Distribution of Responsibility in the Field of Reproductive Health: The Perspectives of Obstetrician-Gynecologists. Summary
In the late modern period health has become a concern of particular attention and care, institutionalized through different practices and social structures. The body and necessity to affect it (to heal, to care for it, to maintain a healthy lifestyle, and so forth) have become a field of struggle between different social actors who claim competency and responsibility for the body’s health. Each of these agents claims to be an expert in the field of healthcare and thus generates a particular set of expectations about other actors in this field. Different problems emerge in this field: it is both normative—creates a complex of expectations and prescriptions—on the one hand, and heterogeneous—there is no consistency to these expectations—on the other. Moreover, not all these expectations are met by the other actors in the field of healthcare. Reproductive health is a particularly illuminating case in the study of responsibility, since it is much more explicitly articulated as a field of moral and political agendas.
Issues of responsibility in the field of healthcare are important subjects of sociological studies as well. It is both empirically and analytically significant to study the relations among different social actors, hierarchies, mutual expectations, and prescriptions. The healthcare system in Russia is often defined—by state representatives, medical professionals, patients, and mass media—as lacking responsibility. In this article I argue that this problem of “irresponsibility” is not always a consequence of institutional ineffectiveness in healthcare, social policy, practices of self-care, or medical professionalism. Irresponsibility can emerge as a result of a multiplicity of social actors claiming responsibility for health. Sociological studies have articulated the problem of responsibility as a central one in the relations between patients and doctors, doctors and administrators (or states), and states and citizens. However, I propose that all these agents interact simultaneously in the field of reproductive health and that the system of expectations includes all of them. Moreover, these interactions do not generate a coherent and consistent set of regulations, norms, and expectations. The multiplicity of the interacting agents of responsibility for reproductive health and the inconsistency of their mutual expectations result in a lack of agreement and satisfaction even within one defined professional group.
Both social theory and empirical sociological studies single out several significant subjects of responsibility for health—individuals (in the case of reproductive health, mostly women), doctors or medical institutions, and the state. In addition they analytically link the notion of responsibility with the dimension of power and control, in terms of the unequal distribution of authority and competition for the right to make key decisions in the sphere of healthcare. Nevertheless few authors investigate responsibility (or the lack of it) as an independent and substantive problem. This explains why those addressing the distribution of responsibility usually investigate it in relation to two, but not more, actors. In particular, sociologists address the allocation of responsibility (in terms of control and authority) between the state and individuals, the state and doctors or medical institutions, and doctors and patients.
On the one hand, such an approach allows for an examination of these issues in a more detailed and thorough way. On the other hand, the scope of analysis in such binary relations excludes additional perspectives. I consider the lack of more complex examination—in terms of the number of social actors interacting in this field—to be an analytical gap. I propose that the field of reproductive healthcare emerges as a situation of “irresponsibility” due to the multiplicity of social actors claiming responsibility for it, contesting the regulation and control of this sphere, and at the same time lacking the resources to meet this responsibility. Analytically it can be studied as a heterogeneous assortment of expectations and normative notions concerning its realization within the frame of the same perspective (in this study—the one of doctors). The empirical data and analysis discussed in this article do not allow me to describe in detail all of the interactions in this field and reconstruct a more complete set of the main subjects of responsibility for reproductive health from medical professionals’ perspective. Nevertheless, I aim to demonstrate the lack of consensus concerning the subject of responsibility and the issues of concern in the field of reproductive health even within a relatively homogeneous expert group of health professionals.
Conceptual framework, data, and methods
I argue that the practices of responsibility of one definite social actor are combined within a system of expectations concerning the responsibility of other social actors involved in the field of reproductive healthcare. This system of expectations not only creates evaluations of interactions but also affects the form of responsibility taken by each participant. Such a definition presupposes that responsibility will emerge in different forms, depending on the position from which expectations towards its realization are being reconstructed.
Moreover, I suppose that the definite social context will determine not only the specificity of the interactions but the system of their evaluations by the involved actors. It can be argued that both the conditions of modern Russian healthcare and the different social contexts within it vary considerably. Thus, on the level of health professionals’ expectations, the distribution of responsibility between key agents may differ across regions, specialties (of which reproductive health forms a specific case), and work conditions (big city/small town, hospital/clinic or outpatient facility). In other words, the Russian context appears to be heterogeneous in both professionals’ practices and their normative models (systems of expectations), as articulated by experts.
In this article I refer to the perspective of experts in the field of reproductive health—medical professionals who work in obstetrical and gynecological medical institutions in a small Russian town in the Central Federal District. My choice of this perspective is justified by the position of the doctors as one of the social groups competing for a monopoly of legitimate competence, for the right to produce expert knowledge about pregnancy and birth. At the same time, doctors in the post-Soviet context already have the status of the most competent experts in this field.
Empirical data was collected as part of an individual research project from 2011 to 2013, designed as a case study using qualitative methodology. The case study explored the system of medical institutions providing reproductive healthcare—three antenatal clinics and the obstetrical and gynecological departments of the Central District Hospital—in one of the Russian district centers. Data was collected through in-depth, semistructured interviews with 1 neonatologist and 13 obstetrician-gynecologists, focusing on the problem of responsibility for reproductive health, its main subjects, and doctors’ professional practices. Additional methods used were participant observation in the largest antenatal clinic and document analysis. The series of observations was conducted in July and August of 2012 in the office of the head of the clinic, with a total duration of 60 hours.
The obstetrician-gynecologists’ perspective
Analysis of this empirical data shows that doctors attribute responsibility for reproductive health to several social agents and describe it in a definite way for each of them. I will now list the main agents of responsibility, as defined by these medical professionals, and provide a summary of their key characteristics.
Patients were treated as the primary subjects of responsibility for reproductive health in the doctors’ narratives. Women are described first of all as (potential) mothers, while their health and responsibility for it mostly are related to the possibility of conception and successful childbirth. Women (they appear to be the only subjects of responsibility among patients in medical discourses, and men are mentioned only rarely, in cases of infertility) are represented as social agents who, more than any other, predetermine the success or failure of “childbirth outcomes.” Their responsibility is also linked symbolically to the reasonableness of expectations concerning successful childbirth—patients are expected to be rationally weighing all the risks and possibilities of their individual reproductive project.
At the same time, doctors can see successful childbirth and sometimes patients’ pregnancies as a consequence of their work. While doctors recognize medical responsibility for reproductive health in this context, they still consider their contribution to be secondary to that of patients.
Doctors consider the state, including the Ministry of Health and other institutions, to be responsible, alongside patients, for reproductive healthcare. From the obstetrician-gynecologists’ point of view, the state’s main task is to provide the structural conditions for medical interactions, allowing all the other key actors in this field to take responsibility. In particular they expect the state to provide for citizens’ (patients’) social welfare in the form of income, education, employment, and other resources. In addition, doctors expect the state to provide satisfactory work conditions for medical professionals—to pay them not for the quantity but rather the quality of their work and to reduce unreasonable administrative demands and paperwork. Moreover, the state’s responsibility was seen as requiring the reorganization of Russian healthcare to support preventive measures and improvement of the demographic situation in order to promote population health.
Obstetrician-gynecologists recognized themselves as responsible in this field alongside other key agents influencing reproductive health. Responsibility was mentioned as an important component of their professional activity. The dimension of responsibility emerged as a distinctive characteristic of professional status not only in comparison with other professions but also in comparison to other medical specialists, since obstetrician-gynecologists are responsible “not only for one, but for two lives simultaneously.” In particular, doctors admitted their own accountability in “making everything possible” to cure patients or improve their health, to manage their conditions, to comply with professional ethics, and to control emotions and avoid conflicts with patients. Doctors recognized not just the importance of their official duties but also the importance of paying attention to their patients and taking care of them. Sometimes this care manifested through additional discussion of recommendations, control and monitoring of compliance, and exercising their medical authority through follow-up calls, invitations to clinic, or even intimidation.
All three agents have been singled out and analyzed in other sociological studies. However, in interviews doctors identified other social actors responsible for reproductive health. In particular, health professionals mentioned patients’ relatives and close social circles as being responsible for upbringing and education. These actors, from the doctors’ point of view, appear to be accountable both for their direct influence on health and for the degree of individual responsibility they cultivated in patients. In addition, obstetrician-gynecologists noted an important institutional shift that came when market structures began to significantly affect social interactions in the field of reproductive health. For example, pharmaceutical companies were mentioned as actors changing the character of clinical interactions and thus bearing some responsibility for them as well.
Analysis of empirical data allows me to conclude that in the professional discourse of obstetrician-gynecologists responsibility is not attributed solely to one or two definite social actors. Doctors defined the content of responsibility for reproductive health, distributing it amongst several agents: the state, patients, medical professionals themselves, and other social actors, including patients’ inner circle and pharmaceutical companies (seldom problematized as key figures in sociological studies of medical interactions).
Thus, the system of reproductive healthcare in modern Russia, as a complex of social interactions relating to health issues, can be seen as a dispersion of responsibility even at the level of expectations of one professional group. In other words, there is a lack of consensus on who is the primary subject or agent of responsibility. All these actors are expected to compete for the right to control and regulate health issues. Existing sociological theories and empirical studies investigating the problem of responsibility in the field of healthcare do not provide a sufficient conceptual framework distinguishing all the possible subjects of responsibility. This partially explains the persistence of the discourse of “irresponsibility” in the field of reproductive healthcare, since both analytically and practically there is not sufficient coordination and regulation of practices and interactions that take into account all the actors involved.