No Perfect Birth: Trauma and Obstetric Care in the Rural United States

Kristin Haltinner’s No Perfect Birth: Trauma and Obstetric Care in the Rural United States analyzes ‘‘cultural and structural forces at play in producing and exacerbating mothers’ trauma’’ by centering thirty rural mothers’ voices. In the national conversation around the perinatal health crisis, greater attention is needed to specific complexities and challenges of rural communities, where 19 percent of U.S. residents live: lack of jobs and high poverty rates; reliance on a single industry (e.g., mining, farming, factory) for economic sustainability and vitality; ‘‘brain drain’’ of highly skilled or credentialed people; high rates of unemployment and poverty and, subsequently, high concentrations of people who are uninsured, underinsured, and suffering from chronic illness; and a national physician shortage that disproportionately affects rural communities, with only 9 percent of physicians practicing in them. The shortage of obstetricians and gynecologists is even more stark, as Haltinner reports: ‘‘Half of the counties (mostly rural) in the United States do not have an obstetrician-gynecologist, while 56 percent do not have a nurse midwife. . . . only 20 percent of rural counties have obstetric care’’ (p. 23). Given this context, Haltinner’s work—each chapter anchored by an opening vignette and supplemented with interview data throughout—makes an important person-centered contribution to understanding rural obstetric care. The book is theoretically grounded in the work of Michel Foucault, specifically his conceptualizations of biopower, governmentality, and discipline. Power, as Foucault teaches, circulates throughout society by way of social institutions and state governing bodies to produce hegemonic systems of knowledge, discourse, norms, and behaviors that are most felt and experienced on the body. Such power surveils, subjugates, and controls populations, seemingly invisibly, and it is a Foucaultian conceptualization of power that grounds Haltinner’s analysis of traumatic birth experiences: ‘‘the structure of a given space, the constraints of time, and the embedded routines— the very themes that arose in my interviews with mothers’’ (p. 8). The first three chapters of No Perfect Birth focus on trauma imposed by time, space, and routine, respectively. Chapter One, in great detail, analyzes the history and contemporary operation of the U.S. insurancebased health care system that creates the conditions that overwork physicians by demanding long hours, incentivizing (financial and otherwise) a high patient volume, and regimenting provider-patient time in ways that, as Haltinner’s data illustrate, often leave women feeling unheard, unimportant, dismissed, and disrespected. Haltinner reports that ‘‘the average doctor sees nearly 2,500 patients annually, 19 people per day’’ (p. 28). Chapter Two analyzes the trauma imposed by space by documenting a history of midwifery, the medicalization of pregnancy and childbirth, and the subsequent rise of obstetric dominance in the United States. Here, the space to which Haltinner refers is birth place, with physician-attended, hospital-based birth standardized in the cultural imagination and by insurance, state licensure, and scope-of-practice restrictions for all midwives—most especially for those primarily practicing in community-based, out-of-hospital settings like private homes and freestanding birth centers. Collectively, Haltinner concludes that ‘‘the separation of midwifery and medical-based obstetrics creates two worlds of care’’ (p. 48). Chapter Three analyzes trauma imposed by routine, most specifically what Haltinner brilliantly describes as ‘‘bureaucratic inhumanity,’’ by focusing on the United States’s lack of structural investments in its people (read: social determinants of health) and how infant and maternal mortality are among the many casualties. Haltinner writes: ‘‘the routinization of health care results in women being unable to access needed care outside the routine practices of obstetrics . . . the U.S. model of insuranceReviews 51