The hospital and the home have evolved in close relation in the American spatial imagination. Until the mid-eighteenth-century, home was the place of healing for the majority of Americans who had means and family members to care for them. The first hospitals emerged as public facilities designed to house the homeless and destitute.[1] As America industrialized in the nineteenth century and modern medical science emerged, hospitals began expanding to serve a growing middle class without the time to care for family members.[2] In this way, hospitals evolved in tandem with the shifting economic and social formations of the home, which constitute the “domestic.” Instrumental to shifting imaginations of the domestic is the transfer of maternity care into the domain of hospitals, or the “medicalization” of birth. In this paper, I trace the ways spaces of maternity reflect contestations over women’s political autonomy, nationality, and the role of science. The maternity ward offers a vantage point on the ways differing scales of spatial embodiment overlap, in particular the national, the familial/domestic, and the bodily. The hospital offers a disciplinary space in which the private and public overlap and make private/bodily life open to institutional control. Despite this reality, recent interventions in critical geography have directed attention towards the hybridity of birth spaces and the intimate geographies of birth. Such research suggests ways women can engage creatively and agentically within the maternity environment.
Historical Context
Birth in America occurred at home until the mid-eighteenth century, and it was almost always managed by a midwife or a woman’s female friends and family members.[3] Techniques of childbirth disseminated through networks of female kinship. The mid-nineteenth century saw the rise of obstetrics. Physicians, armed with new European medical knowledge and surgical tools, began a campaign to expand their profession and authority as experts on birthing practice.[4] This included re-defining birth as a pathological rather than a natural event, one which required advanced medical knowledge, and, often, facilities.[5]
During the transition from midwives to physicians, mortality rates rose as physicians made unnecessary surgical maneuvers and used anesthesia carelessly.[6] Hospital-borne infections posed a significant threat to mothers and infants. Bellevue Hospital in New York was the first to open a dedicated maternity ward, in 1799. During the 1870s, outbreaks of puerperal fever caused by physicians improperly sanitizing their hands after performing autopsies led Bellevue to move their maternity wards to another hospital and to institute a system of nurses to run the operations of the ward.[7] The expansion of the nursing profession saw women re-entering professional spaces of birthing in large numbers.
The process of medicalizing birth has been understood by feminist critics as bringing the processes of reproduction under male control. This process has tracked the expansion of medical authority as the ultimate voice on matters of reproduction and child rearing, a patriarchal intervention into what had previously been regarded as the “private” sphere, and the domain of women. Not until the 1950s and the expansion of female obstetrical nurses did women regain widespread agency in the ways of childbirth.[8]
Domesticity and Hospitality
Witold Rybczynski has tracked the ways domesticity emerged in 17th century Netherlands as a middle class consolidated and the family became the main unit of social reproduction. The emergence of the bourgeois state saw the domestic unify meanings of home, household, and family into a set of meanings that manifested them spatially as the comfortably furnished home, impeccably maintained, neatly and thriftily decorated: a visual manifestation of the order and hierarchy of the family unit. As women became increasingly responsible for the maintenance of this household, the home became “a feminine place, or at least a place under feminine control.” He summarizes: “to speak of domesticity is to describe a set of felt emotions, not a single attribute. Domesticity has to do with family, intimacy, as well as with a sense of the house as embodying—not only harboring—these sentiments.”[9]
Domesticity’s discursive flexibility and the social and political centrality of the domestic sphere to American life makes it a key referent in the act of imagining spaces of healing. But the hospital’s engagements with and imaginings of domesticity also strain one of its key tenets: that of privacy and freedom from institutional control. The home is understood as domestic through its adherence to discourses of normalcy and citizenship. Hospitals offer entirely different spatial circumstances: they are public, professional, and sites of constant surveillance.[10] In the hospital, the state and medical institutions prescribe a model of domesticity as a form of institutional discipline. Early American hospitals distributed this discipline to citizens receiving care precisely because they have failed at incorporation into the proper domestic sphere of the nation.
Hospitals have proven instrumental in the proliferation of ideology on two scales of the domestic—both in the sense of the family unit and of the nation. Elizabeth Temkin has shown how the practice of “rooming-in” emerged during the Cold War in response both to practicalities of care as well as nationalist imperatives.[11] During the late nineteenth century, hospitals began moving babies from their mothers’ rooms to central nurseries to avoid infection.[12] Due to nursing shortages in the 40s infants had again begun to room with mothers, and in the 50s a whole new set of cultural and political rationalizations for the practice emerged. Rooming-in became the figurehead for a new cultural project that foregrounded a romantic sense of a “natural,” affectionate style of parenting that stood in stark contrast to Soviet values of rigid homogeny, science, and obedience. Rooming-in also served to encourage women, whose share of the workforce had spiked after the war, to re-enter the home. The suggestion was that by nurturing affection and intimacy between mothers and infants, “over-educated” women might be “trained” back into the home by encouraging “natural” maternal instincts.[13] Hospitals’ maternity arrangement became the instantiating symbol for a new model of family and worked to inculcate a spatial model of domesticity with social as well as political implications.
In the latter half of the 20th-century midwife and feminist activists began calling for the de-medicalization of birth. Home birth began to re-gain popularity among middle- and upper-class women. As hospital birth has continued to adopt the aesthetics and language of home, and alternative and home-birth advocates (spurred on by midwife movements across the world) have gained an increasing voice, the association between domesticity and birth has only grown. Hospitals have continued to make changes bridging the gaps between domestic and hospital space. Fannin describes the hospital as a hybrid space that works to “spatially mediate conflicts over the very meaning of reproduction through mobilization of the signs of the domestic.”[14] Fannin notes that the space between domestic and institutional spaces is fraught because both functions to limit women’s political agency. As Helena Mitchie puts it: “one cannot escape the discipline of the body by invoking the site of that discipline.”[15] Mitchie casts doubt on the notion that home birth provides an escape from the regimes of control incipient in the medical setting. She notes that generally, three types of women have home-births: upper-middle-class women who choose home-birth as a feminist rejoinder to medicalization, conservative women who value traditionalist privacy and patriarchal supervision, and poor women who have had little prenatal care.[16] This typology suggests that criticizing the hospital’s medicalization of birth by figuring home birth as more natural ignores the ways that home births are themselves figured by power and privilege. The hospital and home have become mutually constitutive in the discourses of domesticity and motherhood. Both are sites of control, and both are figured alternatively as sites of danger, safety, naturalness, and simulation.
Fannin points out that changes in models of motherhood at the institutional level have also shifted with the emergence of mothers as consumers. The privatization of medicine and the emergence of “patient-focused” design has seen hospitals reacting against the perception that hospitals are cold and dehumanizing. Such an approach encourages greater emphasis on hiding medical and supply equipment, a “concierge” model of service wherein patients’ needs are anticipated and met consistently, and the scripting of communication to achieve managerial standardization.[17] Increasingly, hospitals have been implementing management techniques and service models from the hospitality sector in an attempt to improve the patient experience. However, as Bromley cautions, such a “routinization of relationships” may lead to care becoming thought of as a “concrete produce delivered, as if to-order, by an individual whose special expertise is exemplary service.”[18]
Spatially, the patient-centric model works to separate staff and equipment (often by “camouflaging it”) from patients. The “camouflaging” of medical technology into a domestic therapeutic environment—for instance, sliding upholstered headboards that conceal oxygen outlets and emergency equipment, or nightstands that house blood-pressure and fetal monitors—is consistent with this trend of suppressing the reality of the hospital setting.[19] New hospitals are frequently designed explicitly to avoid appearing like a hospital, and instead try to evoke libraries, museums or even trendy bars.[20] This mitigates the anxiety related to hospitals being perceived as sites of danger and death, but such design also disconnects patients with the realities of care. By working strenuously to hide patients from the material medical facts of care, hospitals perpetuate the therapeutic experience’s status as fearful and unfamiliar.
The patient-centric model often includes the allocation of extra space for service corridors and elevators to isolate patient and support traffic. This design means patients do not interact casually with doctors and staff as frequently, widening the gap between patient and care provider.[21] The distance between patient and provider and the mechanization of interactions as a part of a service model of care can work to secure a patient’s “acquiescence to instrumentality,” in which they cede control to the medical system.[22]
Not all patient-centric advances are bad. In fact, many can significantly improve relationships between patients and carers, such as an emphasis on eye contact at the beginning of interactions. Domestic spatial imagination can also resist institutional pressure. As Jean Gilmour argues in her research on nursing practices, that nurses can use the structure of the home to couch the harsh institutional dimensions of the hospital: “Nurses become social agents responsible for generating an environment that feels like a home within the hospital, with all the physical and social freedom that this implies, as well as intimate, extended and personal relationships.” Such a tactic reflects the reality that notions of “home” hold extensive cultural purchase as signifiers of ease, belonging, and kinship, all of which may be both appropriated by institutions for ideological ends, but also used by nurses to form affective bonds and resist the standardization or commodification of patient care.
However, patient-focused design also has the potential to constitute a “commercialization” of the domestic model of care, one in which indirection and standardization make the ideological foundations and material realities of medical care more difficult to discern.
Bodies and the Geopolitics of Birth
Bodily space can be considered a subset of the domestic and the private. Both are linked to the home, familial intimacy, and the satisfaction of bodily needs. Hospitals re-configure bodily experience in ways that distribute institutional and patriarchal power. Rob Imrie has studied the ways popular imaginations of the home prove challenging to materialize for people with disabilities, particularly with regards to independence and privacy. Imrie discusses the ways the spaces of home are embodied by division into the component parts of the body and physiological needs: eating, sleeping, hygiene. When disabled people find that such spaces do not match their abilities and bodily configurations, they experience them as “disembodied spaces.”[23] We might re-orient Imries’ articulation of relationships between embodiment, ability, and domesticity to think about how hospitals figure the bodies of pregnant women. Maternity wards are designed with conflicting ends in mind. Some design features serve to meet the material needs of a woman in labor, and successfully enable health-promoting clinical practice and the avoidance of pain. On the other hand, hospitals also work to pathologize—to disable—women by marking pregnancy as a medical emergency. Under this pretext, women are dissembled as medical objects and re-articulated within the context of the home through the domestic discourses of maternity care. Domesticity is seen as a means of re-asserting “nature” and belonging in the face of the perceived medical “fact” that her stay in the hospital is a priori necessary. These two contrasting and not mutually exclusive situations demonstrate how domesticity is not just differently allocated to subjects along lines of social intelligibility but can be the means by which patients are disciplined and embodied as subjects of power.
The mother’s body is the site that is alternately legitimated, interpreted, and afforded and denied privacy in different ways at different spaces and times of maternity. For instance, the experience and expression of pain have spatial dimensions. Rosengren and DeVault observe an “ecology of pain” wherein pain is accepted in delivery rooms where doctors and nurses have advanced analgesic means for dealing with it, whereas in rooms further from the delivery room (patient meeting rooms, waiting rooms) nurses must deal with pain affectively.[24] More recently, Watson et al. have traced the ways pain is experienced variably in the different spaces of maternity, as well as the fact that pain legitimates the occupation of certain spaces (only mothers in certain conditions can credibly seek certain treatment places and pain management methods). They argue that “flexible” therapeutic landscapes recognize the relationality of this experience and empower patients to make informed decisions about their care.[25]
A focus on the scale of the body raises questions about women’s agency as subjects of power both in hospitals and at home. As McKinnon notes, tracking the polarized dichotomies of birth discourse “leaves little room to maneuver.” (289). She suggests that rather focus so heavily on natural vs. artificial and domestic vs. institutional, we instead pay attention to the “intimate geopolitics of birth” that occur on multiple levels constituting a “litany of overlapping territorial claims… these claims can be made by coalitions of actants who are human (mother, baby, obstetrician, midwife), non-human (wheelchair, clock, scalpel) and sub-human (hormones).”[26] This method draws from feminist and critical geographies and recognizes the maternity ward as the site of competing, overlapping interests at play across all scales. Such a theory allows critics to acknowledge that patient-centric design offers real advancements but also insidious possibilities for recapitulating problematic domestic ideology. “Geographies of birth” might also more readily explain the fact that female nurses in Toronto during the 50s and 60s provided mothers with a much greater number of cesarean section than male physicians did because it was a reliable mode of birth control that afforded some women new reproductive agency.[27] Geographies of birth recognize the body as a site of more dynamic contestation and imagination than the simple opposition between home and hospital, spaces that are not, in fact, separate but functionally bound up with each other.
Endnotes
[1] Marks and Beatty, The Story of Medicine in America, chap. 5.
[2] Vogel, “The Transformation of the American Hospital,” 45–46.
[3] Wertz and Wertz, Lying-In, 1.
[4] Sullivan and Weitz, Labor Pains, 4.
[5] Sullivan and Weitz, 3–9.
[6] Sullivan and Weitz, 17.
[7] Oshinsky, Bellevue, 135–40.
[8] Sullivan and Weitz, Labor Pains, 18–19.
[9] Rybczynski, “Domesticity,” 155.
[10] Foucault, The Birth of the Clinic. This surveillance is integral to the epistemological transformation that accompanies the rise of modern medicine. Foucault argues that the “medicalizing gaze” works by claiming to read the interior of the body from its surface through the diagnostic method. He argues that this opens new avenues of discursive power that constitute bodies through such medical surveillance.
[11] Temkin, “Rooming-In: Redesigning Hospitals and Motherhood in Cold War America.”
[12] This shift was also sponsored by the increasing practice of bottle-feeding (Temkin 273).
[13] Temkin, “Rooming-In: Redesigning Hospitals and Motherhood in Cold War America,” 293.
[14] Fannin, “Domesticating Birth in the Hospital: ‘Family-Centered’ Birth and the Emergence of ‘Homelike’ Birthing Rooms,” 518.
[15] Michie, “Confinements: The Domestic in the Discourses of Upper-Middle-Class Pregnancy,” 261.
[16] Michie, 263.
[17] Bromley, “Building Patient-Centeredness: Hospital Design as an Interpretive Act,” 1060–62.
[18] Bromley, 1064.
[19] Fannin, “Domesticating Birth in the Hospital: ‘Family-Centered’ Birth and the Emergence of ‘Homelike’ Birthing Rooms,” 517.
[20] Bromley, “Building Patient-Centeredness: Hospital Design as an Interpretive Act,” 1062.
[21] Bromley, 1064.
[22] Bromley, 1064.
[23] Imrie, “Disability, Embodiment and the Meaning of Home,” 157.
[24] Rosengren and DeVault, “The Sociology of Time and Space in an Obstetrical Hospital,” 284–86.
[25] Watson et al., “Flexible Therapeutic Landscapes of Labour and the Place of Pain Relief,” 872–74.
[26] McKinnon, “The Geopolitics of Birth,” 290.
[27] Feldberg, “On the Cutting Edge: Science and Obstetrical Practice in a Women’s Hospital, 1945-1960,” 130–35.
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