Women, Health and the State in the Middle East: The Politics and Culture of Childbirth in Jordan 9780755611362, 9781848857575

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To Arnaldo, Pietro and Cosimo

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The Italian Hospital in Amman Private Hospital in Amman Midwife in the Delivery Room of a Private Hospital Royal Suite in a Deluxe Private Hospital Midwife Suctioning the Airway of a Newborn Delivery and Labour Room in a High-Tech Private Hospital Delivery in a Low-Tech Private Hospital Nursery

30 61 97 108 133 137 209 215

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Map of Jordan Labour and Delivery Rooms of a Private Hospital Labour and Delivery Rooms of a Government Hospital Entrance Hall of a Private Hospital Consulting Room of a Maternal and Child Health Centre

xvi 106 115 162 196

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Private Hospitals in Transjordan, 1939 Government Hospitals in Transjordan, 1939 Evolution of Officially Registered Home Deliveries by Region, 1990-1994 MOH Maternal and Child Health Centres, 1980 Growth in the Number of MOH Maternal and Child Health Centres, 1983-2008 Number of Physicians and Midwives by Health Sector, 2007 Hospitals by Region and Health Sector, 2007

32 33 57 64 65 132 143

DOHJT DOHP EFM FFM FP GTZ IPPF IUD IV Drip IVF JAFPP JD JICA JUH KAUH MCH MOH NRT PHC PTJAR RMS SPC UNFPA UNICEF UNRWA USAID WHO

Department of Health of Transjordan Department of Health of Palestine Electronic Foetal Monitoring French Faculty of Medicine Family Planning German Agency for International Cooperation International Federation for Planned Parenthood Intrauterine device Intravenous Drip In-Vitro Fertilisation Association for Family Planning and Protection Jordanian Dinar Japanese International Cooperation Agency Jordan University Hospital King Abdullah University Hospital Maternal and Child Health Ministry of Health New Reproductive Technologies Primary Health Centre Palestine and Transjordan Administrative Report Royal Medical Services Syrian Protestant College United Nations Population Fund United Nations Children s Fund United Nations Relief and Works Agency United States Agency for International Development World Health Organisation

Ains 0 and hamzas (’) are the only diacriticals included in the trans­ literations of Arabic terms, personal names, place names and sources. Commonly accepted English forms are used for some personal and place names. Words in colloquial Jordanian Arabic are transliterated according to that pronunciation.

Acknowledgements This project would not have been possible without the encouragement and support of my colleagues Mounia Bennani-Chraibi, Riccardo Bocco, Kimberly Katz, Mondher Kilani and Franco Panese, who have all in various ways and at different times helped me to prepare for and conduct my research. I am indebted to Alain Clemence and my colleagues in the Faculty of Social Sciences of University of Lausanne who allowed me to take a semes­ ter’s leave in order to conduct fieldwork. Although this might sound a little odd to some of my non-Swiss readers, in my university it is exceptional to allow academic staff such leave unless they are entitled to a sabbatical. A number of researchers of the Institut Fran$ais du Proche-Orient (IFPO) also deserve special thanks, among whom its (then) director Franck Mermier, Myriam Ababsa, Geraldine Chatelard, Fran^oise de Bel-Air and Jalal Al-Husseini, for their valuable contributions during fieldwork. Lucine Taminian, Reham Khresheh, Oona Campbell and Philippe Bourmaud were also very helpful in providing me with valuable information. I am sincerely grateful to all my Jordanian and non-Jordanian friends living in Amman who introduced me to numerous contacts and supported me in my personal life during fieldwork: Ali Maher, Asma and Omar Abaza and their family, Rami and Rawan Daher and their families, Flavia and Guido, Baker and Sana Halasa, Qandil and Tamara Halasa and their families, Muhammad and Paola and their family, and Khaled Jayoussi and his family. I must also express my deep gratitude to Sister Clara, Samira Dajani, Haitham Khalaf, Inam Khalaf, Sanad Kilani, Mai al-Hadidi, Lyanne Outi, Safa Qsus, Munira Sha‘ban, Hanan al-Zayn and Madina for their crucial support and the stimulating conversations we had. I want to thank all the Jordanian mothers I met who opened their hearts to me in agreeing to share their feelings and thoughts with me, although I was often a complete stranger to them.

I owe thanks too to all the obstetricians-gynaecologists, midwives, nurses and social workers who agreed to collaborate with me, who allowed me to enter their world and taught me invaluable things about the culture of childbirth in Jordan. I owe an intellectual debt to Jocelyn Dejong, Ugo Fabietti and Franck Mermier for reading and commenting on provisional versions of some chapters of this book, and providing significant feedback. I am also very grateful to Jean-Franq:ois Tolsa and Ivan Vial for the inspiring conversations we had and their reading suggestions in the field of obstetrics, gynaecology and neonatology. My thanks go also to Michela Canevascini and Roberta Raffaeta for their valuable advices in the field of medical anthropology. Peter Barnes deserves special thanks for his patience and his priceless and careful reading of my sometimes maladroit English. During my fieldwork, the encouragement and assistance of my husband and family were crucial in providing logistical support during my stay in Jordan. I owe very special thanks to my husband, Arnaldo Genitrini, for his strong and tireless support in allowing me to pursue my career, despite all the difficulties and changes in our lives that this entailed. I am also grateful to Calliani and Nawaz who took such good care of my son, and allowed me to feel confident about continuing to conduct my research. Finally, I should like to point out that this research was made possible by the generous support of the S ociete A cadem ique Vaudoise, the F ondation du 45& anniversaire and the B ureau d e I ’E ga liteo t the University of Lausanne, and by a grant from the University’s Faculty of Social and Political Sciences.

Map 1 Map of Jordan

C

h apter i

Introduction Someone steeped in M iddle East anthropology might ask: Well, what else could one talk about? (Abu Lughod 1989: 298)

When I decided to study ordinary childbirth practices in Jordan, I had very vague ideas about what I was going to find in the field, although I was very familiar with the country, having already been doing research there for ten years. My previous research was about the fabrication of cultural heritage and the process of patrimonialisation, seen as pivotal elements in the construction of the postcolonial state (Maffi 2004). Over the years I had dealt mainly with museum curators, archaeologists, artists, archi­ tects, private collectors, historians, teachers and high-school students, so that the social and physical spaces I was familiar with were confined to very specific milieux. Since the ethnographic literature on childbirth prac­ tices in Jordan is almost non-existent I had expected to find dayas (‘tradi­ tional’ lay midwives) working side by side with obstetricians and qualified midwives, trained according to biomedical standards. However, when I arrived in the Kingdom, I discovered that, for most of my interlocutors, dayas were at best a memory, and that a large majority of pregnant women did not even consider the possibility of giving birth at home, being eager to undergo obstetric examinations performed by physicians or midwives. I realised that I had to reorient my research and to relinquish the project of working on the relationships between the natal system inherited from the pre-colonial period and the biomedical obstetric system introduced by the British during the first half of the twentieth century. The biomedical model

of childbirth - characterised by a pathological view of the reproductive process (Davis-Floyd 1992; Hahn 1997) - had made its way into Jordanian society, marginalising previous systems of beliefs and practices. Therefore the places I became most familiar with were medical settings, whether hospitals, clinics or doctors’ offices, rather than the domestic spaces I had anticipated before starting the fieldwork. In 2006, for all my Jordanian interlocutors, pregnancy and birth were medical affairs that physicians and midwives had to supervise and control to ensure a positive outcome of the reproductive process. Sonograms, blood tests, nutritional supplements and hospital deliveries were normal practice for women of all backgrounds. In the light of these facts, how was I to reshape my research topic?

Researching the anthropology of birth in Jordan Although the anthropology of birth, inaugurated officially in 1978 by the publication of Birgitte Jordan’s pioneering work B irth in F our C ultures: A C ross-cultural Investigation o f C hildbirth in Yucatan, H olland , S w eden , a n d the U nited States, has expanded in the 1980s and 1990s, the geographical areas taken into consideration by researchers working in this field have seldom touched the Arab world, as the main edited volumes published in that period show (Kay 1982; Davis-Floyd and Sargent 1997; Dundes 2003; Ginsburg and Rapp 1991; Jolly and Ram 1998; Lukere and Jolly 2002; MacCormack 1994). The United States, Europe, South-East Asia and Latin America are the most studied areas, whereas the Middle East and more specifically the Arab world has failed to attract many researchers, despite the fact that the American government and several US-based foun­ dations have been very active, since at least the 1960s, in promoting repro­ ductive health and family planning in the region (Ali 2002a; Baron 2008; Morsy 1991; Makhlouf Obermeyer 1995). The first ethnographic studies focusing on childbirth practices in the Arab world I was able to identify are Granqvist’s B irth a n d C hildhood A m ong th e Arabs (1947) and Mathieu and Maneville’s Les A ccoucheuses m usulm anes tra ditionnelles d e C asablanca (Traditional Muslim Midwives of Casablanca) (1952). Although several other works entail a paragraph or even a chapter devoted to similar topics, such as the studies of Antonin Jaussen discussed in Chapter 3, childbirth is taken into consideration because of its relationships with family life and kinship rules rather than as a complex social system deserving specific anthropological analysis. The lack of attention to this aspect of social life in the Arab world is also due to the fact that Western observers were usually men, and thus excluded from women’s sphere, and that they perceived childbirth as a ‘natural’

rather than a cultural’ event (MacCormack and Strathern 1980), as well as an essentially feminine affair (Ginsburg and Rapp 1991). However, more recently valuable ethnographic works tackling the topic of repro­ duction and of women’s role in several countries of the Middle East and North Africa have been published, among others (Ali 2002a; Boddy 1989; 2007; Delaney 1991; De Regt 2007; Fortier 2001; 2005, Giacaman 1988, Hoodfar 1994; 1996; 1997; Inhorn 1994; 1996; 2003; Kanaaneh 2002; Morsy 1993; Makhlouf Obermeyer 1995; 2001; Wick 2008.)1 Although not all these works focus on childbirth practices, they are nonetheless related to the field of the anthropology of birth and give precious descrip­ tions of reproductive practices in the various countries they consider. What about Jordan? Aside from some useful demographic, epide­ miological and medical studies,2 various reports on reproductive health topics commissioned jointly by the Jordanian Ministry of Health and USAID,3 several studies funded by UN agencies,4 the Annual Reports of the Ministry of Health and a few historical contributions on the develop­ ment of the health sector during the twentieth century,5 1 could only find an unpublished thesis in anthropology focusing on Palestinian dayas and childbirth practices in Jordan and the West Bank (Young 1997) and two ethnographic studies conducted on a group of women living in a squatter area of Amman (Shami and Taminian 1985; 1991). The paucity of ethno­ graphic works on childbirth practices in Jordan, and more broadly in the area of the ancient B ilad al-Sham (Greater Syria) was both an advantage and a handicap because, while I had to build a new area of study without being able to rely on a substantial literature, I was able - if not to chart a new territory falling outside of the classical ‘zones of theory’ characterising the Arab world (Abu Lughod 1989) - at least to introduce a new topic into the ethnographic literature on Jordan.

Entering the field When I began my research I had two different concerns: a pragmatic one and a personal and ethical one. The first concern was how to get permis­ sion to enter the maternity wards and the Maternal and Child Health (MCH) clinics, while the second was how to meet pregnant women and mothers and talk about very intimate subjects such as pregnancy, birth, body perceptions, marital relationships, etc. The first of these potential problems turned out to be quite easy to solve in the private sector, where access to the hospitals I had chosen was in general rapidly granted once I had negotiated my presence with the hospital director. I usually gave him - hospital directors were invariably male - a short presentation of

my research project, explaining in a more detailed way the kind of work I was willing to do during my visits to the maternity ward. There were two aspects to my project: on the one hand I wanted to attend antenatal consultations to observe the verbal and physical interactions between pregnant women and health providers; on the other, I intended to observe the relationships between birth attendants and parturient women from the moment the latter were admitted to the hospital until the birth of their child. I was particularly interested in observing the interactions between women and health providers, their behaviours, physical gestures and verbal expressions in the labour and delivery rooms. I had decided to interview neither pregnant women during antenatal consultations nor parturient women during labour, for the obvious reason that I had no wish to disturb their interaction with the health provider during exami­ nation, nor to interfere with their birth experience. I also chose not to interview health practitioners during their working hours, so as to let them focus undisturbed on their professional tasks. However, despite my attempts to remain silent in a corner in order to observe the situations occurring in the maternity service, it was often difficult not to interfere, because in many cases the actors concerned did not behave as I expected them to, since they did not consider me a spectator. I had anticipated that my presence would only disturb ordinary interaction to a certain extent — birth attendants, I thought, would have been busy in doing their job and women in undergoing examination or giving birth. These expectations proved to be wrong: in many cases, both the health professionals and their female patients were willing to involve me in their interaction by talking to me, asking questions, explaining, soliciting my attention, requesting my help, etc. In several hospitals, I ended up accomplishing simple tasks such as shutting off an IV drip, receiving the placenta in a metal pan, encouraging the woman during painful contractions, bringing blankets or sheets, etc. Parturient or pregnant women often thought I was a physician or a midwife, and asked me questions that I was not always able to answer. In many cases, either I had no opportunity or no time to tell them that I was an observer rather than a member of staff, or they were not interested in what I had to say. It was difficult to avoid these involuntary impersona­ tions because the patients —not the staff —assigned me a role when they saw the white gown with which I was usually provided by the hospital staff. Even in the MCH clinics where I did not have to wear a gown, I was systematically perceived as a health practitioner. I became conscious of this fact because when, on some occasions, I and the pregnant woman who was undergoing the examination were left alone in the consultation

room, she asked my opinion on various matters she wanted to learn more about. Hence I could only seldom play the role of the silent and motion­ less observer I had wished to be, and this turned out be an opportunity because I was able to learn much from my position of active intruder, such as when I made a mistake or was unable to cope with a specific situ­ ation. Although I did not imagine the presence of even a silent observer would not have had some impact on the persons I wanted to observe, I was unwilling to act in ways that would interfere more directly with ordi­ nary relationships in the medical setting. Moreover, I felt emotionally very involved in the situations I experienced, because listening to the discourses of pregnant women about intimate subjects such as their sexual life and their relationships with their baby, attending a woman during labour or seeing a birth could not leave me indifferent. My empathy was doubtless enhanced by the fact that I had recently had a child, who at the time I began my research was 20 months old. Thus my participation in the field was complex and often out of my conscious and physical control, such as when I almost fainted attending an episiotomy or when I was unable to stop crying when a parturient woman realised that her nine-month unborn baby was dead. Although, owing to internal rules and unwritten conventions related to privacy, I did not have access to all the settings I had wished to observe in private hospitals, in many institutions I enjoyed considerable freedom and found it easy to observe antenatal consultation and women in labour. Indeed, for many directors of private hospitals, my presence in the ward was not unwelcome because they saw it as a means of promoting and marketing their institution, and perhaps of showing a European woman and researcher the high quality of the medical services they were able to provide. In the public sector, on the other hand, to get permission to visit govern­ ment hospitals and clinics was not easy because of the bureaucratic appa­ ratus of the Ministry of Health.6 After some fruitless attempts to get such permission by following ordinary bureaucratic procedures, I was eventu­ ally able to elicit a formal letter allowing me to enter all Ministry of Health institutions related to maternal and child health, thanks to the valuable help of a high official who put me in contact with the right persons within the institutional apparatus. After I obtained this authorisation, there was no obstacle to my visiting the medical institutions I had chosen, though in one hospital the director made me wait several weeks before allowing me to visit the maternity ward. Apparently, despite the letter authorising me to conduct research in all Ministry of Health hospitals, my project had to be approved by the ethics committee of this institution - contrary to what

happened in all the other government institutions where, after a short inter­ view with the director, I was immediately accepted into the obstetrics and gynaecology department. My hypothesis is that the resistance displayed by the director of this hospital was due to the national importance of the insti­ tution he was in charge of, and perhaps to some previous critiques about the quality of its services reported by the local press. Aside from this case, I was usually very well received by pregnant women and health practitioners alike, in both the public and private sectors. Though before beginning the fieldwork I was unsure about the kind of relationships I would be able to establish with pregnant women and staff, I expected to be confronted, at least to some extent, with suspicion and distrust. This seldom happened, however, and both pregnant women and birth attend­ ants were generally eager to talk to me and looked for my company. While for some practitioners I was a foreigner to whom they could freely criti­ cise local practices and attitudes, and a newly arrived ‘expert’ they could teach about local (mis)conceptions and habits, for some women I was a supportive presence during a difficult moment and a source of information different from those they could find locally. My access to other local health institutions was so difficult that I had to relinquish the idea of doing research in some of them, such as the RMS hospitals and UNRWA7 MCH clinics because of the obstacles I encoun­ tered. Indeed, after talking to several physicians and Ministry of Health officials, I decided not to ask RMS for permission to extend my research to the health services run by the Jordanian army,8 because it seemed almost impossible to obtain it in a reasonable time. Some weeks after I made this decision, I was unexpectedly able to spend a whole day in the maternity ward of an army hospital thanks to the good will and the connections of a midwife. I also collected the testimonies of several health practitioners who had worked or were still working in RMS hospitals, and of some of the women who had given birth there. Given the importance of the UNRWA clinics that provide primary care to the large population of Palestinian refugees in Jordan,9 I had planned to conduct part of my fieldwork in its MCH centres. Despite my numerous attempts, I was not only unable to get permission to visit UNRWA estab­ lishments, but even to meet the officials in charge of medical services, who systematically refused to receive me. Nevertheless, since I met several health practitioners who were working or had worked for UNRWA, I was able to get general information about its MCH clinics.10 It should be noted that in Jordan UNRWA does not run hospitals and offers only primary care, while secondary and tertiary care is provided by government institutions to

all Jordanian citizens (JHUES 2000: 70), including those with the status of refugees. This means that women can get antenatal care in UNRWA MCH clinics, but they give birth in government or private hospitals. Given that pregnant women using the UNRWA medical services belong to an underprivileged section of the population,11 most of them are likely to give birth in government hospitals, where it costs them only few dinars because UNRWA provides them with insurance. As for the Jordanian NGOs I dealt with, there was no obstacle to my being authorised to work in the JAFPP12 clinics and in the Soldiers’ Family Welfare Association MCH centre, where I was well received thanks to the friends who had introduced me to the directors.13

Pregnant women and mothers What about my other concern, and the difficulties I anticipated I would encounter in approaching and talking to pregnant women and to mothers? When I began the fieldwork, I had no clear idea of how I was going to meet and select the women I wanted to interview about their pregnancy and childbirth experiences. However, I did know that I wanted to talk to women belonging to different sections of the population, and in a situ­ ation where they would not feel constrained by a medical setting. And indeed, with some exceptions, I was eventually able to conduct the inter­ views outside that setting, as I will explain below. The ways in which I was able to meet mothers and pregnant women were related to various circum­ stances: in some cases my acquaintances introduced me to their relatives, friends and work colleagues, while in others health providers facilitated my meeting their patients outside the medical setting. Sometimes parturient women waiting in the admission room or lying in the maternity ward in the early stages of labour unexpectedly began to talk to me, so that I ended up conducting unplanned interviews. The waiting rooms of MCH clinics were also places where I was able to speak with women before they were admitted into the consulting room. Some of the birth attendants, espe­ cially midwives, were also ready to talk to me of their experiences during breaks or after work, and I talked to many of them both as health providers and mothers. The interviews were thus carried out in several places: at work, at home, in hospitals and MCH clinics. I interviewed 32 women extensively and was able to observe and listen to dozens of others before and just after they gave birth, as well as in the context of examinations by obstetricians and midwives and of discussions with social workers in the MCH centres. Some of the interviews were conducted with small groups: I spoke with

two and sometimes three women at the same time, also letting them talk to each other and listening to their reactions while hearing their friends or colleague’s experiences. The women I met belonged to various social milieux: some were members of the elite, others of the middle class and many of the poorest social class,14 living predominantly in urban areas in the north of the Kingdom.15 Though the ages of the women I met varied from 16 to more than 80, the average was between 25 and 40. Generally, the women were quite ready to talk to me about their experiences of preg­ nancy and birth, partly because I am a woman and a mother and partly because I was usually introduced by somebody they already knew, though this was not always the case. There was only one condition on which all the women, without exception, invariably insisted: no men were to be present, not even their husband. Childbirth and pregnancy seemed to be consid­ ered so intimate a topic that it could not be shared with a man, even when he was a very close relative or friend. Hence, when I conducted the inter­ views in their work place, my interlocutors never forgot to lock the door of the office so that nobody could come in, while in their home we went to another room from which men were explicitly excluded, and in MCH clinics or in the labour room men were generally not present,16 since those settings are exclusively for women —only male obstetricians can enter, in their professional role. Before the interviews, I explained my research topic to the women as clearly as possible, and always remained ready to answer their questions about my own experience as a mother. Even though each time I was able to introduce myself I attempted to explain my scientific interests unambigu­ ously, several of my interlocutors mistook me for a physician —probably because of the nature of the research - and adapted their behaviour and discourse accordingly. This occurred to me not only when I was conducting fieldwork in the labour room, where I usually wore a white gown, like midwives and physicians, but also outside the hospital where I was able to introduce myself properly. It was not uncommon for women to ask me questions about medical issues, such as contraceptive methods, ultrasound scans, medical tests, gynaecological problems, etc. Although I had worked out a questionnaire aimed at eliciting several details about the social and personal profile of my interlocutors, the place(s) where they had given birth, the type of practitioners they had seen or were seeing during pregnancy, the medical procedures they had gone through, among others, I let them talk freely about whatever topics they wished. While some women gave laconic and stereotypical answers, others were ready to tackle intimate topics such as their sexual life during pregnancy or

in the post-partum period, asking me questions about my own experience. I believe that those who were prepared to reveal very confidential aspects of their life established with me in doing so a relationship of complicity, because in return I shared details of my private life with them. Indeed, in my view you cannot ask others to open their heart while maintaining a distant and neutral stance yourself, unless you play the role of the psycho­ therapist, which I was not ready to assume. Most of the women who were prepared to exchange with me confidential details of their life belonged to the middle and upper classes, had a university degree, lived in an urban setting and were more or less of my age, which meant that we had much in common and that they perceived me as less foreign than did the other women belonging to less fortunate sections of the population. Though this was not a rule, it was often the case. Moreover, the well-educated women were better able to understand my questions and the nature of my research, while for others it was not so clear why I was interested in observing child­ birth practices, why I wanted to know what they felt or thought about their unborn child during pregnancy, and so on. Last but not least, I should point out that, although they constitute a small minority in Jordan,17 I interviewed a relatively large number of women who had worked or were working outside the domestic sphere; this was not because I wished mainly to explore the attitudes of this particular category of citizens, but because of the characteristics of my network of friends and acquaintances. Finally, it is worth noting that most of the preg­ nant women I interviewed were not primigravidas but had already had several children.

Geographical and temporal limitations While I have already mentioned the fact that I was unable to work in all types of institutions devoted to antenatal and natal care, there were other important limitations to my fieldwork experience that are related to various personal and professional circumstances. First of all, I was able to conduct fieldwork only in some cities of northern Jordan, because of family constraints: since I lived in Amman, in an apart­ ment with my two-year child and my husband was not with us, I could only conduct fieldwork in locations that allowed me to be home every morning and every evening in order to take care of my son. I had found an excellent baby-sitter and a pleasant kindergarten next to my apartment, but I was reluctant to leave my son in Amman for several days while I visited the south or east of the country. I was thus unable to observe how hospitals and MCH clinics operated in these regions and the attitudes of women

living there; my research was confined to the area between Amman, Zarqa and Irbid, though this is where the majority of the Jordanian population lives and most hospitals are situated.18 The second restriction on the research derived from the shortness of the period I could spend in Jordan: I was able to stay only for seven months, from August 2006 until February 2007, owing to academic obligations19. However, I had been regularly doing fieldwork in Jordan since 1997, and had a good knowledge of the country; this relative familiarity allowed me to get immediately into the field, and one week after my arrival, I had already started to do participant observation in a private hospital and to read the relevant literature in the Jordan University library and the Ministry of Health’s centre for documentation and research. Hence there was no need to go through the period of several weeks that an ethnologist arriving in a new country usually spends in meeting people and under­ standing the local situation; and I already spoke Arabic. This is why I think that, though a longer research period would probably have allowed me to explore more institutions and meet more women, my relatively short stay did not constitute a major handicap and I worked very intensively during the seven months I lived in the Kingdom. I should also point out that I was unable to be present in the hospi­ tals during night shifts because of my son’s presence. This is no doubt a serious limitation since night shifts are of particular importance in the life of a hospital department, as several physicians and midwives have told me, both in Jordan and in Europe. While in all hospital departments during night shifts the ordinary rules followed in the daytime are partially relaxed (Pouchelle 1998), the labour and delivery rooms have a rhythm of their own - parturient women come to give birth day and night, and the latter can often be the more hectic.

The historical urge Another point to be made here concerns my choice to start this book with two chapters which set out the historical perspective. I want to emphasise that this choice derives from what I believe to be the necessity, a belief largely shared within the discipline today, of understanding the present in the light of the transformations which have taken place in the past. It is crucial to trace a geographical and historical map of the imaginary ‘coun­ tries’ we anthropologists create during and through our researches (Fardon 1990), especially when the ethnographic ‘landscapes’ we encounter have not been described before (Borutti and Fabietti 1998). I entirely agree with the ideas of Lock and Kaufert that ‘historically grounded ethnography

permits perceptive comparisons, highlights the resilience of culturally constructed value systems, and above all forces an engagement with body politics within and between societies’ (1991: 9). As for Jordan, given that there are no historical or ethnographic works focusing on the local natal system and its evolution during the twentieth century, I thought it important to trace its history. I had already realised during my previous stays in the Kingdom that in many government insti­ tutions there is no systematic record-keeping,20 and that there is also a kind of official amnesia concerning large sections of the national history (Maffi 2004). Indeed, I was able to find very few works on the medical history of Jordan and even colonial records were scanty since the Emirate of Transjordan was a peripheral area in the British Empire, as I will show in the following chapter. My attempt to give an historical overview of this particular aspect of Jordan’s history is not intended to impose on local scholars a paternalistic version of the past, but rather to contribute to the study of childbirth and more broadly of procreation21 from the point of view of both the women and the health practitioners concerned. The historical period I consider includes the twentieth century until the present-day, from the last years of the Ottoman rule throughout the Mandate period until postcolonial times. Although already during the last decades of the Ottoman Empire vast reforms of the medical system had been undertaken by the central authorities (Bourmaud 2007), the area corresponding to the present Kingdom of Jordan was only margin­ ally touched by the ongoing transformation in health practices (Rogan 1999). It was only when Transjordan was created under the British Mandate (1921) that new discourses and practices in the field of health and more specifically of childbirth and child-rearing were introduced into the Emirate. However, the limited resources the Department of Health could dispose of did not allow the development of a public health system, and thus the few practitioners trained in Western medicine had a restricted impact on the local population (Amadouni 1997, Ziadat 1990). After Independence in 1946, the Ministry of Health (newly founded in 1950) implemented a policy intended to develop hospitals and clinics and train ‘modern’ health practitioners, in order to intro­ duce new concepts of health, cure and care. Even though it took several decades before ideas and practices concerning children’s and mothers’ health began to change, the tireless activity of government institutions, the growing number of physicians and paramedical personnel, and the development of the private medical sector eventually succeeded in trans­ forming the local natal system.

Contemporary practices in and discourses about childbirth reveal the historical transformation of the Jordanian natal system, since they contain fragments of the past that are today inscribed in new configurations, often concealing their previous meanings. In the discourses of my Jordanian interlocutors, feelings of contempt and superiority, or mere obliviousness, generally surrounded the traces of the past I have attempted to uncover in the first two chapters of this work.

Health practitioners, the state and women’s agency Beyond my concern for the past, the research I conducted was intended to explore current practices of childbirth in order to unravel the multifaceted nature of the existing natal system. Since it is a complex arena, of different actors, spaces, logics and relationships, I decided to take into consideration several categories of actors who play a crucial role in that system. I have already mentioned that I considered state policies in the field of maternal health, and observed and interviewed mothers and pregnant women. State institutions and pregnant women were not my only interlocutors, however, since I also took into consideration obstetricians-gynaecologists22 and midwives. Their professional role, social profile, gender, personality, discourses and practices, including their interaction with pregnant women, are very important in understanding how local society looks at childbirth and the role of women and men in procreation, in that health practitioners are in some ways its legitimate representatives23 (Davis-Floyd 1992; Jordan 1993). Thus I have devoted two chapters of this work to each profes­ sional category, one of which is entirely feminine, since only women are allowed to become midwives, and the other is mostly constituted by men, given that about 80 per cent of obstetricians are men (see Chapters 3 and 4).24 All these actors meet in settings that are specific in terms of space, politics and culture and that shape their behaviours, gestures and move­ ments, and the relationships they establish with each other. These often unwritten rules determine or reveal different attitudes and relationships surrounding childbirth that I will examine in detail, in attempting to trace a sort of microphysics of power in which all these actors are caught up. The issue of power25 is central to my work, because I believe that the relation­ ships between the actors playing a role in childbirth constitute a minia­ turised universe, reflecting a larger social logic of domination. By that I mean that in the interactions with health practitioners pregnant women are accorded a role revealing their status both in the family and in the larger community. The study of the natal system thus allows us not only to understand its specific characteristics, but also something of the power

relationships linking men and women, husbands and wives, parents and children, state and citizens, where female and male citizens do not receive the same treatment. To unravel the articulation of power and the cultural logic surrounding childbirth, I have focused on medical culture, obstetric procedures and social habits, and the widespread ideas circulating among the different categories of actors considered in this book, hoping to make an ‘ethnography of the particular (Abu Lughod 1991; 2008). Although the interviews with midwives and physicians were conducted mostly in medical settings during breaks and after work, some health providers began conversations with me while they were working, for instance in the labour room, where constant surveillance of each partu­ rient woman is not necessary, or in the MCH clinics during the regular short pauses between consultations. I met several private physicians in their office, while I talked to others in the hospitals after or before the delivery they had come to attend. Most obstetricians belong to the middle and upper classes and have trained abroad for some years at least. This is espe­ cially the case of the generations who studied before the 1980s, since the first Faculty of Medicine was not constituted in Jordan until 1970. Up to the present, in both public and private sectors physicians who have trained or specialised abroad - above all in Europe, the United States or Australia —are much more valued than those who have received their medical educa­ tion only in Jordan, so that their professional future can be affected by the country where they studied (see Chapter 4). On the other hand, Jordanian midwives are locally trained and tend to leave the country when they enter the labour market, because salaries in the Kingdom are not very attrac­ tive and because their diploma is accepted as conforming to international standards (see Chapters 2 and 3). Unlike physicians, midwives often come from the lower middle class or even from underprivileged social groups, although a distinction has to be made here between different generations in the 1950s and 1960s the profession was socially and economically more valued than today, at least by the state institutions (see Chapter 3).26 It may be objected that I have failed to take into consideration one group of actors who play a major role in childbirth, since husbands and fathers are accorded little space in this book. Though I have to admit that this is a legitimate criticism, I had nonetheless to circumscribe my research in view of the constraints on the time available for it, and thus I decided to exclude fathers from the groups of actors I intended to consider. That decision in no sense implies, of course, that I think that fathers are only minor actors in procreation, but simply that I decided to privilege womens perspective. And indeed women are in many ways at the centre of my work, not only

because they constitute the largest group of persons with whom I spent time —whether mothers, midwives or obstetricians —but also because I have focused on them during interviews with health practitioners, partici­ pant observation and the analysis of historical records. For example, in the interviews with obstetricians, I concentrated on questions aimed at finding out what they consider the attitudes of pregnant women to be, and at how they understand such women’s ideas and behaviours, rather than for instance what they consider correct antenatal care or where they received their medical training (see Chapter 4). My project was to understand women’s experience of childbirth in terms of their own narratives, and of those of obstetricians and midwives who are the main providers of peri­ natal care, and drawing on ethnographic observation, since discourses and self-representations often fail to coincide with practice. However, husbands and fathers are not completely absent from my analysis, since they appear in the narratives of the actors I dealt with, in the relationships between them as well as in the description of the settings in which I worked.

Biomedicine, patriarchal power and sexualised bodies I have identified the main groups of actors I met and the settings in which I conducted fieldwork, and now go on to clarify the main topics I explored and to describe the lenses through which I looked at the situations I expe­ rienced and through which I analysed the ethnographic material collected during my stay in Jordan. The main subjects I have investigated are the medicalisation of childbirth (Ai'ach and Delanoe 1998; Vuille 2010), the particular forms assumed in Jordan by the ‘indigenisation’ of the Western obstetric system (Kleinman 1995), state policies in the field of procreation, the medical culture of childbirth and the discourses and practices of local women. The medicalisation of birth and the integration of Western obstet­ rics into the local culture of childbirth are the subjects of Chapters 2 and 3, where I attempt to show the evolution of the natal system, emphasising the place of state politics in the domain of childbirth, and the social trans­ formations that the institutionalisation of procreation and its shift from the domestic to the public sphere have brought about (Knibiehler 2001). Through the testimonies of several midwives of different generations, I attempt to show, taking the point of view of one particular group of actors, the impact of political and institutional changes on the cultural represen­ tations of procreation and on women’s experience of childbirth, as well as the transformations in the professional roles related to the biomedical natal system. The grafting of Western obstetric knowledge and practices onto local society implies equally a consideration of the interplay between

local and global logics, defined as the complex and changing interaction between transnational fluxes of cultural representations, technologies and power relationships embedded in the biomedical natal system and the local culture of childbirth. By the term ‘local culture of childbirth’ I refer to the complex of medical ‘styles’, procedures and cultural representations taken for granted in a specific social context at a certain time, whatever their place of origin and their history, whereas by ‘transnational fluxes’ I mean Western clusters of knowledge, technologies and practices deriving from and current within the West but presented as universal and scientific. These main themes were cross-cut by very important gender issues, such as the roles of women in the family and the political community, the new possibilities and constraints they encounter in relation to the new obstetric technologies, and the impact of class on their attitudes towards the new models of the feminine body conveyed by biomedical practices. As I have already mentioned, the official politics of childbirth and power relationships have been explored by drawing on a state-oriented history, itself based on official statistics and health reports, on the ethnographic description of the interactions between pregnant women, family members and health practi­ tioners, and on the analysis of their discourses and experiences (Chapters 3 through 5). I have focused particularly on the corporeal dimension of the women’s experience of pregnancy and birth, and the physical interac­ tions between them and the health practitioners during obstetric examina­ tion and delivery. In analysing this part of my ethnographic experience I have found the concepts of embodiment (Csordas 1990), incorporation (Bourdieu 2000) and performativity27 (Butler 1993) particularly insightful; they have allowed me to interpret some stereotypical corporeal expressions of women during pregnancy and birth as produced and enabled by specific cultural, social and political arrangements. For example, I was struck by the fact that the pregnant women I met never touched their abdomen, while this is very common in many European countries where prospective mothers do it very often, both in private and in public. Why do Jordanian women not do so also? For a long time I was unable to find an explana­ tion for this, until suddenly realising how obvious the answer was when I read that in rural Turkey ‘A woman does not announce her pregnancy or draw attention to it, for doing so would draw attention to her geni­ tals, which are shameful and unmentionable. Pregnancy bespeaks sexual activity, which is the prerogative of men to initiate, as are words’ (Delaney 1991: 57). In the light of this interpretation, other bodily expressions I observed among pregnant women acquired a new meaning for me, such as their way of expressing childbirth pain or their common reactions during

pelvic examination or during the very moment their baby is delivered. I realised then that, if I wanted to understand the experience of childbirth among Jordanian women, I had to take into consideration their perception of their own sexualised body and their experience of sexual life, under­ stood as processes mediated by local cultural and social norms (Lock and Scheper-Hughes 1990). I had given little thought to this before beginning my research, because, in my eyes, although obviously related to each other sexuality and procreation could be independently explored, such as in the many studies in the anthropology of birth which I had read before starting the fieldwork. Yet after a while it became clear to me that in the Jordanian case these two aspects were effectively inseparable, since only their inter­ section allows us to understand the complexity of women’s experience of pregnancy and birth (Chapters 4 and 5). Tightly linked to this is the topic of womens agency in procreation, and of the possibility of their making choices within the constraints constituted by patriarchal logics and incarnated by the domination of their husbands, fathers, brothers or mothers-in-law, as well as by the state (Yuval-Davis 1997). Indeed, as many anthropologists have shown, ‘reproduction and the control over it have never been a decision pertaining to the private sphere, but a social issue concerning the whole community and therefore subject to the power relationships crossing it’ (Parini 2006, my translation). Abu Lughod (2008), Inhorn (1996), Joseph (1993), Kandiyoti (1988) and Yuval-Davis (1997), to cite just a few, have shown how in the Middle East the notion of patriarchy and of men’s domination can be articulated in different ways according to specific local intersections of class, ethnicity, race and nation­ alism. Therefore, when I use the term ‘patriarchy’ I refer to a particular configuration of ‘gender regime’ existing in Jordan that is not confined to the domestic sphere, since the Jordanian state has itself promoted an official patriarchal ideology and adapted its administrative and juridical practices to it (El-Azhari Sonbol 2003; De Bel-Air 2003). The ‘modes of discourse’ (Yuval-Davis 1997) and the differential practices promoted by the state in respect of its male and female citizens are the underlying framework of the current natal system, which is both a component and a producer of the Jordanian ‘gender system’ (Parini 2006). Within this system, I analyse the possibility for women of autonomous action or choice, not conceived of simply as acts of acquiescence or resistance but rather, following the sugges­ tion of Mahmood (2001; 2005), as the ability to ‘perform, inhabit and expe­ rience’ norms. Agency is thus intended not simply as resistance, power or authority but as ‘one that must be understood in the context of the discourses and structures of subordination that create the conditions of its enactment’,

so that ‘agentival capacity is entailed not only in those acts that result in (progressive) change, but also in those that aim towards continuity, stasis and stability’ (2001: 212). Mahmood’s theory of the ‘docile agent’ is not in contradiction with the possibility for individuals of subverting or renego­ tiating norms, though the latter is only one of the possibilities for autono­ mous action which agency entails. Furthermore, while agents are subjects enabled, if not produced’ by a specific configuration of norms and thus unable to act outside of it, these norms generate a ‘particular morphology ... within the topography of the self’ (Mahmood 2005: 24). And I will add, that they also produce a particular body geography (Litowitz 2003) that creates different corporeal sensibilities and perceptions in each indi­ vidual according to gender, class and ethnic belongings. Thus I subscribe not only to the notion of ‘local biology’ understood as the variety of ‘types of embodied experiences’ (Lock 2001: 70) in which culture and biology are conflated, but also to that of ‘somatic modes of attention’ introduced by Csordas to indicate the process of perception of one’s own body within a specific socio-cultural configuration.

Obstetric technologies, social constraints and the issue of women’s choice Two important themes mentioned above concern both the impact of the medicalisation of birth on the way women think and feel about their bodies and the possible ‘liberating’ effects of new reproductive technolo­ gies (NRT). While in this book I have marginally addressed the themes of contraception and abortion, I have focused on the cultural and tech­ nical adjustments of Western obstetrics to local discourses and practices of childbirth (Chapters 4 and 5). These adjustments are not to be found only among pregnant women, but also among health practitioners who, even when trained in a Western country, accommodate their practices to local expectations and interdictions. As for the body image, I have tried to understand how pregnant women imagine their relationships with their unborn child, what kind of aesthetic or social representations of their body they have, and how and if their physical interactions with their husband change during the gestational period. The work of Kanaaneh (2002) and Ali (2002a) were particularly inspiring, in the rich ethnographic material they provide about these particular topics. The impact of the ‘technocratic model of birth’ (Davis-Floyd 1992) is not confined to new imaginaries of the body and of mother-foetus relationships, but also includes the transfor­ mation in several aspects of reproductive practices. Indeed, as pointed out by Lock and Kaufert, the new forms of power entailed in the biomedical

model of birth and the policies of surveillance promoted by the institutions ‘at the site of individual body ... may be experienced as enabling, or as providing a resource which can be used as a defence against other forms of power’ (1998: 7). What about the ordinary practices of Jordanian women during pregnancy and birth? I argue that the medicalisation of birth has in many ways enhanced the control both of the families and of the state over the women’s bodies and reproductive capacities. On the one hand, as in Western countries, the strengthening of the medical surveillance of procre­ ation and sexuality has meant the penetration of the state into the most intimate domain of the individual (Foucault 1976; Kligman 1991), gener­ ating strong forms of opposition. An example is the introduction of family planning into the Kingdom in the early 1990s, which caused violent reac­ tions among several sectors of the population (De Bel-Air 2003), including distrust and refusal on the part of many women (Chapters 2 and 3). On the other hand, while in Europe the massive medicalisation of procreation occurred in the second half of the twentieth century - when women had already acquired civic and political equality and succeeded in obtaining the right to contraception and, in several countries, to abortion - in Jordan the advent of medicalised birth has occurred in different circumstances since women were (and still are) in an inferior political, social and jurid­ ical position (Massad 2001). For the state, they are second-class citizens, and legally remain subordinate individuals within the family, since they do not have the same rights as their adult male relatives. Obviously, this is not to say that practically all women are subordinated to the men of the family, but only that they legally and socially do not enjoy the same rights as their male fellow citizens (El-Azhari Sonbol 2003). Unless we consider these facts, we cannot understand why the massive medicalisation of birth that occurred in the postcolonial period has generally reinforced the patriarchal structures of control, rather than enabling women to gain more ‘freedom’. In Chapter 5, some examples are given that illustrate what is being argued here, showing that medical authority and surveillance have been selectively incorporated into the local patriarchal culture in order to enhance its forms of control over women. However, it has also to be noted that women have not been forced to accept the technocratic model of birth: they have willingly become the allies of the new medical power (Arney 1982), since they are not ‘passive vessels, simply acting in cultural deter­ mined ways’ (Lock and Kaufert 1998: 2). Even acknowledging the fact that they have a ‘pragmatic attitude’ aimed at maximising the possibilities of improving their life, ordinary pregnant women in Jordan are caught up in a discursive and pragmatic network that creates inescapable constraints,

and in that sense have little choice but to share ‘the same moral world as their oppressors’ (Scheper-Hughes, cited in Lock and Kaufert 1998: 15). For instance, as I will show in Chapter 5, married women cannot choose to have or not to have children, cannot usually decide to wait some years before having them, and cannot choose to have only one or two children if those they already have are girls. In order to accomplish their social assign­ ments - wives and mothers - as well as possible, they seek medical ante­ natal surveillance and technocratic deliveries because these are culturally valued and socially legitimate. Despite its oppressive character, the medicalisation of birth has brought about several positive developments: all women can receive free or almost free perinatal care, have access to contraception (although social and cultural factors contribute to determining the use and purpose of this tech­ nology), and, in the case of infertility, can even attend public clinics to receive in vitro fertilisation (IVF) treatment. Indeed in 2007 in Jordan there were five government IVF centres where infertile couples lacking the financial means to turn to expensive private clinics were entitled to obtain treatment in order to procreate (Chapters 2 and 4). The existence of these clinics and of the private IVF centres opens up new possibilities for infertile women to overcome the deadly stigma they once had to bear and the social and moral ostracism they had to endure (Inhorn 1994; 1996; 2003). Moreover, the introduction of the NRTs has contributed to changing the widespread belief that it is the woman who is always respon­ sible in cases of infertility. According to the obstetricians I interviewed and to my own observations, men are today recognised as potentially as responsible as women in such cases, although they are not subject to the same social stigma and pragmatic consequences (Chapter 5). Moreover, women have benefited from the medicalisation of birth, since they are enti­ tled to receive medical treatment in cases of pathological events. Over the last decade, maternal mortality has dropped from 41.0 to 19.1 per 100,000 live births (MOH Annual Statistical Book 2009), 91 per cent of pregnant women undergo four or more antenatal examinations, and 97 per cent of deliveries take place in a health facility (High Health Council 2008: 40). However, I will show in the following chapters that although women have certainly gained much from the introduction of modern obstetrics in cases of pathological pregnancies and deliveries, and of infertility, and from the possibility of using modern contraceptive methods, they are not necessarily ‘more free’ or ‘emancipated’. To use the language of the interna­ tional agencies, Jordanian women’s ‘reproductive rights’ are far from being an uncontested issue, since the complex meanings this expression entails

are deeply interwoven in structural asymmetrical relationships between men and women (Browner 2007; Dudgeon and Inhorn 2004; Makhlouf Obermeyer 1999). Therefore, regardless of the benefits Jordanian women have obtained, I believe that in many ways modern obstetrics has rein­ forced their subordination to state and family logics, though the new forms of domination apply to them in different ways according to their social class and education. While some women are able to use them in order to strengthen their position and role within the family, others do not possess the symbolic and material resources to transform obstetric technologies into empowering instruments. In the following chapters, I hope to shed light on the Jordanian context, drawing on the ethnography of the interac­ tions and experiences of the persons I have met, since I agree with Inhorn that we need to draw attention to ‘womens personal lives in patriarchal Arab societies, or the lived experience of patriarchy by the women - and men - who are social actors within these systems’, rather than accept ‘abstract discussions’ ‘plagued by a continuing idealist bias’ (1996: 17, emphasis as in original). Finally, I should point out that, contrary to what Western observers might expect, religion did not constitute a major obstacle to the intro­ duction of Western obstetric procedures into Jordanian society, at least not during the postcolonial period. Women (and men) have accepted them as instruments providing beneficial effects for them and their chil­ dren. Hence, as noted above, biomedical obstetrics has become part of the Jordanian natal system, although many of its procedures infringe the ordinary modesty code and the rules of sex segregation, strong as these are within local society. In Chapters 4 and 5, I illustrate some forms of ‘accommodation’ that the introduction of modern obstetrics practices has produced, showing that social norms common to both Christian and Muslim28 women are more important than Islamic precepts. I argue that the lack of sexual education, the taboos surrounding women’s sexuality, and the forms of embodiment which local norms generate are independent of religious affiliation, and engender similar intimate experiences of preg­ nancy and birth. In many ways, class and related educational differences weigh much more heavily than religion in determining a woman’s sexual life and her experiences of procreation.

C

h apter

2

Medicine, Women and Procreation in Jordan (1920- 2008)

In this way, the discourses on the health and education o f women contributed professional governmentalities that produced continuous form s o f order and truth - new relations o f power, form s o f consciousness, and types o f authority that became the basis fo r the governm ent o f the self and o f others. (Mervat Hatem 2000: 69)

British health policies in Transjordan in the 1920 s In a 1925 letter to Mr Hartman of the Church Missionary Society (CMS), the British Resident in Transjordan, Lt. Col. C.H.F. Cox, wrote: ‘The public health department of this Government has been enough to make one shudder and at the present moment it is not much better’ (quoted in Amadouny 1997: 460). A Department of Health (hereafter DOHTJ) had been created under British supervision after the formation of the govern­ ment of the Emirate of Transjordan in 1921, but apparently undertook no significant initiative until 1926. In that year, the first Annual Report of the DOHTJ was published and the first public health legislation was prom­ ulgated in the Emirate1 (Abu Nowar 1999; Mahafza 1990). The responsi­ bilities of the DOHTJ were restricted by its limited funding. As in many other British colonies, the main health concerns of the colonisers were to assure the good health of the British troops and residents (Arnold 1993). This was due to the colonial ‘school of thought’ in place until the end of the 1920s, ‘which stressed the need to spend money on infrastructure and

“practical research” - i.e. research which yielded useful results quickly’ (Havinden and Meredith 1993: 165). Public health was not a priority until the late 1930s, when the Colonial Development Fund changed its policies and financed an important number of schemes in this field. As Vartan Amadouny points out, the DOHTJ was to provide basic clinical care, above all for the army, through a small government hospital in Amman, a network of dispensaries in the main urban centres of the country, and a number of quarantine stations in border areas such as Ramtha in the north, the Amman railway station, and the Maan railway station in the south.2 Medical services were also provided in the Transjordanian prisons, as indicated in the Palestine and Transjordan Administrative Report (here­ after PTJAR), which the British produced annually for the League of Nations,3 as well as in the annual reports of the DOHTJ. The association between medicine and the military was apparent in Transjordan, as it had been for example in India, where the Indian Medical Service ‘accepted a special responsibility for the health of the soldiers and prisoners under its control’ (Arnold 1993: 61). In Palestine and Transjordan, medical care was provided chiefly to ‘employees, policemen, soldiers, prisoners, workers of the railway line, school pupils, and poor local people’(PTJAR 1921: 257). In order to create safe health conditions in Transjordan, the DOHTJ carried out several campaigns against malaria and other endemic illnesses, as well as various vaccination campaigns against widespread infectious diseases such as smallpox. These campaigns had a positive impact on the Transjordanian population since the local inhabitants were actively involved in them and perceived the state’s intervention as an expression of the authorities’ concern for them (Amadouni 1994; Alon 2007). According to Amadouni, these undertakings played a crucial role in shaping local atti­ tudes towards Western medicine and the role of the state: ‘people began to expect government to take responsibility for certain actions’ (1997: 478-9). Indeed, it was often the only manifestation of central government, since during the 1920s many areas were beyond the reach of the state apparatus, which was still small-scale. If we compare Amadouni’s statement with an earlier description of Jamil al-Tutunji,4 where he depicts local attitudes towards Western medicine in the south of Transjordan, we might reach the conclusion that in less than a decade the inhabitants of the Emirate had substantially changed their opinion about it. Indeed, in his autobiograph­ ical records, Dr al-Tutunji narrates his trips to the south of the country in the years 1918-21. He mentions the very harsh conditions of transporta­ tion and his difficult relationships with local men and women. He points out that it was almost impossible to examine or even to meet the women,

and that the men were very suspicious of him and refused even to answer his questions. He then describes and condemns the ‘superstitious’ healing practices of the local inhabitants, such as drinking water which contained a small piece of paper on which a local sheikh had written some verses of the Koran (MOH Annual Report 1951—57). Mistrust of the new medical practices among the Transjordanian population in the very first years of the Emirate can be explained by the fact that in the country there were no more than five physicians trained in Western medicine, and that all of them lived in the few urban areas (Mahafza 1990).5 Therefore, when the DOHTJ was created, it was staffed chiefly by British, Palestinian and Syrian medical officers (Mahafza 1990). One of the few Transjordanian physicians was Hanna al-Qsus,6 who in 1923 became director of the first public hospital in Amman (Abu Nowar 1999: 223). Yet Western medi­ cine was not entirely new in Transjordan: some Christian missionaries had already started to provide medical services in the northern part of the country - the London-based CMS7 opened a small medical centre in Salt in 1883, during the last decades of Ottoman rule, which in 1904 was to become the first hospital east of the Jordan (Abu Nowar 1999; Rogan 1999). Some decades later, in 1921, the CMS established a small hospital in Amman. It was the first in the country for women and children to be opened east of the Jordan; its aim was to reduce infant mortality and improve conditions for womens health. As we shall see below, infant health was later to become a central concern for the Transjordanian authorities. Already in the first Annual Report of the DOHTJ (1926) the registration of births and deaths on a regular basis —which had been made compulsory by the Health Law promulgated in the same year - was among the few topics addressed. The widespread colonial interest in demography, statistics and numbers should be seen in relation to their economic and political meaning: demographic data allowed the colonisers to count their subjects, to classify them and to locate them in the colonial space, as well as to watch over their numbers (Anderson 1991; Mitchell 1991; Vaughan 1991). The economic factor played a fundamental role, since a ‘declining popula­ tion meant a labour shortage capable of threatening the prosperity and viability of the protectorate’ (Summers 1991: 788). Strategic and military reasons were also very important: for building a strong army, it was neces­ sary to ensure that enough healthy potential soldiers were being produced. These concerns echoed the crucial debate about demographic decline and the necessity of encouraging women to have more children that had been shaping state policies and scientific discussions in many European countries (Koven and Michel 1993). Here, at the turn of the twentieth

century, a movement for the protection of mothers and children had been at the origin of important social and medical reforms aiming to support and educate women, in order for them not only to give birth more often but also to produce children who were healthy (Klaus 1993; Davin 1997). Malthusian discourses had been replaced by an emphasis on a numerous, strong population, which was considered a matter o f‘imperial importance' (ibid: 93). Hence a major colonial concern in the 1920s and 1930s was reproduction, reflecting the discourses and interests dominating the socio­ political arena in Europe (Jones 2004).

Caring for mothers and children: a joint venture between the colonial state and the missionaries Significantly, the Health Law passed in 1926 by the Transjordanian government instituted the school medical service, whose task was to inspect and provide basic care for all pupils of the Kingdom (Mahafza 1990).8 Yet in the Britain itself, as well as in its colonies, the authorities focused less on the socio-economic conditions in which mothers and chil­ dren lived than on women’s education, since the mothers were held respon­ sible for the welfare of their children. Reformers drew public attention to mothers, who became the main target of the policies undertaken in Britain during the first decades of the twentieth century (Jolly and Ram 1998; Van Tol 2007). Great efforts were put into ‘advice and instruction of mother­ hood’ - mothers were to be educated in order to change the detrimental behaviour that was considered the main cause of the high infant mortality rate and the ill-health of the younger generation (Davin 1997). Indeed, in a well-documented study Davin argues that in order to improve the conditions of mothers and children the British state, rather than choosing to ‘expand social and medical services’, focused on mothers as an ‘easy way out’ (ibid: 105). Women, and particularly working-class women, were considered responsible for infant deaths or sick children since ‘the real everyday responsibilities belonged to the mother’ (ibid: 91). Astonishingly, the British authorities did not regard the very difficult economic and social conditions in which the ‘guilty mothers’ lived as determining the high levels of infant mortality and morbidity. It was easier to blame the mothers’ bad habits, ignorance and lack of domestic skills than to undertake serious reforms aiming at improving the socio-economic situation of the working class.9 The creation of the Babies’ Welcome and School for Mothers in 1907 heralded a new, successful model of social intervention aiming at improving motherhood and hence laying the foundation for the construc­ tion of a healthy imperial society. The numerous schools for mothers that

mushroomed in Britain in the 1910s were aimed at changing the hygienic, nutritional, social and moral practices of working class women. These schools were meant to transform both the habits in respect of hygiene and the moral attitudes of the women, as well as to change them into good mothers and good citizens capable of producing physically and morally healthy individuals. In short, they were meant to inculcate in the women what Foucault has called la morale du corps , the moral and social obliga­ tion to follow the rules of hygiene imposed by the state in order to ensure individual and family health. These new institutions were to become an inspiring model for the colonial administrators, who launched several campaigns aimed at improving maternal and infant health, as we shall see below. However, as Megan Vaughan points out: On the issue of maternal and child health, and on ‘womens issues’, ... the missionary discourse has a long, and somewhat distinct, story. It was only rather late in the colonial period that a secularized version of this became evident in government docu­ ments and interventions (1991: 23). According to her, while the missionaries had made maternal and child health their particular concern, the colonial administration was less inter­ ested in taking effective measures to improve their situation. In addition to the European motherhood movement and the activi­ ties of the medical missionaries in the colonies, there were other specific social and cultural factors which were to have an important impact on the colonised societies in the field of maternal health. In Britain, the policies outlined above addressed chiefly working-class women, though a specific discourse was also developed to encourage middle class women to have more children and to underplay their professional aspirations outside the home; in the colonies, however, they were implemented in a different manner, racism and imperial interests in part contributing to a modifying of the policies in the field of maternal and infant welfare. Indeed, in the colonial context, motherhood discourses and practices had to be adjusted to the local ‘inferior’ societies under Western administration. This was consistent with the colonial ideology of the Victorian era, according to which women’s condition was a crucial symbol embodying the inferi­ ority of the colonised society (Chatterjee 1989; Said 1978; Jolly and Ram 1998; Summers 1991). The oppression of women in non-Western societies was a very important factor used by the colonial establishment ‘to render morally justifiable its project of undermining and eradicating the cultures

of colonized peoples’ (Ahmed 1992: 151). Furthermore, the economic and military concerns of the colonisers contributed to imparting a particular shape to the motherhood discourse dominating the European ideology of the time. Colonial officials had to take care of local women as they played a central role in reproducing the labour force necessary to nurture the imperial economy of the Western states. Hence colonised women were not only to be made good mothers, they had also to be civilised and educated in order to realise the larger project of transforming ‘back­ ward’ non-Western society. Once again, the underlying ideology was that women were responsible for the physical upbringing and moral education of the new generation. If the infant mortality rate was high, women had to shoulder the blame, but at the same time they had to be educated in order to improve their social and moral condition as well as that of the rest of the society. Colonised women were also to be redeemed, a missionary project that was consistent with the secular policies of the colonial govern­ ment. In the majority of the colonised areas, Christian missionaries had introduced schools and medical facilities whose aims were not only to offer education and medical care to local people but to convert them to Christianity, in order to eradicate ignorance, sin and superstition (Hardiman 2006; Vaughan 1991). The British campaign against sexu­ ally transmitted diseases in Uganda in the period after the First World War is a meaningful example of the alliance between secular authori­ ties and religious missionaries. The colonial government ‘allowed the missionaries to take the lead in the new campaign’, which was aimed at training midwives and educating mothers, but at the same time condemned the sexual immorality of local women (Summers 1991: 796). Thus a religious and moral judgement weighed heavily on the various medical and social services provided to the local women. Despite its usually secular attitude, the Colonial Office decided to give its financial and political support to the missionary work in Uganda in the name of its beneficial effects. The alliance with religious institutions was an effective means of saving funds, which would otherwise have to be allo­ cated to health schemes in peripheral areas of the Empire. Indeed, this was a major concern for British authorities unwilling to finance exten­ sive health systems in the colonies (Havinden and Meredith 1993). The convergence of the political and financial interests of the state with the religious concerns of the missionaries was typical of the British Empire: such ‘joint ventures’ could be found in many British colonies, such as India, Uganda, and also Palestine and Transjordan.

Doctors, hospitals and healers during the Mandate As noted above, since the DOHTJ had very limited economic resources, the colonial authorities were unable to build a strong web of health services; missionary societies and private doctors were left to provide most of the health care to the civilian population. In 1939 the number of hospitals in Transjordan was very restricted: there were two CMS hospitals (one in Salt and one in Amman), two Italian hospitals (one in Amman and one in Karak) and the English hospital in Ajloun founded in 1938 by the independent missionary Charles McClean.10 There were three government hospitals, two in Amman - one general and one in the central prison - and one in Irbid, the remaining provision consisting of military or quarantine posts where only victims of accidents or infectious diseases were treated. The total number of hospital beds in the government sector was 74, whereas in the private sector there were 117 (DOHTJ Annual Report 1939). In his autobiographical book Story o f a City: a C hildhood in Amman (1994), the Amman-born novelist Abd al-Rahman Munif gives an amusing portrayal of the medical practitioners living in Amman in the 1940s. There were few physicians trained in modern medicine, a substantial number of tradi­ tional healers, and several religious shaykhs. According to Munif, among the trained physicians there were Dr Theodore Zurayqat, a Transjordanian who had studied abroad and returned to his country as honorary Greek consul; Dr Suran, who spoke with an evident Armenian accent and was very much appreciated by the people; Dr Qasim Malhas, who spent many hours rebuking his patients for their lack of hygiene and teaching them proper ways of keeping their bodies and houses clean. There were also Dr Farun, whose office was attended chiefly by Syrian patients, and Dr Fausto Tesio,11 the founder of the Italian hospital, which for a long time was the best hospital in Transjordan. Not far from the Italian hospital was located the hospital of the ‘lame lady’, the first maternal and children’s hospital in Transjordan. It was run by the CMS, and acquired its name from the bodily defect of Dr Charlotte Purnell, the British physician in charge in the 1920s and 1930s. When she died in 1943, an American missionary couple, Ray and Dora Whitman, took over its direction for some years. In Amman there was also a dispensary where Drs Mustapha Khalifa and Shawkat al-Mufti saw their patients, since they did not have a private office in the city. In addition, Munif mentions the Quarantine, the hospital for infec­ tious diseases located beside the Arab Legion headquarters, affirming that the inhabitants of Amman were afraid of the place and many tried to avoid the street where it was situated. Finally, there was a dentist, Dr al-Battikhi, whose medical equipment frightened the majority of the patients, who

often preferred to visit Abu Hassan, the local barber. Two doctors had a special status and treated a very selected category of patients, Dr ‘Izz al-Din and Dr Jamil al-Tutunji (mentioned above). A very important figure during the 1940s was Hajja Anisa, the first municipal midwife in Amman who started to practise in the capital in 1927. She assisted the majority of the better-off families of the city, and was very well-known at the time. Elise Young writes that ‘Jordanian governmental officials’ used to kiss her hands when they met her in the street (1997: 10). I will come back to her story in the following chapter. Besides the few medical doctors trained in biomedicine, there were many healers, men and women, specialising in various fields: the mujabbir or bone-setter, various herbalists and other figures expert in blood-letting, cupping, psychological healing, cauterisation, etc. Most of the physicians trained in modern medicine whom Munif mentions had private offices, since the British had laid down the founda­ tions of a medical system open to competition and market forces (Shepherd 1999; Young 1997). Marcia Inhorn illustrates very clearly the kind of medical system British administrators imported first into Egypt and then into Palestine and Transjordan. According to her, while government services were minimal, the model of ‘fee-for-services private medicine, practised by physicians as a trade for financial gain’ made inroads in the colonised societies after the British imposed their health system (Inhorn 1994: 65). Yet, the situation in Transjordan was very different from that the British had found in Egypt, insofar as in the Emirate there was nothing comparable to the advanced Egyptian educational system, which aimed to train physicians in Western medicine and to provide medical services to various categories of the population (Kuhnke 1990; Panzac 1995; El-Azhari Sonbol 1991). If in Egypt the British medical model wiped out the health system developed earlier by Muhammad ‘Ali, in Transjordan no government medical institutions existed before the Mandate period.12 However, here as in Egypt, the British paved the way for the establishment of an important private health system, which has undergone tremendous development,13 so that Jordan has become today a very important centre in the Arab region, attracting ‘medical tourists’ from numerous neighbouring countries (WHO-Emro 2004; Lautier 2007). The colonial health system had important economic and social conse­ quences for the work of midwives and dayas. First, a large proportion of them were living in poverty, having lost their privileges when women started to give birth in the hospitals.14 Not only was the practice of dayas discounted by the colonial authorities, but the local lay midwives became

increasingly marginalised when they were allowed to practise only in limited geographic areas. Although they doubtless enjoyed better status, qualified midwives also had great difficulty in coping with the economic conditions determined by the new health order (Young 1997). Their diffi­ culties derived from the fact that they were only permitted to practise in the district to which they were appointed, and had to pay substantial amounts of money in order to abide by the rules of the colonial health system. Young points out that ‘charging fees for licences, equipment, drugs, and [paying] a minimal fee for deliveries in government hospitals, the Mandate govern­ ment used health as a form of economic leverage with the goal of keeping the health budget low’ (ibid: 114). Furthermore, the British opened up their colonies to European and American drug companies eager to sell medical equipment and medicines in the region. Hence, during the Mandate, ‘health was becoming a commodity to be bought and sold on the market’ (ibid). Given that government health facilities were by a wide margin insuf­ ficient to cover the needs of the population in Palestine and Transjordan, except for the very poor, ‘most of the sick either had to pay private doctors or to knock on the doors of charities’ (Shepherd 1999: 143).

Maternal and child health services in Transjordan during the Mandate period As noted above, the first (small) hospital for women and children in Amman was instituted by Dr Charlotte Purnell,15 a British physician working for the CMS. The latter, and not the Mandate government, took the initia­ tive in establishing the two first maternal and infant welfare centres in the Emirate, until 1950 almost the only medical facilities for women and chil­ dren.16 What was behind the missionary concern for women and children? CMS was a religious institution whose aim was to convert local people to Christianity. As stated above, the missionaries made their inroads into local society through education and medical care. European and American female physicians, nurses and midwives were to play a crucial role, since they were allowed to practise in the area of women’s health. It might even be said that they were only allowed to practise medicine in this field, since they were considered as ‘naturally best suited to practise among members of their own sex’ (Arnold 1993: 265). They were often the only persons to gain access to indigenous women: the great majority of the European physicians were men, and in some countries local cultural and social norms would hinder physical contact between female patients and male physicians. The colonisers’ pronatalist preoccupations notwithstanding, at the turn of the twentieth century, there was a ‘colonial reluctance to see women’s

Illustration 1 The Italian Hospital in Amman health as a state responsibility’ in the territories administered by the British state (ibid: 268). This reluctance accounts for the important presence of religiously motivated female doctors, midwives and nurses active in the field of women’s health. In fact, in spite of the important role played by the feminist colonial discourse among the British elite - a discourse supporting the liberation of oppressed native women from the male yoke - colonised women were generally seen as subjects of secondary importance, and their care was relinquished to subordinate Western citizens such as European female physicians, nurses, midwives and missionaries. A clear expression of this political attitude is the fact that the funding and staffing of colo­ nial medical and social institutions for women were almost completely left to private initiatives. While in India the Dufferin Fund, the main source of funding for women’s health policies since the 1880s, was instituted by the wife of the viceroy and operated outside the local administration, in Transjordan the maternal and infant welfare centre in Amman was admin­ istered by Lady Cox, the wife of the British Resident, together with Dr Purnell. The maternal and infant clinics in Amman and Salt were estab­ lished and run by the CMS, with a little financial support from the Mandate government. No other maternal and infant welfare centre was created

during the period 1921-46, with the exception of a clinic in Zarqa set up in the late 1930s by the Transjordan Frontier Force17 to provide care for the families of the soldiers, though it was attended equally often by the inhab­ itants of the rural areas surrounding the town, and by Bedouins. However, the Zarqa clinic was not a DOHTJ-run institution and as a consequence was not entitled to government funds. By contrast, the cost of medicines and some of the personnel in the Amman and Salt clinics were met by the government, with the rest of the expenditure covered by donations and voluntary work. However, the DOHTJ’s financial support was insufficient, and the clinic in Salt was closed down for several periods because there were no staff to provide services to the local women and children. Indeed, in the late 1920s the DOHTJ paid the salary of one nurse working in central Amman, but only provided the Salt centre with medicines; it could open on only one or two days a week, when the missionary personnel from the CMS hospital had time to come.18 The number of registered patients and home visits performed by the staff of the two clinics clearly show the difficult situation of the Salt centre, where the services were highly discon­ tinuous. For example, in 1929, the clinic was closed down for nine months because the CMS woman in charge of it had left for Britain. Some years later, in 1932, the DOHTJ’s Annual Report affirmed that the maternal and infant welfare centre in Salt was not providing services on a regular basis because the doctor had too much work in the towns CMS hospital. In the same year, the Amman clinic registered 10,197 cases and 2,764 home visits, whereas the corresponding figures for the Salt centre were only 504 and six. In the late 1930s, the Amman centre was able to provide continuous care, as it received more state support than the Salt clinic. While in the capital the clinic was staffed with two nurses and a physician, whose salaries were paid by the DOHTJ, the Salt centre continued to be run on a voluntary basis by the personnel of the nearby CMS hospital. Despite the centre’s success, the DOHTJ paid only for medicines and basic equipment. Even if since its foundation in 1927 it had not stopped (unlike the Salt centre) providing maternal and infant services, the Amman centre still only opened on two days a week, and was able to offer only very basic care. The main services provided by the two clinics were general consultations, the weighing of babies and health education for mothers (DOHTJ Annual Report 1929). The Salt maternal and infant welfare clinic had decreased its activity by the late 1930s, since there was a severe staff shortage; in 1939 the centre dealt with only 918 cases and eight home visits, while the Amman clinic registered 11,091 cases and 2,252 home visits.19 In 1938, an independent volunteer opened a very small clinic in Jerash, and this was supported by

the DOHTJ. The local district medical officer was appointed as the centres physician, and the government provided the medicines and the uniforms.20 Despite the frequent calls for building other maternal and infant welfare centres in the country, the authorities took only a very few initiatives, such as the opening of a small (20-bed) maternity ward in a new government hospital in 1939. Generally, health facilities were few before the second half of the 1930s and by the 1940s the majority of them were still run by missionary institutions (see Table 1). Indeed, although several new government hospitals were opened between 1937 and 1939, the five private hospitals already operating in the Emirate provided the bulk of the health services.21 The majority of the public hospitals were small military posts with a medical officer and some beds whose main aim was to guard against infectious diseases and provide care in case of accident (see Table 2). The DOHTJ policies were chiefly aimed at offering curative medical services, and were completely insufficient. As reported by Amadouni, in 1934 Dr G.W. Heron22 complained bitterly of his situation writing that: “In general the Department of Health of Transjordan was conducted with surprising efficiency considering the small credits available, but it is clear that many of the services considered essentials in other countries have to be almost entirely neglected’” (1997: 478). Thus the scarcity of the maternal and infant services reflected a wider situation in which the DOHTJ was unable to provide even basic services to various groups in the local population. For example, the Bedouin tribes living in the desert area of Transjordan were left almost completely without medical facilities until 1937, when the Desert Patrol Medical Mobile Unit was established. This unit was meant to provide medical care for the Bedouin tribes living in the southern and eastern areas of the Emirate that until then in order to receive ‘modern

Table 1 Private Hospitals in Transjordan, 1939 Name and location

No. o f beds

No. o f admissions

Italian Hospital in Amman Italian Hospital in Karak English Hospital in Amman English Hospital in Salt (CMS) English Hospital in Ajloun Malhas Hospital

85 36 30 28 40

1,828 799 118 736 308

Source: DOHTJ Annual Report 1939

Table 2 Government Hospitals in Transjordan, 1939 Name and location

No. o f beds

No. o f admissions

Surgical hospital (Amman) Ophthalmic hospital (Amman) Maternity hospital (Amman) Hospital of Internal Medicine (Amman) General hospital (Irbid) Hospital for Infectious Diseases (Irbid) Government hospital (Karak) Government hospital (Ma‘an) Government hospital (Jerash) Government hospital (Tafileh) Government hospital (Aqaba) Hospital of the Central Prison (Amman)

37 12 20 40 12 8 8 8 4 4 4 12

828 181 262 550 502 228 -

Source: DOHTJ Annual Report 1939

medical treatment had to travel to the sedentary areas or ... were sent abroad by Glubb’23 (Alon 2007: 134).

Regulating childbirth and the foundation of the new public health system Another paragraph of the Health Law of 1926 established compulsory licensing of medical and paramedical personnel.24 Physicians, dentists, pharmacists and midwives had to obtain a licence and be registered in the respective official roll in order to practice their profession legally. Even if a system of registration for medical doctors and midwives25 already existed during Ottoman rule (Bourmaud 2007), the meticulous colonial admin­ istrative system imposed a far more effective and articulated bureaucratisation of the medical sector.26 Particularly in the field of childbirth, the colonial period laid the foundations of an entire new social and cultural system in which women’s role was to be deeply transformed. Until the nineteenth century, when the first schools and faculties of Western medi­ cine were established in the Arab provinces of the Ottoman Empire, child­ birth was a feminine domain dominated by dayas. In order to become a daya, a woman did not have to undergo a formal training, but rather acquired experience attending births as assistant to a skilled lay midwife. The art of midwifery was usually inherited within the family. It was the

mother or one of the female relatives of the apprentice daya who passed on her knowledge and techniques. Midwives were also herbal healers and knew various remedies for overcoming sterility, increasing milk production during breastfeeding, recovering after miscarriage or infection, etc. While dayas did not usually deal with women during pregnancy, they were in charge of the delivery as well as of receiving the newborn child and admin­ istering the socially legitimate ritual. Yet it is difficult to give an accurate portrayal of dayas’ role because there were differences in their social status, their techniques, knowledge and training according to the community to which they belonged. For instance, midwives in the cities were often treated as specialised professionals, whereas in the rural areas or among the nomadic tribes they were usually elderly women who had acquired experi­ ence over their lifetimes but were not recognised as practising a specific profession. The British government in Palestine and Transjordan decided to enforce licensing in order to improve the medical system and particularly to bring order to the domain of reproduction. The project was to eradicate the practice of employing dayas and to replace them with qualified midwives, trained according to modern medical standards. However, the local natal system could not be discarded in one day: its abolition had to pass through various phases. In fact the transformations that occurred in Palestine and Transjordan were very similar to the process that had taken place in Europe and North America only several decades before, when the medical establishment had succeeded in monopolising the area of reproduction (Wertz and Wertz 1977; Gelis 1988; Donnison 1999; Loudon 1992; Marland and Rafferty 1997). For example, if we look at the evolution of the natal system in Britain, the Midwives Act of 1902 was passed in order to submit midwives to rigid state control which aimed ‘to secure the better training of midwives and to regulate their practice’ (Mottram 1997: 134). During the first years of the Mandate in Palestine, the registration of local midwives or dayas had already been made compulsory and their activities put under British control. In 1919 regulations were issued for the training of nurses, and in 1929 the Midwives Ordinance was passed in order to control the training and practice of midwives. They were to be trained in officially recognised medical centres according to the standards established by the British Central Midwives Board. Thus, in 1922 a training centre for midwives was established within the Jerusalem Government Hospital where the Princess Mary Maternity ward was inaugurated in that year thanks to the funds ‘collected for the Palestine gift to Her Royal Highness’ (PTJAR 1922; Shepherd 1999: 141).27 The training centre had been created

because in the Palestine and Transjordan Administrative Report of 1921, there was a paragraph stressing that: Midwifery in Palestine is almost unsatisfactory, The 51 qualified women are confined to a few of the larger towns and there are no less than 884 untrained and, in most cases, grossly ignorant, prac­ tising midwives registered at the District Health Offices. There are few problems more urgent than the establishment of centres for the teaching of midwifery and infant management (ibid: 271). Medical officers depicted dayas as dangerous women who with their ‘malpractice’ caused ‘an inevitable toll of maternal and child mortality’ (Young 1997: 96).28 Their techniques were attacked and condemned as primitive, unhealthy and deleterious. For instance, the British medical officers engaged in a struggle against the ‘medieval high stool with the hole in the centre’ used for deliveries in the Palestinian towns (ibid: 98), as well as against: [other] cruel practices carried out by some of the old women ... such as burning the skin of the baby here and there and leaving open stores all over the body, putting lemon juice in the babies eyes, giving a male child’s urine as a medicine to those suffering from measles (ibid: 99).29 The British depicted local birth practices in such a way that they ‘resem­ bled more a list of fantastic habits and absurd superstitions rather than a body of knowledge shared by real social groups that faced and managed specific conditions of risk, distress and illness’ (Falteri and Bartoli quoted in Pizza 2005: 164, my translation). Owing to the necessity of eradicating these erroneous practices, the British authorities established a course for retraining local midwives in the government hospital of Jerusalem (Young 1997: 97). Not only had dayas to be registered on the official roll and to accept administrative control over their practice, but they had to be retrained or re-educated since they were represented as ‘grossly ignorant’, and ‘causing unnecessary suffering’ (PTJAR 1932: 137-8). The report echoes well-established discourses used by the medical establishment to campaign against lay midwives or handywomen in Europe and North America, as well as in other colonies. Lay midwives were represented as dirty, ignorant, superstitious, deleterious and causing harm to women and children (Wertz and Wertz 1977; Leap and Hunter 1993; Gelis 1988; Ehrenreich and English 1973).

During the nineteenth century in particular, they were the object of violent accusations, and their practice was severely limited (Arney 1982). They were eventually evicted altogether from the domain of childbirth in some countries, such as the United States and Canada, where they disappeared for several decades (Davis-Floyd 2006; DeVries 1996; Saillant and O’Neill 1987). Where midwives were not eradicated from local societies they had to submit to a hierarchical system dominated by male doctors. Licensing of midwives brought about the careful surveillance of their work and implied a strict control over their private life as reported in the following passage in the British journal Nursing Notes of 1905: She should be sure that she lives in a healthy house, that her rooms are clean and well ventilated and the drains in order ... The midwife ... should avoid very rough work such as scrubbing, grate-cleaning or polishing. If she has to do much work of this sort it is wise to wear housemaids’ gloves (quoted in Leap and Hunter 1993: 5). The Midwife Act of 1902 established that every handywoman who wished to practise had to pass an examination, or to produce a reference from a clergyman, for admission to the roll. At the same time rules were issued concerning the equipment and clothing considered necessary for practising midwifery. The regulations enforced in Palestine and Transjordan were very similar to those that the state had passed two decades before in Britain, and were aimed at abolishing the existing natal system that relied on dayas. In Britain, as in the colonies, lay midwives were eventually to be outlawed as soon as a sufficient number of qualified midwives and doctors were available to provide perinatal care. Indeed, in 1926 ‘the Third Midwives Act banned unqualified midwives from attending a woman in childbirth unless they could prove that it was a sudden emergency’ (Leap and Hunter 1993: 7). Similarly, in 1939 the 1,239 registered Palestinian dayas were allowed to practise only in the areas where no qualified midwives were available. By the end of the 1930s, dayas were mostly confined to rural areas, since in the urban centres there were already enough qualified personnel and numerous medical facilities. According to the official data of 1937, in Palestine there were 513 qualified midwives and 2,206 physicians, 35 government or semi­ government maternal and child health clinics, and 42 maternal and infant welfare centres run by several Jewish voluntary associations (PTJAR 1937).

The first generation of qualified midwives During the 1930s the public health system in Transjordan was far less developed than in Palestine and dayas were still playing a very important role in childbirth. In its first Annual Report (1926), the DOHJT had already pointed out that in the Emirate there was a great number of dayas whose names should be registered in order to issue them with ‘Certificates of Registration for control purposes’ (shahadas)', the registration of dayas was meant to allow health officers to verify their capabilities and control their practice. Furthermore, the report complained about the fact that ‘practically every woman acts as a midwife’. Only four qualified midwives were available in that year, and they were employed respectively by the municipalities of Amman, Irbid, Karak and Ma‘an. Two years later, in the PTJAR of 1928, health officials complained that the DOHTJ’s project to send several young women to study in the training centre for midwives in Jerusalem had failed, owing to lack of funds. Shortage of personnel was a constant problem for the DOHTJ as it could never rely on suffi­ cient annual budgets. According to the figures reported by the Jordanian historian Muhammad Mahafza, in the period between 1926 and 1939 the annual expenditure of the DOHTJ was usually between 2 and 3 per cent of the already exiguous national budget, and never exceeded 3.6 per cent of it (1990: 285).30 In fact, over the whole colonial period, there were very few qualified midwives working in the country; for example, in 1928 there were two, in 1930 three, but in 1931 again only two - and none of them native of Transjordan.31 Their number fluctuated every year, often decreasing, until the mid-1930s when it started to grow. Generally, there was great instability in the effective number of medical personnel who settled in the Emirate. For example, the Annual Report of the DOHTJ of 1930 noted that 55 licences had been issued to physicians, but that only 29 of them were practising in the Emirate.32 Several British midwives settled in the country for some years, but they did not practise continuously. Though the project was already mentioned in 1926, only in 1935 was the DOHTJ able to send a group of young Transjordanian women to Jerusalem to study midwifery at the training centre in the government hospital; the project was to employ at least one midwife in each health district. In its Annual Report of 1935, the DOHTJ also declared its intention to establish a similar training centre in Amman, and this idea was mentioned again in the 1939 Annual Report, when the first government maternity unit was inaugurated in Amman. However, the project was not finally brought to fruition until 1951, when the first group of young Transjordanian women entered the newly established training

centre for midwives in the capital, in the building previously occupied by Dr Purnell’s hospital (Sultan 1998). As for the young women who had gone to Jerusalem in 1935 to train as midwives, their two-year course was not funded by the DOHTJ but by the five municipalities that intended to employ them once they had obtained their diploma. The British adminis­ trators in the Emirate applied the same policies they had employed in many other colonies, where the costs for staff training and medical facilities had to be paid by local institutions (Arnold 1993; Van Tol 2007). More broadly, the Colonial Office was unwilling to allocate large amounts of money to finance colonial medical institutions; they were instead to be supported by the government of each colony, by local philanthropic initiatives and by municipal administrations (Arnold 1993; Havinden and Meredith 1993). Its meagre budget meant the Transjordan government was unable to pay for specialised health facilities and staff, despite its explicit concern for the welfare of children and women, and the task was therefore left to private initiative, which in the Emirate meant chiefly missionary institutions. British colonial authorities adopted the same strategy in Palestine, where they delegated an important part of the economic burden of health services to volunteers, local authorities and wealthy citizens.33 For example, in the 1920s the maternal and child health centre in Jerusalem suffered from a ‘chronic shortage of basic equipment’ since the Department of Health of Palestine (hereafter DOHP) did ‘not stretch further than the payment of doctors and nurses’ (Shepherd 1999: 142). Indeed, British administrators not only thought that buildings ‘for clinics and accommodation of staff had to be provided by the towns and villages’, but some lamented the reluc­ tance of wealthy municipalities to pay for the health services (ibid: 142).34 While Palestine was a rich and fertile country with important urban centres, the population of Transjordan was very poor and the towns were few, with only modest municipal incomes. The municipalities’ restricted financial means did not allow them to sponsor significant initiatives in the domain of health; nor did the central government dispose of substantial sums of money, as its annual budget depended largely on tax collection. All these factors contribute to explaining the DOHTJ’s unwillingness to pay for the education and salaries of the first Transjordanian midwives to be trained in Jerusalem in the 1930s. Instead, the municipalities of Irbid, Zarqa, Madaba, Karak and Maan were held responsible for the costs of both the training and the salaries of the newly qualified women, since one of the latter was to work in the health district of each town. By 1937 there were nine qualified midwives practising in Transjordan three in Amman and one in Salt, in addition to the five mentioned above (DOHTJ Annual

Report 1937). By 1939, however, the number working in the Emirate had increased significantly: there were 19 in Amman, two each in Salt, Irbid and Madaba, one each in Karak and Ma‘an, and four in Zarqa. In the same year, there were 27 registered dayas in Amman, six in Salt, 31 in Irbid, three in Ma‘an, 15 in Ajloun and 34 in Madaba (DOHTJ Annual Report 1939). The low number of officially registered dayas can be explained in two ways: on the one hand many areas were only formally under the control of the health authorities, and on the other in several rural and nomadic commu­ nities every elderly woman could act as a midwife, but was unlikely to be registered as a daya. To sum up, despite the modest achievements of the colonial public health system imposed during the Mandate, new social figures, institutions, ideas and practices had begun to penetrate in Transjordan after the First World War. By independence in 1946, large groups of the urban popula­ tion had become familiar with the state-sponsored biomedical system, and had began to internalise new notions of and attitudes towards matters of health, a (still tiny) network of health institutions was providing services to the local population, and a few medical and paramedical practitioners had acquired a recognised social role.

Social reactions to the medicalisation of women’s health In the previous paragraphs I have tried to show some aspects of how a Western medical system was introduced into Transjordan, and will now turn to the local population, to explore as far as possible its reactions towards this new system imposed by the British colonial authorities. As has already been mentioned, the Transjordanian population welcomed the initiatives of the DOHTJ, which were perceived of as a form of concern on the part of the authorities for the citizens of the Emirate. This was true also in the domain of womens and childrens health, since, as noted in various official reports of the DOHTJ, women were aware of the benefits they would receive from the new health services - or at least this was the opinion of health officers. The few contemporary sources reveal that by the late 1920s women did not refuse to visit clinics and medical offices run by male doctors, although deliveries were still attended exclusively by dayas or qualified midwives. Births took place at home, which the colonial authorities still considered as perfectly normal even in Britain the large-scale hospitalisation of childbirth did not occur until after the end of the Second World War. Thus in Transjordan and in Palestine, the infant welfare centres were welcomed by the local popula­ tion, which accepted Western medicine but, as in many other colonial

contexts, integrated it among a plethora of other local treatments and healing methods.35 The high number of cases registered in the clinics and of home visits indicates the success of the new medical regime among the Transjordanian population. Indeed, in 1939 the infant welfare clinic in Amman registered 11,004 new cases and 2,424 home visits, and the centre in Zarqa 2,086 and 1,776 respectively. However, the colonial medical system was to face some forms of resist­ ance from the local population: on the one hand dayas were important social figures whose practice could not be eradicated so easily, and on the other ordinary women were not willing to be examined by a male physi­ cian in a gynaecological or obstetric context (Bourmaud 2007; Young 1997). By 1936 in Palestine, where the Department of Health had more financial resources, the government employed two female doctors to run two clinics for gynaecology and obstetrics. These were attended mainly by poor Arab Muslim women and were a great success (PTJAR 1935; 1936; 1937). Their services were so well received that even during the troubled years of the Palestinian Revolt (1936—39) they were not attacked, and Palestinian women went on attending them. However, the fact that local women welcomed some services does not mean that they passively accepted the biomedical system and its constraints. Indeed, for a very long time, despite the efforts of the Departments of Health in Palestine and Transjordan, local women preferred dayas to qualified midwives and doctors.36 The well-established practices of dayas and the reproductive habits of Arab women had already been a topic of debate among European physi­ cians working in the two Western medical schools in Beirut during the 1890s. Besides the medical school founded in Egypt by Clot Bey during the first half of the nineteenth century, those in Beirut were the only ones in the Arab provinces of the Ottoman empire, and were to attract many medical students from all regions of B ilad al-Sham. The two schools were the French Faculty of Medicine (FFM), established in 1888 by the Jesuits within the University of Saint-Joseph, and the medical school of the Syrian Protestant College (SPC), founded in 1867 by Daniel Bliss, an American missionary. At the turn of the twentieth century some FFM physicians expressed the intention of opening a maternity ward, after having successfully started a gynaecological clinic within the Sacre-Coeur hospital. The promoters of this project held an extensive discussion on the problem of attracting local women who disliked the hospital, and usually relied on the services of dayas.37 The French physi­ cians considered dayas as dirty and ignorant women whose practices

were to be discarded in the name of hygiene, science and the medical profession, and obviously because they were their main competitors. Another important argument used by the French clinicians to justify the necessity of opening a maternity ward was that Western medicine was ‘a weapon against taboos and a tool to break mental padlocks’ (Bourmaud 2007: 356, my translation). Western male-dominated medicine was thus consciously presented as a ‘science of transgression’, which was to help in bringing about a profound transformation of the local culture, and particularly women’s behaviour; as has already been stressed, this represented a typical motif of the colonial discourse. That biomedicine in various ways infringed social norms in several colonised societies, emerges clearly from the accounts of David Arnold on India and of Eugene Rogan on Transjordan. Arnold (1993) shows that in India the practice of Western medicine encountered important obstacles insofar as it was at odds with several social and religious rules of the local society. For instance, childbirth was conceived of as a highly polluting process, and local birth attendants or days were women belonging to a very low caste whose task was to deal with polluting substances. As a conse­ quence, it proved extremely difficult to turn maternal and infant welfare clinics and maternity wards into attractive places that Indian women of middle and high status would have liked to attend. In Transjordan the violation of social norms entailed in the Western practice of medi­ cine was at the origin of the difficult relationships between physicians working for the CMS clinic of Salt and the local population. Indeed as Eugene Rogan points out: By its methods of examination, Western medical practice violated norms separating the public and private spheres. The doctors made house calls, and examined men and women alike, behind closed doors. And they were bachelors. Little wonder that their activities provoked a lurid fascination (1999: 178). The three doctors who worked at the mission in Salt between 1883 and 1905 were unmarried Syrian men who had received their training at the Syrian Protestant College in Beirut. Two of them, Drs Ibrhaim Zourab and Elias Saba, who worked in Salt in the years 1883-85 and 1885-89 respectively, were dismissed or forced to leave after they were accused of violating moral norms. Dr Zourab was accused of ‘immorality’, and Dr Saba o f‘sodomy and dishonesty’ for ‘sharing his room with his servant boy’ (Rogan 1999: 179).

Voyeurism, intimacy, and women’s education The idea that Western medicine could contribute to eradicating ‘irra­ tional’ and ‘oppressive’ social norms was consistent with the colonial voyeurism of the Western administrators (Said 1978). If medicine was a colonial device of surveillance and control, obstetrics and gynaecology were to allow the penetration of the Western administrative gaze into the most private sphere of the colonised life (Arnold 1993; Vaughan 1991). In other words, entering the world of women was conceived of as equivalent to penetrating into the more intimate domain of the colonised society, since according to the Western ideology of the time ‘women represent a society’s true nature and worth’ (Arnold 1993: 126). Therefore, in south­ east Asia and the Near East as well as in Africa, many Christian missions were established with the aim of thus penetrating into the women’s sphere. Female spaces and women’s social and intimate behaviour became the target of religious agents and colonial officers in India, Malaya and Uganda, as well as in Palestine and Transjordan. Education and health constituted the principal domains on which the actions of missionaries, and later of colonial administrators, were focused. In this sense, medicine played a pivotal role, as it allowed the modelling of the colonial discourses and practices on the basis of scientific and technical arguments. Western ideas of hygiene, health and education were to be introduced into the local feminine space, seen as dominated by darkness, dirt, disease and igno­ rance. Those features embodied by one category of individuals, women, were emblematic of the whole society’s inferiority. The colonisers’ access to the women’s sphere brought about their penetration into the field of reproduction. Childbirth and child-rearing practice were the two main areas to be reformed: mothers as well as tradi­ tional midwives had to be educated, and their habits transformed. In India, Uganda, the Belgian Congo and Malaya, as well as in Palestine, schools for training midwives were established in order ‘to convert them to Western ideas and techniques’ (Arnold 1993: 259). Although the final aim of the European administrators was to abolish local practices altogether, the colonial and missionary initiatives usually attempted to co-opt, and hence to control, rather then eradicate local lay midwives. Missionaries and colonial medical officers instituted maternal and infant welfare centres with the goal of teaching women ‘the “art” of child-rearing, cleanliness, and hygiene, and to struggle against harmful “errors and prejudices’” (Hunt 1997: 288). Women, whether midwives or mothers, had thus to go through an educational programme that was to change not only their attitude towards the physical environment but also their

perception of the body and more broadly their ideas about the family (Hunt 1997; Summers 1991; Ali 2002a; Inhorn 1994). Women had to internalise new norms about marital and sexual relationships, new rules about child-rearing and education, and new ideas about their social role as good mothers, good wives and good citizens. Furthermore, they were urged to shift from an indigenous patriarchal definition of their social role to an exogenous model characterised by a ‘Western-style male domi­ nance’ (Ahmed 1991: 162). Despite the European call for the liberation of oppressed non-Western women, the colonisers’ educational project for indigenous women was aimed at submitting them to a more familiar model of male domination, in which the women were to be instructed in order to become good wives and good mothers rather than to emancipate them from the yoke of a patriarchal society. As a result, colonial medicine was entangled within a complex arena where the imperial competition between the Western powers, the missionaries’ ambitions to convert nonChristian populations, and the economic and political plans for exploiting the colonised labour force were all intertwined.38 The gendered nature of colonial medicine is another crucial feature worth mentioning. On the one hand, women were held responsible for reproduction and thus became the main object of blame and reform. The ethnocentric view of women’s central role in reproduction shaped the colo­ nisers’ health policies, and as a consequence the role of men in decisions on family matters was completely ignored.39 On the other hand, colonial administrators paid very little attention to women until the last decades of the nineteenth century, when demographic preoccupations arose in the European countries. The rising concern at the decreasing birthrate caused the emergence of a debate about children’s and women’s health in Europe as well as in the colonies. New policies were planned and implemented in order to increase the birthrate, and with it the health of children and mothers. Yet, as mentioned above, in the colonies more effort was put into military medicine rather than in maternal and infant care, which was often left to the voluntary work of missionaries and European women of the colonial elite. The wives of colonial officers,40 as well as physicians, nurses, and midwives working for the missionary societies, were mainly responsible for the health of women and children. Moreover, when they did decide to take action, colonial authorities did not attempt to improve the socio-economic situations of the population but focused on mothers’ education. Thus policy faithfully reflected the attitude of the British state (as mentioned above) in the field of reproduction, which held working-class mothers responsible for the well-being of the new generations.

Taming the wild: imposing medical surveillance over colonised women As stated above, the high infant mortality rate was a primary concern for the European states at the turn of the twentieth century in the metro­ politan countries as well as in their colonies (Koven and Michel 1993). By 1918 the registration of births and deaths had already been made compul­ sory in Palestine and Transjordan, in order to control the reproductive trends among the local population. In the administrative reports on Palestine and Transjordan produced for the League of the Nations, as well as in the Annual Reports of the Palestine and Transjordan Departments of Health, a section was devoted to demo­ graphic data: birthrate, mortality rate, infant and maternal mortality rate, and morbidity were carefully registered. A high infant mortality rate was a constant preoccupation for the colonial authorities, and in several reports the British administrators attempted to identify its main causes. In order to improve the conditions of mothers and children, great emphasis was placed on the services of maternal and infant welfare clinics, as well as on the educa­ tion of dayas and mothers. From the beginning of the 1920s, the British authorities tried to control the activities of local ‘untrained midwives’, in exactly the same way as they did in Britain. From 1922 onwards, dayas in Palestine were given courses at the government hospital in Jerusalem, and later in other centres around the country. This was aimed at creating an efficient system of surveillance over the work of Arab handywomen. In one of the official reports of the time the policies of the Department of Health are clearly expressed: unqualified midwives are given lectures by Medical Officers each year when their permits are renewed, and emphasis is laid on simple rules for their work. The standard equipment which they are required to maintain is subject to periodic inspection. In two Centres their work is under close supervision of Super­ intendents of Midwifery, and in 1933 two further appointments of this nature will be made to extend the work of superintendence of dayas in other parts of the country (PTJAR 1933: 138). In a previous report, there was a more detailed passage about the content of the instruction imparted to dayas, in which was indicated that ‘they receive instruction in general procedure and cleanliness and their work is subject to inspection and periodical review’ (PTJAR 1931: 665). While in Transjordan there were no training centres for midwives, a report

of 1928 states that ‘dayas were receiving from time to time a course of simple lectures by the Medical Officers of Health’ (DOHJT Annual Report 1928). As I will show in the following chapter, the instruction and supervision of dayas was to become an enduring policy of the local health authorities, lasting until the 1980s. Regulations issued by the colonial government established ‘their duties to mother and child, medication they were permitted to dispense, limitations and functions, situations calling for doctor intervention, and notifications required for the medical officer in her district’ (Young 1997: 104). In addition to dayas, the British considered the mothers responsible for the high infant mortality rate in Transjordan, British officers accusing local women of ignoring appropriate methods of dressing and feeding their chil­ dren. However, they had to acknowledge that, since the population was very poor, mothers had to go to work, often leaving the newborn child with a little sister who in reality was too young to take care of a younger sibling (PTJAR 1933). According to British medical officers, the other causes of the high infant mortality were very limited resistance to infectious diseases in the poorest areas, and impure water (PTJAR 1934; Young 1997). It is striking that in Transjordan and Palestine, as well as in Britain, socio­ economic circumstances were not identified as the main factors deter­ mining infant mortality. Arab mothers, like their working-class sisters in Britain, were considered as the primary objects of reform.41 As expressed by Mrs E. Cotching, MD, in charge of the Haifa Infant Welfare Association’s Centre, Palestinian mothers were ‘mere children’ whom it was therefore necessary to teach ‘not only how to prevent their children dying, but how to keep them healthy and well, free from such diseases as diarrhoea; how to preserve their eyesight and how to save them unnecessary suffering’ (quoted in Young 1997: 99). Obviously, the great majority of Western prac­ titioners either ignored local healing treatments or considered them cruel, barbarous and useless. Mrs Lampitt, who worked in 1928 and 1929 at the maternal and infant welfare centre in Salt, gives a significant description of the activities at the clinic: The work at this Centre was commenced in January 1928, by Miss E. Lester, in a room on the Jedda Hill, at first only 2 or 3 mothers could be persuaded to attend, and were afraid of evil happening to their children if they were weighed,42 but by the end of May there were 8 or more attendances each afternoon twice a week, and some of the homes were visited. Simple teaching was given and before Miss Lester left for England the mothers were

questioned as to their knowledge and a prize given for the best answers, also for the cleanest baby (quoted in Young 1997: 101). As we can see, mothers were turned into children to be educated by European medical personnel who considered themselves as possessing superior knowledge: the mothers could be rewarded with prizes if they proved that they had learned the lesson. This practice was common also in Palestine and in many other colonies, where mothers were encour­ aged in various ways to attend classes and adopt new, ‘appropriate’ habits (Summers 1991; Van Tol 2007; Young 1997). Owing to the British atti­ tude of superiority, it is not surprising that at the beginning local women manifested a diffident attitude and were not so eager to attend the new clinics. It also needs to be taken into consideration that during Ottoman times local healers, dayas and sheikhs were almost the only practitioners in Transjordan, since both Ottoman and Western medicine were late in penetrating into the country (Rogan 1999; MOH Annual Report 1957; Abu Nowar 1990). Yet, as noted above, Transjordanian and Palestinian women soon started to appreciate the available maternal and infant welfare centres, which registered a constantly increasing number of attendances.

Building government maternal and child health services in the 1950 s If in Palestine by the end of the 1920s there were already antenatal clinics all over the country, as noted by Shepherd, the situation of infant and maternal welfare centres in Jordan was much less encouraging, and did not improve significantly until after independence. The first official Annual Report of the new Ministry of Health (created in 1950),43 which covered the years 1951—57, states that during this period only 11 MCH centres were functioning in the Kingdom and all of them were located in the West Bank. They were the clinics inherited from the colonial period, which were now run by the MOH. A project to build 11 new MCH centres in the East Bank was immediately set up, and implemented in 1958.44 By the mid-1950s the first government MCH centre was about to be completed in Amman within the newly established government hospital for children, located in Jabal Ashrafiyya.45 The project, started in 1955, was funded chiefly by the Jordanian MOH, but received the technical aid of the United Nations Children’s Emergency Fund (UNICEF), and of the World Health Organisation (WHO). UNICEF provided equipment, cars, medicines, powdered milk, vitamins and soap, whereas WHO provided the experts - physicians, nurses and midwives - supervising the centre. In 1953,

these two international organisations, together with the Lutheran World Federation, were also responsible for the opening of a training school for nurses and midwives at the Augusta Victoria hospital in Jerusalem (Bahis and Matuk 1996). In 1951, UNICEF and WHO supported the founda­ tion of another training school for nurses and midwives in Amman (Sultan 1998). This was established together with the Amman MCH centre within the paediatric hospital mentioned above (Risalat al-Urdun 1959). By 1959, 60 Jordanian midwives had already successfully completed their training in the school, and started work in the rapidly expanding public health structures. The fundamental aims of the MCH centre in Amman were ‘to protect women during pregnancy and the breastfeeding period, and to take care of children until the age of six’ (Risalat al-Urdun 1959: 54, my translation). The personnel had to carry out the medical examination of mothers and children, to offer counselling and to distribute vitamins, milk and soap. The MCH centre was also to supervise home deliveries and to follow up women and babies after birth for a period of ten days. Its mission and its principles were very similar to those enunciated by colonial officers in order to justify their policies towards women and children. There was thus a substantial continuity between the two periods, although the independent government was able to realise the objectives that the colonial rulers had very partially accomplished. The Amman centre was also given other tasks, such as organising MCH services in the Kingdom, appointing staff, laying down the standards and rules and arrange courses for personnel (MOH Annual Report 1951-57). By 1959 the number of MCH centres in Jordan had reached 28, and there was an ‘intention of building hundreds of MCH centres so that all citi­ zens of the Kingdom would benefit from them’ (Risalat al-Urdun 1959: 55, my translation). The development of the MCH services in Jordan from independence until the present day is the accomplishment of government officials’ expectations. If in 1955 only one MCH clinic existed in the region east of the Jordan, by 2008 the Kingdom had 419 MCH centres located throughout the country, as I will discuss below. However, by the end of the 1950s the great majority of the population did not yet use the MCH services, as shown by the fact that in 1956 only five home deliveries46 were assisted by MCH midwives; in 1957 there were 168, while pregnant women registered in government clinics numbered 1,532 in 1955 and 4,471 in 1957. Despite low attendance, these figures show an important increase in the number of cases treated between 1955 and 1957. For example, the number of registered pregnant women had

more than doubled in two years. This means that Jordanian women were not averse to medical treatment and were ready to embrace new practices, despite the fact that they were embedded in new forms of state control. Indeed, not only did they not openly oppose the new official policies aimed at monitoring reproduction and spreading ‘health education’ among the Kingdoms female citizens, but they were eager to use the new services, as the MOH statistics of the following decades clearly indicate. Starting from the 1950s, the MOH placed a strong emphasis on expanding services, and at the same time on enhancing health consciousness and education among Jordanian women. Yet before educating its citizens, the Jordanian state had to train the educators, who were to be sent to Western countries to assimilate the new ideas and principles constituting the basis of the emerging public health system. As indicated in the Annual Report of 1951-57, in the 1950s several members of the MOH were sent to Britain and the United States in order to attend courses in the domain of health education and several other medical fields. For example, in 1951 Nabiha al-Wirr, who became the first director of the School for midwifery in Amman, was sent to Britain for a year in order to become a midwifery instructor (Sultan 1998). Several Jordanian midwives, nurses and physicians were able to complete their education in Europe or in the United States thanks to the scholarships accorded by international institutions such as the Red Cross, UNICEF and WHO. Furthermore, it has to be noted that after 1950, the majority of the projects in the health field were implemented either in collaboration with the ‘American mission’ - within the ‘Point Four Program’47 - or with UN international agencies. The American mission48 funded the construction in 1955 of the new school for nursing and midwifery in Amman (mentioned above), and helped in setting up its administrative structure and educational organisa­ tion. It also provided several scholarships for Jordanian physicians, nurses and midwives to complete their training in the United States. In the 1950s and 1960s the school’s training course was of two years (22 months), and many of its teachers were non-Jordanians: there were eight permanent teachers, and six physicians who taught classes on specific topics (MOH Annual Report 1951-57). Most teachers were sent by UNICEF and WHO, and either Western or Arab. The Jordanian teachers were few in number: Dr Nivin al-Tutunji, the nurse-midwives Nabiha al-Wirr, Jeanne al-Mufti and Fadwa Mansur Kuru, and several prominent Jordanian physicians who gave regular lectures in the school such as Ghalib Qsus and Muawiya al-Khalidi (Sultan 1998).

In the Annual Report for the years 1960-69, the educational aspect of the MOH policies emerges even more clearly than in the previous reports. Women were the major target of these policies, which were meant to instruct mothers about how to care for their children, how to feed them, how to wash them, how to keep their home clean, etc. In order to apply the new health directives, milk, vitamins and soap were distributed in the MHC centres. New educational tools were developed in order to reach the greatest number of women: short films, lectures, photographs, etc. If the women did not attend the centres, at least some of them were reached through a vast programme of home visits. Nurses and midwives visited women’s houses to check on their health and that of their children, and on their housing conditions. According to the MOH reports, Jordanian women were totally ignorant of the proper way of rearing children and taking care of the house. They had equally to be educated about how to prepare the house before a birth, how to dress when about to go into labour, etc. The authorities’ attitude was paradoxically very similar to that of the colonial administrators some years earlier. In the 1950s and 1960s, Jordanian women were deemed ignorant and dirty, and as a consequence had to be educated in order to make them abandon their useless knowledge and harmful habits as well as to acquire proper notions of health. However, as in Europe in the first decades of the twentieth century, women were represented as responsible for the upbringing and education of the future generation of citizens. Given that they were deemed the guardians of the family and the nation’s source of reproduction, they had to be educated in order to build the future of the community. As a result, both the colonial and the postcolonial health authorities focused on women as the category of citizens that could and should be educated. Thus, an early report argues that ‘given that women are the pillars of the society, their progress will bring the progress of the whole society’ (MOH Annual Report 1958-65: 110, my translation).

Hie bureaucratisation of women’s health The Annual Reports of the MOH continued to focus on women’s educa­ tion throughout the 1970s and 1980s, and into the first years of the 1990s. Towards the end of the century, however, the emphasis on women’s health education began to decline, and by the 2000s almost disappeared. Indeed, until the end of the 1990s the statistics of the MOH carefully indicate the number of pregnant women registered in the MCH centres, the number of children under the age of six, the number of lectures and films attended by the women, and the number of home visits and home deliveries. The

MOH reports pay also careful attention to the specificities of the services provided in each area of the Kingdom, making the administrative picture more and more precise. For example, in 1969 there were six health depart­ ments, corresponding to the areas of Amman, Zarqa, Balqa, Irbid, Karak and Maan. Statistical data on MCH services was indicated for every district, to show the differences and hence the specificities of each. There were a total of 95,618 pregnant women registered at the government MCH centres, 3,528 attendances at home deliveries, 12,432 home visits during confinement and 8,723 other home visits; in addition, 5,969 lectures were given (MOH Annual Report I960—69). While by the end of the 1960s the Kingdom could boast 52 MCH centres, the 22 clinics located in the West Bank were lost in 1967, when Israeli forces occupied the area. The MOH continued to administer the 30 clinics in the eastern part of the country that had been constructed over the previous 20 years. It is worth noting that the MOH had developed many more health facilities in the area east of the Jordan, as more than half of the hospitals, MCH centres and dispensaries were built in the Transjordanian territory. The reason for this was two-fold: on the one hand, at the end of the Mandate in the West Bank there were a good number of health facilities compared to those existing in Transjordan, and on the other the Jordanian government privileged investment in the eastern part of the Kingdom (Katz 2005; Maffi 2004). For example, between 1955 and 1967 the MOH established 30 MCH centres east of the Jordan and 22 new clinics in the West Bank territory. After the Israeli occupation of the latter area, the number of MCH centres and hospitals in the Kingdom decreased dramatically: while in 1965 there were 28 government hospitals and 31 private hospitals, 27 of them were lost, of which 10 were government and 17 private. To sum up, in the second half of the 1950s, the Jordanian health system underwent a process of increasing bureaucracy and complexity. The state developed a system of welfare and started to provide health education and facilities for the whole population. The growing number of services, personnel and local facilities, as well as the increasing financial investment in the public health sector, led to a cultural transformation in the social and cultural representation of health. The modern health system was at the origin of the dissemination of new notions of health, body and self. The idea that the state was responsible for public health was consolidated, and new concepts of individual responsibility began to penetrate the local culture. Substantial efforts were put into transforming ‘the aware­ ness of individuals in such a way that they become more self-regulating

and productive both in serving their own interests and those of society’ (Petersen and Lupton 1996: 12). It is not a coincidence that in the MOH Annual Report of 1958-65, in the section about maternal and child health, two new concepts are mentioned: sahha ‘a mma (public health) and sahha fardiyya (individual health). As it had in Western countries, the new view of public health - in which are embedded neo-liberal ideas about the ‘entre­ preneurial ethos’ of the individual —started to make inroads into Jordanian society. A new system of power emerged, since the new notion of public health ‘is, if nothing else, a set of discourses focusing on bodies, and on the regulation of the ways in which those bodies interact within particular arrangements of time and space’ (ibid: 11). Indeed, as will be shown in the following chapters, Jordanian women developed new ideas about their role within the family, new conceptions of their body, and a new sense of responsibility for their health and that of their family members (Ali 2002a; Inhorn 1994, 1996). The bureaucratisation of the health sector brought about the elabora­ tion of new regulations that were conceived of and implemented in order to standardise the behaviour of health-service users as well as that of its providers. If we look at the MOH Annual Reports of the 1950s and 1960s, there is a clear trend towards the definition of increasingly precise direc­ tives aimed at regulating women’s and children’s life as well as that of the medical professionals. Women’s and children’s habits had to conform to a rigid schedule deter­ mining the frequency of their visits to the MCH clinics and the type of treatment they had to undergo. For instance, pregnant women were supposed to come once a month until the seventh month, every three weeks in the seventh month, twice a month in the eighth month, and every week during the last month. According to the new rules, 40 days after her confinement, the mother had to go to the nearest MCH centre and register her child for regular monthly weighing and vaccinations. At the same time she would receive instruction on how to feed the baby and how to take care of him/her in the appropriate way. While during the baby’s first year they had to visit the centre every month, during the second year such visits were scheduled every two months, and then only once a year. Among the new rules there were also those for the medical personnel. If we consider the regulations pertaining to the work of midwives, among the duties of those in charge of the MCH clinics was instructing women about home deliveries, attending them, and visiting them before and after birth (MOH Annual Report 1958-65). For example, in the late 1950s it was decided that midwives had to visit the women who had just given

birth twice a day during the first three days, and then once a day until the tenth day. They were to ascertain the health status of mother and child, to give a bath to both of them, and if they noticed any abnormal condition in the mother or child, to report it to the physician. Thus the new directives attributed the midwife the role of mediator between the women and the physicians in charge of maternity services. They had to monitor the health condition of the women during pregnancy and confinement, and that of their children and refer difficult cases to the MCH clinics or to the hospitals. Until the beginning of the 1980s home births were the norm, and hospital deliveries still a minority. However, this did not mean that qualified midwives supervised the birth of all children, because during the first decades after independence dayas still attended the majority of deliveries, especially among rural communities and the urban poor. Qualified midwives working for the MOH attended only a small number of births, as shown by the figures in the MOH annual reports: they have never exceeded 6,000 per year. In the 1980s and 1990s, the number of home deliveries assisted by MCH personnel were carefully indicated, with special attention paid to their geographical distribution. Interestingly enough, the majority of the registered home deliveries occurred in East Amman, in the northern region and in the Jordan Valley (al-Ghawr), where there were greater numbers of MCH centres. In the south, home deliveries attended by MCH staff were few. While in the majority of the areas officially registered home deliveries decreased rapidly, in the 1990s in some regions they increased, such as in the districts of Tafilah and Irbid, probably because dayas were being replaced by qualified midwives - by the mid-1990s the last generation of dayas was gradually disappearing (Young 1997). During the postcolonial period in particular, midwives thus became crucial figures linking the medical establishment to the local society (Young 1997). They controlled the women, and were themselves under the control of the physicians in charge of the health district. The hierarchical relationship was clear, shaped according to the medical model that started to develop in European countries at the end of the eighteenth century, when midwives had to submit to the control of the medical class and relin­ quish their autonomy. Midwives were also key figures in conveying the new concepts of health, self and society embedded in the new organisation of the health system. This was explicitly acknowledged by the Jordanian authorities, for midwives played a crucial role in monitoring the health of mothers and children, as well as in increasing the level of health education among Jordanian women generally (MOH Annual Report 1958-65).

Midwives and nurses were also responsible for giving regular lectures and showing films and photographs to the women attending the MCH centres. In the 1950s and 1960s the lectures given there focused on caring for the baby and on the health of pregnant women. Physicians did not play an important role at the time because they were still very few in the country, and their task was mainly one of supervising midwives’ and nurses’ activities and handling more complex cases. Indeed, in 1965 - before the Israeli occu­ pation of the West Bank - the total number of physicians in the Kingdom was 420 and that of midwives 280 - serving a total population of 1,000,000 people. During this period, low salaries persuaded medical and paramedical personnel to leave the country for work in the Gulf states or Saudi Arabia, where there was a serious shortage of such personnel, and the rewards were much higher. This migratory movement continued for several decades, and was not restricted to physicians but also involved nurses and midwives (MOH Annual Report 1958-65; Longuenesse 1995). While the shortage of midwives and nurses appears as a constant feature of postcolonial Jordan (Abushaikha 2006; Curmi 1993), a tremendous increase in the number of physicians since the end of the 1970s has contributed to the development of a public health system of relatively good quality (Curmi 1993; Oweis 2005; WHO-Emro 2004), and to a flourishing private medical sector, as will be illustrated below. Thus, in 1964 the MOH was able to appoint a physician to each MCH clinic in the various health districts of the Kingdom (MOH Annual Report 1964). In addition, in that year, the MOH launched a new programme for educating the dayas practising in areas where there was an MCH centre. Regular courses were organised to improve their knowledge of the protection of pregnant women and children’, since the MOH Annual Report of 1964 continued to complain about the fact that the great majority of deliveries were still being attended by dayas. In 1965 1,290 dayas were given lectures in the MCH clinics (MOH Annual Report 1958-65). By 1977, there were 51 MCH clinics in the Kingdom, ten of which were established in that year. In addition, there were 10 MCH centres run by UNWRA for the women and children living in Jordan and officially-registered as refugees.

From health education to family planning The expansion of the health sector, the very rapid increase in the number of physicians and hospitals has had very important consequences for local society, including in the field of reproduction. Pregnancy and birth have become medical events that are controlled by the state through its health institutions. The concern of the state for the control of the population has merged with the interests of the physicians who, as in many other countries,

have progressively gained a monopoly in the field of reproduction (Arney 1982; Ehrenreich and English 1973; Gelis 1988; Knibiehler 2007; Martin 1987). Today, Jordanian medical institutions take a pathological view of pregnancy, birth and the post-partum period, which have consequently to be subject to continuous medical scrutiny. Since the dominant cultural view of the reproductive event is that it is dangerous, most Jordanian women are persuaded that careful medical surveillance is necessary if their baby is to be healthy. Despite several social and cultural differences in their ideas and attitudes, no women now wish to give birth at home, and almost all seek antenatal care during pregnancy. According to the official reports of MOH, by the end of the 1990s more than 90 per cent of women gave birth assisted by a qualified care-provider and in a health facility. If until the 1990s the state control of reproduction was not explicitly aimed at limiting the number of births, during the last two decades things have started to change. Difficult economic circumstances, regional polit­ ical instability and international pressure have persuaded the Jordanian monarchy to change its previous laissez-faire policy and to take active measures in the domain of reproduction. Although the authorities have taken several initiatives to lower the high fertility rate, as de Bel-Air (2003) persuasively argues, important transformations were already taking place among the local population. Indeed, fertility had already been decreasing for several years before the Jordanian authorities began official interven­ tions in the domain of reproduction.49 It is possible to say that after the state decided to implement policies of birth control, the content of womens education has changed. While until the end of the 1980s the explicit goal of the MOH courses was to provide education about general health, hygiene, nutrition and child care, later they began to focus on family plan­ ning methods and spacing between pregnancies. Jordanian women were now openly exposed to new ideas that included not only Western concepts of health and all the related notions discussed above, but also new concepts of sexuality, reproduction and self-realisation. One of the main instigators of this educational shift was the United Nations Population Fund (UNFPA), which began its activities in Jordan in 1975. Long before the Jordanian state began to follow active policies in the field of reproduction, this agency introduced the first elements of change into the government sector. In 1977, the sum of $750,000 was allocated for the construction of six new MCH centres each year over a period of three years. However, UNFPA did not offer this sum of money without imposing some conditions: it asked the Jordanian authorities to estab­ lish a family planning service. Until 1977, in the area east of the Jordan

there were no government family planning service, and the state had never encouraged birth control among the population, despite the high fertility rate registered in the Kingdom (De Bel-Air 2003). Only the Jordanian Association for Family Planning and Protection (JAFPP), an NGO related to the International Federation for Planned Parenthood (IPPF),50 had been active in the West Bank since 1964, when the Jordanian mufti had allowed the use of contraception (ibid: 289). However, the JAFPP was not allowed to establish its clinics east of the Jordan until 1972. The UNFPA project provided also for the improvement of the existing MCH services through a new programme of health education for mothers and of health inspections, as well as through the introduction of new administrative regulations. Yet, interestingly enough, the MOH reports contained no data at all about family planning until the 1988 Annual Report, which included one page of figures on the use of contraceptive methods in the Kingdom. The UNFPA project implied also the organisation of several courses for physicians, midwives and nurses working in the MCH centres, with the aim of improving their scientific knowledge and technical skills, and provided a number of scholarships for additional training in various Western coun­ tries.51 At the same time, an internationally funded nutritional programme provided MCH clinics with milk to be distributed to children between the ages of six months and six years all over the country, and with olive oil for pregnant or sick women. Thus by the end of the 1970s the network of MCH centres offered an important number of services: antenatal and postnatal care, home visits, home deliveries, medical examinations for mothers and children, vaccinations, health education and nutritional aid. While these services were offered free to the female population, men the husbands and fathers of the women and children attending the MCH centres - were left out of consideration. Indeed, until the end of the twen­ tieth century, both the Jordanian authorities and international agencies almost completely ignored adult male Jordanian citizens, as the following chapters will show.52 During the 1970s, meanwhile, the number of women and children registered in the MCH centres rose steadily: in 1972 42,722 pregnant women underwent at least one examination, in 1974 53,748 and in 1977 55,922, while the total population had reached 2,000,000 people. Over the same period, the number of women attending health education lectures rose from 125,476 to 202,260, and the number of home visits from 8,854 to 26,213 (MOH Annual Report, 1977). Despite the expansion of the MCH network, however, the majority of women and children were still not using the government services and private facilities were accessible only to a small fortunate minority. By 1977,

the number of obstetricians working in the government and private sectors was still very restricted: 19 in the former and 39 in the latter. Midwives were much more present in the public facilities, since they were responsible for several services in the MCH clinics and attended the uncomplicated or ‘normal’ deliveries in the government hospitals. Indeed, in 1977, the MOH employed 144 midwives: 67 worked in the government hospitals and 21 in the RMS. There were only 42 in the private sector, since here the obstetricians provided the antenatal care and attended the deliveries. By 1980, the number of midwives working for the MOH had reached 153, but there were still no more than 49 in the private sector. Since the mid-1960s, midwives had mainly been employed in the government sector, where as we have seen they played a major role in providing health services to women and children. Indeed, several of them worked in the central directorate of the MOH, where they were in charge of the administration and coordi­ nation of all the MCH centres in the Kingdom. As for obstetricians, in 1980 their number in the MOH had risen to 29, while there were 71 in the private sector. By the same year there were 80 MCH centres in Jordan, most of them located in Amman and in the northern urban areas, as shown in table 3.

From home births to hospital deliveries: the emergence of new practices As mentioned above, officially registered home deliveries were never very numerous, and their number started to decline during the 1990s. By the end of the century, the attention focused on home deliveries that was a constant feature of the MOH reports in the 1980s had disappeared. It is likely that in the 1970s and 1980s, most women were still being assisted by dayas, and it was only in the following decade that they began to give birth in hospital. Hence, the shift that occurred was not from home births attended by dayas to home deliveries attended by qualified midwives, but from home to hospital deliveries. For instance, in 1980, there were 2,508 registered home births, against 48,933 in private and government hospitals. Almost a third of the hospital deliveries took place in the private sector. It is worth noting here that the difference between giving birth in the private and in the government sector did not and does not constitute simply a class divide, but also a cultural split in the field of medical practice. The private sector provides a more technocratic and highly medicalised model of peri­ natal care, whereas the public sector offers a ‘low-tech’, less pathological model (Davis-Floyd 1992; Jordan 1993). The consequence of this double medical culture is that in the private hospitals physicians are considered

Table 3 Evolution of Officially Registered Home Deliveries by Region, 1990-1994 Health district

Amman East Amman Madaba Zarqa Balqa Central Jordan Valley Deir Alla Northern Jordan Valley Ajloun Kura Ramtha Jerash Bani Kananah Mafraq Karak Tafilah Irbid Ma‘an Aqaba

Home deliveries 1991

1993

173*

52 107 138 111 26 14 627 13 18 473 145 13 16 36 55 123 194 155 15

-

229 96 15 730* -

13 59 801 189 22 114 38 23 171 183 12

Source: MOH Annual Reports 1991, 1993, 1994. Note:

*These areas were transformed into separate districts in the 1990s. In 1991 they were still part o f a greater district, respectively East Amman was part o f Amman district, and Deir A lla was part o f the Central Jordan Valley.

legitimate birth attendants, while in the government sector midwives attend the majority of births.53 Although this division of labour dates back to the first years of independence, the different status of midwives in the private and government sectors became very evident at the beginning of the 1980s, when the development of the former accelerated thanks to the increasing number of physicians in the Kingdom. Obviously, the divi­ sion of labour between midwives and physicians in the two sectors is less a question of competence, knowledge or skills than of economic benefits. As midwives are classified as paramedical personnel, and thus occupy an

inferior hierarchical position in a health system dominated by physicians, in the private sector, they are not allowed to play the main role in the birth event. The system being dominated by economic logic, the status of physicians is directly related to the services they offer to their patients (or clients) and to the individual relationships they establish with them. They will therefore tend to appropriate all the health-care domains they can, including those of other practitioners, where they will be paid for their services. To examine the case of private obstetrical care, although midwives have the necessary knowledge and skill to provide antenatal and postnatal care and to attend the delivery, if the pregnancy and birth remain within physiology, they are completely marginalised. They play a minor role and are treated as mere assistants to the physicians. However, as will be shown in the next chapter, in several private hospitals midwives do most of the work during the delivery and sometimes they are even left in charges if the obstetrician is absent; but the importance of their work notwithstanding, the obstetricians receive the merit and the economic benefits. The patients are their clients, e.g. they pay the doctors to take care of them and of their babies, and midwives are perceived as ancillary practitioners executing basically unimportant tasks. Furthermore —in Jordan as in many other countries - midwives are paid less than doctors for providing essentially the same service, since they do not enjoy the social and cultural authority of the physicians (Davis-Floyd and Sargent 1997). They do not possess the ‘authoritative knowledge’ normally attributed to doctors, and also tend to belong to lower social strata (Jordan 1991). The marginal position of midwives in the high-tech model of perinatal care is at the origin of their small numbers in the private hospitals, as the following figures illustrate. While in 1995 there were 631 in government facilities and 213 in the private sector, in 1999 the corresponding figures were 75954 and 313. By 2003, the difference between the two sectors had increased further: while the MOH employed 893 midwives, the RMS 69 and the KAUH 16, only 498 midwives worked in the private sector. On the contrary, in the government sector, where the salary is inde­ pendent of individual relationships with patients and of the specific services provided, the division of labour in the obstetrical domain is very different. Here, the physicians are responsible for complicated cases that cannot be dealt with by midwives. Consequently, the latter do the bulk of the work in the labour and delivery units, where only a small contingent of resident obstetricians are present. Resident obstetricians who are hierar­ chically inferior to their senior colleagues have usually a minor role such as repairing episiotomies or tears, prescribing analgesics or medication for

inducing and accelerating labour.55 They very seldom intervene in cases of serious problems, because patients are usually referred to another unit of the hospital, where obstetricians are in charge. In fact, midwives are responsible for the labour and delivery rooms, which in some hospitals are completely separated from the area of the surgical theatres where caesarean sections and other operations are carried out. Finally, in addition to the rapid move towards the hospitalisation of birth, another important feature of the natal system in Jordan concerns the marked preference among Jordanian citizens for the private sector, evident since the end of the 1970s. Two phenomena confirm this trend: on the one hand, the establishment in various parts of the country of a substantial number of private hospitals specialising in obstetrics and gynaecology; and on the other, the proliferation of private obstetricians that derives from the already well-established practice of consulting a private physician for ante­ natal care. In recent decades, antenatal care has become a very lucrative business because, although the majority of women give birth in govern­ ment hospitals, they usually prefer the private sector for antenatal care. This was confirmed by most of the women I met (during the research on which this book is based), even including those belonging to the poorest social strata.56

Hie postcolonial health system: the development of the private and government sectors Before concluding this chapter, I would like to trace a rapid story of the health sector in Jordan in the postcolonial period. I think it is important to understand its evolution because the medicalisation of procreation can not be separated from the larger process, which has caused the imposition of a bureaucratic medical gaze over all spheres of the social life. Hence, the modern evolution of the natal system is but an aspect, though an important one, of the general medicalisation of the Jordanian society orchestrated by the state and supported by a powerful medical establishment. Since the 1950s, there has been a progressive development in Jordan of both the private and public health sectors. The latter sector is divided between two bodies: the Ministry of Health and the Royal Medical Services. In order to illustrate the remarkable expansion of the Jordanian health system in the postcolonial period, I will refer to the data of the MOH annual reports. If we look at the number of hospital facilities, in 1965 in the East Bank there were 18 public hospitals, two of which belonged to the Royal Medical Services,57while there were 14 private hospitals. The number of physicians in the government sector rose from 100 to 176 between 1959

and 1965, whereas the corresponding figures for the private sector were 165 and 244. By the end of that period, there were 27 female physicians in the country. The figures of the MOH reports of the time indicate that both the private and the public sector were growing, although the former was still dominant in terms of hospital facilities and staff. However, the government sector was expanding at a rapid pace and by the beginning of the 1970s had become the main provider of health services, while the private sector had lost its previously dominant position.58 As for qualified midwives, most were working in the private sector until the mid-1960s when their number in government institutions saw a remarkable increase. This was due to the necessity of staffing the growing number of government hospitals and MCH centres established during those years. Indeed, by 1977 the govern­ ment hospitals had 2,833 beds - 1,749 MOH and 1,084 RMS - and the private sector 647. The majority of the facilities were located in Amman and in the urban areas in the northern part of the Kingdom. The relatively high density of hospitals in the northern region is a constant feature of Jordanian medical geography, mirroring the distribution of the popula­ tion, which is concentrated in this part of the country. In 1970, the first Faculty of Medicine was opened at the Jordan University in Amman, and the Jordan University Hospital (hereafter JUH) in 1971. In addition, by the 1970s there were several government colleges and schools of nursing and midwifery in the Kingdom (Abushaikha 2007; Sultan 1998). In 1973 the Hussayn medical centre (al-M adina al-Tibbiyya ), a complex run by the RMS encompassing several specialised hospitals that were unique in the region, was opened in Amman.59 In 1980, there were 19 private hospitals in Jordan, with a total of 815 beds, and a much more extensive public health sector. In that year a large cohort of physicians were studying abroad, many of them supported by scholarships provided by the Jordanian government or by foreign countries (MOH Annual Report 1980): there were a total of 9,276 Jordanian doctors studying in more than 25 states, including various Arab and European countries, the United States, and several other, non-Western nations. Among them were 7,529 men and 747 women. The main destinations were: Egypt, Spain, Italy, Romania, Russia, Syria and Iraq. The Annual Report of 1981 indicates that the MOH provided medical services to 45 per cent of the Jordanian population, the RMS to 21.8 per cent, the JUH to 8.2 per cent and the private sector to 25 per cent.60 At the beginning of the 1980s the Kingdom had 41 hospitals, with a capacity of 3,887 beds - 1,461 in the government sector and 813 in the private. There were 2,417 doctors - 1,115 of them in the private sector - and 238

Illustration 2 Private Hospital in Amman midwives. It is apparent that while the number of doctors had risen very quickly, there was still a severe shortage of both midwives and nurses (MOH Annual Report 1981). The network of primary health care (here­ after PHC) centres, MCH centres and dental clinics had also undergone a significant expansion by 1981: there were 89 PHC centres, 283 village clinics, 69 MCH centres, 43 dental clinics, and 18 chest disease centres. By the end of the 1980s, the number of hospital facilities had increased further: there were now 26 government hospitals, with 4,080 beds, and 28 private hospitals with 1,555 beds (MOH Annual Report 1988) serving a total population of about 3 million people. The growth in the number of doctors was so rapid that in 1991 there were already 17.1 for every 10,000 inhabitants, while the number of nurses in all categories remained very low: no more than 3.0 per 10,000 inhabitants (Curmi 1993). The 1980s witnessed the development of a very dynamic private sector that provided services to patients from other Arab countries such as Libya, Yemen, Syria and the Gulf states, as well as to the Jordanian population. The remark­ able expansion of the private sector is mirrored by the number of doctors working in it: in 1992 there were 2,667, while the MOH employed 1,417, the RMS 152 and the JUH 118. Despite the adverse economic circumstances at the time, by the mid1990s, the government was able to expand its services, opening new

hospitals and clinics all over the country. In 1995, there were 32 public sector hospitals - 22 MOH, nine RMS, and one JUH - and 41 private. Accordingly, the number of government medical personnel increased by such an extent that doctors in the public sector outnumbered those in the private.61 The MOH provided medical care to 40 per cent of the popula­ tion, the RMS to 23 per cent, the JUH to six per cent, and the private sector to 31 per cent. Yet in the late 1990s, the competition between the two medical sectors continued, with private services still rapidly expanding, so that again they overtook their government rivals: of the 83 hospitals established in Jordan by the end of the century, 50 were private, 10 belonged to the RMS, 23 to the MOH and one to Jordan University (MOH Annual Report 1999). In ten years, the number of private hospi­ tals had almost doubled, and the sector had become one of the more active in the Kingdom. Unsurprisingly, the private-sector doctors outnumbered those employed by the government (5,852 to 3,753). While the number of physicians had thus almost reached 10,000 (9,686), that of midwives was still insufficient (Sultan 1998): in 1999 there were 1,096 in total 759 in government facilities, 313 in the private sector - serving a total population of 4,900,000 people. In the 2000s, despite its already considerable size, the growth of the medical sector continued. In 2003, the physicians practising in Jordan were 12,375 —22.6 per 10,000 inhabitants - and the midwives 1.500 —2.7 per 10.000 inhabitants. The PCH centres were 333, the Comprehensive Health Care centres 47, the MCH clinics 345, and the Peripheral Health centres 265.62 The hospitals were 97; of which 56 were private, 29 belonged to the MOH, 10 to the RMS and two were University Hospitals —the JUH and the newly opened King Abdullah University Hospital (KAUH, hereafter). The MOH provided 36.8 per cent of the total medical services, RMS 18.5 per cent, JUH and KAUH 8.4 per cent, while the private sector 36.3 per cent. Therefore, if during the 1970s the public sector had become largely dominant thanks also to the favourable economic situation, during the 1980s the private sector began to develop in a very important way and today provides more than one third of the services. Indeed, during the 1990s, it has grown more rapidly than the public sector and in the 2000s its services are equivalent of those provided by the MOH, the bigger govern­ ment medical institution. In 2006, when I began my research, in the Kingdom there were 101 hospitals of which more than half were private (see Table 7). The physicians were 24.9 per 10,000 inhabitants and nurses of all categories had reached 33.2 per 10.000 inhabitants (see Table 6). The web of government health

clinics has been growing together with the population and is today easily accessible for the population of all regions of the country. The population in 2006 was of 5,600,000 and the health centres were 1,427 of which 68 Comprehensive Health Centres, 375 PHC centres, 240 Peripheral Health centres, 419 MCH clinics, 12 chest disease centres and 313 dental clinics. Finally, I want to state that during the last decades, the Jordanian health system has been growing not only in terms of the number of available facilities but also in terms of quality of care. Thanks to many international aid programmes funded by UNFPA, UNICEF, USAID, GTZ (German Agency for International Cooperation), JICA (Japanese Cooperation International Agency), IPPF, etc. and to the active role of the state and other private, semi-private, and non-governmental actors, the quality of the health services, of the medical and paramedical training as well as of the equipment has been constantly improving and currently Jordan is wellknown for its medical services in the Arab region and beyond. Moreover, since medical tourism has become a crucial resource for the country, the government has sought in various ways to support the development of the private sector, which is the main actor in the field of medical care (Lautier 2007; WHO-Emro 2004).63

The medicalisation of reproduction between local and global logics The government concern to impose a policy of modern public health (Lupton 1994) with the goal of transforming the health practices of Jordanian citizens brought about the medicalisation of many areas of life, among which reproduction was undoubtedly one of the most impor­ tant. As noted above, the postcolonial health system further developed the basic principles and practices of the previous colonial administra­ tion. International agencies helped in dictating the national agenda, as they imposed conditions for allocating the necessary funds for improving and extending the medical services. The collaboration with European and North American organisations and experts, the training of local personnel in Western institutions and the necessity of adjusting to international programmes in order to get funding ail led the Jordanian authorities to introduce ideas and practices which were exogenous, and sometimes disturbing for the local population.64 The new public health system not only brought about medical control over childbirth, the consequent disappearance of the dayas, and the trans­ formation of ideas about child-rearing, domestic and bodily hygiene, nutri­ tion and womens role in the family, but contributed also to the introduction

of antenatal and postnatal care. The almost complete medicalisation of women’s reproductive cycle, which took place in Western countries after the Second World War (Arney 1982; Martin 1987; Thebaud 1986), became a Jordanian priority, which was realised mostly during the 1980s and 1990s. An evident acceleration in the expansion of the network of MCH clinics occurred in these two decades, as illustrated by the figures in table 4. It is clear that the Jordanian government has made important invest­ ments in this sector, and in this it has been assisted by several inter­ national and foreign organisations - UNICEF, UNFPA, USAID and other Western cooperation agencies - as will be illustrated in Chapter 5. Foreign aid was chiefly aimed at improving ‘reproductive health’, and above all at enhancing family planning strategies, and this, as already noted, has since the 1990s strongly influenced the Jordanian authori­ ties’ agenda (De Bel-Air 2003). The preference of Jordanian women for the private sector in the domain of antenatal care has been empha­ sised above, and the statistics on MCH services are revealing about that shifts in women’s (and their families’) preference. While until the 1970s the number of MCH users continuously increased, in the first half of the 1980s it surprisingly began to decrease. It was still a period of economic prosperity for the country, and the private medical sector was expanding at a rapid pace. The hypothesis adopted here, therefore,

Table 4 MOH Maternal and Child Health Centres, 1980 Health district

No. o f MCH centres

Amman Madaba Zarqa Balqa Irbid Jerash Mafraq Ramtha Karak Tafilah Ma‘an Total

21 3 5 7 21 3 3 2 10 2 3 80

Source: MOH Annual Report 1980

Table 5 Growth in the Number of MOH Maternal and Child Health Centres, 1983-2008

No. o f centres

1983

1986

1989

1991

2000

2008

All health districts

83

102

153

227

345

419

Source: MOH Annual Reports 1983-2008.

is that the diminution of the number of women and children registered in the MCH clinics may be considered a symptom of the preference for the private sector.65 However, by the late 1980s the MCH clinics were registering a new increase in users, and this trend was constant during the 1990s, a period during which the Kingdom underwent difficult economic conditions. In addition to the economic factor, the number of MCH clinics increased, especially in the big urban areas, where the population was constantly growing,66 and in the peripheral rural regions that had been marginally affected by the process of medicalisation. Both factors could have contributed to the new increase in the number of women and children registered in the MCH clinics from the late 1980s onwards. If antenatal and postnatal care services registered substantial growth, some previously important services showed a continual decline. Notably, home deliveries and home visits were becoming marginal, to such an extent that by the beginning of the new century figures about their use no longer appear in the MOH annual reports.67 The annual statistical books, as these reports are now called, include other informa­ tion related to the ordinary functioning of the MCH centres, as well as of outpatient clinics and hospital maternity wards. The data indi­ cates the number of women who are examined during pregnancy and after delivery, distinguishing between ‘new’ and ‘continuing clients’, the type of examination they receive, the type of analysis and tests they undergo, and in the case of ‘special care cases’ (i.e. women with health problems) whether they had to be referred to a specialist, whether they are vaccinated, etc. The data also includes the number of children registered in the MCH centres, who are again divided into ‘new ‘and ‘continuing clients’, and shows the type of treatment they have received and whether they have been referred to a specialist. All this data are listed according to health districts. In the section devoted to hospital services, the statistical books report the number of deliveries in each MOH hospital and the number of new births, as well as whether the

babies weigh more or less than 2.5 kg, which is considered the minimal weight for a healthy newborn baby. Finally, they report the number of deliveries that occurred in each sector: the MOH, RMS, JUH, KAUH and private hospitals. Interestingly, there is no data at all about the use of contraceptive methods, although data relevant to this field is collected by the directorate of the MCH clinics {Mudiriyya um um a wa tufula ), the MOH body in charge of these services. In the 2000s, USAID, in collaboration with the MOH, launched several programmes to improve the standard of antenatal and postnatal care and of the family planning service, and campaigned to promote the notion of reproductive health. These programmes have made a strong contribution to the standardisation and bureaucratisation of the MCH services. The R eproductive Health/Family P lanning C linical G uidelines (2006), an MOH publication detailing the major results of the mentioned programmes, summarises the principles and procedures that all health professionals working in the MCH services have to follow in their practice.68 The manual tackles ‘the most common Reproductive Health and Family Planning subjects: Client Health Assessment, Pelvic Examination, Counselling, Preconception Care, Premarital Examination, Antenatal Care, High Risk Pregnancy, Post Natal care, Post Abortion Care, Family Planning, Infertile Couples, Reproductive Tract Infections, Breast Cancer Screening, Cervical Cancer Screening, Adolescence and Menopause, and Referral’ (2006: 8). These topics constitute the objects of study and reform carried out by joint working groups formed by MOH members, as well as by USAID and UNFPA experts, who during the last two decades have all contributed to the definitive medicalisation of reproduction in Jordan, thus conforming to the well-known Western paradigm which today is dominant (Arney 1982; Davis-Floyd 1992). The plurality of discourses and practices in the area of reproduction produced by the penetration of the Western biomedical system into Jordanian society constitutes one of the main topics which this book addresses. When I started my fieldwork in August 2006, the process of stand­ ardising and bureaucratising the natal system was already well advanced. Therefore I had to work mainly in a medicalised milieu with which the mothers I met were already very familiar. In the next chapter, I will focus on the midwives, a category of actors who play a key role in the Jordanian natal system. I will argue that their profession has undergone deep trans­ formation during recent decades, and therefore that there are important dissimilarities between different generations of midwives. I will attempt to

give a portrayal of the professional life of some of the midwives I met who belong to different generations, in order to illustrate the way their role has changed. I will describe their professional itineraries, their present posi­ tion in the health system as well as in society. I will examine the web of power relations in which they are caught up, their social status and more specifically the kind of relationships they build with pregnant or parturient women. Before attempting a description of the system itself, however, I will go back to the pre-colonial period in order to show the social and cultural organisation of the birth process before the beginning of its massive medi­ calisation. Drawing upon the few existing ethnographic fragments about pre-colonial dayas and the oral testimonies collected by several authors and myself in more recent periods, I will also try to represent how lay midwives experienced the transformation in the natal system.

C

h apter

3

Dayas, Pioneers and Technocratic Midwives

... Important sources o f professional recreation are changes in society and culture. Included am ong the many influences exerted on m edicine by society are changes in the economy and in the political environment, the reorganiza­ tion o f health care financing, and demographic shifts such as baby booms, ageing populations, and increased urbanization. Health care systems must also adjust to shifts in cultural ideas about gender, family, work, science and religion. (DeVries and Barroso 1997: 250)

This chapter investigates the transformation in childbirth practices in Jordan, focusing on its effects on the professional and social role of midwives. Before examining the present, I will look back at the history of midwifery in Jordan and Palestine in the first decades of the twen­ tieth century. There are two main reasons for doing so: on the one hand, this historical digression will allow me to show that the pre-colonial natal system was not merely a barbarous complex of practices domi­ nated by unclean, superstitious dayas (lay midwives), as represented in the official colonial and postcolonial documents; and on the other hand, a description of the pre-colonial customs shows that some features of the old system have been perpetuated up to the present and continue to shape contemporary birth practices. Thus I will begin this chapter with an analysis of the ethnographic material available on birth practices in the first decades of the twentieth century. I will then focus on the few existing narratives left by dayas in the postcolonial period, and examine

several written and oral testimonies about their status and social role. The practices of dayas, their social role in pre-colonial times, the meta­ morphosis of the cultural universe they represented during the Mandate and finally the circumstances of their disappearance are examined in the first part of the chapter. The next section is devoted to the analysis of the life stories of several Jordanian midwives, belonging to different generations. First, I will take into consideration the pioneers, the first medically trained midwives, whose names are still alive thanks to some of their younger colleagues and their previous students, as well as to a number of Jordanian historians. I will then focus on the older generation of still practising midwives, whom I designate ‘low-tech’ midwives and who were working while numerous dayas were still permitted to prac­ tise. I will examine their life stories and their discourse in order to show how in their eyes the natal system has evolved, what space is left for the profession of midwife and what are the characteristics of obstetric care in today’s Jordan. In the last part of the chapter, I will focus on the professional stories of several younger midwives trained in the era of technocratic childbirth, in order to explore their perception of past and present work conditions and more broadly their views about the way the natal system has changed. In short, through these interviews I attempt to rewrite the history of birth practices, giving voice to some of those protagonists whose role is usually silenced, downplayed or discounted by the dominant medical discourse. Finally, I will give a description of the interactions between midwives, doctors and pregnant women in the labour rooms of several public hospitals, in order to draw a sort of micro­ physics of power centred around midwives.

Ethnographic fragments from the past: Antonin Jaussen and Hilma Granqvist In his pioneering ethnographic work, the French Dominican Antonin Jaussen describes several communities living in the territory of Palestine and Transjordan as well as in the northern part of Arabia. The groups he observed had different social organisation: urban, rural, semi-nomadic and nomadic. His travels in this area date back to the two first decades of the twentieth century, and the accurate ethnographic descriptions he has left are unique (Chatelard and Tarawneh 1999). In his three ethno­ graphic works1 he pays special attention to family life and women’s condi­ tion, showing an original attitude towards these topics. He demonstrates an acute interest in the life of Arab women, who are represented neither as exotic sexual objects nor as victims oppressed by local men and social

customs, as was common in most Western descriptions of that period (Ahmed 1992; Said 1978), but as full members of the local society. However, despite the richness of Jaussen’s ethnographic material, his descriptions of women’s practices and ideas do not usually derive from direct observation or personal conversations with them, but reflect the point of view of his male interlocutors since, as he points out, ‘it was impossible to have access to them [the women], especially for Europeans’ (1907: 28).2 Hence, while his ethnographic works contain very interesting information about family life, women’s points of view are as a rule not taken into consideration: their ideas and attitudes towards such things as ordinary life, sexuality and childbirth are absent from the representa­ tion - all details about women’s ordinary life and practices are filtered by men’s discourses. In any event, it is worth quoting some excerpts concerning childbirth practices, since they give interesting information on the customs of the populations described by Jaussen. In the book Coutumes des Fuqard (1920), written in collaboration with another French Dominican, Father Savignac, there is a paragraph dedicated to ‘the woman’ among the Fuqara, a Bedouin tribe living in the north of the Arabian Peninsula.3 Despite or perhaps owing to their religious status, the two authors are eager to know every detail of family life and do not hesitate to ask one of their informants about indigenous childbirth prac­ tices. Qoftan, their interlocutor, who stated he had never witnessed a birth, gives them the following description: The patient sits on an object higher than the floor, a big stone or more often a camel saddle. Hie women who assist her, holds her from the upper part of the body and strongly pulls her backwards. One of the mother’s relatives receives the baby in a fold of her dress. The husband never attends birth; it would be shameful for him; when the moment comes, he goes out from the tent4 (1920: 14).5 Jaussen is more explicit about childbirth practices in the first chapter of his book Coutumes des Arabes au pays d e M oab , where he describes the family life of the Bedouin tribes living in the area of central Transjordan. Several paragraphs are dedicated to women, their life cycle, their social status and their role in the family and in the kin group. A few lines describe childbirth: When the moment of giving birth approaches, the Bedouin woman sometimes sits on a sack that will be thrown away when

everything is over; the midwife {daya) takes the woman’s shoul­ ders and tries to help her in this difficult moment. If she remains sitting, it would be taken as a sign of weakness; a Bedouin woman or a fellaha must stand while giving birth. The Bedouin man does not attend the event; it would be considered sham eful for him ... The newborn child is received in a wooden basin, washed in hot water, greased with olive oil and salt, and often rubbed with myrrh (sabr ). The Bedouins have even ruder habits. Once the sack or the rug is thrown away, the child is washed in the urine of a camel or a sheep in order to make his or her body stronger! (1907: 55). The passage does not contain much detail about the birth event, nor does it tell us much about what it meant for women. However, we learn that there was a code of honour, according to which women had to show their courage and value during the delivery by giving birth standing rather than sitting. The passage also mentions the presence of a daya, whose task was to assist the parturient woman during the delivery. The daya was also present during childbirth in the urban areas of Palestine, where Jaussen observed the local customs. While the French Dominican only briefly mentions childbirth practices in Jerusalem, he gives a more extensive description of those in Nablus. About Muslim women in Jerusalem, he writes that they used to give birth sitting on a special wooden chair in the shape of a crescent, brought to the parturient’s home by the midwife (1907: 55). However, Jaussen gives a much more detailed description of the birth practices of Nablus, apparently because they stimulate his imagina­ tion more than others. He writes: When the woman feels the first painful quivers of labour, she sits on a cushion on the floor or on a low chair: the hollow or flat space before the patient sitting in this position is called al-djawrah. The expression al-mar'a f i al-djawrah means in ordinary language: ‘The woman who is giving birth’. In this critical moment when she gives birth to her baby, she undergoes a very singular practice. The midwife or the elderly woman who assists her comes to her side holding a living snake, which she girds around the patient’s hips. The snake remains for a while girded around the mother’s body like a rope; after that, it is laid down around the djawrah and eventually its head is cut: the bleeding head is held by the patient until the end of the delivery (1927: 33—4).

The passage continues by illustrating the cultural reasons for this curious ritual, which Shaykh Ahmed, one of Jaussen s informants, had told him about.6 Although it is unclear whether it was performed during every birth or only in exceptional circumstances, the French friar does not miss the opportunity to condemn this habit, like many others, defining it as u n p etit dram e d e la superstition charlatanesque - ‘a little drama of quackery super­ stition’ (1927: 34). In the following pages, he describes several rituals which dayas performed in order to protect the newborn child against various dangers, such as attacks by qarina , (the domestic jin n or bad genius), the evil eye {darb al-ayn) and the nashqa (a deleterious aspiration).7 Unfortunately, the quoted passages contain very little information about the daya and her role in the community. If Jaussen, as a European man, was unable to enter the local women’s world and observe it from inside, another pioneering ethnographer in the region, Hilma Granqvist, has left us valuable descriptions of the life of Arab women and children in Palestine. During the Mandate period, she lived for several years in Artas, a small village south of Bethlehem, and wrote five books dedicated to womens and children’s life cycle.8 One of her works, Birth a n d C hildhood am ong the Arabs (1947), contains the only first-hand and detailed descrip­ tion of practices relating to pregnancy and birth in the region during the 1920s. Her sources were two-fold: first, she carried out extensive interviews with two women of the village, Alia and Hamdiyya, as well as with Louise Baldensperger, the daughter of an Alsatian missionary who had lived all her life in Palestine; and second, she was herself able to attend a number of childbirths during her stay. Granqvist’s main informants were women, and because another woman ‘can sit with the women at the birth of a child and see what is done, and how it is done and hear discussions and remarks’ (1947: 25), the quality of her ethnographic work is completely different from that of Jaussen, a male observer who could only exceptionally enter an ordinary woman’s sphere. Thanks to her privileged access to the women of Artas, Granqvist was able to write incredibly rich texts that illustrate many original aspects of Palestinian rural society, including those related to procreation and child-rearing. She lived in the village for several years, sharing the ordinary life of women and listening to their discourses, that were in many ways different from those of men and disclosed a distinctive social and cultural world. As Granqvist writes, women ‘are interested in a mass of details which native men would not notice and which perhaps is below their dignity to notice and tell about’ (1947: 26). Hence the Finnish ethnographer was able to collect original material that reveals a completely unknown dimension of the social life of Palestinian society. As

for the reproductive habits, she gives precious information about theories of conception, pregnancy and birth, as well as about the complex of practices related to these events. In the following excerpt, Granqvist describes the role of the daya during childbirth: ... the most important person, however, is the midwife who must be so old that she has ceased to menstruate. This is because she can always be pure, and is connected with the fact that only a woman who has reached this stage can be with a sick person who is isolated as a remedy, and with the fact that women then seri­ ously begin to fast and pray, while earlier their periods of impu­ rity put hindrances and difficulties in the way. It is also connected with the respect an older woman can enjoy as mother. Often the midwife is an imposing personality who understands how to win respect for her wish and arrangements, so that their orders are obeyed. Her knowledge has been obtained mostly empirically, in some cases perhaps from her own mother, and in any case she employs old-fashioned methods (1947: 60-1). Thus the midwife was a well-known figure in the community, enjoying authority among both women and men, not only because of her role but also because of her age9 and her status as mother and wife. The midwife attended only for the delivery, pregnancy being deemed an ordinary period of life subject to few special ‘precautionary measures, advice, and warn­ ings’ (1947: 45)- Such measures as there were did not prevent peasant women from carrying on their daily ‘heavy and severe work’, since they were mainly related to ritual behaviours, such as walking in a cemetery or kneading the dough (1947: 45). The daya was summoned when labour had begun - and sometimes even later, as the family tried to avoid paying her fee. The midwife came to the parturient’s house and coordinated the activi­ ties of the women —relatives and neighbours —who were there to help the prospective mother.10 She would ask the other women to prepare a room for the birth, and ‘they bring a stone which is placed on the floor and scatter a little earth in front of it’ (1947: 61). A rag was put on the stone, while the parturient woman sat on it, supported by her mother and sister or two other relatives, and the daya sat in front of her to receive the baby. While this was the habit in the rural areas, in the cities ‘the woman who is to give birth to a child sat on a “birth chair”, or if that was not at hand she sat on the bed. But the use of a birth chair is forbidden since the English came to the country’” (1947: 62). It is therefore clear that there were differences in

midwives’ practices according to their place of residence: in poor peasant villages, dayas could not afford to use birth chairs, substituting stones or sacks to accommodate women for the delivery. When the baby was about to emerge, the midwife was helped by some of the women present:11 Either a woman stands behind the confined woman and lifts her up under her arms, or a woman sits with her back strained against her back while two other women stand one on each side: the natural chair. The women who support her also do their best to help her. They lift her by the arms and shake her as if they would shake the child out of her ... She [the midwife] puts out her hands for the coming child in order not to let the head of the child strike the stone, and says ‘Oh, Prophet Noah, divide one spirit from another!’ and ‘The servant, the daughter if Thy servant, asks relief at Thy hands!’ (Granqvist 1947: 70). Midwives did not only possess technical skills, but also played a spir­ itual and religious role insofar as they had to make sure that the partu­ rient woman was ritually pure, and to regulate access to the delivery site, allowing only certain categories of persons.12 During the delivery, the daya prayed to God and performed prescribed rituals according to the phase of labour, received the baby and accomplished several ritual acts after birth. However, it is worth noting that the rituals the daya performed on the newborn children in Artas were not as complex as they were in Nablus, at least according to the description Jaussen has left us. In Artas, imme­ diately after birth, the newborn was swaddled and put in a tray of straw. The afterbirth, wrapped in a rag, was put under the child. Contrary to Jaussen, who describes numerous ritual acts that were to be accomplished during and after the delivery (1927: 33—40), Granqvist mentions only a few such rituals, performed to ward against harm to mother and child. One was performed immediately after the delivery, and consisted in the mother stepping three times over the threshold and back while carrying her child. Later that day, if the baby was born in the morning, or the next morning if in the evening, the midwife came again to cut the umbilical cord, which had been left intact for many hours since ‘it helps the child who drinks of its blood’ (Granqvist 1947: 93). The cutting of the cord represented a very important moment, since the gates of heaven were open again, as during the delivery, and the people attending the ceremony were able to express wishes that could easily reach God’s ears. When the cord

was cut, the midwife ‘puts salt and olive oil13 on the child ... She anoints the whole child, even his eyes, ears and nose, and his mouth ... and [he] remains one day and one night in this ointment’ (Granqvist 1947: 95). The daya was also responsible for the treatment of the afterbirth, which was used to keep away Karine (. It was only some years later that these techniques started to be accepted, when they were judged to be in accordance with the Islamic precept that invites Muslims to have numerous children. According to a Jordanian obstetrician specialising in NRT, today there are religious leaders who regard these technologies as good, useful and in conformity with the Koran. However, as in the Catholic church, Sunni religious leaders do not accept artificial insemination by donor. Many couples from other Arab countries come to Jordan to undergo IVF. According to several obstetricians specialising in NRT, in some private hospi­ tals in Amman, only 40 per cent of the patients are Jordanian. On this topic, see Inhorn 2003. At the time I was doing fieldwork in Jordan, a group of local obstetricians had presented a project for legal regulation of embryo sex selection, because they considered it a problematic issue. As far as I know, however, such a law has yet to be passed. In the literature, there is substantial focus on the Internet as a source of infor­ mation for patients. On this topic see for instance Larsson 2009. Yet as a young obstetrician told me, smiling somewhat malevolently, partu­ rient women often change their mind when in the middle of labour and ask for medical treatment (interview with Dr T., Amman, 12 October 2006). Only in 2006 did the Jordanian authorities start to introduce notions of reproductive health and family planning in national school textbooks (inter­ view with Myriam Ghanma, Amman, 15 January 2007). However, the new textbooks had not yet been published when I left Jordan, and I was therefore unable to find out how these notions are to be presented. A lack of informa­ tion about sexual issues is apparently widespread in several other Muslim countries, as pointed out by Delaney (1991: 92-3). See also Chapter 5. Contrary to what Inhorn (1994) writes about poor Egyptian women who are unable to get pregnant, in present-day Jordan local healers or dayas are usually no longer an option (1994).

56 57 58 59

60 61 62

63

64 65

66 67

68

69 70 71

72 73

Several studies have shown that in various Muslim countries medical exper­ tise plays a very important role in determining the women’s social destiny (Ferhati 2007; Jansen 1987; Parla 2001). The obstetrician was a woman with around 15 years of professional experience. She told me that one of her sisters was in this situation. During my fieldwork, I met few women who were living by themselves and who had their own apartment. All of them lived in Amman, and were usually middle aged. Two were in their seventies, four in their sixties and one in her forties. Four were unmarried, two were widows whose children had already married, and one recently been divorced from her husband. All these women belonged to the middle or upper classes, and were able to earn their own living. This appears very clearly also in the work of Inhorn (1994; 1996) on sterile women in Egypt. On this topic see, for example Dudgeon and Inhorn 2004 and the rich bibli­ ography it contains. About Jordan see Clark et al 2008; Petro-Nustas 1999. For example, though she already had several children, boys and girls, the wife of a Bedouin man living in Wadi Rum decided to have more chil­ dren, though she had stopped for several years, when the second wife of her husband conceived the first child. At that moment, the first wife began a sort of symbolic war against the second one in which the battles were fought through the production of babies. On this issue see also Chapter 5. However, a well-informed midwife told me that several years ago the already mentioned obstetrician Zayd Kilani translated into Arabic a popular book on pregnancy and birth originally in English. Yet no one of the women I inter­ viewed said that she had read a book in Arabic on pregnancy and childbirth. Interview with Dr A., Amman, 14 January 2007. This is particularly important because, as already mentioned, in 2006-07 epidural anaesthesia was not widely used. For more details, see below in this chapter. Interestingly, this idea was also very widespread among obstetricians in the United States at the beginning of the twentieth century (Hahn 1987; Wertz and Wertz 1977). Several private physicians told me that 90 per cent of their pregnant patients regarded themselves as sick and behaved accordingly. This attitude seems to be even more widespread among upper and middle class women than among poor mothers. Interview with Dr. L., Amman, 22 January 2007. While young men are also under pressure, they are not subject to the same violence as women since their structural position in the society is stronger. While specific rules (although of course culturally variable) about preg­ nancy and birth are present in all societies, the biomedical paradigm accords almost the whole responsibility for the outcome of a pregnancy to the woman concerned. For a more detailed discussion of this topic, see Chapters 2 and 5. Unfortunately, this practice is still widespread in many countries, including several in Europe. For more details see Goer 1995; Davis-Floyd 1992; Hartmann et al 2005.

74 Interview with Dr U., Amman, 16 October 2006. 75 Jordan notes a similar phenomenon in Mexico during the 1970s, where local parteras (midwives), who had been retrained by government medical officials according to modern biomedical standards, employed the term enfermas to designate pregnant women (1993). In Jordan, the term marida to designate a pregnant woman seems to be a recent acquisition, since Granqvist, while describing the practices and discourses about pregnancy and childbirth in Artas in the first decades of the twentieth century, never attributes to Palestinian peasants a pathological view of these events (1947: 3-75). 76 Delaney points out that in the Turkish village, where she conducted fieldwork, the mother who had just given birth says a word which means ‘I am saved’, which is very similar to the Arabic expression used in Jordan (1991: 64). 77 Physical aggression against medical staff have become common in Jordanian government hospitals, as attested by several articles published in the Jordan Times over the last five years (see for example the issues of 9 August 2007, 12 November 2007, 28 December 2007, 24 July 2009, etc.). Moreover, a Jordanian female obstetrician who in the late 1990s has worked at the Bashir hospital told me that she and one of her colleagues had been subjected to aggression more than once by one or even several male family members of their patients. Though sometimes such aggression is merely verbal, it is unfor­ tunately sometimes also physical (interview with Dr T., 26 January 2010). 78 In the early 2000s, Layla, a nurse-midwife trained as a childbirth instructor in the United States, had also been giving childbirth classes for some years. While her classes were in Arabic, those of Samira Dajani were in English. However, by the time I began my research, Layla was preparing her PhD and had stopped giving classes. She told me that she had stopped not only because she no longer had time, but also owing to the opposition of several physicians in the private hospital where she worked. At the same time, her attempts to obtain the financial support of the MOH for her teaching on childbirth to midwives and nurses working in the public sector had failed, although a few private obstetricians had supported her efforts to create an institutional frame­ work for such classes (interview with Layla, Amman, 18 November 2006). 79 An experienced midwife told me that she had observed that hormonal methods can cause secondary infertility. This idea was very widespread among the Jordanian women I met, especially the less-educated. Moreover, a study by Petro-Nustas (1999) shows that men were also convinced that hormonal methods can cause female infertility. 80 Amman, 12 December 2006.

5 Becoming Mothers: Ethnography of an Intimate Experience 1 2

The Economic Advancement o f Women in Jordan: A Country Gender Assessment. World Bank Social and Economic Development Group, Middle East and North Africa Region (MENA 2005). For more details about juridical inequalities between women and men in Jordanian law, El-Azhari Sonbol 2003; Massad 2001; In Search o f Equality: A

Survey o f Law and Practice Related to Womens Inheritance Rights in the Middle East and North Africa (MENA) Region 2006.

3 For example, they were not entitled to live on their own, and/or had to take care of other family members. 4 Interview with Dr. M., Amman, 1 February 2007. 5 Although during recent decades the average age at first marriage has increased for men and women alike, women are usually regarded as too old after 30 (De Bel-Air 2008). Women older than that can ‘aspire’ to marry older men who are divorced or widowed and already have their own children. 6 On the importance of procreation and the social stigma which derives from infertility, see Inhorn 1994; 1996; Ali 2002a. 7 Since women register at the MCH clinic in the district where they live, atten­ dance at each centre faithfully reflects the socio-economic context of the area. 8 The midwife and the nurse were extremely surprised by the fact that the girl was not pregnant three months after the marriage. Indeed,many health providers share ideas and stereotypes typical of their society, as noted by Knudsen (2006). 9 Another obstetrician told me that it is not uncommon for families to consult a doctor if on the wedding night the bride does not bleed after sexual inter­ course; the physician is called upon to give her medical advice which could determine the woman’s destiny (Husseini 2002—03). It is a very heavy respon­ sibility, since in Jordan honour crimes are still common practice and the non­ virgin bride risks not only tainting her family’s reputation but losing her own life, if the gynaecologist does not declare that she was still a virgin when she married. This shows that medicine possess a great social authority and plays a crucial role in local society. See also, for example, Parla 2001; ShalhoubKerkovian 2005). 10 In Jordan, women are usually regarded as more responsible than men in cases of reproductive failure, as a result of the patriarchal ideology dominating local society. As Inhorn puts it: ‘Just as men are seen as giving life, women are seen as taking life away by virtue of wombs that fail to facilitate the most impor­ tant act of male creation’ (1996: 24). 11 However, in other countries, it has become routine to let prospective brides be examined by an obstetrician before marriage in order to verify their virginity. This is the case in Algeria, where state officials require a ‘certificate of virginity’ before officially registering the marriage (Ferhati 2007). Thus the medicalisation of women’s health has brought forward the cultural practice aimed at proving their virginity, which was until recently verified only after the wedding night (Jansen 1987; el-Saadawi 1980; Wikan 1991). 12 See for example Shami and Taminian 1985. 13 At least theoretically, ‘Marriage should guarantee sexual satisfaction for husband and wife and protect both partners against seeking satisfaction outside it’ (Mernissi 1987: 59). However, refusal to have sex with the partner is sanctioned differently for women and for men: ‘Muslim law grants the husband whose wife refuses his advances to withhold maintenance (food, clothing and lodging), which it is normally his duty to provide.’ On the other hand, ‘the woman has the right to ask the judge to initiate divorce if she can testify that her husband is impotent’ (ibid: 60). However, if the husband is not impotent but refuses to satisfy his wife’s desires whenever she manifests them, she has no juridical means to force him to comply. Moreover, women

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23 24 25

26 27

are supposed not to overtly manifest sexual desire, because it is a masculine prerogative that would be completely inappropriate in a woman (Ali 2002a). Interview with Dr T., 13 May 2010. At the same time, there exists a cultural attitude which women can assume when they are pregnant or new mothers, which derives from social norms and beliefs. For instance, Mouna, a woman in her thirties, told me that after the delivery, when she was back home and received the ritual visits of family members and friends, her mother-in-law told her to stay in bed and simulate exhaustion and indisposition so that she would not attract the evil eye. According to the female obstetrician in charge of the same clinic, very few men living in the area served by the JAFPP centre were prepared to use condoms. One of them had even told her that for him to use condoms was as if he had to kiss his wife behind a pane of glass. Several women were also unwilling to use condoms because they were afraid of their uterus drying up, if the male semen did not moisten it during sexual intercourse. According to many doctors I met, gynaecologists often refuse toperform tubal ligation on women who are less than 40 years old. The same social worker told me that she usually does not give any indica­ tions to women willing to end their pregnancies, because it is forbidden, and because the rumour would circulate very quickly and the clinic might be crowded by women seeking abortions. According to the physicians I met, illegal abortions are not very widespread in Jordan, as confirmed by Knudsen (2006). Their cost varies according to the womans status: they are much more expensive if the woman is unmar­ ried. One obstetrician told me that at the beginning of the 2000s the average cost was JD 150 for married women, JD 800 for unmarried. In Amman, there is a private hospital which is well-known as a place where it is easy to have an abortion. My interviews confirm the data of the research conducted by Petro-Nustas 1999. Indeed, the usual protocol is that from 32 weeks on a woman should undergo regular examinations every two weeks, and during the last month every week as indicated in the Reproductive Health/Clinical Guidelines published by the MOH in 2007. For a similar situation in Syria, see Bashour et al 2005. In Arabic Jam iiyya li riayyat usrat al-jundi. In the outpatient clinic of the Salt government hospital, I met another woman who was in her 39th week of pregnancy but had never seen a physician or a midwife. She came to the clinic with her husband because she had started to feel strong contractions. She was 42 years old, and was the second wife of a man of 70 who already had more than ten children. According to Kanaaneh, the same idea is present among Palestinians living in the Galilee (2002). Christian girls in many ways receive the same education as Muslim girls, and are usually subject to the same rules of honour, as honour crimes perpetrated by Christian families demonstrate (Latte-Abdallah 1997). However, there exist some juridical and religious differences between the two groups which can be expressed inter alia through clothing style (Droeber 2005).

28 29

30

31 32

33 34 35

36 37 38 39

For a basic description of Islamic dress, see Hoffman-Ladd 1987. In all MCH and NGO clinics I visited, ultrasound machines were equipped only with abdominal transducers, which require that only the stomach of the woman be seen and touched. Machines with transvaginal transducers can be found only in public and private hospitals, and in well-equipped private offices, and are not normally used in routine monthly examinations in the government sector. There exist infinite variations in what I have called the ‘Islamic vestimentary code’, which is characterised by the head-scarf but which also includes a great number of styles. There are women who wear Western-style clothes, including very tight blue jeans showing the shape of their body, or very large and covering all their body, others who wear xhcjilbab, and others again who wear both the niqab and the 'abaya (a large cloak covering the entire body). Even among the more ‘puritanical’ interpretations of the Islamic dress code there are many differences - the veil and clothes women wear can be black, beige, white or even green, they can conceal their eyes or show them, use make-up or not, and so on. According to Lucine Taminian, mothers go out with some of their children in order to show their status as married women and mothers (interview, 10 December 2006). According to the obstetricians and midwives I met in the various hospitals I visited, more than half of the women receive some kind of augmentation (Khresheh 2008), because neither the physicians nor the women and their families like to wait for many hours before the delivery. In government hospitals the ‘active managment of labour’ is also practised, to discharge each patient as quickly as possible and thus free a bed for another patient. According to Khresheh, in 2004 46 per cent of cases involved augmentation in the three public hospitals selected for the study (2007: 6). It is important to stress that this hospital, although private, does not allow the presence of family members in the labour room. My observations are supported by the studies conducted by Oweis and Abushaikha (2004) and Khresheh (2008). Le Breton notes that ‘pain sharpens the feelings of loneliness and forces the individual into a privileged relationship with its suffering. The human being who suffers withdraws from public life and cuts himself off’ (1995 : 31, my translation). Women who have had a physiological delivery do not usually stay in hospital for more than one day after the birth, and in government hospitals often only for a few hours. See also Bouhdiba, who states that women who die while giving birth are shahidas (‘witnesses of faith’) like men who lose their life while fighting in a holy war (1975: 266). For more details, see O’Driscoll, Stronge and Minogue 1973. I am grateful to Barbara Brookes for drawing my attention to the positive aspects of the biomedical natal system. Given that I chose to work on physio­ logical pregnancies, I sometimes tend to forget the substantial improvements in women’s health that Western medicine has brought about in cases of failure or disorder in the reproductive process.

40

41

42 43 44

45 46 47 48

In some situations, this physical contact can become real violence as attested by the following episode. In a government hospital I have seen a midwife several time pushing her fingers violently into the vagina of a woman who was very tired and unable to push as strongly as the birth attendant wished, while shouting in a very harsh and unpleasant voice kammili, kammili (‘go on, let’s finish with it’). See also Chapter 3 above. The definition of this expression is clearly given in an article by Begley, Gyte, Murphy et al 2010, according to which ‘In “active” management of the third stage of labour, the clinician chooses to intervene by using the following package of interventions (Prendiville 1989): 1. the routine administration of a prophylactic uterotonic drug just before, with, or immediately after, the birth of the baby; 2. early cord clamping and cutting (i.e. prior to, alongside, or immediately after administration of oxytocic, which is before cord pulsation ceases); and 3. controlled cord traction to deliver the placenta. [Note: current (2006) WHO recommendations are to delay cord clamping, although NICE still supports its taking place at an early stage (NICE 2007)]. These interven­ tions are implemented routinely and prophylactically in an attempt to reduce the blood loss associated with the third stage of labour and to reduce the risk of PPH. There are many possible variations with this package of interven­ tions’ (2010: 3-4). Recent scholarly contributions show that the active management of the third stage of labour including controlled cord traction is not always beneficial since it can have several adverse side-effects (Begley, Gyte, Murphy et al 2010) Not only are curtains seldom used, but they are sometimes not materially present, although the metal rails on which to hang them are visible on the ceiling. Interestingly enough, the more luxurious and medicalised is the hospital, the more is the woman relegated into a passive role. Indeed, in very deluxe hospitals, labouring women never walk after labour begins, even if they are not administered epidural anaesthesia, while in less expensive hospitals they might walk during labour. Only in government hospitals they walk after the delivery, while in the other hospitals they are carried on beds or wheel chairs. Interview with Umm ‘Omar, Amman, 16 November 2006. This sub-title alludes to the title of a work edited in 2007 by Inhorn. Only once, in a government hospital of a small city in the north, I saw that the staff had allowed the mother of a young primipara with a dead foetus of six months in her uterus to be present during labour. In 2007, according to the Annual Statistical Book, the infant mortality rate in Jordan was 19 per 100,000 live births.

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Statistical Tables fo r Program Planning te Adolescent Experience In-Depth: Using Data to Identijy the Cost o f Family Planning in Jordan. USAID, 2010. The Economic Advancement o f Women in Jordan: A Country Gender Assessment. Social and Economic Development Group, Middle East and North Africa Region (MENA), World Bank, 2005.

Websites , accessed 16/10/2010. , accessed 23/11/2010 , accessed 29/09/2010 , accessed 29/10/2010

, accessed 18/08/2010 , accessed 24/08/2010 , accessed 25/08/2010 , accessed 24/11/2010

Index abdomen, 15, 96, 116, 190, 194, 210 Abdullah, 62, 86, 88 abnormal, 52, 106, 125, 219-20 abnormality, 97, 219 abortion, 17,18, 66, 100, 141, 172, 186-8, 218 accommodation, 20, 83, 108, 210 admission room, 7, 112, 117, 125, 151, 199, 217 afterbirth, 75, 77, 83, see also placenta agencies, 3 foreign, 93-4 international, 19, 48, 55, 63, 142, 224-5 agency, 12, 16-17, 54, 149, 174, 190, 206, 221 Ajloun, 27, 39 Amman, xvi, 3, 9, 10. 22, 23, 27-8, 29, 31, 32, 33, 37, 38, 39, 40, 46, 47, 48, 50, 52, 56, 60, 78, 81, 84, 85, 86, 90, 94, 95, 96, 103, 105, 110, 114, 115, 125, 129, 131, 133, 134, 139, 140, 144, 154, 155, 159, 163, 175, 179, 180, 186, 187, 193, 213, 215, 216, 217 amniotic fluid, 129 anaesthesia, 137, 162, 167, 174, 203, 205-6 analgesia, 162, 168, 203, 205 anxiety, 107, 146. 156, 169, 170, 174, 179, 189, 191, 204 Artas, 73-8 Augusta Victoria Hospital, 47, 95,

101

authoritative knowledge, 58, 91, 101, 103,108 authority, 18, 58, 74, 89, 91, 100, 103, 104, 108, 109, 110, 114, 116, 129,

148, 151, 164, 165, 166, 180, 181, 192, 214, of obstetricians, 108, 147-8 of dayas, 74 of husbands, 168 of midwives, 58, 89, 91, 103-4, 110-15 women’s relationships with, 149-51 autonomy, 52, 86, 89, 107, 111, 125—6, 189, 192 babies, 5, 9, 16, 35, 46, 51, 53-4, 66, 71-2, 74, 75, 76, 77, 79, 81, 82, 83, 91, 92, 97, 99, 100, 102, 104, 105, 109, 113, 114, 116, 117, 118, 119, 125, 127, 128, 132, 135, 142, 146, 150, 155-61, 162, 167, 168, 169, 172, 175, 187-8, 190, 191, 192, 193, 194, 202, 203, 206, 207, 211, 212, 213, 214,215-19 sex of, 192, 193 unborn, 9, 17, 125, 216-18. Basma bin Talal, 94 bath, 52, 76, 212 bed, 32, 74, 96, 113, 114, 177, 119, 129, 130, 134, 181, 195, 199, 200, 202, 206, 207, 208, 209, 210, 211, 216, 217 birthing, 116, 118, 200, 209, 210, 212

Bedouin, 32, 71—2 Beirut, 40, 41 Bethlehem, 73 biomedicine, 14, 28, 41, 79, 80, 128 paradigm, 102, 156, 157, 160, 169, 205, 222 system, 39, 40, 66, 79, 141, 142, 171, 190

birth, 1 attendant, 4, 6, 7, 41, 57, 84, 95, 105, 117, 120, 128, 129, 132, 134, 197, 199, 200, 203, 206, 207,210, 209,210,211,212, 215, 216, 217 at home, 52, 56, 81, 90, 96, 98, 115 control, 54, 55, 81, 93, 96 practices, 35, 69, 70, 72, 77 rate, 43, 44 technocratic model of, 17, 18, 99, 107, 113, 135, 141, 142, 146, 162,172,173, 192, 205 Bliss, Daniel, 40 blood, 2, 28, 75, 90, 96, 29, 141, 170, 189, 214, 217 bodily ideal, 191 body, 3, 11, 15, 16, 17, 18,35, 43, 50, 51, 66, 71, 72, 97, 98, 101, 127, 128, 135, 149, 152, 155, 157, 163, 166, 174, 175, 186, 189, 190, 193-4, 196-8, 202, 204, 207-11, 215, 221, 224 corporeal, 15, 17, 197, 209 geography, 17, 196-8, 204 sexualised, 16 boy, 41, 78, 85, 102, 156, 157, 158, 160, 178, 182, 183, 190, 216, 219, 221 bride, 146, 158, 163, 164, 179, 179, 181, see also wife Britain, 24, 25, 31, 34, 36, 39, 44, 45, 48, 86 British: administrators, 28, 38, 44, 76, 78 colonies, 21, 26 Empire, 11, 26 government, 34 officers, 45, 88 bureaucratisation, 33, 49, 51, 66 caesarean section, 107, 116, 127, 217 capital, 28, 31, 38, 84, 134, 140, 143, 151, 159 care, 6 antenatal, 7, 14, 54, 56, 59, 64, 66, 89, 138-41, 154, 157, 170, 189, 191, 192, 197-8,211,218,219

perinatal, 14, 19, 36, 56, 58, 90, 142 postnatal, 55, 58, 64, 65, 66 childbirth, 1 as natural, 2-3 classes, 174, 214 culture of, 14, 15, 142, 168 natural, 162, 172, 214 pain, 15, 154, 166, 201-5 practices, 9, 69, 71, 72, 76, 77, 78, 82, 88,89, 94, 97, 142,221, 225 Christian, 20, 23, 26, 42, 43, 87, 203 citizen, 7, 9, 13, 16, 18, 25, 30, 38, 39, 43, 47, 48, 49, 55, 59, 63, 124, 127, 142, 157, 159, 179, 221, 224 female, 16, 48 male, 13 cleaner, 78, 117, 119, 120 client, 66, 58, 65, 108, 109, 136-8, 141-2, 154, 160, 167, 171, 213 clinic, 31, 32, 40, 41, 45, 47, 53, 86, 96, 139, 141, 145, 149, 151, 154, 156, 158, 163, 164, 179, 186, 187, 188, 190, 195, 219 MCH, 3, 4, 6, 7, 8, 9, 13, 47, 51, 52, 53, 55, 56, 62, 63, 64, 65, 66, 86, 96, 101, 139, 146, 149, 155, 156, 158, 163, 174, 186, 193, 195, 198, 216, 223 outpatient, 65, 138, 139, 141, 151, 156, 165 Clot Bey, 40 clothes, 36, 77, 88, 135, 191, 193, 209,

210

CMS (Church Missionary Society), 29, 30, 31, 32, 41, 85, 96 colonial: 11 government, 26, 45, 78 context, 25, 40, 78 colonisers, 21, 23, 26, 29, 42, 43 consulting room, 7, 194, 195, 196 contraception, 17, 18, 19, 55, 89, 93, 94, 100,153,165,174, 183 condoms, 93, 187 pill, 93, 175, 187, 192 tubal ligation, 94, 166, 187 contraceptive methods, 8, 19, 55, 66, 93, 175, 176, 192

cupping, 28, 92 curtains, 134, 195, 208, 211 Damascus, 82, 86 dayas, 1, 3, 28, 33-6, 37, 39, 40, 44, 45, 46, 52, 53, 56, 63, 67, 69, 72-82, 83, 85, 87, 88, 89, 92, 93, 95, 96, 97, 98, 101, 103 Palestinian, 36, 79 Deir Alla, 90, 92 death, 77, 82, 105, 119, 151, 151, 203, 218,219 delivery room, 4, 10, 19, 59, 83, 86, 97, 98, 101, 105, 106, 111, 112, 113, 114 115, 117-21, 129, 130, 134, 135, 136, 196, 200, 205, 208, 209, 210 , 211,212

Department of Health, 11, 21, 32, 38, 40, 44, 86 disorder: genetic, 216, 220, 222 health, 182 physical, 223 reproductive, 161 disruption, 216, 222 DOHP (Department of Health of Palestine), 38 DOHTJ (Department of Health of Transjordan), 21, 22, 27, 31, 32, 33, 37, 38, 39, 76 domestic sphere, 9, 16, 87, 93 domination: male, 43, 147-8 education, 13 health, 31, 48, 49, 53, 55, 88, 93, 94, 95, 109 Islamic, 182 medical, 13 moral, 26 mothers’, 43 sexual, 20, 149, 183 women’s, 24, 42-3, 49, 54, 98 EFM (Electronic Foetal Monitoring), 95, 116 Egypt, 28, 40, 60, 92 emancipation, 223 embodiment, 15, 20

embryo, 101, 160, 197 Emirate of Transjordan, 11, 21, 22, 23, 28, 29, 32, 37, 38, 39, 76, 88 epidural, 137, 203, 205, 206, 214, 224 episiotomy, 5, 58, 82, 111, 112, 113, 116, 119, 172, 207,210, 224 equality, 18, 221, 223 eroticization , 150 error 42, 84, 85, 102 erroneous practices and knowledge, 35, 102, 113, 166, 169 ethnography, 10, 13, 20 Europe, 2, 10, 13, 18, 24, 34 35, 43, 48, 49, 95, 124, 140, 142, 161, 203, 205 examination: internal, 96, 173, 195, 197, 199 medical, 47, 55, 164 monthly, 138, 139, 156, 173 pelvic, 16, 66, 173-5, 196-8, 206,

210

expert, 6, 28, 46, 63, 66, 76, 95, 120, 153, 157, 180, 212, 223, 225 constraints, 9 family, 2 life, 2, 70, 71, 87, 178, 187, 221 members, 15, 51, 77, 78, 82, 129, 130, 132, 134, 135, 137, 146, 163, 168, 173, 177, 179, 195, 200, 201, 202, 205, 206, 210, 215 planning, 18, 53, 54, 55, 64, 66, 99, 100, 101, 111, 139, 141, 153, 175, 221, 225 pressure, 162, 175, 179, 183 father, 13, 14, 16, 55, 71, 85, 134, 159, 162, 175, 179, 180, 221 Father Savignac, 71 fear, 137, 156, 168-71, 173-6, 183, 185, 199, 201, 204, 207, 214 fertility, 54, 55, 152, 165, 175, 220 age of, 147, 181, 182, 223 rate, 54, 55, 152, 220, 223 in women, 147, 169 foetus, 17, 108, 125, 139, 140, 141, 146, 155, 157, 173, 175, 192, 197, 216-20

freedom, 5, 18 gender, 12, 15, 16, 17, 69, 94, 147, 150, 202,221 general practitioner, 91 genetics, 141, 161, 216, 219, 220 genitalia, 129, 198, see also sexual organ girl, 78, 85, 87, 88, 93, 100, 102, 119, 146, 158, 160, 163, 172, 178, 180, 181, 182, 184, 185, 192, 196, 198, 215, 216, 217, 219, 221 gown, 4, 8, 96, 135, 209 grandmother, 81, 223 Granqvist, Hilma, 2, 70-8 groom, 184 GTZ (German Agency for International Cooperation), 63 gynaecology, xv, 6, 40, 42, 59, 124, 127, 153, 224

133, 151, 164, 165, 172, 199, 200, 205, 206, 208,210,211, 212,213, 214,216, 217 Italian, 27, 30, 32 Islamic (in Amman), 161 MOH, 65, 110, 111, 113, 116 private, 5, 7, 10, 32, 50, 56, 58, 59, 60, 61, 62, 66, 89, 96, 103, 104, 105, 106, 107, 108, 109, 110, 114, 115, 125-38, 139, 140, 141, 153, 154, 156, 159, 160, 161, 172, 174, 175, 187, 199, 201, 204, 206, 209, 211,212,213,214, 215, 216, 217 RMS, 6, 114, 119, 187 university, 62 hotel, 108, 114, 136 humour, 147-9 husband, xv, 8, 9, 13, 14, 16, 17, 55, 71, 76, 85, 86, 89, 94, 107, 130, 132, 133, 134, 138, 140, 152, 154, 155, 156, 157, 158,159, 161, 163, 164, 165, 166, 168, 170, 175, 176, 177, 178, 179, 180, 182, 183, 184, 187, 189, 195, 198, 211, 216, 217, 219 hygiene, 27, 35, 41, 42, 54, 63, 91, 93, 101, 102, 132, 135 rules of, 35 hymen, 183

Haifa, 45, 85 handicapped, 219, 220 Hashemite Fund for Human Development, 94 healer, 27-8, 34, 46, 78, 79, 80, 82 bone-setter, 28 herbal, 34, 82 health, 2 facilities, 19, 29, 32, 38, 50, 54 primary, 61, 95 provider, 4, 7, 13, 138, 146, 147, ignorance, 24, 26, 42, 84, 85, 163, 166,183 152, 170, 173, 189 public, 11, 21, 22, 33, 37, 39, 47, incorporation, 15 induction, 107, 199, 216, 224 48, 50, 51, 53, 59, 60, 63, 84, 97, 93, 96, 102, 120, 192 infectious disease, 22, 27, 32, 45 reproductive, 6, 66, 89, 94, 95, 100, infertility, 19, 80, 92, 156, 160 141, 163 in women, 19 Hebron, 84 inspection, 44, 88 hierarchy, 91, 103, 110, 124, 128, 136, intensive-care station, 116 IPPF (International Federation for 139, 147, 150 High Health Council, 19, 123, 124 Planned Parenthood), 55, 63 Iraq, 60 honour, 72, 186, 193 hospital, 2 Irbid, 10, 27, 33, 37, 38, 39, 50, 52, 57,64 geography, 139, 140 government, 5, 7, 27, 29, 32, 33, 34, Islam, 20, 100, 190, 184, 191, 193, 35, 37, 44, 46, 56, 60, 61, 80, 194, 203, 218, see also Muslim Israeli occupation, 50 81, 85, 87, 90, 109, 110-20, 130,

IUD (Intrauterine device), 93, 94, 111, 153, 165, 184, 187 IV bag, 117 IV drip, 4, 109, 117, 121, 199, 206 IVF, 19, 154, 159, 160, 161, 216 JAFPP (Association for Family Planning and Protection), 7, 55, 95, 96 99, 139, 152, 153, 186, 187 Jaussen Antonin, 2, 70-8 Jerusalem, 34, 35, 37, 38, 44, 47, 72, 84, 85, 94, 95 JICA (Japanese Cooperation International Agency), 63, 94 Jordan Medical Association, 123 Jordan Medical Council, 123 Jordan Nursing Council, 111 Jordan Valley, 52, 57, 89, 90, 92, 97 Jordanian Private Hospitals Association, 123 Jordanian Society of Obstetricians and Gynaecologists, 123 JUH (Jordan University Hospital), 60, 61, 62, 66, 132 Karak, 27, 32, 33, 37, 38, 39, 50, 57, 64, 81, 94, 140, 144, 154 Karine see Qarinah KAUH (King Abdullah University Hospital), 58, 62, 66 kohl, 92 labour, x, 4, 5, 7, 8, 10, 13, 26, 43, 49, 57, 58, 59, 70, 72, 74, 75. 76, 77, 82, 88, 90, 91, 92, 96, 97, 101, 104, 105, 106, 107, 108, 109, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, 121, 123, 124, 125, 126, 127, 129, 130, 131, 132, 134, 135, 137, 154, 159, 162, 166, 167, 168, 171, 172, 174, 178, 186, 193, 198-203, 204, 205, 206, 207, 208, 211, 213, 216, 217, 224 acceleration of, 125 active, 199 division of, 57, 58, 112, 130 force, 26, 43, 178 pain, 201-5

room, 70, 104, 106, 107, 109, 111-21, 124, 127, 130, 131, 132, 134, 135, 137, 168, 205, 214, 217 stages of, 7, 70, 117, 125, 126, 127, 128, 129, 130, 132 unit, 117, 124, 125, 126, 129, 130, 131, 134, 135, 154, 168, 199, 210 ward, 200 Lebanon, 198 license, 92, 101 London, 23, 95 M aan, 22, 33, 37, 38, 39, 100 Mafraq, 57, 64, 144, 186, 187 malformation, 118, 141, 164, 181, 187, 217 malpractice, 35, 173 marriage, 87, 158, 160, 163, 164, 175, 176, 177, 178, 177, 178, 179, 180, 181, 183, 184, 185, 220, 223 married women, 84, 85, 156, 169, see also unmarried women Maskubiyya Hospital, 84, 85 maternity ward, 32, 34, 40, 41, 65, 85, 104, 110, 116, 124, 125, 149, 165, 200, 213 medicine, 11, 13, 14, 21, 22, 23, 27, 28, 29, 31, 32, 33, 35, 39, 40, 41, 42, 43, 46, 60, 69, 79, 80, 128, 146, 180, 189, 203 Arab, 80 colonial, 43 modern, 27, 28, 80 medical: culture, 13, 14, 56, 124, 213, 214 establishment, 34, 35, 52, 52, 59, 91, 171 procedure, 8, 169, 171, 173, 194, 225 school, 40 setting, 2, 5. 7, 13, 138, 149, 195 surveillance, 18, 44, 54, 100, 169, 170, 191, 192, 194, 223 system, 11, 28, 34, 39, 40, 66, 79, 88, 99, 142, 155,171, 190 tourism, 63

medicalisation, 14, 17, 18, 19, 39, 59, 63-7, 88, 89, 99, 141, 170, 191, 192, 213, 222, 223 memory, 1, 84, 213 midwives, 4, 6, 28, 33, 36, 37, 38, 39, 58, 70, 72, 74,75, 76, 79, 80, 81, 82, 83, 84-122,124,125,126,127,128, 129, 132,133,134, 136,137,138, 139,141,145,146,150,152,153, 163,171,172,173, 174, 175, 179, 180, 189, 191,195, 198, 199, 202, 206, 207,212,214,215,217,221,223 head, 85, 104, 105, 109, 113, 114, 119, 129, 217 lay, 35, 36, 42, 67, 69, 78, 79, 80, 81, 88, 103 -led unit, 125-30, 132 old generation of, 88, 89, 102-7 Palestinian, 78, 87 qualified, 1, 29, 34, 36, 37, 38, 39, 40, 52, 56, 60, 69, 79, 80, 83, 84-8, 96, 101, 102, 103, 107-10 shortage of, 53, 61, 104 technocratic, 69, 107, 110 young generation of, 110 Midwife Act, 36 midwifery, 33, 35, 36, 37, 44, 48, 60, 69, 82, 84, 85, 86, 89, 90, 96, 96, 97,98,99, 103, 109, 111, 113, 116 diploma, 109 instructor, 48, 86, 113, 114 school, 95, 96, 97, 98, 109 miscarriage, 34, 155, 159, 175, 217, 218,219 missionary, 21, 25, 26, 27, 29, 31, 32, 38, 40, 42, 43, 73, 154 mistreatment, 113, 115-19 moaning, culture of, 168-71 modesty, 20, 130, 148, 149, 192-6, 208-11 norms of, 130, 194, 209, 210 MOH (Ministry of Health), 19, 23, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 59, 60, 61, 62, 64, 65, 66, 78, 86, 90, 92, 93, 95, 96, 97, 102, 109, 110, 111, 113, 116, 119, 120, 123, 132, 139, 145, 153, 164, 188, 205, 220

morbidity, 24, 44, 205, 222 mortality, 19, 23, 24, 26, 35, 44, 45, 205, 218, 222, 223 infant, 23, 24, 26, 44, 45, 205, 218, 223 maternal, 19, 44 mother, xiv, 3, 7, 8, 11, 14, 15, 16, 17, 19, 24, 25, 26, 31, 34, 42, 43, 44, 45, 46, 47, 49, 51, 52, 55, 66, 71, 72, 74, 75, 76, 77, 78, 83, 85, 87, 90, 94, 95, 97, 100, 102, 105, 108, 112, 116, 117, 118, 119, 126, 127, 128, 133, 134, 138, 140, 141, 142, 146, 148, 151, 155, 157, 159, 164, 169, 170, 171, 172, 177-220, 223, 225 expectant, 126, 206 first-time, 146, 155 prospective, 15, 134, 189, 197, 203 mother-in-law, 82, 134, 164, 181, 182, 217 motherhood, 24, 25, 26, 83, 87, 181, 204 as natural, 87, 184 multipara, 155 Muslim, 20, 40, 72, 87, 93, 99, 161, 184, see also Islam Nablus, 72, 75, 84 natal system, 1, 11,12, 14, 15, 16, 20, 34, 36, 59, 66, 67, 69, 70, 79, 83, 88, 89, 94, 99, 101, 102, 107, 113, 121, 124, 128, 130, 157, 171, 191, 192, 205, 212, 224 Near East Council of Churches, 96 newborn, 34, 45, 66, 72, 73, 75, 76, 85, 105, 109, 116, 121, 128, 132, 133, 167, 172, 211-16, 218, 221 New Reproductive Technologies (NRT), 17, 19, 160, 161, 171, 224 NGOs, 7, 55, 94, 96, 138, 139, 141, 162, 190, 192, 195, 219 norms, 16, 17, 20, 29, 41, 42, 43, 52, 87, 89, 97, 130, 132, 136-41, 148, 149, 150, 164, 169, 170, 171, 174, 178, 177, 179, 187, 192, 193, 194, 196, 195, 197, 198, 207, 208, 209, 210, 211,218, 222, 224, 225 moral, 41, 211 normality, 97, 112, 210

normative roles, 149 nudity, 208-11 nurses, 29, 30, 31, 34, 38, 43, 46, 47, 48, 49, 53, 55, 61, 62, 81, 84, 85, 86, 87, 88, 90, 95, 96, 98, 99, 103, 107, 108, 109, 110, 111, 114, 116, 117, 118, 121, 126, 128, 130, 131, 132, 136, 163, 168, 173, 179, 180, 194, 195, 196, 199, 212 obstetric, 109, 130, 132 paediatric, 109, 132, 212 nursery, 212, 213, 215 nutritional supplement, 2, 146, 157, 190

70, 72, 73, 77, 84, 87 refugees from, 6, 139, 178 parturient women, 4, 7, 10, 67, 89, 92, 104, 107, 108, 109, 113, 115, 116, 117, 118, 119, 120, 121, 125, 126, 129, 131, 135, 136, 167, 168, 169, 171, 200, 208, 209, 210, 214 paternalistic, 11, 150, 152 pathology, 112, 141 pathological view, 2, 54, 99, 128, 169, 170, 171, 173 of the reproductive process, 2, 169 of pregnancy, 54 of birth, 170, 171, 173 obstetrician, xv, 1, 7, 8, 12, 13, 14, 19, patients, 4, 7, 27, 28, 29, 31, 58, 59, 61, 56, 58, 59, 90, 97, 99, 103, 104, 71, 80, 90, 92, 104, 105, 107, 109, 114, 115, 117, 118, 119, 120, 121, 105, 106, 107, 109, 111, 112, 113, 125, 126, 129, 130, 131, 132, 133, 114, 115, 116, 119, 121, 123-76, 178, 179, 180, 181,183, 186, 188, 134, 135, 136, 139, 145, 147, 148, 189, 190, 192, 193,194, 197, 198, 149, 151, 152, 153, 159, 161, 166, 168, 169, 172, 174, 175, 180, 181, 199, 200, 206, 211,215, 217, 217, 187, 200, 201, 203, 206, 208, 210, 219, 218, 221 female, 91, 111, 123, 131, 133, 147, 211,215, 221 female, 4, 29, 147-61 148, 150, 152, 153, 162, 163, 169, 170, 172, 173, 174, 178, mistreatment of, 113, 115-19 180, 190, 206,211,218 uncooperative, 117, 172, 206 patriarchy, 16, 20 male, 8, 133,146,147, 148, 149,150, patriarchal: 153,158, 159,161, 165,167,211 culture, 18 resident, 58, 109, 112, 113, 114, 115, 116, 119, 127, 130-2, 174 logics, 16 performativity, 15 senior, 112, 113, 115, 131, 148, 217 performative: sex of, 131, 194,211 obstetrics, xv, 6, 14, 17, 19, 20, 40, 42, act, 197 action, 192 59, 91, 103, 124, 126, 127, 141, 153, 222,224 perineum, 119, 198 biomedical, 20 personnel, 11, 31, 33, 36, 37, 46, 47, modern, 19, 20, 126, 141 50, 51, 52, 53, 57, 62, 80, 81, 90, setting, 148, 194, 208 108, 129, 158, 151, 213 local, 63 olive oil, 55, 72, 76, 77, 92 operation theatre, 112, 113, 116 medical, 37, 46, 51, 62, 63, 80, 81, 90, 108, 129 151,211 Ottoman Empire, 11, 23, 33, 40, 46 paramedical, 11, 33, 53, 57 pain, 4, 72, 107, 116, 118, 119, 162, qualified, 36, 83, 213 168-71, 174, 184, 186, 199, 200, shortage of, 37, 53 pharmaceutical pain relief, 199, 203, 202, 203, 205, 207, 217 205, 206, see also painkillers painkillers, 104, 120, 167, 206 physician, 1 Palestine, 22, 26, 28, 29, 34, 35, 36, British, 27, 29 37, 38, 39, 40, 42, 44, 45, 46, 69,

female, 29, 30, 60, 124, 147, 153, 174 Jordanian, 48, 126, 162, 167 male, 29, 40, 99, 124, 147, 148, 150, 153, 175, 175, 194, 210 number of, 11, 53, 57, 59, 62, 99, 111, 132 private, 13, 59, 138, 139, 140, 145, 152, 156,188 resident, 104, 111, 112, 113, 121 Transjordanian, 23 physiology, 58, 101, 112, 163, 183 placenta, 4, 83, 101, 107 Point Four, 48, 86 postcolonial: health, 49, 59-63 period, 11, 18, 20, 52, 59, 63, 69, 78, 79 state, 1, 142 post-partum, 9, 29, 54, 101, 116, 117, 192, 213, 222, 224 room, 116, 117,211,213 power, 12, 13, 14, 15, 16, 18, 21, 43, 51, 67, 70, 79, 80, 106, 110, 142, 148, 150, 165, 166, 181, 182, 185, 186, 192, 196, 218, 224 mychrophysics of, 12, 70 relationships, 15, 16, 79, 80, 106, 114, 124, 150, 182, 185, 192, 221

pregnant women, 1, 3, 4, 5, 6, 7, 8, 9, 12, 14, 15, 17, 19, 47, 49, 50, 31, 53, 55, 70, 77, 96, 98, 121, 124, 129, 136, 138, 139, 140, 141, 145, 148, 149, 151, 152, 154, 155, 157, 158, 159, 164, 166, 169, 173, 174, 182-92, 194, 205, 218, 225 relationships with obstetricians, 145-52 prenatal screening, 89 Professional Association of Nurses and Midwives, 95, 96 primigravida, 9, 106, 117, 146, 147, 195, 199, 200 privacy, 5, 130, 134, 206, 208, 211 pubic hair, 129 Qarinah, 76

Red Crescent, 86, 96 Red Cross, 48, 86 religion, 20, 69, 180, 193 religious leader, 100 religious precept, 100 reproduction, 3, 16, 24, 34, 42, 43, 48, 53, 54, 63, 66, 94, 99, 154, 158, 164, 168, 181, 185, 188, 221 reproductive: behaviour, 158, 224 capacities, 18, 100, 164, 165, 169 cycle, 64 decisions, 93, 165 habits, 40, 74 life, 142, 186, 223 practices, 3, 17, 95 process, 2, 105, 182, 204, 208, 210 role, 152, 169 work, 152 resistance, 6, 16, 40, 45, 81, 85, 102, 107, 129, 133, 157, 174, 178, 191, 192, 224 risk, 35, 66, 81, 97, 141, 173, 181, 203 high, 66, 81, 97 low, 81, 141 ritual, 34, 73, 74, 75, 76, 124, 138-42, 145, 157, 170, 195 RMS (Royal Medical Services), 6, 56, 58, 60, 61,62, 66, 109, 114, 119, 123, 132, 145, 160, 187 rumours, 163-6, 169, 184 rural: areas, 15, 31, 34, 36, 65, 74, 76, 77,91 communities, 39, 52, 73 salaries, 13, 31, 38, 53, 58, 81, 104, 118,154 Salt, 23, 27, 30, 31, 32, 38, 39, 41, 45, 72, 80, 85, 90, 91, 92, 94, 144, 155 Saudi Arabia, 53, 84 scan, 8, 138, 139, 140, 141, 146, 156, 157, 164, 167, 170, 173, 188, 189, 190, 192, 193, 194, 216, 219, see also ultrasound sexuality, 16, 18, 20, 54, 71, 100, 149, 152, 182, 183, 184, 185, 186, 195, 198, 204, 224

sexual: intercourse, 133, 153, 158, 159, 161, 163, 174, 180, 183, 184 organ, 133, 149, 161, 185, 198, 208 parts, 184, 185 soap, 46, 47, 49, 78, 92 social worker, 186, 187 somatic mode of attention, 17, 197, 198 sonogram, 2, 188, 194, 218, see also ultrasound specialist, 65, 112, 125, 220 staff, 4,6, 31,38,47, 52,60,85,92,103, 104,106,109,112,114,116,117, 120,121,130,131,132,134,135, 136,138,145,147,150,152,153, 186,194,199,200,205,206, 207, 208,209,210,211, 216, 217, 224 hospital, 4, 116, 120, 121, 205, 210 medical, 106,132,136,138,152,153 paramedical, 104, 131, 136 shortage of, 110, 113, 115-19, 120 standardisation, 66 stillbirth, 218, 219 stomach, 181 subordination, 16, 20 suffering, 35, 45, 78, 85, 87, 92, 168-71, 190, 201-5, culture of, 166—7 surgical operations,127, 154, 161, 207 Syria, 3, 60, 61, 82 Syrian Protestant College, 40, 41 teacher, 1, 48, 85, 88, 89, 95, 98, 101, 103, 184, 220 technology, 15, 17, 19, 20, 91, 135, 138, 140,142,152,154,155,160, 182, 192, 212, 214, 223 high-tech, 58, 135, 136, 137, 139, 140, 141 low-tech, 56, 70, 135, 139 telephone, 90, 104, 109, 118, 125, 135 test, 2, 8, 65, 90, 140, 141, 146, 156, 167, 170, 186, 187, 190, 219, 220 blood, 2, 90 pregnancy, 146, 156, 186, 187 urine, 189 transgression, 41 transgressive behaviour, 150

Transjordan, 11, 21-33, 26-42, 44, 45, 46, 50, 70, 71, 84, 86, 88 tribe, 32, 34, 71, 76 ultrasound, 8, 138-41, 146, 156, 157, 164, 167, 170, 173 174, 181, 188-9, 190, 192-6, 216 umbilical cord, 75, 77, 83, 92, 117, 119, 162, 207,212 UNFPA, 54, 55, 63, 64,66, 93,96,224 UNICEF, 46, 47, 48, 63, 64, 86, 212 unmarried women, 87, 164, 178, 179, see also married women UNRWA, 6, 7, 78, 79, 80, 81, 97, 132, 133, 188 United States, 13, 36, 48, 60, 95, 128, 140, 162, 222 USAID, 3, 63, 64,66, 93, 111, 153, 222, 224 uterus, 83, 106, 107, 110, 119, 164, 181, 187 vagina, 92, 117, 168, 175, 183, 207, 214, 215 vestimentary: codes, 135, 191, 193, 194 rules, 135 village, 38, 61, 73, 75, 76, 77, 93, 100, 102 virgin, 163, 173, 180 virginity, 182 wedding, 92, 146, 150, 164, 180, 183, 184 night, 184 weight, 66, 109, 155, 189, 191 WHO, 28, 46, 47, 48, 53, 63, 188, 222, 224 wife, 30, 74, 85, 86, 91, 33, 34, 88, 132, 133,148,160,161,164,165,175, 179,180,184,187, 204, 216, 219 workload, 109, 113, 116, 118, 119, 120, 139, 146, 200 World Bank, 221, 223 Zarqa, 10, 31, 38, 39, 40, 50, 57, 64, 82, 86, 105, 139, 143, 145, 154, 155, 165, 190, 219

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