Maternal Mortality, Midwives, and Cesarean Sections in China, 1900S–2000S
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Reproductive Modernities in Policy: Maternal Mortality, Midwives, and Cesarean Sections in China, 1900s–2000s Suzanne Z. Gottschang Technology and Culture, Volume 61, Number 2, April 2020, pp. 617-644 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/tech.2020.0055 For additional information about this article https://muse.jhu.edu/article/761578 [ Access provided at 1 Feb 2021 22:45 GMT from University Of Southern California ] 11_Gottschang 617–44.qxp_03_49.3dobraszczyk 568– 6/24/20 10:10 AM Page 617 SPECIAL SECTION Reproductive Modernities in Policy Maternal Mortality, Midwives, and Cesarean Sections in China, 1900 s–2000s SUZANNE Z. GOTTSCHANG ABSTRACT : China is one of a few countries to reach the 2015 United Nations Millennium Development Goal of reducing maternal mortality by 75 percent in fifteen years. The longstanding and intractable problem of maternal mor - tality in the Global North and South makes China’s success all the more re- markable. This article examines relationships between China’s reproductive health policies aimed at reducing maternal mortality and technological changes in managing childbirth associated with them from the early twenti - eth century to the present day. Tracing technological choices to prevent ma- ternal deaths at junctures in the history of health-based reforms makes visible China’s broader economic and political priorities in its internal moderniza - tion projects and in its interest in raising the nation’s global standing. Finally, the consequences of state reproductive priorities emerging in recent years suggest that women’s decisions to delay childbearing or to bear multiple chil - dren, may bring about circumstances increasing the risk of maternal death. In 2010, news reports circulated that the deaths of mothers in childbirth had decreased globally by more than 40 percent since 1990. 1 A key target in the eight United Nations Millennium Development Goals (MDGs) was to en- courage member countries to change infrastructure, health care systems, Suzanne Z. Gottschang is professor of anthropology and East Asian studies at Smith College. She would like to acknowledge the generous funding and research support pro - vided by the Research Grants Council of the Hong Kong S.A.R. (RGC CRF HKU C7011- 16G). This work was presented at a panel on reproductive technologies organized by Gonçalo Santos and the author at the Society for the History of Technology’s inaugural meeting in Asia, held June 2016 in Singapore. This article has benefitted from comments and discussions during the conference from Francesca Bray, Ruth Cowan, Gonçalo San- tos, Azumi Tsuge, Chiaki Shirai, Wu Chia-Ling, and Zhang Jun. Finally, she would like to thank Gonçalo Santos, Karen Turner, and Suzanne Moon as well as the anonymous reviewers of Technology and Culture for their helpful feedback. ©2020 by the Society for the History of Technology. All rights reserved. 0040-165X/20/6102-0009/617 –44 1. See for example in the United States: Donald G. McNeil Jr., “Maternal Deaths Plunged.” 617 11_Gottschang 617–44.qxp_03_49.3dobraszczyk 568– 6/24/20 10:10 AM Page 618 TECHNOLOGY AND CULTURE and practices that could bring about significant reductions in maternal mortality ratios (MMR). Global attention to maternal mortality, defined by the United Nations as any death of a woman during pregnancy, childbirth and up to six weeks postpartum, is not necessarily new. Vital statistics like maternal and infant mortality have long represented the measure of the suc - cess or failure of social and medical reforms aimed at modernizing societies APRIL and continue to serve as a measure of how well a nation cares for its women 2020 and children. 2 The Millennium Development Goal to reduce maternal mor - VOL. 61 tality represented the most ambitious effort to bring the world closer to a global aspiration of modernity in which women survive the risks of repro - duction. Yet reducing maternal deaths has proven difficult. Most countries in the Global South could not meet the MDG goal to reduce maternal mor - tality by 75 percent. Moreover, though not a signatory to the MDGs, the United States has the highest rate of maternal mortality among countries in the Global North. 3 Despite such difficulties, however, China stands out as one of only a few countries to have made significant progress. 4 China’s success in lowering MMR resulted from large-scale state ef- forts to improve access to hospital-based childbirth for women throughout the country with an eye to making emergency obstetrics care more widely available. Although great strides had been made in the twentieth century, since signing on to the MDGs in 2000, China has sought to make certain that every woman in the nation, no matter how remote their location and irrespective of their income, has the chance to give birth in a hospital. To date, the state has implemented this plan by expanding the number of maternity hospitals or clinics throughout the country so that by 2016 more than 95 percent of births would occur in these institutions. 5 In addition to the increase in institutionalized childbirth, the training and role of hospi - tal personnel who supervise these births also changed. Since the mid- 1990s, China abolished midwifery training and the place of midwives in overseeing childbirth, while concurrently training obstetric physicians to replace them. 6 These two widespread reforms fundamentally altered the landscape of childbirth in twenty-first-century China. Still, while decreases in MMR might be cause for celebration, increased cesarean rates in China suggest that reproduction in women’s lives may remain a potentially risky proposition. Ultimately, however, China’s successes in lowering maternal mortality represents an achievement that not only reinforces the power of 2. See Theodore M. Porter, The Rise of Statistical Thinkin g; and Michel Foucault, “Governmentality.” 3. GBD 2015 Maternal Mortality Collaborators, “National Levels of Maternal Mor- tality,” 1784. 4. World Health Organization, “The Top Ten Causes of Death.” 5. Y. Gao et al., “Progress and Challenges.” 6. Ngai Feng Cheung, Rosemary Mander, and Linan Cheng, “The Doula Midwives in Shanghai.” In some urban hospitals midwives assumed the role of a birth attendant who supports the mother during birth but is not involved in her medical care. 618 11_Gottschang 617–44.qxp_03_49.3dobraszczyk 568– 6/24/20 10:10 AM Page 619 GOTTSCHANG K|KReproductive Modernities the state to bring about significant health reforms for its citizens but also reminds the world of China’s increasing importance in world affairs. China’s recent efforts to prevent maternal deaths represent the culmi - nation of policies and plans spanning the twentieth century. This article follows policies and programs designed to reduce maternal mortality in China from the early twentieth century to the present day to document transformations in the spaces, technologies, and subjects of maternal gov - SPECIAL ernance. China’s modern history, in promoting maternal and child health, SECTION has been shown to reflect a dynamic process centering on the selective em- brace and adoption of Western medical and technological developments as part of efforts to modernize the nation. This focus represented a response based on the belief held by China’s reformers in the late nineteenth and early twentieth centuries that “women’s subordination was . explicitly linked to weaknesses in Chinese culture and the Chinese state, and moder - nity to women’s emancipation.” 7 While these trends have been well researched, as in Tina Johnson’s work on childbirth in Republican China , this article takes a longitudinal perspec - tive to make visible how technological choices reflect changing economic and political priorities in the interests of pursuing modernity. 8 With regard to childbirth, for example, Chinese medical reformers in the Republican era (1911–49) went against efforts in the West to bring birth into the purview and practice of physicians. Instead they promoted the use of trained mid - wives as a means to bring modern birthing practices to Chinese mothers. 9 Tracing maternal mortality reduction as a global and national health prior - ity through time in China’s history, this article adds to these insights as it helps makes visible the ways that programs and policies create possibilities for both adopting and discarding technologies and techniques designed to save women’s lives. For the purposes of this article, I focus on policies related to the role of hospitals, midwives, and physicians and then explore some of the technological consequences resulting from these changes. Drawing on studies of maternal mortality as well as anthropological analy - sis of policy and governance, the article demonstrates the ways that China’s efforts to reduce maternal deaths represent a form of coproduction of local circumstances and national and global agendas and interests. 10 It is important to reemphasize that at all junctures examined here we see in these changes a reflection of an aspiration to modernize China and establish its legitimate role among world powers. In the Republican era (1912–49), for example, Chinese health reformers sought to incorporate Western medical knowledge, technology, and practices to strengthen a 7. Gail Hershatter, Women in China , 86. 8. Tina Phillips Johnson, Childbirth in Republican China . 9. Ibid. 10. Suzanne Ilcan and Lynne Phillips, “Developmentalities and Calculative Prac- tices,” 874. 619 11_Gottschang 617–44.qxp_03_49.3dobraszczyk 568– 6/24/20 10:10 AM Page 620 TECHNOLOGY AND CULTURE poor and war-torn country by training midwives in basic aseptic tech - niques and by establishing maternity hospitals in urban areas. With the founding of the People’s Republic of China in 1949 and throughout the 1950s, the Communist government worked to bring childbirth into the hospital and established clinics throughout rural areas. After the Cultural Revolution and with China’s economic reforms in 1978 that brought more APRIL market based approaches to the economy and to governance, hospitals 2020 started to lose essential state subsidies and the rural health care system be- VOL.