The Public Pregnancy
How the Fetal Debut and the Public Health Paradigm Affect Pregnancy Practice

JEN RINALDI

The routinized, ritualized use of ultrasound technology during pregnancy produces imagery that has affected cultural understandings of the fetus such that pressure to preserve and to terminate pregnancy alike may be framed as obligatory, in either instance carried out for the purpose of maximizing public health. In this chapter, I investigate the cultural effect of the ultrasound ritual and its product, “baby’s first photograph.” I go on to discuss the association of ultrasound visuals with normalcy and health, and the implications of that association: that women are the gatekeepers of public health, such that abortion, often opposed by those making use of fetal imagery as a political tool, comes to be the logical, inevitable conclusion to an ultrasound appointment gone wrong, in the same way that abstention from caffeine comes to be framed as good pregnancy practice. My interest is in exploring the range of maternal responsibilities that functions as a consequence to the social and political work fetal imagery accomplishes.

In reproductive contexts, ultrasounds employ sound waves to produce images of what is interior to the body—the contents of the uterus.1 Originally a military and industrial tool used to detect underwater phenomena, the technology was discovered to have medical application in the 1950s.2 Use of ultrasound has become such a prominent pregnancy ritual that it is assumed to be standard, even compulsory, and often desired by the prospective parent(s). Indeed, Susan Sontag describes the ultrasound as an example of “an aesthetic consumerism to which everyone is now addicted.”3 But Gordon Fyfe and John Law caution against the power of fixed visuals: “A depiction is never just an illustration. It is a material representation, the apparently stabilized product of social difference. To understand a visualization is thus to inquire into its provenance and into the social work that it does.”4 We turn, then, to the social work accomplished: the mandate built into the fetal imagery produced via technological intercourse, and how that mandate may be internalized.

Ultrasound imagery has been used to frame fetal-maternal identities and relationships.5 The technology affords the opportunity to, according to common cultural understandings, “see the baby,” and accessing this visual representation is thought to facilitate bonding. Having a window into the interior of the womb has come to be understood as a medically mediated quickening, a confirmation of the experience of pregnancy and a chance to forge a more personal connection with the fetus.6 But this intimate peering into the uterus renders public that which is private, and this publicization of the fetus has an individuating effect: “the technological removal of the fetus from the ‘secrecy of the womb’ through ultrasound . . . gives the fetus social recognition as an individual separate from the mother.”7 The relationship that the prospective mother forges with the fetus is cultivated through the technological medium that makes it possible for mother to meet fetus, for one individual entity to encounter another, because it sharpens the focus between the two.

Although in the early days of ultrasound use, the images produced were difficult to decipher—little more than static and snow—the idea that the interior of the womb could be explored by technological means came to be an enticing prospect and an engrossing preoccupation. Technologically produced fetal imagery first became public—to much fanfare—thanks to a 1965 Life Magazine cover and photo spread featuring Scandinavian artist Lennart Nilsson’s pictures of fetuses in utero. Described at length in the magazine feature are the art pieces’ dark backgrounds, sometimes depicting outer space, replacing the uterus in which the fetus is actually situated.8 Carol Stabile argues that this background, together with the captions discussing the thriving child, has the effect of disappearing the mother: “both visually and textually, the embryo-fetus enjoys a thoroughly autonomous status.”9 Images like these have functioned as tools used to “personify” the fetus and to render the female body invisible at best, and often even as hostile terrain.10 Tongue in cheek, Shelley A. M. Gavigan describes the picture painted: “the virtually autonomous foetus [is] trapped in its mother’s womb, begrudgingly serving a nine-month sentence of confinement.”11 The pregnant woman’s role is erased and reshaped through the production of fetal identity such that she, far from facilitating fetal development, is regarded as potentially standing in its way.

This effort to individuate the fetus for the purpose of protecting the fetus does not require technological mediation, but the materiality of the ultrasound image furthers the project of individuation. Indeed, according to Barbara Katz Rothman, “the sense of separation of the fetus and mother was already there as a concept; the new technology allows the separation to be reified.”12 Normalization of ultrasound, along with the power of the image, is compatible with long-standing anti-abortion politics. And opponents of abortion have recognized this compatibility, evidenced by their wielding visual imagery as political strategy. Organizations have fundraised to provide counselling and crisis pregnancy centres with ultrasound machinery and have lobbied in the United States and Canada to pass laws that would render ultrasounds legally mandatory when women express an interest in having an abortion.13 The Windsor Star, a Canadian publication, reported that the American evangelical group Focus on the Family spent $4.2 million in the 2005 fiscal year to equip crisis centres with ultrasound machines and to provide training for their use, and the Canadian-based Christian Association of Pregnancy Support Services points to the persuasiveness of fetal imagery: “anti-abortion advocates say an ultrasound image makes a far more effective case against abortion than any legal or bioethical argument.”14 Rosalind Petchesky argues that anti-abortion advocates have sought “to make foetal personhood a self-fulfilling prophecy by making the foetus a public presence” in “a visually oriented culture.”15 While activists against abortion have used imagery of the mutilated, aborted fetuses of Silent Scream fame, far more common is the “friendly fetus” or “the familiar and well-articulated fetus who is already a member of the family.”16 This cultural icon has proven to be a powerfully influential device in political activism waged against reproductive rights, one that manifests personal vulnerability, calls for legal protection, and inspires maternal shame.

So far, though, a piece of the picture is missing: while this political history has fallen away from collective memory and the ultrasound appointment has been taken up as a banality, even a cause for celebration in cases of wanted pregnancies, there are times when the diagnosis rendered via ultrasound radically changes the appointment’s tone. Ultrasounds are only effective as ritual to the extent that they produce imagery that is universal and publicly recognizable. The canonical experience of pregnancy includes obtaining the same picture every other pregnant woman has received of her fetus: as Rebecca Kukla notes, “our pleasure in these first ‘encounters’ with our ‘baby’ is inextricably bound up with our pleasure in the conformation of our experience to the shared norm.”17 This can only happen when the fetus lives up to health expectations, where health is understood to be the absence of disease and disability.18

Often overlooked in the ritual of obtaining that first family photo is what happens when the visuals are not recognizable, when deviations to canon are detected. While ultrasound carries a social meaning that “dominates its medical uses,” the tool was originally used in the 1950s to detect not merely the innocuous fetal positioning and the presence of twins but also anencephaly, or the absence of a fetal skull and upper brain.19 Currently, ultrasounds are employed “to detect increasingly subtle structural and functional abnormalities such as gastrointestinal tract anomalies, urinary tract anomalies, congenital heart defects and skeletal dysplasia.”20 The Society of Obstetricians and Gynaecologists of Canada (SOGC) developed guidelines specifically recommending the use of ultrasound to detect chromosomal anomalies that result in intellectual disability.21 The social work of the ultrasound appointment abruptly shifts because the fetus can no longer be personified, for its identity comes to be entirely constituted by impairment.22

When the fetus cannot be idealized or regarded as friendly, the social purpose of the ultrasound ritual deviates, for the experience is no longer about facilitating the relationship between mother and child. The responsibilities of the woman change such that she is socially—perhaps even medically, morally, and civically—expected not to nurture and protect her offspring, not to ensure that it is healthy, but to abandon the pregnancy. That is, responsibilities shift to disability deselection, which, in the absence of cures for many fetal conditions or effective and safe surgeries performed on the fetus in utero, equates to termination of the pregnancy. Abortion has come to be the “logical follow-up” and “action imperative” to diagnoses of fetal impairment.23 Here, I would stress the difference between abortion as reproductive right and abortion as reproductive responsibility. Although I would not advocate for limiting a woman’s reproductive access even if it meant the termination of a pregnancy where fetal impairments have been detected, I nevertheless hold that the social work of the ultrasound image includes expectations and imperatives around termination.

Some scholars have gone so far as to consider whether it is morally wrong to reproduce or to refuse to access reproductive technologies when the risks for a disease or disability are high.24 Women who refuse ultrasound run the risk of being considered irresponsible for not doing everything within their power to promote fetal health.25 Susan Sherwin argues that while women are not legally coerced into consenting to ultrasounds, “it is so commonly used and so generally valued that it is difficult for anyone to resist its use without being judged irrational and irresponsible.”26

Has the analysis gone too far? Fetal imagery has been taken up by opponents of abortion, after all; must they, too, be wary of cultural appropriations getting away from them, of the picture meaning more than they had intended? I would wager as much: the friendly fetus promoted in anti-abortion campaigns is also the healthy fetus and thus is only effective when in compliance with our current health paradigm. Health as absence of disability is understood to be, at least in part, pictorially representable. The social meaning of ultrasound is built on the condition that health can be seen and disability can be marked. That the image is normalized, that there is a universal, ideal image sought at ultrasound appointments, carries the (perhaps unintended) implication that there is such a thing as abnormality, and the presence of abnormality in an ultrasound picture precludes women from the social conventions of pregnancy. Abortion comes to be an obligation in the interest of public health, for the fetus as a public figure—one that makes its social debut with the help of sonographic waves—must be familiar.27

Through ultrasound, then, we have seen the woman disappeared, cast in an adversarial role, and consigned to the gate, responsible for not only bringing persons into but also “barring the entry of disabled persons” from a community.28 Women as gatekeepers safeguard and maximize public health, the health of a polity, by denying passage to identifiable impairments, to deviations from the ideal. They are responsible for preventing, and thus at fault for reproducing, disability. There are myriad ways in which they are obliged to manage pregnancy or to have pregnancy managed in order to avoid health complications, ranging from regimenting caffeine and fish, to taking folic acid and iron supplements, to avoiding too much or too little weight gain, to forgoing alcohol and cigarettes.29 Fetal health is such a pressing public concern that women are little trusted with its preservation and promotion: “they are constantly judged by family, friends, and strangers, in the transformation of pregnant bodies into objects of public concern.”30 Social compliance is framed as personal responsibility: women are to blame for not maintaining a proper diet; for not submitting to medical scrutiny; and for not terminating when the fetus is marked, abnormal, and unhealthy. This range may seem to admit contradictions, but I mean to defend a woman’s right both to terminate and to carry through with a pregnancy, for I am interested in the way in which neither reproductive choice is entirely hers when her womb and the contents of it become public theatre and when her decisions and activities come to be measured according to standards like the needs of the fetus or the demands of the social good. In either case, our preoccupation with the imagery that the ultrasound yields perpetually casts women to the background.

So in sum, the evocative and voyeuristic ultrasound picture has factored into social efforts to draw attention away from women’s needs, interests, and entitlements. The fetus as a political figure has accomplished much since its appearance on the public scene sixty years ago, for it has served to reify reproductive control and to reframe that control as maternal responsibility. This is not to say that a woman should not derive pleasure from a technologically derived sneak peek or that she should decline folic acid or opt out of exercising a hard-fought legal right to terminate pregnancy. I mean only to claim that social context—replete with so many pressures around good pregnancy practice—does not make authentic choice easy and that fetal imagery has been used to further muddy the waters. If we ever hope to disentangle ourselves from the problematics of pregnancy maintenance, even of pregnancy termination, more work needs to be done to consider how ultrasound has been culturally taken up—that is, how visual representations are interpreted and in turn embedded within our valuing systems.