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The importance of anthropological theory in biomedical practice has been a topic of discussion over the past three decades see, for example, Christman and Johnson ; Kleinman ; Kleinman and Benson This discourse has created an epistemological space within biomedicine 247 binary options trading malm which to focus on the social and political construction of care, particularly among marginalized and vulnerable populations. These challenges set the stage for clinically evaluating patients living at the margins of care, particularly those who challenge everyday notions of morality and agency.

In the world of obstetrics, one particular figure emerges: Through her narrative, I discuss the maternal-fetal unit MFU as a biosocial object to think with in a clinical setting, particularly in relation to the ethical and biomedical concerns surrounding substance use in pregnancy.

Though this definition is limited in scope, it stems directly from discussions surrounding moral pioneering, described by Rayna Rappin the context of amniocentesis and genetic testing, and further elaborations regarding its social construction see Gammeltoft I met Carla in her antepartum room during my fourth year as a medical student.

As a sub-intern at a large county hospital in the northeastern United States, I spent a majority of my day taking care of pregnant women admitted to the hospital for a multitude of fetal and maternal medical issues. In the outpatient setting, these women 247 binary options trading malm also continually managed by a multidisciplinary care team in order to continue synthetic opioids.

They are further subjected to urine toxicology screenings to assess for adherence and the use of other substances. Talking to her in her sparsely furnished room, Carla positioned herself upright in her bed, untangling the loose IV lines from the edge of her bedrail. The multiple rings on her fingers clacked gently on her meal table as she spoke. She looked frail and unkempt, with her short, dirty blond hair left uncombed, and her bony frame swimming under the 247 binary options trading malm, white hospital gown.

I sat in a chair at her bedside, doing an initial evaluation to understand her history, medical condition, and what brought her in to the hospital. Carla detailed a long history of abusing oral and intravenous narcotics with intermittent cocaine use, gesturing 247 binary options trading malm the multiple scars on her arms when she would discuss any aspect of her drug use. She did not state when she started using heroin, her drug of choice, but told me that she began using oxycodone from a local dealer over the past few years.

I directly asked her about whether she had exchanged sex for money or drugs, and she told me that she never engaged in this behavior. She denied having ever attempted to maintain sobriety through the use of methadone or buprenorphine; however, she was sometimes off of substances for periods of days to weeks while trying to coordinate easy access to both money and housing.

Both unemployed and homeless, Carla had been living outdoors in different parks and highway underpasses on the outskirts of the city. She had not been in the shelter system in the city, and when pressed, did not give any reason as to why she had not reached out to these programs. She was unsure about the timing of her last menstrual period, but felt that she might have been about four to five months pregnant.

The father of the baby was not currently involved in her day-to-day life. She had little to say about him, except that he was not supportive of her and that he was also actively using heroin. Her previous viable pregnancies had ended 247 binary options trading malm normal vaginal deliveries. However, due to her active substance use during those pregnancies, CPS was involved and acquired custody of her children. She told us that she was unable to go to see them due to problems in accessing transportation.

Carla fit into the category of women predominantly seen at the hospital: Her admission for methadone titration was seen as a way to mitigate the multiple risks to both herself and her fetus brought on by her substance use.

However, these clinical concerns, and the subsequent care provided to Carla, bring up important questions about the science of substance use in pregnancy and the conception of the MFU. 247 binary options trading malm MFU is understood by scholars through a variety of lenses, primarily via qualitative understandings of new technologies geared 247 binary options trading malm improving overall fetal and neonatal health.

Whether through studying amniocentesis Rapp, fetal ultrasound imaging Gammeltoftor assisted-reproductive technologies Inhorn, Shrivastav, and Patriziothe anthropology of reproduction has examined biomedical practices to chart the construction of both the mother and the fetus. Questions of agency, risk, suffering, and care are evaluated through these frames — and are driven, and ultimately limited, by the biomedical and state apparatus within which women receive care.

Discussions of prenatal care and forms of governmentality Foucaultelucidated by authors like Lealle Ruhl on risk and care of the self, make important links between prenatal care, public health, and state power.

But this focus, I argue, while important in formulating sound public policy, must be accompanied by a thorough examination of how the pregnant woman is constructed in relation to the fetus. A woman who is simultaneously pregnant and actively using substances is a unique and challenging figure in the world of modern obstetrics.

This directly impacts the maternal-fetal oxygenation system and causes fetal hypoxia and, if severe enough, fetal demise. These clinical instances dictate important considerations for management options for practitioners in regards to the timing and method of delivery, and the care of both the mother and newborn Niebyl and Simpson They also inform a significant amount of counseling provided to women who are actively using substances during 247 binary options trading malm pregnancies.

Adherence and toxicology tests, as is well documented in the social-scientific literature Knight, forthcoming; Murphy and Rosenbaum ; Sufrinare both a mechanism of enforcing sobriety and judging the deservingness of women in regards to custody over children. The work of the National Advocates for Pregnant Women NAPWparticularly Jeanne Flavin and Lynn Paltrow Flavin ; Flavin and Paltrowhas documented the effects of prosecution and imprisonment of pregnant women using substances and put forth important critiques of misogynistic and unjust state laws.

The logic behind the legal apparatus focused on pregnancy outcomes lies in the biological relationship between woman and fetus, with the ability of chemical intoxicants that pass across the placenta to affect the growth and well-being of the 247 binary options trading malm.

This perceived one-way biological relationship is translated into social and moral codes regarding motherhood and fitness for custody; ultimately, 247 binary options trading malm MFU is writ into governmental and clinical apparatuses focused on 247 binary options trading malm the object on the receiving end 247 binary options trading malm any given maternal action: In this vein, Vania Oka-Smith writes about the construction of bad motherhood in Oaxaca, Mexico; her analysis has, at its heart, the attribution of risk by biomedical providers to women deemed as indigenous.

Substance abuse in pregnancy brings these concepts to the fore with regard to how risk is understood within this population as a function of marginality and class. For further discussion on substance use in pregnancy, see Fordyce and Maraesa and Hamilton However pronatalist the legal system is in America today, the method in which a clinician provides prenatal care and counseling to a woman actively using substances does not focus solely on the fetus.

Their focus on maternal mortality in developing countries, and their critique of the technology-driven aspects of modern obstetrical care, pushed many 247 binary options trading malm both biomedicine and public health to realign their focus on the mother.

This prioritization of the mother moves away from analyses devoted solely to neonatal and fetal outcomes, and, as a result, forces clinicians to rethink the tripartite relationship of the caregiver-woman-fetus, and to see it as dynamic. In particular, studies in both public health and the biomedical sciences have focused on the long-term effects of the in utero maternal environment on health outcomes. The most well known of these discussions, elucidated by David J.

Barker and colleaguesfocuses on the impact of low birth weight on cardiovascular risks later in life. However, critics note the focus on the maternal body alone as the nidus site of origin for improvements in health outcomes as constituting a form of somatic determinism, emphasizing the immediate social realm of the mother instead of 247 binary options trading malm public and social policy Lock ; Richardson A woman who is pregnant has a biomedical and social trajectory that overlaps with, but does not necessarily adhere to, a particular definition of motherhood and health, one that is driven by a highly racialized, classist, and misogynistic conception of 247 binary options trading malm see Bridges ; Foucault ; Ruhl Clinicians and researchers need to account for the aforementioned assumptions if, for nothing else, one is to avoid the reductionist model of caring for the woman or the fetus — as if each were isolated in their own silo — rather than caring for both at different periods in time.

Ethnographic studies and philosophical works have already engaged in redefining the MFU, particularly in relation to abortion see Thomas [] ; Marquis []genetics see Buchbinder and Timmermanand surrogacy Malm [] Most recently, Nancy Scheper-Hughes has examined the role of 247 binary options trading malm in regards to rethinking maternal well-being and motherhood.

By discussing fetal incompatibility from a maternal point of view, she creatively begins to question the core components of motherhood and maternal love:. The important question within the aforementioned analyses, as it relates to substance use, is not simply the de personification of the fetus or neonate as it relates to maternal behavior Scheper-Hughes ; McDonough a, b or the relationship between mother and fetus, but how clinicians understand the complex biological phenomena of the MFU and the sociopolitical space that pregnant women inhabit.

247 binary options trading malm conception of the MFU as it relates to substance use echoes back to the need for clinical praxis in caring for marginalized and vulnerable populations, like pregnant homeless women who are using substances.

As a physician, this disconnect is felt most importantly in the 247 binary options trading malm of the clinic. Counseling and caring for these women well demands a clinician to be savvy about biomedical, legal, social, and political structures that impact access to care while simultaneously navigating those barriers to provide compassionate and individualized care.

Existing alongside the ever-expanding biosocial framework of pregnancy are the personal experiences of agency, violence, and suffering of individual women. How clinicians and substance-using pregnant women interact, disperse, collide, and adjust beckons those with one foot in research and the other in clinical practice to think about a more fluid conceptualization of the MFU.

After Carla talked about her current use of heroin and oxycodone, she explained what brought her to the hospital. She initially began speaking of her need to withdraw from opiates because she had recently begun using them again. When pressed about why she relapsed or what conditions precipitated her relapse, she began describing the physical, sexual, and emotional violence she experienced over the previous three days. She was attempting to travel into the city, and was hitchhiking on the side of the road.

An unnamed man, who had promised her that he would drive her into the city, picked her up. Carla said he took her to a rural cabin off of the main highway, where she was locked up without food or means of contact for three days. She related stories of being tied up and burned with cigarettes, and being injected with some form of narcotic against her will.

She described the lull, akin to a high, she felt after the injection, and was convinced that the abductor had administered some form of an opiate. She also described being sexually assaulted multiple times, but 247 binary options trading malm not elaborate as to whether or not he used condoms. She displayed scars on both thighs, which she described as remnants of 247 binary options trading malm burns she sustained from his cigarettes.

Finally, Carla stated that after three days, she was driven to the edge of the city and let out on 247 binary options trading malm side of the road. She made her way to our local emergency department for evaluation and admission. As the medical student on the team, I visited her daily throughout 247 binary options trading malm inpatient stay as part of my rounds. Like many clinical encounters, her narrative came in fits and starts, whether by describing her story to me from different temporal perspectives or by revealing her signs of abuse during daily physical 247 binary options trading malm procedures.

During her initial evaluation, Carla had requested a complete physical examination, including a genitourinary exam, and police presence in order to file a report; she rescinded both requests almost one hour later. One of the resident physicians with whom I worked was called in to help counsel Carla about undergoing a post-assault evaluation and filing of police charges.

After almost forty minutes in the room, she stepped out with a look of confusion on her face. The resident explained that she had counseled Carla both about the safety of the mother and the fetus, particularly regarding sexually transmitted diseases, and also emphasized that it was her right to file a report with police services.

Her attitude, considered peculiar by the care team, was contextualized after a brief review of her previous admission: She had not disclosed these facts to the care team during our initial examination. Had she 247 binary options trading malm ever been abducted, tortured, and assaulted?

The fact that she was subjected to abduction, rape, and torture twice in the past few months attested to her embodied vulnerability as a homeless, 247 binary options trading malm, substance-abusing woman. Alternately, if Carla was, in fact, fabricating the details of her recent abduction, perhaps she knowingly described such sexual violence in order to gain access to housing, food, and opiates from a sympathetic staff.

Relying on the stereotypes surrounding opiate addiction and homelessness, especially in the context of gender inequity, the tropes of violence and pregnancy could engender more sympathy for Carla, and thus give her a better chance of acquiring needed goods and services.

This viewpoint, held by many of the care staff, aroused feelings of outrage. For further discussion regarding the demonstration of the suffering body and the provision of care in the American context, see Crane, Quirk, and van der Straten The MFU, in this circumstance, was divorced into 247 binary options trading malm binary: Upon leaving, she promised our care staff that she would follow up both at the local methadone dispensary and in prenatal care.

Looking back, I ask: Maternal agency has famously been described in the anthropology of reproduction, particularly as it relates to engaging with reproductive technologies. In the context of my argument, this becomes important for understanding not only agency, but also how assemblages of care create new trajectories for pregnant, substance-using women.

Tine Gammeltoftin her analysis of prenatal diagnosis of fetal malformations in Vietnam, reorients the notion of agency to include biomedical and familial structures. In both circumstances, maternal agency is constructed in the realm of the care of the self Foucault ; Ruhlwith a heavy reliance on subjective utilitarianism. Though a primarily economic term, Byron Good47 critiques subjective utilitarianism in the context of patient care-seeking behavior: In subjective utilitarianism, the maternal subject exists in an unhindered world of choice; moreover, the rationality employed by a given individual is rooted primarily in a cost-benefit analysis.

Concepts like moral pioneering, situated within the complex social and political relationships forged by a given pregnant woman, are stripped from any construction of maternal agency.

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