welfare, traditionalist and neoliberal. Within each discourse, I analysed risk articulations in terms of what is considered a risk, who was described as the risk victim and how the articulations of risk intersected with gender, class, place and heteronormative power structures. Remarkably, the pregnant woman was rarely the focus of newspaper descriptions of risk. When she was, risk articulations were often deeply gendered and aligned with norms that reinforced normative perceptions of motherhood and femininity. The majority of articles that addressed risks to pregnant women adopted a welfare perspective and favoured opposition to closure. However, articles also commonly focused on a number of risk victims, entailing more than one ideological discourse. For that reason, the selected quotes are not always representative of the entire article but highlight perspectives that appeared repeatedly across the data set.

Welfare discourses on pregnancy and risk

Risk articulations appearing in articles that described the closure as a risk commonly drew on a welfare discourse, emphasising equal distribution in healthcare. However, risks articulated within this discourse targeted different victims, among whom the most common ‘victim’ was the family. These family-centred risk articulations typically appeared in Allehanda, the local newspaper in Örnsköldsvik, and sometimes in ST, the newspaper distributed in Sundsvall. The negative impact of closure on families was commonly associated with risks to Sollefteå as a town (or sometimes the whole Swedish countryside). In this way, family-centred risks were often interpreted in terms of a deeper and more extensive risk. In an article about a protest outside the hospital, a man is quoted expressing his fears about the situation:

Me and my wife have two children; if we are going to have more children, we will be more than two hours from the nearest hospital in Örnsköldsvik. It feels like a nightmare – and what will happen if people have a critical condition?/…/Not everyone lives in an urban area. (Berlin, Allehanda, 2016-11-03)

In describing his frustration concerning the decision to close BB Sollefteå, this man ascribes symbolic meaning to family, referring to his fears about the possible implications of the closure for the countryside. The quote conveys to the reader the picture of a man who is angry, sad and scared by the thought of the impact that the closure may have on his family. Following Giritli Nygren et al.’s (2017) theoretical development of risk as something done in relation to social categories and norms, how the newspaper article does risk parallels doing of a (heteronormative) family situation, making visible the countryside as a politically abandoned place. Notably, this father mentions his fear of what will happen if ‘people’ have a critical condition, but he does not specify who is (or is not) included in ‘people’. The gender-less terminology leaves the reader with the impression that the risks may affect anyone in the family. A polemical article written by Monika Thelin, a member of Lapplandsupproret (an organisation that campaigns for the rights of Sweden’s most northern county) illustrates how risks parallel the doing of family and place:

Stressed dads are driving on this road, fearful of not making it to the hospital in time. Many don’t make it in time. Some headlines from the newspapers: ‘The baby was born in his taxi’; ‘Their son was born in a police car’; ‘Bianca was born by the E10 road’/…/These babies survived; these others did not: ‘Lost three babies in three years’ (one pair of twins and one other baby), ‘Baby’s death investigated again’, ‘Medical team arrived too late – the child died’/…/This is what politicians dismiss as events that ‘rarely’ occur. For normal births, the closure of the maternity ward means that pregnancy becomes a time of unsafety, fear and worry rather than a time of harmony and joy about a new life. (Thelin, ST, 2016-11-19)

In this quote, the closure appears to pose both an immediate risk to babies’ lives and a more abstract risk to families’ well-being. Both the risks to babies and the expectant parents’ anxiety are described as anomalies – a departure from what is considered ‘normal’ during pregnancy. A normal pregnancy is described as ‘a time of harmony and joy’ – the opposite of a time of stress and anxiety. Thelin’s outline of a normal pregnancy rejects the possibility that it could be anything other than joyful. In reality, a pregnancy might equally be a time of economic stress, anxiety or physical illness, but the author pictures an idealised family situation, where the only real problem is the distance to the hospital. In this way, the doing of risk intersects with other implicit categories such as class or heteronormativity.

As in the first quote, only the stressed father driving the car is directly mentioned; the pregnant woman is not, although one can assume that the worry as described also applies to her. Here, feelings of worry about the closure seem to be especially linked to the risks for unborn babies. As Douglas (2002) showed in her research on risk and morals, how risks are prioritised reveals norms and ideas. In many of these articles, the family unit (articulated as a risk object in itself or as a metaphorical link to risks to Sollefteå’s survival) is prioritised over the pregnant body. When analysed from a feminist standpoint, this reflects a broader culture of deprioritising women’s health issues and reveals the family’s symbolic status. Drawing on the earlier work of feminist risk scholars (Leppo, 2012; Lupton, 2012; Rothman, 2014), pregnancies are often considered ‘risky’ to the unborn baby (representing the family’s core), while the woman is rather seen as a potentially risky environment. In the sample of newspaper articles, it is also common to find that risks to the family are associated with risks to a place, as addressing risks to the family can serve as a tool for resisting the process of neoliberal centralisation that threatens the existence of smaller towns. At the same time, the focus on family serves to reinforce a heteronormative (and in many cases classed) discourse around family.

Nevertheless, some of the risks referred to in the research material focused instead on the pregnant woman as the main victim of risk. As in the case of family-centred risks, these articulations reflect a collectivist, welfare-oriented perspective on the closure of BB Sollefteå, in which immediate health risks to women often co-existed with a wider complex of risks associated with the deprioritising of maternity care. These articulations appeared in all three newspapers but were more rare prior to February 24 – the day when the first baby was born in a car. Many journalists interviewed the mother or quoted her Facebook post about her experience. On February 25, DN described her recollection of the day her daughter was born:

On the radio [in the car], she hears that a road has been shut because of roadworks. Because of this, they have to drive another way (via Bjästa). When still almost 20 km from the maternity ward, they stop at the side of the road, and Emma Andersson gives birth to a girl. She estimates that it takes ten seconds. She writes: ‘A nightmare for me. Panic-stricken. Unsafe. Don’t think that the baby has screamed or breathed. Which in reality she did’. Three minutes later, the ambulance arrives. The midwife helps the mother and her new-born daughter to the ambulance. It is below freezing, and the mother, having just delivered, steps out into the snow without shoes, the baby on her chest and the umbilical cord hanging. (Letmark, DN, 2016-02-25)

The articles telling Emma’s story brought a women’s rights perspective to the fore. Experiences of ‘trauma’ and ‘unworthiness’ have since been advanced as risks for women who, like Emma, may not make it to the hospital in time. Emma’s experience had the effect of shifting the discourse from more family-centred risk articulations to a focus on the pregnant woman. Even so, the ‘woman-centred’ risks in these articles are selective; as very few highlight risks to women’s physical health, these articles succeed in shifting the focus to women but fail to take women’s risks entirely seriously. For example, none of the articles mentioned birth injures. By describing risk only as ‘trauma’ and ‘worry’, the articles reinforce the normative image of mothers worrying about their children’s health rather than risks to the own body. Although the risks seemed often to focus on the mother’s health, the baby was implicitly constructed as the main victim to medical risks. Previous studies of risk as gendered (Leppo, 2012; Lupton, 2012; Rothman, 2014) have shown how pregnancy and risk discourses often link to normative discourses on motherhood. In reproducing a normative (and idealistic) discourse on femininity and motherhood, several articles strengthen norms that prescribe women’s behaviour as mothers: caring, selfless and self-sacrificing. From this perspective, the newspapers’ focus on ‘women’s risks’ as ‘worry’ and ‘trauma’, but never medical risks to the own body, mirrors the deeply gendered norms that set the boundaries for how women are supposed to act and feel during pregnancy.

Traditionalist discourses on pregnancy and risk

In some articles, the closure of BB Sollefteå was not described as a risk, and the vast attention devoted to the closure was characterised as overstated. This perspective appeared only as letters to the editor published in ST. Although also referring to a kind of family perspective, these articles drew on a more traditionalist discourse in doing risk, favouring a close social network (family or neighbours) over welfare services. On February 15, someone signing themselves ‘Tant Agnes’ (‘Old Agnes’) wrote as follows.

The focus cannot be confined to young fertile women. Being pregnant in a big city area today does not guarantee being able to give birth in the closest hospital. You might have to travel many miles – it is up to you to take the place you are offered. Of course, I understand that no one wants to give birth in a car, but I wonder if there’s a need for causing such a fuss by occupying [the maternity ward]. We all want healthcare as nearby as possible, but one may have to adjust [one’s living situation] after one’s needs. If someone thinks I’m old-fashioned, my way of being reflects the fact that I was born in the 40s in a small cabin (100 km from the closest hospital) on roadless land, and my young mother had her own grandmother as her only assistant, who heated the iron scissors in the stove before cutting the umbilical cord. (Tant Agnes, ST, 2017-02-15)

In this article, the author opposes the welfare discourses that portray the closure of BB Sollefteå as a risk. By downplaying the need for maternity wards, she rejects the discursive articulation of the closure as a risk. Giving birth is described as natural – something that women have done throughout time, with or without public healthcare. In this way, the author is doing gender while reproducing particular discourses on femininity and motherhood; women-becoming-mothers are expected to be strong and uncomplaining (not causing ‘a fuss’). The quote could also be read as opposing medical expertise and institutionalisation, as well as the attention Sollefteå has attracted following the closure. The argumentation reveals an ideological and regional conflict between the county’s expanding urban centre and those towns experiencing population decline. The author suggests that smaller towns are demanding too much, and she expresses dissatisfaction about how money is being used in the county. Similar arguments can be found in the article entitled ‘Don’t scare expectant mothers – giving birth is natural’.

I feel sorry for women that, while expecting – [a time] when they should be happy – have to share this worry. I have had several children without any problem on a maternity ward, a mere ten kilometres away. There was plenty of time to prepare for the delivery. But I understand your concern! So, I want to tell you that I was myself born in a sofa bed in the countryside, with the help of an older woman consulted by the people in the village. She was brought [to the place] by horse and sleigh, or a sled if it was winter. One could not call someone to get help, as there were no telephones. This was normal 80 years ago for most homes in the village, but everything went well. Good luck, all future mothers! You are in good hands and can feel safe. Instead [of worrying], look forward to soon having a loved little homemade one. (Söderberg, ST, 2017-02-12)

In contrast to the previous quote, ‘Söderberg’ identifies pregnant women’s worries as a risk but does not associate those worries with the closure, unlike those articles that used welfare rhetoric to address risks to families. Instead, the author indicates that the worry derives from the rhetoric used by the protesters. As in the welfare discourse, the implication here is that worrying departs from how a pregnancy should be: a time when the woman looks forward to meeting her loved (and homemade) baby. Here, how risk is done relates closely to normative motherhood; in the quote, the pregnant woman is described as if already a mother, who should be occupied with (imagining) nurturing her baby. In this case, the doing of risk as pregnant women’s worry intersects with the doing of countryside as place; the author does an ideal femininity that – opposite to today’s mothers – does not complain or count on support from outside the community. As in the previous quote, the author’s anecdote about being born outside hospital, without modern technology, can be read as a resistance to the Swedish discourse on (institutionalised) maternity care and related problematisations of women’s bodies and processes. In both cases, the author is recalling a time when people relied on the community rather than the state.

Both of these authors address pregnancy and childbirth as natural and unrisky. As Enloe (2014) noted, naturalisation is commonly deployed when referring to women’s issues, and claiming that something is ‘natural’ or has always been a certain way makes it harder to problematise. As such, naturalisation often leads to depoliticising, as there is no need for political intervention. In both articles, the authors use nature and tradition to disconnect risk from the closure of BB Sollefteå. Interestingly, the articles drawing on traditionalist ideological discourses were most likely to focus exclusively on the pregnant woman, with no mention of a second parent.

Neoliberal discourses on pregnancy and risk

In several articles, risk articulations were accompanied by suggested strategies, focusing on the individual parents and what they should do to avoid or manage risks. For example, this individualised focus might appear in opinion pieces in ST, written by county council politicians, or as fragments in Allehanda, reporting on expectant parents’ preparations to minimise risks. A Worker’s Educational Association course was arranged to teach future parents how to prepare for delivery in a car, and this soon attracted the attention of Swedish news media and some international news channels. In an article in Allehanda on the day the course started, one of the midwives was interviewed about what the course participants would learn.

We do not focus on complicated deliveries; it is not a course in the art of delivery, Karlström notes. But we end up giving a lot of support and advice. Make sure to have warm and dry blankets or towels in the car. The most important thing is that the baby is kept warm and dry. Put the baby on the chest and let it breastfeed, says Karlström. (Daniel Haugen, Allehanda, 2017-02-03)

In drawing attention to the consequences of the closure, this course can to some extent be seen as resisting neoliberal discourses and the political decision to close BB Sollefteå. However, it also contributes to an individualist discourse that makes expectant parents responsible for navigating the risks entailed by the longer distance to a maternity ward. As stressed by Giritli Nygren et al. (2017), the doing of risk often intersects with the doing of normative discourses. In the advice that Karlström offers future parents about preparing for the birth, the doing of risk parallels the doing of the norm that the baby’s health should be in full focus after the delivery. The article does not include any advice from the course leaders about what parents should do if the mother’s condition becomes critical. Following Foucault’s (2008) perception of risk as a form of power wielding, the midwife expertise offered to the course participants can be seen as a way of governing expectant parents’ behaviour. As the parents are taught how to act in a situation where they would not make it to the hospital in time, responsibility is redirected from politicians to individuals. Further, it is interesting that the article refers to all participants as couples, and the course seems to assume that the parents have their own car. The risk articulations in the article tend, then, to draw on discourses around the normative family, as well as strengthening norms about pregnancy as a time of stability (were it not for the closure of the maternity ward).

Responding to distressed reactions after the course, Eva Back, the Social Democratic politician who was head of Västernorrland’s county council at the time, wrote an article in ST in an effort to calm expectant parents and to shift attention away from the health risks that many believe the closure entails.

(…) it is natural that giving birth, especially for the first time, is a very overwhelming and dramatic experience in the lives of future parents, and I understand that one may experience worry and fear. However, there are many occasions during the pregnancy when one can talk about their worry and fear [with a midwife] and get information about when to go to the hospital, etc. (Back, Sundsvalls Tidning, 2017-2-4)

By highlighting how one can obtain information from a midwife about when to go to the hospital, Back emphasises the parents’ own responsibility to navigate the new situation. She stresses that it is ‘natural that giving birth, especially for the first time, is a very overwhelming and dramatic experience’, and she acknowledges that ‘there are many occasions during the pregnancy when one can talk about their worry and fear’. In so doing, Back addresses future parents’ worry as a risk but articulates it as an individual problem rather than as the result of the maternity ward closure, suggesting that the parents’ worry is a natural part of pregnancy. In light of Enloe (2014) theorisation of how naturalising certain (gendered) issues serves to depoliticise them, Back’s argument can be seen to individualise and naturalise worry, disconnecting it from the county council’s decision to close the maternity ward. By addressing ‘future parents’ but never the pregnant woman, Back implies that pregnancy and giving birth involve both parents equally, serving to portray pregnancy-related risks as non-gendered. Describing risks as worries can, therefore, be seen as a way of abstracting risks, disconnecting them from political decisions, as well as from physical bodies and power structures.

Back’s quote can be seen as typical of a number of articles reflecting aspects of a neoliberal ideological discourse that emphasises information and individual choices. Given the available information about the new situation and their alternatives, future parents are expected to navigate risks individually. Leppo (2012) noted how the reorganisation of healthcare in Scandinavian countries has changed the conditions for maternity care. Dominated for a long time by a strong welfare discourse characterised by interventions and institutionalised control, it is now structured by a combination of welfare and neoliberal discourses. Centralisation and specialisation have had the effect of weakening discourses on institutionalisation, as healthcare becomes less tied to the hospital as a place.

Conclusion

In the article, I have used a critical feminist perspective to explore health-related risk articulations in newspaper articles reporting on the closure (and on-going occupation) of a maternity ward in Sweden’s northern inland. Inspired by Norman Fairclough’s (2013) critical discourse analysis (CDA), the paper’s analysis was structured in three ‘levels’: a micro-, a meso-, and a macro-level. On the first, micro-level, Douglas (2002) sociocultural approach to risk helped to sort the risks that appeared in the newspaper articles, as well as distinguishing which actors were described as ‘risk victims’, and what risks they were associated with. Most commonly, the family appeared as the main ‘risk victim’ – either because the article’s author explicitly referred to the closure’s effect on families, or because they mentioned several members in a family when addressing the damage that the closure would cause (e.g. mothers worrying, or stressed fathers driving the car to the hospital). Family-centred risks could also be linked to risks to Sollefteå as a place (or in some cases; Sweden’s northern inland or the countryside more generally), as the closure might result in families not seeing a future in the area, and, therefore, move closer to bigger towns. Returning to Cynthia Enloe’s (2014) approach to feminist research, which centres on the women involved in a given issue, it is notable that the pregnant woman was so rarely the focus of risk descriptions in the newspaper articles. Although an in-car birth in February prompted a large number of articles focusing on the woman, these emphasised trauma and unworthiness rather than focusing on the physical risks to women’s bodies.

On the analysis’ meso-level, I used intersectional risk theory (e.g. Giritli Nygren et al., 2017) to analyse how the risks that appeared in the newspaper articles were discursively done parallel to the power structures gender, class and heteronormativity. This part of the analysis showed how the risk articulations commonly reproduced normative discourses on motherhood and family, which appeared both in arguments outlining the closure as a risk, and in arguments rejecting a view where the closure was seen as risky. For example, risk articulations could be linked to an understanding of pregnancy as a period when the pregnant woman should be peaceful and concerned with imagining nurturing her baby. Furthermore, a middle-class or traditional family situation was often taken for granted, which was manifested by the fact that the articles assumed such things as owning a car or being in a man–woman relationship.

On the last, macro-level, I focused on ideological discourses that appeared in the newspaper articles, as well as processes of normalisation (Foucault, 2008) within the different discourses. I found that risks could be articulated within either a welfare discourse (which was the most common ideological discourse in the material), a traditionalist discourse, or a neoliberal discourse. Discourses could overlap with each other, yet they differed in regard to certain characteristics. In the discourse, I have chosen to term a welfare discourse, the importance of equal distribution of health services was emphasised, and risks were most commonly described to affect families, although the child/foetus and the pregnant woman also appeared as victims to risk. The more traditionalist discourse was characterised by a favouring of the social network (family and close friends) over welfare services. Within this discourse, the closure was not articulated as a risk; instead, articles drawing on this perspective emphasised how giving birth is natural and unrisky. From this point of view, the occupation of the maternity ward and the media attention it sparked were instead seen as sources of risk, as these could cause worry among pregnant women (and disturb the positive experience of expecting a child). Naturalisation also played a role in neoliberal discourses, where worry was described as a natural part of any pregnancy (independent of the distance to maternity care). In arguments drawing on this discourse, worry was disconnected from the closure as a political decision, and the individual was made responsible for adjusting to the new situation – for example by talking to a midwife about feelings of worry.

The three-level approach that I have used to analyse health-related risks in the newspaper articles enables an integrated analysis of how a set of processes make it possible to depoliticise and profit from the naturalisation of pregnancy-related risks. The abstraction and individualisation of women’s risks serve to disconnect those risks from the maternity ward closure as an event linked to political decisions, instead constructing risk as a natural part of any pregnancy. Intersecting with individualised discourses, this naturalisation of risks serves to depoliticise risks and solutions. By reducing women’s risks in this way, economic cuts can be presented as less problematic.

I conclude by arguing that the paper’s main contribution is a deeper understanding of how risks related to health are mediated within different ideological discourses, and on different discursive levels. In this sense, I have sought to shed light on how risks are understood and interpreted in sociopolitical contexts where healthcare has been restructured from a welfare model to NPM, yet in which welfare ideals remain strong. Further, using the ‘doing risk’ theory to analyse political interests and processes of depoliticising, I also aim to contribute to the growing field of intersectional risk studies – a theoretical approach that enables an understanding of how health-risks interact with a complex of power structures.

Disclosure statement

No potential conflict of interest was reported by the author.

Notes

1. BB is an abbreviation of ’barnbördhus’, an old Swedish term for maternity ward.