“Send me a rule”: Risk and Blame in Maternal Healthcare

A maternal health study critiqued the Center for Disease Control (CDC) for its publication of misleading estimates concerning the number of alcohol-exposed pregnancies. The study highlighted how a legitimate concern over risks posed to unborn children had resulted in the over-regulation of pregnant women’s behaviors. Specifically, the study’s authors alleged that the CDC’s purposeful miscalculations contributed to unnecessary moral panic and potentially to larger social stigma, punitive policy approaches, less use of prenatal care, and, ultimately, adverse birth outcomes. Their work joined an ongoing debate among the general public, public health advocates, law makers, lawyers, judges, and social organizations over the efficacy of punitive action against pregnant women for unsuccessful pregnancies. This trend has historically impacted women of color and socio-economically disadvantaged women in the U.S. The debate has highlighted how such women have limited say in the creation and implementation of maternal health policies. Yet, these are the very women who are most likely to endure the negative consequences of such policies and prescriptions, both socially and legally.

Such regimens were clearly intended for aristocratic women, and all but excluded with little to no regard for those of lower social classes, who were likely unable to follow cumbersome prescriptions or afford expensive remedies. By default, non-affluent women were incapable of bearing the “best” children because the specialized medical advice would have been both fiscally and physically impossible for most. Yet, the stakes were higher than optimization of the infant. Inherent in ancient medical advice was the assumption that non-compliance would result in damage to, or the death of, the unborn child. While the convergence that we see in the contemporary US between race, low socioeconomic status, and criminalization in pregnancy loss looks different than in the ancient Mediterranean—indeed, within the late antique world, it seems that the more affluent a woman, the more likely she was to face legal consequences following the loss of a pregnancy (Dig. 25.4.1–4)—ancient medical writers still imagined that a pregnant woman’s behaviors directly influenced the outcome of the pregnancy, and as such, they placed great emphasis on those behaviors.

And yet, ancient women had some agency during their pregnancies and subsequent parturition—as is attested by the medical texts themselves, which instruct doctors to ignore pregnant patients’ desires and to caution pregnant women against disobedience (Sor. Gyn. 1.47, 53; Aët. Tetrab. 16.10). But what of women’s voices? How do we account for the ways that specialized medical knowledge and advice impacted them? Here, I would like to turn to evidence outside medical sources: a letter by a woman named Esther from sixth-century Egypt.

Addressed to a Christian monk, Esther’s letter was found at the Monastery of Epiphanius in Thebes (located in Upper Egypt, near modern-day Luxor). Its survival in Egypt comes as no surprise—Egypt’s climate has safeguarded countless historical documents and the emotions recorded in them. Esther’s letter survives on an ostracon (writing on a potsherd), a common mode of communication in late antique Egypt, and it preserves the grief of a mother who has lost multiple children:

Although it is evident that some text is missing, the gist of Esther’s inquiry is clear. She has become pregnant and borne children on more than one occasion, and those children have died. In her grief, she is seeking advice from a spiritual authority to prevent future deaths.

We should not be surprised that Esther reached out to a monastery for aid. In Egypt and elsewhere, monastic communities dispensed both medical care and spiritual succor (the line between them being indistinct in antiquity), which led to the eventual establishment of monastic hospitals. (The decisive discussion of this historic development is Andrew Crislip’s From Monastery to Hospital.) These institutions served the rich and poor alike, as well as the monks who staffed them. In this way, monasteries filled a dire social need. Esther, then, sought advice from one of the few healthcare resources available to the poor. Esther’s letter speaks to her ability to exercise some form of personal agency in the medical marketplace, where she may have had limited options.

This passage also makes clear that Esther perceives her children’s deaths as a potential personal failing—“Perhaps (I) do something unfitting”—that needs correction: “send me a rule.” These utterances betray her anxiety that she bears responsibility, even unwittingly, for shortening her children’s lives. Her request for a rule reinforces this point. In late antique Christianity, a rule was religious instruction intended to order one’s life and correct spiritual failings. Esther’s insistence that the holy man send her instruction indicates that she believes her action or inaction has directly affected the outcome of her pregnancies. Through her words, we witness the grief and hopelessness that accompany the loss of her children.

Esther’s writing draws attention to some troubling questions. We do not know whether she had access to doctors or midwives. We are even less cognizant of whether she would have been able to comply with any instructions these health specialists might have provided. Given, however, the propensity for medical texts to insist that women’s compliance with medical prescriptions determined the viability of their pregnancy and the health of their children, it would be fair to conclude that Esther’s losses would have been perceived as a personal shortcoming—her children’s deaths would have been a testament to her behavioral deficiencies. Esther voices this assumption through her own words; she takes on responsibility for her children’s deaths.

Esther’s concerns over her body’s inability to produce healthy children has much in common with articles highlighting the quiet that accompanies miscarriages and the sense of failure associated with pregnancy loss. Although, Esther and her contemporaries would not have necessarily thought of pregnancy loss or stillbirth as a criminal offense. Prosecution of pregnancy loss was more concerned with the deprivation of a possible heir than the loss of the child (Dig. 48.19.39). There remain clear echoes in the social and psychological consequences of the criminalization of pregnancy loss and miscarriage. For instance, the CDC’s misrepresentation of statistics allows individual women to more easily become the focus of censure, even if they fall within acceptable guidelines for alcohol consumption during pregnancy. It heightens women’s propensity to receive and accept blame for the loss of pregnancies no matter the circumstances. In the most egregious cases, women face criminal charges regardless of fault and even when pregnancy loss occurs through the fault of someone else.

Nonetheless, Esther’s epistolary grief reflects the impact of attributing responsibility for pregnancy loss to the behaviour of those who are pregnant. Reflected in her words, we see how all too often debates and theories about poor pregnancy outcomes conceal unstated assumptions about the relationship between class and lack of compliance with medical advice. We are also reminded about how larger issues, such as lack of healthcare equity, are so easily transformed into problems of individual choice and accountability. Esther’s letter reveals how the impulse to explain unsuccessful pregnancy outcomes through behaviour during pregnancy encourages women to internalize blame and leaves them to grieve their losses alone.

PRIMARY SOURCE

Bagnell, R. & Cribiore, R. (2006). Women’s Letters from Ancient Egypt, 300 BC–AD 800. Ann Arbor: University of Michigan Press, p. 247.

RECOMMENDED READINGS

Bonnell Frieden, A. (2016). “Well-Born. The Ancient History of Making Babies.” Eidolon.

Cockle, W.E.H. (2016). “ostraca.” Oxford Classical Dictionary. https://doi.org/10.1093/acrefore/9780199381135.013.4624.

Crislip, A. (2005). From Monastery to Hospital. Christian Monasticism and the Transformation of Healthcare in Late Antiquity. Ann Arbor: University of Michigan Press.

Goodwin, M. (2020). Policing the Womb. Invisible Women and the Criminalization of Motherhood. Cambridge & New York: Cambridge University Press.

Knight, K.R. (2015). addicted. pregnant. poor. Durham: Duke University Press.

Rabinowitz, N.S. & McHardy, F. (2014). From Abortion to Pederasty: Addressing Difficulty Topics in the Classics Classroom. Columbus: Ohio State University Press.