Privileges of Birth: Constellations of Care, Myth, and Race in South Africa centers around the natural birth movement in South Africa, where births are largely determined by socioeconomic factors. Jennifer Rogerson argues for examining care in relation to race and privilege, specifically what care means in specific contexts. Privileges of Birth is an ethnography about the “constellation” of care, race, and privilege among an atypical group of women in South Africa.
For three days a week from August 2014 to August 2015, Rogerson became a fixture in a midwifery practice located 10 minutes from her home in Cape Town, observing seven midwives give nearly 800 midwifery consultations, and conducting interviews with midwifery clients outside of consultations. In total, Rogerson interviewed 19 midwifery clients and developed comfortable relationships with six of these clients. While her nearby residence made her an insider to the socioeconomic experiences of the women she interviewed, having never given birth herself prompted her to ask questions as an outsider to the birth experience.
Similar to natural birth movements in Mexico and Brazil, natural birth is a form of resistance to how birth usually unfolds in South Africa. Rogerson acknowledges that while natural birth aspirations are typical for Rogerson’s particular group of informants, they are atypical in the context of South Africa, where the vast majority of births occur via cesarean section.
While the midwives Rogerson describes are all biomedically trained and rely on obstetricians for back-up support, both midwives and their clients explicitly contrast midwife-assisted natural birth with the “technocratic/obstetrics model of birth.” The birthing mothers in Rogerson’s study considered the right practitioner to be someone who believes in the power of a woman’s body and does not insist on unnecessary ultrasound scans. For both midwives and mothers, what distinguishes natural birth is midwives’ framing of birth as a normal and natural process and their assertions that unnecessary interventions are, in fact, detrimental to pregnant women and babies. At the same time, natural birth takes effort. Midwives counsel their clients on how to exercise, eat well, and practice multiple sitting, kneeling, and standing postures to coax the baby into an optimal position for birth. Thus, women hoping to achieve a natural birth through private midwifery services were resisting what they identified as paternal biomedical intervention and were instead advocates for feminism.
The group of midwifery clients Rogerson describes is also distinctly atypical with regard to the socioeconomic context of South Africa. Rogerson identifies her informants as women who have enough money to pay for private health care out of pocket. Further, the women in Rogerson’s ethnography are professionals who employ housekeeping and nannying services, own a car, and possess tertiary education. Indeed, 13 of the 19 women Rogerson interviewed had a university education and of those, six were medically trained.
While Rogerson readily acknowledges that these women are atypical, given the enormous gap between the rich and the poor in South Africa, she also defines these women as middle class, using criteria of affluence and lifestyle from developed countries and her informants’ self-description as middle class. Yet the question remains whether this classification is appropriate, especially since Rogerson acknowledges that their lifestyles would be described as elite by most South Africans. At stake is the question of which perspective to highlight—how the majority of South Africans classify natural birth seekers, or how women seeking natural birth self-identify. Rogerson chooses the self-identification of her informants. Rogerson is able to relate to her informants’ lifestyles, which gave her insider status among the women she studied. While Rogerson critically analyzes her informants’ atypical privilege, I would have liked to see deeper analysis of how Rogerson’s own class standing led her to privilege her informants’ perspectives over those of the general population.
Rogerson emphasizes that financial capital gave her mostly white informants the option of planning and thinking about their birth as a choice-based practice. That is, their inclusion in the natural birth movement is facilitated by their access to private health care, which, in turn, provides them with the rare ability to choose how they want to give birth. Freedom of choice is buttressed by their belonging in South Africa’s financially elite class. The midwifery clients Rogerson observed sought care from white midwives—breaking away from South Africa’s predominately black tradition of midwifery. Socioeconomic class then overlaps with racial privilege which, in turn, allows for choice.
To unpack this process further, Rogerson turns to South Africa’s history of apartheid. She asserts that the present medical reality in South Africa is rooted in its racialized beginnings, as access to hospitals, health services, and health care providers historically have been segregated along racial lines. This segregation produced gender- and race-stratification among birth attendants. Through a series of overlapping binaries (black vs. white, rural vs. urban, incompetent vs. expert), midwives—black women presumed to lack knowledge—were responsible for care in rural settings, while urban, hospital-based births became the domain of white obstetricians possessing medical expertise. While South Africa’s apartheid ended in 1994, the chasm separating the rich and the poor, the white and black population, persists to this day.
Due their degree of privilege, Rogerson’s informants are able to avoid difficult conditions in public hospitals that span from overburdened personnel to outright patient abuse. While less privileged counterparts may hope for adequate care that facilitates a successful delivery, the women in Rogerson’s study expected continued close attention by midwives with whom they have built close relationships with over time. Rogerson’s informants approached care as consumers and defined care in terms of quality. For less-privileged counterparts faced with high childbirth mortality rates, adequacy was determined by whether they survived childbirth and delivered live babies.
When making decisions about care, Rogerson signals that midwifery clients possess advanced knowledge and the necessary skill set for engaged research. Midwifery clients research every detail of the physiological processes of pregnancy, birth, and postpartum, and in so doing, they strongly connect good mothering with being well informed. During consultations, midwifery clients position themselves as informed consumers, using highly technical language to ask questions, and, thus, demonstrating discursive agility. Rogerson argues that having a pregnancy plan serves as a method for rendering visible good women’s work. Furthermore, women described childbirth pain as character-developing work, thus imbuing these experiences with moral judgments.
Rogerson’s critical examination of care—and her exploration of the different factors that enable choices about care—are the most significant contributions of her work. Rogerson offers the concept of a “care world,” in which socioeconomic factors loom large. She writes, “Thinking through care as a world draws attention to the multiple ways and factors that come to act on how care and relations are made. It also places an emphasis on the ways in which both carers and care-receivers actively produce care” (p. 9). By looking at how care is made as a practice, Privileges of Birth demonstrates how privilege instantiates racial difference in South Africa. White people almost exclusively access the midwifery care Rogerson describes. Thus, Rogerson frames choices about care in childbirth within a broader network of race and privilege.
Privileges of Birth is accessibly written, making it appropriate for introductory courses in medical anthropology, and especially those focusing on midwifery, class, race, and privilege.