Distribuirana subjektivnost u trudnoći: self, telo i medicinska tehnologija

Abstract

RezimePredmet empirijske i teorijske analize u ovoj tezi predstavlja oblikovanje i promenasubjektivnosti žena tokom trudnoće i porođaja, posebno s obzirom na dramatične telesnepromene koje se tada odvijaju i s obzirom na način na koji medicinska znanja, prakse itehnike posreduju ovaj proces. Cilj istraživanja bio je da se kroz analizu trudničkih iporođajnih narativa rekonstruišu transformacije doživljajne subjektivnosti žene tokomtrudnoće i porođaja u lokalnom kontekstu koji sa sobom nosi niz, pre svegainstitucionalnih, specifičnosti.Teza je započeta izlaganjem i kritičkim preispitivanjem reprezentacija i praksi kojesu povezane sa tretiranjem trudnoće i porođaja u savremenom društvu, kao irekonstrukcijom njihove istorijske geneze. Savremena situacija može se videti kaokulminacija istorijskog procesa stavljanja ženskog reproduktivnog zdravlja pod nadležnostmedicine koje je započelo u moderni. Između ostalog, ovaj proces podrazumeva to da sutrudnoća i porođaj posmatrani kao potencijalno rizični i patološki, pa su zbog toga tretiraniod strane medicinskih stručnjaka uz oslanjanje na brojna tehnološka sredstva, i to uinstitucionalnom okruženju. To svakako nosi određene posledice po doživljajnog subjekta iove posledice su u drugom, empirijskom, delu teze detaljno ispitane.Na kraju uvodnog dela rad je pozicioniran unutar aktuelnih debata okoreproduktivnih pitanja. Specifičan vid ovog pozicioniranja, omogućen je oslanjanjem najednu drugačiju teoriju kako subjekta, tako i tehnologije, koji se više ne posmatraju kaoneke date, koherentne i dobro individuirane celine, već kao kompleksne konstelacije kojesu lokalno situirane i koje se mogu samo empirijski opisati. Oslanjanje na ovu promenjenuperspektivu koja potiče iz studija nauke i tehnologije i savremenog feminizma, odnosno presvega na teoriju aktera-mreže (ANT) kao njeno konceptualno-metodološko jezgro, u radu jeomogućilo stavljanje akcenta na materijalne aspekte društvenog okruženja iinstitucionalno-tehnološku praksu.I pored svog potencijala ovog savremenog shvatanja, njemu nedostaju određeniresursi specifično podešeni za analizu subjektivnosti, kojoj s e u o vom r adu p rilazi i zperspektive prvog lica, kao i njene telesne situiranosti. Zbog toga je uveden dodatnifenomenološki teorijski okvir koji omogućava diferenciranu konceptualnu rekonstrukcijuotelovljenog iskustva subjekta. Pored toga, u ovom teorijskom delu rada izvršeno je idodatno teorijsko situiranje unutar psihologije, kroz razmatranje dve relevantne oblastikoje se ovom temom bave – psihologije žena i zdravstvene psihologije.Metodološko poglavlje sadrži refleksivni narativ same autorke o izvedenomempirijskom istraživanju. Osim detaljnog obrazlaganja svih relevantnih metodološkihodluka, u njemu se preispituje uloga istraživača u svim aspektima istraživanja – od izborafenomena i formulisanja pitanja, do realizacije istraživanja. Osnovni empirijski materijal nakome je zasnovana kvalitativna analiza čini dvadeset pet polustrukturisanih intervjua,prosečnog trajanja od po dva sata, obavljenih sa trinaest sagovornica – prvi pri krajutrudnoće, a drugi nakon porođaja. Podaci o lokalnom institucionalnom okruženju imedicinskim praksama i tehnikama dopunjeni su sekundarnim materijalom: beleškama saterenskog istraživanja koje je obavljeno u jednom beogradskom porodilištu, informacijamadobijenim iz razgovora sa malobrojnim lekarima koji su pristali na intervju i analizommedicinskih udžbenika. Osnovni metodološki okvir za tumačenje trudničkih i porođajnihnarativa predstavljala je interpretativna fenomenološka analiza koja za cilj ima detaljnurekonstrukciju individualnog iskustva, ali i njegovo situiranje kako u socio-kulturnom, takoi u teorijskom kontekstu.Druga polovina teze posvećena je izlaganju i komentarisanju empirijskih nalaza. Onaje podeljena u dve veće celine – u prvoj detaljno je analizirano iskustvo trudnoće, a u drugojiskustvo porođaja, uz navođenje relevantnih citata učesnica u istraživanju. Kroz diskusijukonkretnih iskustava pokazano je to da su posebno na početku trudnoće, ali i tokom nje,telesni doživljaji nejasni i višesmisleni i da se žene, po pravilu oslanjajaju na različitemedijatore – medicinska znanja, tehnološka sredstva (kao što su hormonski test iliultrazvuk), kao i na iskustva drugih osoba – u pokušaju da ispravno protumače, odnosnodiskurzivno obrade svoje stanje, i da se praktično odnose prema njemu, odnosno daplaniraju i izvode aktivnosti i organizuju svoje ponašanje.Veoma često medicinske tehnike imaju značajnu ulogu u razrešenju neizvesnost iomogućavaju ženi i potrebno znanje i priliku da informisano bira svoje postupke, ali oneponekad vode i indukovanju ili produbljujivanju neizvesnosti. Dakle, tehnologija imarazličite uloge tokom trudnoće i porođaja i vodi različitim ishodima za žene kao otelovljenesubjekte. Postoje najmanje dva značajna faktora kojima je to određeno – odnos prematelesnom iskustvu i organizacija prakse u kojoj se tehnologija pojavljuje tj. konkretni načinna koji je tehnologija institucionalno situirana. Oba aspekta detaljno su ispitana tokomanalize narativa.Značajan aspekt iskustva trudnoće, koji postavlja specifičan izazov predsubjektivnost žene, predstavlja činjenica da u njenom telu raste drugo biće koje vremenompostaje sve diferenciranije i autonomnije. Beba za trudnu ženu dobija sve određenije obrisei počinje da se doživljava kao nezavisno biće. I medicinska znanja/tehnologija i otelovljenoiskustvo žene igraju značajnu ulogu u individuiranju bebe i kroz analizu praćena jedinamika relativnog doprinosa i proces interakcije ova dva modaliteta iskustva. I nezavisnood ovog specifičnog aspekta otelovljenog iskustva koji se tiče prisustva bebe, ženino teloprolazi kroz velike i mnogobrojne transformacije tokom relativno kratkog perioda odnekoliko meseci. Analizirano je kako žena doživljava ove promene i kako se na njihprilagođava tokom svakodnevnog funkcionisanja.Znanja i veštine koje je tokom meseci trudnoće stekla i odnos prema sopstvenomtelu koji je izgradila omogućavaju ženi izvesna pozicioniranja i definišu njene potrebe ipreferencije na samom porođaju. Ipak, stvarni ishodi u velikoj meri zavise od materijalnih isimboličkih karakteristika institucionalnog okruženja u kome se porođaj odvija, što jedetaljno analizirano u delu teze posvećenom razmatranju porođajnih iskustava. Ukazano jena to kako konkretna konstelacija medicinske prakse, implicitne i eksplicitne norme,obrasci odnošenja, ali i materijalne karakteristike institucionalnog okruženja presudnoodređuju to kako će žena doživeti porođaj i svoju ulogu u njemu.Žena je tokom porođaja suočena sa donekle netransparentnim nizom povremenodramatičnih telesnih događaja koje ne može sasvim dobro da anticipira i da kontroliše, štosamo po sebi predstavlja izazov za njenu otelovljenu subjektivnost. Činjenica da nemakontrolu, a često ni uvid, u tok medicinskih intervencija kome je podvrgnuta, ovu situacijudodatno komplikuje. Detaljno je analizirano to kako se žena odnosi prema nizu telesnih imedicinskih događaja tokom porođaja, odnosno da li uspeva da prisvoji i bude akter togprocesa koji joj se dešava. Empirijski deo teze završen je razmatranjem mogućnosti zadrugačije ishode po subjektivnost žene koji se, makar u izvesnoj meri, nalaze i u trenutnojlokalnoj konstelaciji porođaja, i pored svih njenih nesavršenosti i nedostataka.S obzirom na to da su poglavlja u kojima su diskutovani nalazi istraživanja bilafokusirana na različita konkretna pitanja i aspekte transformacije ženine subjektivnostitokom trudnoće i porođaja, u zaključnom poglavlju ocrtane su neke opštije tendencije iponovo razmatrana, ovaj put u svetlu empirijskih uvida, neka od pitanja koja su otvorena uteorijskim delovima rada. U opštim terminima ispitane su različite uloge tehnologije injihov odnos prema otelovljenom iskustvu žene, koje tokom trudnoće i porođaja sa sobomnosi niz specifičnosti. Ukazano je na to da individualni subjekt ne mora da bude redukovansusretom sa tehnologijom, on kroz taj susret može tek da dobije specifične oblike iskustva iprilike za agensnost. Na kraju, istaknuto je da analiza trudničkog i porođajnog iskustva,koja ukazuje na distribuiranu, procesualnu i (tehnološki) posredovanu prirodusubjektivnosti uopšte, može da nam posluži kao značajan resurs za zasnivanje jedneadekvatnije psihološke teorije subjekta.

AbstractThe subject of empirical and theoretical analysis in this thesis is the process ofshaping and transformation of women´s subjectivity during pregnancy and childbirth,especially considering the dramatic bodily changes that occur and considering the way inwhich medical knowledge, practices and techniques mediate this process. The aim of thestudy was to reconstruct the transformations of experiential subjectivity of women duringpregnancy and childbirth, through analyzing pregnancy and birth narratives, in a localcontext which possess a number of (primarily institutional) specificities.The thesis begins by discussing and critically examining the representations andpractices associated with treating pregnancy and childbirth in contemporary society, aswell as reconstructing their historical origins. The contemporary situation can be seen asthe culmination of a historic process of putting women's reproductive health under thejurisdiction of medicine that began in modern period. Among other things, this processimplies that pregnancy and childbirth were viewed as potentially risky and pathological,and were therefore treated by medical professionals relying on numerous technologicalmeans, in the institutional environment. This certainly entails certain consequences for theexperiential subject and these consequences are examined in detail in the second,empirical, part of the thesis.At the end of the introduction part, the thesis is positioned within the currentdebate about reproductive issues. A specific aspect of this positioning was enabled byrelying on a different theory of both, the subject, and the technology, which are no longerconsidered as given, coherent and well individualised wholes, but as complexconstellations that are locally situated and that can only be described empirically. Relyingon this altered perspective that comes from the study of science and technology andmodern feminism, or primarily on the actor-network theory (ANT) as its conceptualmethodologicalcore, permitted placing emphasis on the material aspects of the socialenvironment and institutional and technological practice.Despite all the potential of this modern understanding, it lacks certain resourcesspecifically tuned for the analysis of subjectivity, which in this work is approached from thefirst person perspective, as well as being bodily situated. Therefore an additionalphenomenological theoretical framework is introduced, that allows for differentiatedconceptual reconstruction of the embodied experience of the subject. Further, in thistheoretical part of the work, additional theoretical positioning of the thesis withinpsychology was carried on, through considering two relevant areas that deal with thissubject - psychology of women and health psychology.The methodology chapter contains a reflexive narrative, by the author herself, aboutthe performed empirical research. In addition to a detailed description of all relevantmethodological decisions, this chapter examines the role of the researcher in all aspects ofthe research – from choosing the phenomenon and formulating questions, to performingthe research. The main empirical material on which the analysis is based consists oftwenty-five semi-structured interviews with thirteen interviewees, first at the end ofpregnancy, and second after childbirth. Data on the local institutional environment andmedical practices and techniques are complemented with secondary material: notes fromthe field research that was conducted in one of the Belgrade maternity hospitals,information obtained from interviews with the few doctors who agreed to an interview andanalysis of the medical textbooks. The basic framework for the interpretation of pregnancyand birth narratives was the interpretative phenomenological analysis that aims to achievea detailed reconstruction of individual experience, but also to position it in both sociocultural,as well as theoretical context.The second half of the thesis is dedicated to the presentation and discussion of theempirical findings. It is divided into two major parts - the experience of pregnancy is analyzed indetail in the first part, and the experience of childbirth in the second, both including relevantcitations of the participants in the study. Through the discussion of specific experiences, it isshown that (particularly at the beginning of pregnancy, but during it as well) bodily experiencesare vague and ambiguous and that women generally rely on different mediators – medicalknowledge, technological means (such as pregnancy test or ultrasound) as well as theexperiences of others – in an attempt to correctly interpret and discursively analyze theircondition, and to practically orient themselves towards it, or in other words, to plan and conductactivities and organize their behavior.Very often the medical techniques play an important role in resolving the uncertainty andallow women both the knowledge and opportunity to choose their actions in an informed way,but they sometimes lead to inducing or deepening that uncertainty. Thus, the technology has avariety of roles during pregnancy and childbirth, and leads to different outcomes for women asembodied subjects. There are at least two important factors that determine that – the relationshipwith the bodily experience and organization of practice in which the technology occurs, that isthe specific manner it is institutionally situated. Both aspects are examined in detail during theanalysis of narratives.An important aspect of the experience of pregnancy, which sets a specific challenge tothe subjectivity of women, is the fact that in her body grows another being that eventuallybecomes increasingly differentiated and autonomous. For a pregnant woman, the baby getsincreasingly more specific and begins to be perceived as an independent being. Medicalknowledge/technology and woman’s embodied experience play significant roles in theindividuation of the baby and the dynamics of the relative contribution of these two modalities ofexperience and the process of their interaction are followed through the analysis. Apart from thisspecific aspect of embodied experience concerning the presence of the baby, a woman's bodyundergoes significant and numerous transformations over a relatively short period of time. It wasanalyzed how women experience these changes and how they adapt to them in their dailyfunctioning.Knowledge and skills that a woman gained during pregnancy and the relationship sheestablished towards her own body, enable her certain positioning and define her needs andpreferences during childbirth. However, the actual outcomes largely depend on the material andsymbolic characteristics of the institutional environment in which the birth takes place, which isanalyzed in detail in the part of the thesis dedicated to the discussion of birth experiences. It waspointed out that the specific constellation of medical practice, implicit and explicit norms,relationship patterns, and material characteristics of the institutional environment cruciallydetermine how a woman will experience the birth and her role in it.A woman during childbirth is faced with a somewhat non-transparent series ofoccasionally dramatic bodily events that she cannot anticipate and control very well, which itselfis a challenge for her embodied subjectivity. The fact that she does not control, and often has noinsight into the course of medical interventions performed on her, makes this situation even morecomplicated. How a woman relates to a series of both bodily and medical events during birth,and whether she manages to appropriate and be an actor of the process that is happening to her,is analyzed in detail. The empirical part of the thesis is completed by considering the possibilitiesfor different outcomes for women’s subjectivity which are present, at least to some extent, in thecurrent local constellation of the birth, in spite of all its imperfections and flaws.The chapters in which the research findings were discussed focused on various specificissues and aspects of the transformation of the woman's subjectivity during pregnancy andchildbirth. Therefore, in the concluding chapter, some more general tendencies are outlined andsome of the questions that were opened in the theoretical parts of the work were discussed again,this time in the light of empirical insights. Different roles of technology and their relation to theembodied experience of women (which has a number of specific features during pregnancy andchildbirth) were examined in general terms. It is pointed out that the individual subject does nothave to be reduced through encounters with the technology – she could even get specific formsof experience and opportunities for agency through this encounter. At the end, it was suggestedthat the analysis of pregnancy and birth experience, which indicates distributed, processual and(technologically) mediated nature of subjectivity in general, can serve as an important resourcefor the establishment of a more adequate psychological theory of the subject.