Rebecca Howes-Mischel Department of Sociology and Anthropology James Madison University (E-mail: [email protected])

“With This You Can Meet Your Baby”: Fetal Personhood and Audible Heartbeats in Oaxacan Public Health This article examines how amplified fetal heartbeats may be used to make claims about fetuses’ social presence. These claims are supported by the Mexican Public Health system’s selection of the maternal–child relationship as a key site of clinical intervention, intertwining medical and moral discourses. Drawing on the robust literature on cross-cultural propositions of “fetal personhood,” this analysis uses ethnographic material from public health institutions in Oaxaca, Mexico, to explore how doctors use diagnostic technology to materialize fetuses for their patients. I argue that Spanish’s epistemological distinction between saber (to have knowledge about) and conocer (to be acquainted with) is key to how diagnostic technologies may be deployed to make social claims. I use one doctor’s attempts to use technology to shift her patient from saber to conocer as illustrative of underlying cultural logics about fetal embodiment and its proof. Focused on the under-theorized socio– medical deployment of audio fetal heartbeat technology, this article suggests that sound—in addition to sight—is a potent tool for constructing fetal personhood. [fetal personhood, heartbeat, Latin America, affective relations, public health]

Dr. Analisa,1 a family medicine resident, lifts her head from the light aluminum fetal stethoscope pressed into her patient’s 23-week gravid belly. She had been timing the heartbeat with her cell phone’s stopwatch feature and now looked up, speaking to Icela for the first time: “Ok, I heard the heart and it sounds good. On account of this and the physical exam, I know that everything seems ok for your baby” (A causa de esto y el examen f´ısico, s´e que todo parece bien para su beb´e). Noting the diagnostics on Icela’s chart, Dr. Analisa tells her to set another appointment in three weeks. It is the first and last time she will see this patient, her seventh this morning, and the exam has taken 17 minutes. (Field notes, April 2008) As Maria Elena climbed onto the exam table, arranging herself so that only her 26-week pregnant belly was exposed, Dr. Celia, the gynecological MEDICAL ANTHROPOLOGY QUARTERLY, Vol. 30, Issue 2, pp. 186–202, ISSN 0745C 2016 by the American Anthropological Association. All rights 5194, online ISSN 1548-1387.  reserved. DOI: 10.1111/maq.12181

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resident, showed her a plastic fetal heart Doppler and said: “Don’t worry about your baby; see with this everyone can hear not just me. With this, you can meet your baby and know that everything is ok” (Con esto, se puedes conocer a tu beb´e y saber que todo esta´ bien). Maria Elena is her fourth patient of the morning; it is her second day in the hospital, and she has tried to establish a warm sociable rapport with them. The nurse, Ramona, has already chastised her for spending too much time with patients; so far her average is 25 minutes. (Field notes, September 2008) This is an article about how doctors communicate to women on ways to “know” their fetuses: as diagnosable objects and as social subjects. While there is a robust literature on the cross-cultural production of fetal personhood—recognizing a fetus as a social subject—much of this literature has emphasized the importance of sight in constructing fetuses as individuated. Here I query the use of sound to make similar claims by situating the above interactions between indigenous women and doctors in Oaxaca, Mexico, within extant public health discourses about motherhood, medical technologies, and affective relations. The basic structure of Dr. Analisa’s interaction with Icela could have been any of other 50 prenatal exams I recorded over nine months of participant observation in this public hospital in 2008: Doctors in their short interactions with their patients relied on their authoritative knowledge to frame information about their fetuses to their patients. Thus, I was surprised when Dr. Celia used a diagnostic technology that directly presented the fetus and framed this presentation as a chance to conocer, to know her baby as a social subject. It is notable that as she switched technical modalities, Dr. Celia also changed her rhetorical framing of this encounter by moving from using the verb form of knowing saber (having knowledge) to conocer (being acquainted).2 While subtle, and without an exact English equivalent, Dr. Celia’s shift moved the epistemological register from professional knowledge to social recognition, marshaling purportedly neutral medical technologies to facilitate a particular form of affective encounter. Dr. Celia’s use of conocer instead of saber may seem incidental, but I argue that this distinction between forms of knowing is a key element for constructing claims to fetal personhood through diagnostic technologies. Mexican public health policies have long targeted reproductive and maternal health care as a key site of modernizing the nation (Birn 2006). And, while Article Four of the 1917 Constitution guarantees all citizens the right to health, this access has lagged behind the limitations of public service infrastructure, especially in the rural mountainous and indigenous southern states. The Hospital Rural, where I conducted the bulk of my research, stood between the large hospitals in the capital city and small village clinics; medical residents completing their obligatory service year fulfilled its mission of maternal, child, and elderly care. Working in underresourced conditions and under pressure to improve maternal health outcomes while working efficiently, these doctors grappled with what they experienced as an “existential gap” (Rapp 2011) between themselves and their patients. They asked: How should they best make their medical knowledge socially and culturally meaningful so that women would “cuidarse mejor” [care for themselves better]? Dr. Celia, approached this dilemma by offering her patient an intersubjective encounter: bringing her into “acquaintance” with her fetus. Shifting from an aluminum fetal

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stethoscope to a small pink plastic Doppler fetal monitor, she transitioned from offering expert assessment of the fetus as a medical subject to offering Maria Elena, her pregnant patient, what she understood to be a direct experience of her fetus as a social subject. Deployed in the service of “better self-care,” fetal heartbeats served as both diagnostic and symbolic tools through which doctors could combine relational and medical information for their mostly indigenous patients. Focusing on the rhetorical enrollment of fetal heartbeats to make personhood claims, I am interested in how diagnostic technologies may be used to assert social and political claims about women’s need to know their fetuses as publicly social subjects. The use of fetal heartbeats as evidence of bio–social personhood reflects an unmarked slide from saber to conocer or a slippage from a form of knowing about bodily materiality to a form of knowing predicated on social recognition. These claims are linked through logics that travel alongside the global circulation of medical technologies (Oaks 1999)—namely, that they are able to deliver universally legible information about the social status of the fetus. Technological mediation (ultrasounds or fetal Dopplers) alone are not enough; instead, women must learn to sense their fetuses as publically social entities through the narrative logics of their cultural and political reproductive milieus. While the women I interviewed in the Zapotec village just outside the Hospital Rural laughed at the idea that their ultrasonic images might be “baby’s first picture” (Mitchell 2001) and usually left them archived in their medical charts, ultrasonic fetuses were prominently featured in the baby albums their relatives in Southern California proudly showed me. This is not to say that the availability of technology determines women’s experience of their pregnant bodies and fetuses (Mitchell and Georges 1998), rather that diagnostic information is increasingly incorporated into broader cultural (and transnational) narratives about the possibilities for sensing fetal bodies as extant persons. This argument draws together two related pieces: first, the uses of diagnostic technologies to make specific claims about personhood as connected to relational love and second, the presumed ontological status of heartbeats as a key and shared signifier of personhood. While much of the classic literature on fetal personhood has focused on their emergence within North American pregnancy cultures (Mitchell 2001; Petchesky 1987; Taylor 1998, 2008), here I argue that doctor–patient interactions in a small rural hospital in Oaxaca present a window onto the emergence of the underlying logics through which fetuses are made to seem obvious and commonsensical. There, Dr. Celia’s expectation that Maria Elena could (and should) conocer her baby reflects a long history of Mexican public health institutions rhetorically medicalizing maternal affect, as clinical attendance is linked to showing “a mother’s love” and better “self-care.” To expand the discussion about how fetuses are made into social and cultural subjects, I focus on the enrollment of particular kinds of diagnostic proof into longstanding narratives about gender, bodies, and the importance of medical expertise in reorienting the relationship between maternal knowing and feeling. Feminist anthropologists have productively explored the emergence of fetuses as being at a frontier of possibilities for personhood, illustrating that persons—or invading wandering spirits or the fleshly evidence of sustained human and non-human relationships (Conklin and Morgan 1996; Morgan 1989)—are “made” through

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(and from) ideas about developmental potential (Kaufman and Morgan 2005) and social recognition (James 2000). Fetuses are incarnated cross-culturally as both material subjects and symbolic objects through “epistemic choreographies”3 of individuals, ideologies, and institutions that reveal powerful ideas about gender, personhood, kinship, and health. Just as biological viability is a cultural achievement (Christoffersen-Deb 2012), so, too, is social recognition. Living fetuses are, by their very nature, publically accessible only through mediation, and these narratives also illustrate potent ideas about how to sense a fetus as an ontologically self-evident “person.” The rich literature about the authoritative claims made by the uses, reuses, and appropriations of fetal ultrasound images in medical, personal, and political domains (Gammeltoft 2007; Georges 2008; Mitchell 2001; Oaks 2000; Petchesky 1987; Taylor 2008) has largely focused on medicine’s authority to “picture” “the baby” against pregnant women’s centrality for asserting knowledge claims. Here, I focus on the under-theorized socio–medical deployment of audio fetal heartbeat technology, arguing that sound—in addition to sight—is a potent tool for constructing fetal personhood. These claims rely on the heart’s niche within the Western bodily imaginary as the site of both energetic and emotional life, which is crucial for this slippage between medical and social knowing. Anthropologists have increasingly attended to the senses (Classen 1997; Howes 2003; Porcello et al. 2010; Stoller 1997), and to sound in particular (Erlmann 2004; Feld and Brenneis 2004; Samuels et al. 2010), to understand the materialization of social worlds. I draw on these literatures to illustrate that the mobilization of fetal heartbeats as technologies of truth rely on deep assumptions about hearing as a practice of objective, and yet intimate, public sensing. Ultimately, I argue that these epistemic choreographies reflect presumptions about the use of technological evidence to make deeply moral claims about the necessity of a specific mode of “knowing” (conocimiento) fetal life to “place the unborn” (James 2000). While for centuries mothers’ haptic reports of kicks and flutters transformed fetuses from potential to present subjects, new diagnostic technologies have reshaped public expectations that fetuses can be directly experienced without maternal mediation. These directly experienced, yet mediated, fetuses emerge through the imbrication of diagnostic authority and affective rhetoric that reframes maternal care as an apt moral target for public health intervention (paralleling shifts in expectations of mothers’ and fetuses’ separable medical interests; see Casper 1998; Wendland 2007; Williams 2005).

Research Methods and Ethnographic Context The symbolic and practical challenges for constructing coherent public health narratives about pregnancy animated my nine months of ethnographic fieldwork with public health institutions, indigenous communities, and their sites of intersection in 2008. Based primarily in a regional hospital and two small community clinics (one a satellite of the hospital) in Oaxaca’s Central Valley (southern Mexico), I shadowed community health educators who served as initial sites of contact between these institutions and the surrounding communities; family practitioners as they enrolled women into medical practices of diagnosis, surveillance, and accounting; and obstetricians as they covered those patients whose condition was labeled “higher risk.”

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At different phases of the project, I interviewed the program directors of six local nonprofit organizations, including an urban health clinic, about their work. Research in the out-patient clinic of the regional hospital serves as the primary basis for this article. During this period there were five family doctors and one obstetrician staffing the clinical wing, all of whom were completing a mandatory service period within the public health system; my research period coincided with the end of one cohort’s service period and the beginning of another’s, enabling me to observe how new doctors were socialized into culture of the hospital. Within the hospital, I traced the institutional circuits pregnant women moved through—from nurse to doctor, from social worker to lab—conducting informal interviews with women and their families about their care-seeking deliberations. Moving between the crowded waiting room and cramped exam rooms, I observed socio–medical encounters between 60 pregnant women and their doctors, 50 of which I recorded, all augmented with detailed notes. During days in the hospital, I shadowed a specific doctor and observed and recorded all of his or her interactions with pregnant patients. After exams, I conducted numerous short informal interviews with the doctors during which they elaborated on the previous exam, contextualized their concerns within larger demographic, reproductive, and health politics, and generally served as ideal key informants. To the extent possible, I interviewed women about their experiences in the waiting room either before or after their visit. To complement this institutionally centered research, I conducted further community-based research in a local Zapotec village through which I learned about the home life of lay individuals and medical narratives about pregnancy, health, and care. Following the nine months of research in Oaxaca, I spent another nine months with Oaxacan immigrants in Los Angeles researching immigrant home life and their reproductive health practices. I situate my ethnographic research within a larger set of narratives (anthropological and national) about Oaxaca as particular place within Mexico—a place that inspires odes to its cultural and ecological diversity and consternation about its low place on development indices. Within the Mexican national imaginary, Oaxaca is prefigured as an “indigenous state” and one marked by the statistics of poverty—not only high rates of maternal mortality, but also child malnutrition and illiteracy— and these two indices are conjoined as indigenous women have approximately three times the risk of dying in pregnancy or childbirth as non-indigenous women (cited in Mills 2006). Over the last hundred years, rural public health (as both a revolutionary ideal and an indicator of a particular kind of modernity) has been a site of increased cultural and political interventions for crafting a modern Mexico (Birn 2006). Yet, the lag of investment in rural and indigenous regions points to the interstices between the ideal and instantiation of Mexico’s public health promises. Oaxaca’s current high rates of maternal mortality not only reveal lapses in the state’s ability to care for its most marginalized populations’ public health responses but also magnify long traditions of national and international attention to indigenous women’s pregnant bodies as in need of more responsible and scientific intervention (see also Smith-Oka 2012). Public health professionals in rural Oaxaca are thus faced with a challenging mandate: Improve the region’s epidemiological profile in a context of high patient loads, under-resourced clinics staffed by doctors rotating through their national

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service obligations, and deeply entrenched narratives about the cultural differences within their largely indigenous catchment area.

Mexican Public Health, Maternal Affect, and Expert Knowledge The logic of care that structures Mexican public health institutions’ approach to preand postnatal health already displays an entanglement between the forms of knowing marked by saber and conocer—or affective relation and expert knowledge. The Mexican State began medicalizing women’s reproductive practices and childbirth in the 1970s as part of larger projects to modernize the nation and its population (Sesia 1996). Not only are women required to demonstrate their regular attendance at prenatal consults and pregnancy education workshops in order to qualify for public assistance (Smith-Oka 2009), but clinic staff taught women “medical” breast-feeding techniques, with the explanation that this was the best way to “show a mother’s love.” This invocation of love as taught by and mediated through public health institutions was replicated in the large colorful clinic-sponsored murals that dot the walls of rural communities, reminding women to “think of their children” and choose a family planning method. Yet, while women are encouraged to approach prenatal health as an important reflection of their affective relationship with their child (present or future) using terms such as “love” and “consideration,” medical professionals in the clinic stressed the importance of their expert knowledge and ability to know (saber) women’s health. Emphasizing that their diagnostics were based on science, whereas women might come into the clinic with beliefs (creencias), doctors socialized their patients into medical subjects through didactic routines about how to properly account for their pregnancies. Under their own pressures to improve epidemiological outcomes in the face of exhausting patient loads and the lack of sophisticated machines many were accustomed to, the residents themselves were institutionally steered away from an emphasis on sociality largely due to time pressures (as seen in the September field note excerpt). Thus, while a logic of affective connection was used to bring women into the clinic’s domain, inside the exam room, women’s affective relationship and ability to conocimiento their baby was filtered and reframed through a doctor’s ability to know (saber) through the mediation of diagnostic technologies. However, what I argue is that this context sets the stage for the very interaction that structures this article, that Dr. Celia’s shift from saber to conocer is ultimately consistent with (and perhaps productive of) a cultural logic of fetal personhood that relies on ostensibly neutral and transparent information about the biological body to make social and emotional claims.

From Saber to Conocer “Is it moving, right now, your baby?” On her second morning as the resident gynecologist in the small regional public hospital, Dr. Celia was having trouble finding a fetal heartbeat. Her patient Maria Elena, an 18-year old woman about 26 weeks pregnant, had just been referred by one of the hospital’s general family practitioners to the specialist due to a concern about her possibility for pre-eclampsia4 — a common experience of triage and referral in this facility. With medical encounters

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structured by the protocols of a highly centralized health system and the demands of seeing 20–30 patients a day, the work of routine prenatal care in this site was often truly routinized. What was unique about this visit was Dr. Celia’s current task: attempting to both find and share Maria Elena’s fetus’s heartbeat using her personal plastic electronic fetal Doppler. Over the course of the six months that I had been conducting observations of prenatal exams, I had grown accustomed to the doctors’ reliance on haptic rather than technological diagnostic techniques— especially manually feeling the fundus for placement and using a small metal fetal stethoscope (similar in design to an ear trumpet) to detect the pace of fetal heartbeat. Although listening to the heart’s beat was central to this basic sequence, it was a silent assessment based on expert listening in which the only public sound was a loud “plopping” sound as the doctor created amplifying suction for the scope. Once she had manually assessed fetal position and placed the small hollow “horn,” the doctor leaned her ear into the amplifier’s flat end and tracked the fetus’s heartbeat using her watch or personal cell phone timer. This technology required practices of expert listening to detect and evaluate fetal cues for clinical diagnostics— as I discovered in my recurrent inability to distinguish the fetal heart from other bodily gurgles in spite of doctors’ careful guidance. In these Oaxacan rural public health contexts, fetuses usually emerged as knowable and social phenomenon only through diagnostic and second-order mediations—i.e., through doctors’ assessments and women’s bodily experiences, rather than through an immediate audio–visual appearance as is normative in U.S. fetal encounters. Doctors without access to the kinds of immediate diagnostic equipment that have become standard within cosmopolitan medical settings sent patients into the capital city for ultrasound exams and assessed the visual results upon return. Patients rarely expected that doctors would engage in the kinds of affective labor that often characterizes the socio–medical experience of fetal sonography in the United States in which diagnostic information is transformed into the substance of parental bonding. In contrast, most rural Oaxacans shook their heads with disbelief at the notion of a seeing their baby in a meaningful social dimension, noting that ultrasound images belonged in the hospital record instead of a photo album. They were medical artifacts, and parents “personed” their fetuses through other haptic and interactive forms of knowing that relied on movement, bodily placement, and maternal cravings (Howes-Mischel 2012). Doctors in the rural hospital reinforced the separation between objective medical information and what they glossed as cultural knowledge (lit., creencias, beliefs). In their (often brief) exams, doctors emphasized the strength of their professional knowing, using forms of the verb saber—i.e., fetuses were the subjects of clinical evaluation and description rather than being intersubjective participants in these encounters. While doctors acknowledged that women already had social and affective ties to their fetuses, these ties were not the subject of the clinical encounter. Doctors followed a standard language practice of using “baby” in ways that acknowledged that these fetuses were already enmeshed in relational and affective ties, using “fetus” only in their discussions of hypothetical standards. For example: “When a fetus is 15 weeks old it is small, like this size [he shows her the space between his hands], kind of like a small tortilla, your baby is this big [gesturing with his hands wider] so the dating must be off.” One doctor, Dr. Alfredo, who often incorporated

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explicit moral and affective messages into his work with patients whom he deemed inadequately prepared, even coached these messages as “knowledge about” not “acquaintance with.” In his occasional practice of drawing fetal caricatures on his adolescent patients’ bellies to “make it real” for their absent partners, he emphasized that would promote better knowing rather than better acquaintance (saber rather than conocer). Although Dr. Alfredo clearly promoted a form of relational knowing that implicates the absent boyfriends’ affective orientation—having more knowledge about fetal development should lead to his greater involvement in the pregnancy— his mode of persuasion emphasized the knowledge that “it will be a real baby soon.” Dr. Celia proposed something very different in her work with Maria Elena. Instead of giving knowledge about, she would enable acquaintance with. As Maria Elena lay on the small room’s exam table, Dr. Celia worked with her gravid belly following the standard practice of feeling and listening diagnostics. While the exam had initially been structured by her medical assessment of Maria Elena’s risk possibilities—“I know that you are worried, that is why they sent you to me, but from what I hear, I know (saber) that he sounds ok”—Dr. Celia now shifted the emotional register toward one of sociability. Presenting the small machine with a smile she explained: “Look, with this you can really meet (conocer) your new baby. Everyone can hear, not just me.” In this moment she moved from addressing Maria Elena’s fetus as a medical subject to a potentially social and intersubjective one. Earlier that morning when I had asked the gynecologist how she was going to approach this year of service in an unfamiliar region working with a population whose epidemiological profile raised concerns within the national medical community, she emphasized the importance of affective as well as effective medical work: They come to me because of concerns, you know that they have to be referred from the other doctors. So I think that’s important for them to really understand what’s going on, to make it real and to show them that it’s all ok. So I help them meet the baby. Then, after this, they can understand the process better and maybe it helps them care for themselves better. The other doctors could pronounce “your baby’s heart beat sounds good, everything is ok,” but Dr. Celia would instead offer direct (and presumptively unmediated) proof as to its presence—i.e., rather than make an assessment based in expert listening, she would offer Maria Elena a direct experience. In this shift, both linguistic and technological, she moved from knowledge about to acquaintance with the fetus as an immediately social presence, albeit a technologically mediated one. While Dr. Celia drew on her medical training and professional knowledge to frame the diagnostic sequence, here she suggested that Maria Elena did not need this expertise to recognize her fetus as a social person. Merging her clinical emphasis on teaching women to “care for themselves better” with a more jocular attempt to bond with her patient over this experience, Dr. Celia posited that through sound both she and Maria Elena (and the observing anthropologist) can together meet her baby. Tinny static sounded as Dr. Celia moved the ultrasonic probe across her belly, and Maria Elena lay quietly. Finally, we could all clearly hear a rapid and recognizable pulse emerging from the tinny speakers. “There it is, you hear that?” Nodding briefly to acknowledge an aural presence, Maria Elena made no other responsive gesture

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and quickly straightened her clothes when the doctor abandoned her attempts to engage in this form of sociality. When I caught up with Maria Elena in another wing of the hospital later that afternoon and asked her what she had learned from Dr. Celia, she shrugged, “The doctor said that baby is doing ok, so I learned that’s good. That’s all.” For her, the fetus in the exam room remained an object of medical rather than personal engagement as Dr. Celia had framed the encounter—Dr. Celia could know (saber) the fetus’s health status but Maria Elena did not know (conocer) her fetus through its aural presence (as opposed to their existing haptic engagements).5 This medical encounter was in many ways an example of the quotidian experience of delivering public health amid complicated expectations about medicine, pregnancy, and development. Yet, this mismatch of expectation and interpretation reveals something more about Dr. Celia’s presumptions about the easy collapse of social and medical knowledge in her seamless transition from diagnostic knowing to social acquaintance—from saber to conocer. It is this collapse that underpins much of the implicit power of fetal heartbeats’ power as technologies of ontological proof. That is, she was implicitly making an argument about fetal ontology bolstered by a kind of public declaration—the fetus could, with her assistance, assert its own intersubjective ability to be “met” with its heartbeat. Further, tying this recognition to “better understanding,” Dr. Celia simultaneously makes a medical and affective claim about Maria Elena’s need to know her fetus in new technologically mediated form.

From Seeing to Hearing the Fetal Person This slippage between an amplified heartbeat and maternal–fetal recognition exemplifies complicated negotiations over the claims of diagnostic technologies and the construction of fetal personhood that animates much of the anthropological scholarship on fetal subjects. Much of this literature focused on fetal personhood has stressed the importance of “seeing” the body as the result of a mediated process that fuses the technological and the embodied (Petchesky 1987). This vast and productive literature that has illuminated the pleasures, politics, and production of fetuses as multifaceted and contested social and political phenomena (Casper 1998; Mitchell 2001; Mitchell and Georges 1998; Taylor 1998, 2008) largely emphasizes the relationship between visuality and “objective” ontological status (Daston and Galison 2007). While fetal subjects are not necessarily cross-culturally intelligible as autonomous persons (Conklin and Morgan 1996; Gammeltoft 2007; Georges 2008; Mitchell and Georges 1998; Morgan 1989), American expectations about seeing embodied personhood circulate globally alongside the spread of diagnostic technologies and anti-abortion rhetorics (Oaks 1999). In visual forms the fetus emerges as a “mechanically objective” whole person (Palmer 2009), incarnated through the classic 3-quarter profile technicians work hard to present to the expectant parents. Indeed, the expansive literature on fetal personhood stresses the ease of “disembodying” the fetus from the maternal body because of presumptions about the objective nature of the sight of a human figure. Nilsson’s (1965) classic and stillused book of medical photography illustrated that within American reproductive cultures, “a child is born” when it can visually float outside the womb as a recognizable human “person.”6 As the routinization of fetal ultrasounds accelerated,

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parents, families, and publics have learned to interact with visibly mediated fetuses as subjects already enmeshed in family contexts and public politics (Draper 2002). Through these visualizing practices, a specific kind of personality is read from the body; parents and families construct narratives about knowing their fetus through a recognition of heritable features such as ears and noses while also animating them as (often gendered) subjects through intrauterine activity (Han 2008).7 In these interactions, the fetus gains its ontological status from the integration of visual mediation, expectations about how to recognize a person as fleshly embodied, and incorporation into familial and affective relationships. As fetal images circulated from laboratory and clinical settings into popular culture and familial domains, they have become enmeshed in extant debates about the nature of personhood, its connection to biological materiality, and abortion politics (Condit 1994; Dubow 2011; Gilbert and Howes-Mischel 2004). As Condit (1994) argues, the rhetorical deployment in American anti-abortion activism since the mid-1970s of the fetus as concretely and already human has heavily relied on photographic proof of its material form and substantiality to anchor their claims—i.e., the ability of non-expert audiences to see a developed rather than developing person. Similarly, Petchesky’s (1987) classic analysis of the centrality of visual evidence to build a public discourse of fetal personhood as already empirical and self-evident highlights the enrollment of medical and diagnostic images to make political and cultural claims. While her analysis presciently tied the semiotics of visuality and photographic images to multivalent practices of surveillance and affective attachment, I argue that aural cues offer similarly evocative potential to imbue fetal biology with social significance. Sound, like sight (and unlike smell or taste), is phenomenologically understood to exist independently of an observer’s subjective perception—once he or she has learned how to hear. Further, although anthropologists have persuasively argued against universalizing from American reproductive politics (Luehrmann 2013, Mitchell and Georges 1998, Morgan 1989), Oaks’s research in Ireland (1999), and my own observations in Mexico point to the traction that these narratives can have as resources for translocal activism. In the United States, we can also see an entangling of medical, cultural, and political discourses in the rise of informed-consent abortion restrictions. Taking fetal personhood as a settled (rather than contingent) claim, anti-abortion activism since the 1992 Supreme Court Casey decision8 has pursued an effective and affective strategy to incarnate the fetus as a social person (Halva-Neubauer and Zeigler 2010); the 22 states that currently mandate ultrasounds before termination rely on this preexisting discourse about the affective force of fetal bodies (Sanger 2008). The ability to give informed consent to a medical procedure is thus seemingly predicated on a presumed objective emotional response to an already symbolically dense sight that has been incorporated into normative practices of bonding and attachment; Hopkins et al. (2005) argue that this is also central to British abortion politics. Following the marginal success of mandated ultrasounds, American activists have turned to fetal heartbeats to amplify their claims that social and legal personhood is tied to the energetic and material body. Ultrasound images and audible heartbeats are thus both employed to provide “better information” through already emotionally laden mediated forms—knowing and feeling are tied in these propositions (even as “personhood bills” remain heavily resisted and face strong legal challenges). New

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movements to tie personhood to abortion restrictions emphasize the symbolic and emotional importance of the heart to signify social “aliveness.” However, unlike early personhood claims that rely on displays of the fetus’s physical form, the heart gains its lay epistemic traction from the mediation of its sound rather than sight, although medical practitioners rely on visual cardiac assessments as well. If sonograms are thought to derive a large part of their lay affective and empirical power from an ideological association between seeing and objective believing, it is sound rather than sight that makes the heartbeat persuasive outside of diagnostic contexts. While clinicians rely on a complex combination of aural and visual fetal heart rate and tone patterns to provide crucial data about fetal health and development, this is information that is not accessible or legible to patients—especially those served by Oaxaca’s rural public clinics. The heart’s symbolic pliability was especially evident at a free women’s health fair in Oaxaca City in which women were given basic ultrasounds alongside sexual health information and diagnostic screenings. After her screening, one pregnant woman returned to her friends as they conferred about what they had each learned in their consultations. Showing off her fetus’s facial features on the creased blackand-white print out and recounting that “they showed it moved well,” she was momentarily stumped when one of her friends pointed to the other quadrant and asked, “Where’s the baby in here?” Laughing, she peered at the spikes and valleys of the heart’s visual patterns and concluded: “This is a forest and the baby is lost. He’s in the forest, all I see is a forest. He is only [in the image] above.” Visually frozen, the heart remains a clinical and diagnostic artifact, only its aural quality animates it as a potentially social and intersubjective presence—yet its sound must also be mediated into public through medical practitioners’ expert amplification and transformation.

Hearts and Sounds Within the Western bodily imaginary, the heart occupies a tricky position as both the mechanistic pump at the hub of a body’s ecosystem and the symbolic center of personal and emotional life; it is in this dual sense of mechanistic and subjective life that fetal heartbeats are employed to bridge diagnostic and social registers. The heart in popular and clinical discourse is more than just another body part (Bound Alberti 2010), fusing biological and symbolic expectations about the heart as at the center of human life.9 While moves to redefine proof of life from heart to brain have been largely driven by the intersections of advances in life-support technology, a need for healthy transplant organs, and culturally informed values (Lock 2004), literature on the aftermath of transplantation illustrates the traction of the heart’s sentimental distinction within the pantheon of organs, poignantly illustrated in the emotional labor required to integrate a transplanted heart into an embodied person (Sharp 2006). The heart is more than simply a mechanistic pump—symbolically laden, it regulates both blood circulation and affective sentimentality. Thus, when Dr. Celia tells Maria Elena that she will “conocer tu beb`e” through the sound of its heart, she is proposing that the sound of the fetus’s heart is a “voice” that communicates something obvious and persuasive about its social presence— about the possibility of an intimate intersubjective exchange based on a heartbeat’s

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aural presence. This is a proposition very similar to the one Taylor (1998) classically explored as an ultrasound image that asked parents, “Is something inside you telling you to buy a Volvo?” Or the subsequent AT&T advertisement in which a fetus responds to (and bonds with) his father by kicking when the phone is held up to his mother’s belly—ironically selling a product called “True Voice” (Taylor 2008). Yet, these instances of entangling love and intersubjective communication with fetal development rely on an audience to “translate” fetal communication—in the latter example the mother’s body literally is the instrument of its communication. While the consuming fetus in Taylor’s analyses makes public claims, the proposition underlying the alignment of heart’s sound and the social knowing of conocimiento is slightly different. In this proposal, the technological interface amplifies an already existing voice rather than translating it into being; with the selection of a symbolically laden sound as a vehicle for intersubjective relationship, fetal personhood is then located in the mediation of a biological body. Further, heartbeats’ “obvious” ontological status as a kind of social proof relies on the entangling of this particular socio–medical discourse about the heart as the site of both bio–mechanical and emotional life and expectations about the objective transparency of sound (Erlmann 2004; Samuels et al. 2010) as a kind of shared and public sensing of this life. It requires technological mediation to assert a public (or social) presence—i.e., we sense our own hearts primarily through a language of beats and pulses and those of others through sound and amplification. Yet, ultimately, for a life to be transparently illustrated by sound, this technological mediation must be subsumed. When Dr. Celia suggested that Maria Elena would conocer her fetus as a social person, she attached a particular kind of social and affective claim to the signal of a heartbeat. Her pronouncement that it was this publicly broadcast sound that would trigger this social recognition further suggested that Maria Elena did not already have an incredibly intimate and bodily relationship with her fetus as an independent subject. This kind of technological trust that ultrasonic mediation amplifies something already present rather than producing a “new” subject, I would argue, also undergirds more explicitly politicized claims about the social status of fetal bodies.

Personhood Claims, Diagnostics, and Maternal Affect What ties a routine prenatal exam in Oaxaca to reproductive politics in the United States is their reliance on the sound of fetal heartbeats to incarnate social personhood and the importance placed on women’s recognition of this sound as an expression of good mothering. There has been scant anthropological attention to the epistemological underpinnings of the medical and moral production of fetal personhood through sound, and this article seeks to expand the registers through which we approach fetal personhood as a negotiated status. As diagnostic technologies are deployed to provide proof for propositions about embodied registers of subjectification, they collapse social and medical claims about what it means to recognize life. Implicit in these transformations is a moral claim made about the need to make women aware of their fetus’s existential presence by offering non-haptic proof. How might Dr. Celia’s understanding of her patients’ risky epidemiological profile have influenced her insistence on shifting from a diagnostic register of assessment to an

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affective one of recognition? The claim about the necessity to know implies that Maria Elena’s affective relationship with her fetus is a medical concern and is key for improving health outcomes. As particular ideas about the symbolic importance of the heart’s sound as a key register of social knowing gain ontological traction, they open a discursive space in which to make specific claims about what it is to be (and recognize) a person. These claims about how what it means to objectively know through sensed information are key to the various politics—of poverty, indigeniety, and nationalism in Mexico—through which the fetuses’ significance exceeds medical and diagnostic landscapes. In these moments of coming to know, women are implicitly encouraged to make “the baby real” in socio–moral rather than either purely diagnostic or haptic frames—and this “better” knowing is tied to their future actions. These fusions of technical and sentimental registers of knowing illustrate the enrollment of clinical and technological assessments to mediate between biological viability and social personhood. As Christoffersen-Deb (2012) illustrates, fetal viability is achieved through interactional work and biological development together via “recalculation through social, medical, and legal practices” (p. 587). At the margins of embodied life, medical personnel must work with families to recognize possible outcomes by negotiating between diagnostic, affective, and moral ways of knowing (Weiner 2009). Foregrounding this production of a diagnostically medicated social subject as a kind of existential gap (Rapp 2011) highlights the degree to which participants in clinical encounters must rely on a presumption of a shared understanding about the bodily object on hand or actively work to achieve it—i.e., Dr. Celia leaves implicit the expectation that she and Maria Elena have a common understanding of both the materiality and mediation of this proof of life. As medicine’s diagnostic tools are marshaled to make social and existential claims, they circumscribe the sensorial terrain through which embodied subjects are publically recognized and leave implicit the collaborative work required to instantiate consensus. As we are asked to recognize the fetuses’ social presence and affective pull in a specific sound, it is imperative to also recognize them as complex assemblages of clinical, moral, political, and interpersonal epistemologies.

Notes Acknowledgments. This research was made possible in part by support from the Wenner Gren Foundation (Grant #7615). I am indebted to the generosity of the women and medical personnel who allowed me into their lives and exam rooms. This manuscript has benefited greatly from on-going conversations with Rayna Rapp and Damien Stankiewicz.

1. Pseudonyms are used for all people and institutions discussed in this article. 2. Spanish has two words for “to know”: saber and conocer. The first describes possessing information about the subject or object, while the second refers to having a personal relationship or familiarity with the subject or object. In large part, the interaction between Dr. Celia and Maria Elena turns on the subtle distinction between these two forms of knowledge.

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3. In characterizing fetal personhood as the result of “epistemic choreographies,” I am drawing on Charis Thompson’s insight that relatedness is actively made through “ontological choreographies” in which families and medical practitioners creatively draw on technological objects to construct both themselves as persons and their relational ties (Thompson 2005). 4. Pre-eclampsia is a common life-threatening and yet etiologically confusing condition indicated by high blood pressure and protein in the urine. The doctors with whom I worked spoke extensively about the condition when I asked them to tell me about local reproductive health concerns and drew associations between their worries about pre-eclampsia and local rates of maternal mortality. 5. This is not to say that Maria Elena did not already have an intersubjective relationship with her fetus nor that she is rejecting Dr. Celia’s diagnostic assessment. Rather, Maria Elena is rejecting the invitation to engage intimately with her aurally mediated fetus in this form and location. 6. As many feminist analysts have pointed out, Nilsson’s photos actually used aborted and miscarried fetuses to pose as their subjects. Yet his visualizations were (and are) used to dramatically conscript views into the belief of the relative autonomy of fetuses-as-embodied persons. 7. Although English does not make this distinction, narratives about intrafamilial knowing rely on the same sentiment of conocimiento as Dr. Celia proposed, parents often describe routine ultrasounds as both offering a kind of existential reassurance and providing a window into their future child’s personality and learn to engage with their mediated fetuses as if they were already-born infants. 8. The 1992 Supreme Court Decision in Planned Parenthood of Southern Pennsylvania v. Casey upheld a woman’s Constitutional right to an abortion but allowed states to regulate abortions before viability as long as these restrictions did not place an “undue burden” on women’s access. 9. The relative hegemony of biomedical explanations of the body in Mexican public health discourses (Finkler 2000) suggests an equivalence between Dr. Celia’s and Ohioan legislators’ expectations about the importance of the heart’s beat.

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