Towards the end of the nineteenth century obstetric mortality became defmed as a social problem. The State was then seen as responsible for solving the problem of the deaths of mothers and their babies as were the midwifery and medical professions (Oakley, 1 984). According to O'Dowd and Philip ( 1 994, p. 22), maternal mortality rates have long been used as an indicator of the effectiveness of maternity care. From 1 9 1 2 to 1 980, duration of labour was one of the variables assessed in the literature as a measure of the uterus' ability. Other variables identifIed were maternal morbidity, fetal presentation and position, fetal morbidity and mortality, congenital abnormalities and the type of intervention required during labour.
In the early twentieth century, the medical profession'S concern was directed more to the wellbeing of the mother. It was not until a few decades later that the obstetric profession's concern shifted more to the wellbeing of the baby. In 1 949, Randall & Champneys Taylor asserted that the infant of the "elderly" primipara was more likely to "bear the major risk" (p. 1 2 1 8). Later, MacDonald and MacLennan ( 1 960), in their analysis of the risks for the "elderly" primipara and her baby, found that maternal mortality was no longer a problem but argued that instead "the high perinatal loss is the kernel of the present day problem in the management of "elderly" primigravidae" (p. 448). MacLauchlan ( 1 998) argues that the shift of attention to the fetus had two effects. One was that it has given the fetus a "sanctifIed state" and as such
appealed to the mother to seek antenatal care. The second effect was that it ensured the position of the obstetric profession and their role in the surveillance and monitoring of the fetus.
The words used to describe the babies of "elderly" prnmpara convey importance. Some authors state that they are of "more value" (Quigley, 1 93 1 ; Schulze, 1 929; Tew et aI, 1 938; Waters et aI, 1 950), or that they are "precious" (Fliehr, 1 956; MacDonald & MacLennan, 1 960). Other authors have described the pregnancy and birth of an "elderly" primipara as a "premium" or "precious" pregnancy (Hillard, 1 982; Edge & Laros, 1 993; Peipert & Bracken, 1 993; Tuck et aI, 1 988). The words reveal a belief that becoming a mother is an important event for the "older" woman. The birth of her first child is made more significant by her decreasing fecundity. There may be no other opportunities for her to have another child. Therefore, it must be born alive and well by whatever means. Consequently, the assertion that the baby of an "elderly" primipara is "precious" is deployed as the justification for the practice of caesarian sections.
Silent in this valuing is the younger primipara and the potential for the existence of a double standard of practice. Because the younger woman has a greater opportunity for becoming pregnant, the above belief assumes that her baby is of less value. Therefore, the parameters for intervention may be broader. However, given the interests of the state in maintaining a healthy population, and the obstetrician's interests in avoiding discipline should the baby be born damaged or dead, it remains unspoken as for whom the baby is more or less precious: the mother, the obstetrician or society.
4.2.5.1 The discursive practices of the "elderly" primigravida/primipara sub discourses
A primary practice associated with the discourses is surveillance: the careful watching and examination of not only the mother but also her baby. During the antenatal and intrapartum periods the woman is assessed and examined.
The examination combines the techniques of an observing hierarchy and those of a normalizing judgement. It is a normalizing gaze, a surveillance that makes it possible to qualify, to classify and to punish. It establishes over individuals a visibility through which one differentiates them and judges them.
Foucault, 1 977, p. 1 84 The medical eye, which examines the mother and her baby, draws on norms that are based on the behaviour and performances of younger women. Within the scientific
medical discourses, the criteria of age and parity situate any first time pregnant and/or birthing woman aged 35 or over, and her baby, into the domain of non-confonning, abnonnal and at risk. As such, she is subjected to a surveillance that is different from that given to women categorised as nonnal. Prysak and Kisly ( 1 997) recommend the practice of "extreme diligence" (p.300) when caring for "elderly" nulliparas. Hansen ( 1 986) urges physicians to be aware of the increased risks associated with "older" pregnant women. Thus the future holds the potential for danger and its signs can be seen in the present, but only if the examiner is especially watchful and knows what signs slhe is looking for.
The woman submits herself to surveillance. In doing so, she is subjected to
examination and becomes its object, the known. The practitioner is the one who has the knowledge to detennine and the power to detennine and classify. Through the process of examination, the practitioner comes to know the woman.
For Foucault (1 977), the act of examination is a mechanism of discipline ''the specific technique of a power that regards individuals both as objects and instruments of its exercise. This power is not triumphant, excessive, omnipotent, but modest,
suspicious and calculating" (Sheridan, 1 980, p. 1 52). It is a system in which the
"elderly" primipara is disciplined to confonn to the nonnal. Her inability to maintain a healthy environment for her baby in utero and to birth and produce a healthy baby needs
to be corrected so that these nonns can be attained. In essence, this is a fonn of
F oucault' s (1 977) disciplinary punishment that attempts to lessen the space between abnonnal and nonnal. The obstetrician is the maternity practitioner who can prescribe and perfonn the corrective interventions and the hospital is the only place where these interventions can occur.
A second practice associated with the "elderly" primipara discourses is that of caesarian sections. The mention of caesarian section is consistent throughout the "elderly" primipara literature. Caesarian sections were uncommon until the 1 950s (Tew, 1 995). Factors such as blood transfusions, antibiotics and modem anaesthetic techniques have contributed to making the operative procedure, once considered dangerous, safe (Savage, 1 992). The "absolute indications" for women having caesarian sections are those when either the mother or baby's life or wellbeing are threatened: for example, praevia, or abruptio placenta, and prolapsed umbilical cord. However, more recent studies have asserted that the obstetricians' attitudes rather than maternal/fetal
McParland & Farine, 1 995; Gordon et aI, 1 99 1 ; Peipert & Bracken, 1 993; Tuck et aI, 1 988).
Kessler, Lancet, Borestein and Steinmetz ( 1 980) compared primiparas aged 20 to 25 with two groups of other women aged from 35 to 39 and 40 and over. They found that the "older" primiparas had a higher rate of caesarian sections than did the "older" multiparas. In comparing the reasons for caesarian sections, Kessler et al found that the reasons cited for "older" primiparas caesarian sections were more to do with ''the dynamics of parturition" and breech presentation (p. 1 67) whereas the "older" multiparas had a greater variety of reasons. Further fmdings were that the "older" primiparas were more likely to be induced and to have decisions made to have elective caesarian sections sooner in the course of labour than were the two other groups, especially if the women had a history of infertility or poor obstetrics. Kessler et al attribute the higher rates to the attitudes of obstetricians rather than clinical indications.
The researchers suggest that the obstetricians believe that the babies have a high social value. This belief is combined with the other belief that perceives the "elderly" primipara as potentially at risk. Thus when caring for "elderly" primiparas, the obstetrician may recommend that she has an elective caesarian or may decide to intervene before the signs of distress are established. The above researchers argue that maternal age in itself is being used as an indicator for caesarian sections.
Two conditions, dystocia (difficult/prolonged labour) and fetal distress, which have been used more recently, do not have clearly defmed criteria (Savage, 1 992). Tew ( 1 995) asserts that the standard for what constitutes dystocia is "arbitrary". Peipert &
Bracken ( 1 993) noted the subjective nature of diagnosing "failure to progress, dysfunctional labour and unspecified abnormalities of labour" (p. 201 ) in "elderly" primiparas. Rosenthal and Paters on Brown, ( 1 998) inferred that the high rate of fetal distress documented in their data on "elderly" primiparas was brought about by the junior practitioners' lack of experience and stress.
A diagnosis of fetal distress is often based now on continuous electronic monitoring which by itself may not be a consistently reliable tool (Savage, 1 992; Tew, 1 995). Savage ( 1 992) states that even with the use of continuous electronic monitoring, agreement on a definition of fetal distress has not been reached. There is evidence that obstetricians may not correctly identify fetal distress (Savage, 1 992). Babies born by emergency caesarian section because they had been diagnosed as having fetal distress were found at birth not to show signs of stress (Tew, 1 995). Fetal blood samples have
been found to reduce the unreliability of continuous electronic monitoring but utilisation of such resources does not always occur (Savage, 1 992).
Consequently, the potential for incorrect diagnoses and unnecessary caesarian sections exists. The majority of authors did not discuss the influence of obstetricians' attitudes or the possibility that some of the rationales for caesarian sections might have been subjective and socially constructed. Instead, the high rate of caesarian sections is interpreted as indicative of the "elderly" primiparas' inability to labour and birth within "normal" times. As a result, the practice of caesarian section because of the shifting parameters of its use constructs the "elderly" primipara as problematic and incapable.
The scientific medical discourse's representation of advancing maternal age as an intrinsic biological process that complicates pregnancy and birth in women aged 35 and over has in the last twenty years been opposed by the natural birth discourse. This discourse offers the "older" primigravida/primipara the space to resist the scientific medical discourse's identification of her as problematic and to remain undifferentiated from younger W8fB8B primigravida/primipara.