Corresponding Author: Joan M Humphries, RN PhD Nursing, University of Victoria Email: jmhumphr@uvic.ca Journal of Applied Hermeneutics ISSN: 1927-4416 August 3, 2023 ©The Author(s) 2023 DOI: 10.11575/jah.v2023i2023.77836 The Pull of the Stars: Reflections on Perinatal Nursing from Pandemic (1918) to Pandemic (2019) Joan Humphries & Lenora Marcellus Abstract Global pandemics have been increasing in frequency over the past several decades, with infectious diseases constituting the third leading cause of death worldwide. Emma Donoghue, in her novel The Pull of the Stars, tells the story of Nurse Julia Power, working in an Irish maternity ward at the height of the 1918 influenza pandemic. During a period of three days, she is responsible for caring for expectant women with influenza who are quarantined together. In this paper, we draw on themes from this novel, employing Heideggerian and Gadamerian hermeneutic tenets as a central approach for analysis and interpretation. The perinatal experience for those described in the novel, as well as a century of experience for women and nurses, underscore the profile of the perinatal realm, and its implied meaning for Dasein. We describe experiences of maternity care as described in the Canadian Nurse journal (1905 to 2019), which contribute to a context of both evolving and unchanging conditions. We identify themes relating to practices of infection control, privacy, dignity, and holistic care and integrate these ideas in the discussion. The historical and contemporary ethical and practice tensions bear consideration for emerging and future impacts from the COVID-19 pandemic on nurses, families, and perinatal nursing practice. Keywords Pandemic, nursing, childbirth, maternity, perinatal When drawn into a piece of literature, the immersive experience of becoming “transported” can occur for the reader – across geography, across experience, and across time. For two perinatal Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 2 nurses (authors Humphries and Marcellus), the experience of reading Emma Donoghue’s 2020 novel The Pull of the Stars had the effect of transporting us into 1918 Ireland. We found ourselves catapulted into a paradoxical journey of familiarity/ revelation, as we contemplated the sameness/divergence of maternity care during the 1918 influenza pandemic, and maternity care during the 2019 COVID-19 pandemic. Donoghue tells the story of Nurse Julia Power, working in an Irish maternity ward at the height of the 1918 influenza pandemic. During a period of three days, she is responsible for caring for expectant women1 with influenza who are quarantined together. Pre-Understandings In Donoghue’s (2020) novel, the lives of the birthing women and their infants are very much at risk. The bravery and heartbreak of the individuals that she depicts in her writing invites broader understandings of the experience of giving birth, and in particular, giving birth during a pandemic. Her work also inspires a cascade of scrutiny about perinatal practice then and now. The interweaving of sources, ideas, interpretations, and reflections of our analysis constitute what Jardine (2012) describes as “crisscrossing.” The crisscross for us as authors fuses together as an “altogether” sort of awareness, combining the parts and the whole of our ruminations. An historical vision of perinatal nursing practice emerges, across the time span of two pandemics, with implications that extend beyond the incursive intrusion of large-scale societal disruptions such as pandemics into the everyday experience of birthing. Dialogical rigor underpins hermeneutic reading (Moules et al., 2015), as a way to “keep the conversation going” (p. 68). As Marshall (2004) describes, the task of hermeneutics is entering into dialogue, involving an interplay with the text, encompassing question and answer. We access the texts of varietal resources to inform our interpretations. In addition to accessing the novel, for example, we extract and interact with literature that is pertinent to maternity care from the Canadian Nurse journal, which is a national professional nursing journal with which Canadian nurses are familiar. The journal serves to acta as a national and global voice for almost half a million nurses across the country. The scholarship of second author Marcellus (2018) that evolved from examining historic approaches to maternity care identifies textual markers and major patterns in Canadian maternal–infant health and nursing practice, from 1905 when the inaugural issue was printed, through to the end of 2015. The excerpts we choose are examples of contributions that stand out as relevant to this discussion. In addition to the Canadian Nurse journal, we interact with other literature, inviting social, cultural, political, and structural synthesis that exposes how nurses have practiced with childbearing families over the past century. The title of the novel, The Pull of the Stars, is intriguing, but it is not until well into the novel that a fusion of impressions is revealed, situating the meaning of the title in an “aha” kind of moment for the reader. The question – the address – of revealing and concealing, coming and going, present and absent is the work of hermeneutics (Moules et al. 2015, p. 23). We are pressed to enter into the interpretation of a century of perinatal care, guided by various texts. An original conception of the temporal nature of Dasein, our existence and being-in-the-world, is thus exposed, urging entry into a unique hermeneutic address. In this discussion, the meaning of the Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 3 title unfolds in what we experienced as a transformative experience into that distinct moment of understanding. We are Thrown Is it possible that, in the reading of this novel, we are thrown into nursing settings of our previous perinatal careers? In many ways, it seems so, but the inevitable contradictions of the time and place represented in The Pull of the Stars also shape what we bring to this moment of inquiry. In Heideggerian terms, the dimension of a global pandemic resonates strongly too, for there are many parallels to be drawn about our “thrown-ness.” For many of us, the context of a global pandemic generates a profound new understanding relating to the world into which we are and have always been “thrown.” Indeed, the characters in the novel live and move through their worlds – their experiences – with many of the difficulties and joys of human life we all lived during the recent pandemic. These immersive experiences are made visible in the reading. Our shared experiences of perinatal care and living through the current pandemic allows the two worlds - theirs and ours – to conjoin with unexpected familiarity, seemingly allowing Dasein to situate itself in 1918 Dublin. Many forces touch, it seems, and create the impetus to both decipher and unify understanding. Lebenswelt (Lifeworld) Acknowledging the grounding of the “lifeworld” or Lebenswelt permeates our analysis, and we contemplate our “unthinking” immersion into the perinatal experience, garnered by decades of practice, and tempered with knowledge of the everyday experience of perinatal nursing. Our being-in the-world, in fact, inhabits an inextricable link to the perinatal world, and a connection with the everyday experience of birthing. The Authors Each author (Humphries and Marcellus) occupies a unique lifeworld but share common understandings of what it has meant to practice perinatal nursing during a time of evolution and change for practice, and societal changes for women. Our positioning as new graduate nurses in the 1970s and early 1980s offers a unique perspective of historical Western practices, and what was involved in the shift towards the person/woman/family-centered model of birthing that is held up as ideal practice. We reflect on the axis of change that marked our entry into the world of maternal/infant nursing, because the vestiges of the practices that shaped the first part of the last century were visible to us as young and novice nurses. Over time, we lived the emergence of social, political, and scientific advances that altered practice. Ironically, some practices and foci have disappeared, only to re-emerge in circuitous persistence. Fusing Horizons of Understanding with the Command of Color The centrality of art in hermeneutic interpretation presents itself in this exploration of literature. Gadamer (1964) summarizes his reverence for the influence and congruence of art with hermeneutics. He poses that the work of art speaks most directly to us, because it possesses “a mysterious intimacy that grips our entire being, as if there were no distance at all and every Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 4 encounter with it were an encounter with ourselves” (p. 95). As participants in hermeneutic inquiry, we also have the potential to be “gripped” with the altogether experience that can accompany the experience of art. Donoghue’s (2020) artful novel has indeed “spoken” to us. We find ourselves transfixed with how precisely and evocatively the author is able to reveal the intricacies and intimacies of nursing practice, as if a nurse herself. Three phenomena of interest surface for us in this reflection, each one with relevance for nurses who care for individuals giving birth during a pandemic and beyond that context. The notions of infection control, privacy and dignity, and holistic care emerge as a guiding design for the articulation. Other phenomena align, and we describe them where relevant. Each of these ideas contribute to the whole of understanding and illuminate understanding of the perinatal experience. These phenomena reflect a mere sampling of rich possibilities with which to unearth the intricacies associated with more than a century of maternity care. In the novel, Donoghue (2020) tracks the progression of the influenza virus of 1918 in a person by a color that indicates its progression. The trajectory of that virus is known to affect the individual with a series of colors, which represented the stage of progression. This progression, from red/healthy to black/death informs the foundation of the organizing structure for the novel. We discuss our wonderings and interpretations below, drawing on Donoghue’s intriguing colour categorizations. The trajectory of coloration depicted by Donoghue renders a sense of resignation for the reader, as the inevitability of further deterioration for the characters depicted in the book unfolds. As readers, we become immersed in a process that may be familiar to those of us who are health care providers, when we bear witness- and perhaps participate in - the loss of personhood in the face of illness (Gadamer, 1996, p. 81). Red Well, I said, it starts with a light red you might mistake for a healthy flush. (Donoghue 2020, p.48) The Canadian Nurse journal publications include many examples of how infection control manifests as a priority for individuals during labour and birth (Brereton, 1912; Cunningham, 1959). Similarly, in 19182, Nurse Powers is aware of the importance of infection control. She explains to a subordinate (Bridie) “our only modern defense is asepsis – that means keeping germs from getting into patients. So now do you see how cleaning one’s hands thoroughly could save a life?” (Donoghue, 2020 p. 50). Throughout the century many procedures have been developed, with the intention of infection prevention and control, positioning birth as fraught with risk for infection (Marcellus, 2018; Mitchinson, 2002). There are reasons for this positioning, given the real need to prevent puerperal sepsis, or “childbed fever” as it was once known. However, it is also possible to interpret an evolution of practice – a reorganizing and upheaval of what was expected (Gadamer, 2007) that diverted from observing aseptic practice to a social context that supported paternalistic sensibilities, which pervaded birthing for much of the 20th century (Cahill, 2001). Brereton (1912), for example, describes the process that begins immediately on admission for a Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 5 woman in the first stage of labour at Toronto General Hospital. The description includes instructions for an enema, perineal clip, vaginal douche, tub bath and perineal scrub for the laboring woman. All of this was done to prepare the woman for the event of physician examination, which was overwhelmingly represented by males in those times. The recounting of these protocols calls into question the circumstances under which women subject themselves to interventional practice that have the potential to limit personal agency during the highly particular experience of birthing. Gadamer (1996) cautions that doctors should “confront the temptation of wanting to play the authority, not only on account of the superior scientific knowledge and medical experience which they do enjoy, but also through the pressure of the patient’s need for their authority” (p. 124). Gadamer thereby reflects traditional assumptions of power/helplessness in the health care context. However, other examples emerge of women who voluntarily instigate invasive practices on themselves, citing aesthetic reasons. Gadamer (1996) may attribute these practices as exhibiting “genuine freedom” (p. 123), which includes a recognition of the authority of others, but also others’ recognition of one’s own authority. We describe an interesting “full circle” example below. Authority and Genuine Freedom Jolly (2017) attributes the accoutrements of pre-delivery cleansing of the perineum as perceiving women’s bodies as “unclean, dysfunctional, and dangerous” (p. 7). However, our best available evidence today centers around a growing awareness of the importance of the microbiome in birth. It appears, in fact, that the many organisms that are present in the birth canal actually facilitate safe transition for the infant and serve as an early inoculation process for the infant’s immune system. Therefore, what was cleansed, disinfected, and scrubbed is now known to support, rather than detract from, infant health. In an ironic twist, the social context of asepsis now reverts to concerns about eliminating organisms that reside naturally in the birth canal (Dunn et al., 2019). According to Jolly (2017), the perineal shave became a flashpoint for exposing dominant social norms about the flawed female body. Yet, currently (and somewhat ironically), women often arrive in the birthing unit with a perineal shave they completed prior to admission. Researchers are now warning women, among other cautions, about genital burns from waxing, vulvar and vaginal irritation and infection, and the spread of sexually transmitted infections. Apparently, there is a full circle of possibilities surrounding authoritative practice in relation to social influences, interactions with science, and freedom. Interrogating the Enema: This Was Someone’s Birth We turn to further consideration of enemas in labour, and the rationales that accompanied the routine use of enemas, including shortening the duration of labour, reducing the risk of infection and making delivery “cleaner” for doctors and nurses (Cuervo, Bernal & Mendoza, 2006, p.1). The enema is but one example of practice that purported to support the best available evidence at the time. However, how do we account for what appears to be, in retrospect, an assault on women, under the guise of infection control for a process that nature never intended to be “sterile?” The stated desire to preserve the dignity of the mother from contaminating the delivery table with fecal material, as a result of the enema, often resulted paradoxically instead, in Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 6 feelings of humiliation and pain for women and in some cases, precipitate and unnecessarily violent progression in labour. An element of moral distress for the first author (Humphries) accompanies this reflection, for indeed, there were expectations for student nurses in the early 1970s to administer enemas to laboring people as described above, along with the described precipitate outcomes. The “flip flopping” of practice can be rationalized as science that has since been dismissed under the guise of new knowledge. However, in the meantime, this practice has blemished someone’s precious experience of birth. Kay et al. (2017) surmised that women’s recollections of ritualistic and authoritarian practices in childbirth during the 1970s took on a mantel of “mystery.” According to these authors, the mysteries were taken as a matter of course, and to which women were content to succumb. We understand the historicity of our exploration in two ways. First, as Moules et al. (2015) explain, “historicism is the idea that phenomena have to be understood in relation to their own time” (p. 14). The relevance of this understanding is significant, since we are examining historic impressions about perinatal care. We also emphasize that it is not the responsibility of the interpreter to pass moral judgment on past practices. For example, given the evolving sociopolitical, economic, religious, and other influences that informed practice over the past century, including the historic context of higher rates of infant and maternal morbidity and mortality, the sensibilities of the current context may not have meaning. Yet, a temptation remains to be horrified and even outraged at the practices that people endured under the guise of medical progress. For example, we consider efforts towards excellent nursing practice that are interrupted unceremoniously, against a setting of sometimes alarming experiences that women endure, while the profession of nursing grapples with how to provide care to birthing individuals (Kay et al., 2017; Reingold et al., 2020). Our understandings evolve with new knowledge, which in some cases, contribute to a sense of public mistrust for this “science” that is said to drive health guidelines (Kukura, 2016). For example, Smythe (2010) reflects that as a midwife, she is complicit in the paradox of safety, suggesting that “perhaps in being safe, we were sometimes causing harm” (p. 1476). The lived experience, interrupted by science and technology, urges a hermeneutic awareness regarding the limits of bodily objectification (Gadamer, 1993). Interpreting Public Health Guidelines Within Donoghue’s (2020) novel, there are frequent “ditties” that interject the narrative, hearkening familiarity with social media campaigns and misinformation that plague current times. In 1918 these rhymes are found on posters which are positioned every few feet in highly populated areas of Dublin. Some serve to educate, by listing many of the same kinds of public health cautions as have been recently expressed during the pandemic: The public is urged To stay out of public places such as cafes, theatres, cinemas And public houses. See only those persons one needs to see Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 7 Refrain from shaking hands, laughing, or chatting closely together If one must kiss, do so through a handkerchief. Sprinkle sulphur in the shoes. If in doubt, don’t stir out. (Donoghue, 2020, p.170) In the context of COVID-19, we contemplate what appears to be an inevitable conflation of public health recommendations for infection control and the politics surrounding individual freedoms (Hegland et al., 2022). Similarly, in Donoghue’s (2020) novel, Nurse Powers confronts a barrage of influences relating to societal reactions and responses to the influenza pandemic. Ironically, in the novel there are references to a public longing for a vaccine to mitigate the devastation of influenza. The context of COVID-19 reveals that not all long for a vaccine, a dilemma that shapes much of the significant political discord associated with the pandemic. Aletheia (revealing and concealing) in this circumstance presents as an undercurrent of suspicion towards evidence-informed recommendations, and uncovers disillusionment with assumptions of scientific supremacy. Brown If the patient gets worse, her cheeks go rather mahogany. (Donoghue, 2020, p.48) Gadamer (1993) muses about the meaning of health and well-being in the context of hole ousia or “the whole of being.” He asks, “what is well-being if it is not precisely this condition of not noticing, of being unhindered, of being ready for and open to everything?” (p. 73). His words inspire renewed attention to holism, health, and well-being in the perinatal experience. Akrich and Pasveer (2004) inquire about the role of women’s bodies, and muse about the influence of technology and medical interventions as determinants of how we position the notion of “body” in the childbearing experience. What meanings, then, inform understandings of the body and holism, and represent a unifying ideology for nursing practice? Cunningham (1959) notes criticisms that nurses are too apt to provide physical care and are not accepting of a philosophy of providing supportive care. She wonders: “have we oversold ourselves on institutional, mechanized care? In order to make more efficient the care provided in hospitals, have we lost the essence, the heart and soul of that care? I think we have!” (p. 991). The circumstance of a pandemic invites examination of the ways that usual caring practices by nurses have the potential to be subsumed by dictates for distance, isolation, and caution (Reingold et al., 2020; Wilson et al., 2021). With medical intervention, nursing focus can shift from the recipient of care as someone-in-the- world to a more detached, objective, and ultimately disembodied object of treatment. A robust analysis of embodiment and its meaning to human existence is beyond the scope of this work. However, it is relevant to acknowledge the contributions of phenomenologist Merleau-Ponty (1908-1961) concerning this topic, and his supposition that it is through the body that humans understand their world – not as a series of isolated sensations, but as sensations in concert with Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 8 one another to inform perceptions of the world (Harrison et al., 2019). Perceiving a sense of embodiment can be challenged in the context of a complicated pregnancy, whereby holistic visions for new life and fulfilled mothering have the potential to be extinguished with the progression of illness. The onset of “brown” awakens a fusion of meaning– a sinking realization about the trajectory of the illness described. The dialectical interaction (Laverty, 2003) infolds between the author and the text. Caring for the Whole Person: Beyond the Biomedical Funny to think the two of them had been one a quarter of an hour ago and now were severed forever. (Donoghue, 2020 p. 226) In the context of childbirth, curious and contradictory relationships exist surrounding the notion of holism, and an accompanying exploration of disembodiment. The very act of birthing, in certain contexts, could be interpreted as a human exercise in disembodiment, as the infant that has been “part” of the pregnant woman’s body emerges from the uterus as its own entity. The placenta, representing the nourishing connection between mother and infant, also emerges, and is examined and discarded. As Bergum (1989) describes, birthing represents the transformation from woman to mother, and is accompanied by complex and disparate notions of loss and completion. There is much to contemplate about the existential finitude associated with the birthing process, and what it represents in the fullness of Dasein. Because the banality and everyday-ness of childbirth surrounds us, it can be tempting to overlook or dismiss the profound transitions that occur for people enroute to mothering. Surveillance What is it to be-in-the-world of birth that is mediated by technology, and how might that inform understandings of the meaningful presence of things? (Heidegger, as cited by Kay et al., 2017). Any discussion of objectification of the body, in the context of perinatal care, must include the incursive presence of surveillance, and with it, the potential for the loss of personhood (Kukura, 2016). In the past century, maternity care has evolved with the forethought that obstetric practice can assume the investigative privilege of surveillance, increasingly through technological means. Gadamer (1996) expresses fortuitous concern about the potential for science and technology to evolve from enhancing the natural world to providing an “artificial counterpoint” (p. 6) to nature. The presence of technology in birthing may indeed challenge hole ousia in the current context of maternity care. Contextualizing birthing as an occurrence of human experience gives rise to broader understandings of human essence. Gadamer (1996) posits that “what is manifest in concrete detail and belongs as such to historical knowledge is of interest not as the particular but as ‘the human’ – though it may always become visible only in particular occurrences (p. 29). According to Gadamer (1996) the “inexact knowledge” (p. 28) of the humanities (the Geistesswissenshaften) offers dimensions of breadth about humankind. Gadamer’s attention to the Geistesswissenshaften sustains attention to Donoghue’s (2020) literary enterprise, as the reader becomes entangled with the depth of joy and tragedy that shape human experience as Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 9 depicted in the novel. In Donoghue’s (2020) rendering, for example, the transitions that accompany the act of birthing elicit a sense of deep poignancy. There is a suggestion of an innate and visceral promise of new life that occurs for women across socio-economic spectrums in this quarantined maternity ward. The women in the novel share the experience of illness and expectancy. In spite of possibilities to achieve well-being in the birthing context, not every woman in the novel overcomes influenza, however, and not every woman takes a new life home with her. Below, Donoghue depicts Nurse Power’s reflections in the following description of infant loss that is suffered because of influenza. Donoghue (2020) writes: Delia Garrett coughed as if she were choking on a rock and began to sob. Bridie was rubbing the woman’s shoulder, stroking her damp head, murmuring to her: Shush, now, shush. It wasn’t protocol, but there was such instinctive gentleness in it, I didn’t say a word. Bridie whispered, Mrs. Garrett, do you want to see your daughter? I stopped in my tracks. I’d been taught to take away a still as soon as possible and encourage the mother to start putting the loss out of her mind. (p. 87) Nurse Power is caught off guard by the initiative of her uneducated and inexperienced helper, Bridie. The authenticity of Bridie’s intuitive approach to the loss - her “knowing but not knowing” (Smythe, 2010, p. 1478) reflects an instinct that defies the evidentiary norms of the time. However, her actions exemplify what we now consider to be a more highly evolved and compassionate approach to perinatal tragedy, and embodies notions of holism in her resolve to unite the stillborn infant with the grieving mother. Once again, the sensibilities of today collide with practices of the past, since uniting that dyad in life – and death- is now considered an expectation. The nudge of historicity resonates, urging attention to time and context. Attention to evolving sensibilities comprising the lifeworld once again emerge. In the context of the many elaborate prescribed procedures to prepare for birth during the early 20th century, Cunningham (1959) writes, “the doctor orders it, the nurse performs it, and the patient endures it” (p. 993). Her words signal a paternalistic and medicalized approach to birth, accompanied by limited agency of the nurse and birthing woman. The world of birthing into which women and nurses are thrown indicates a lack of autonomy for either. In some instances, nurses are complicit with unnecessary intervention and procedures that reflected medicalized, reductionist practice, as opposed to advocacy for holistic approaches (Corbin, 1950). These interruptions of a path towards well-being may well typify what Gadamer described as an “art of great difficulty” (1996, p. 88). Donoghue addresses these paradoxical implications when she describes an unexpected elevation of nursing agency for Nurse Powers. The physician sanctions what we might ascribe as clinical nursing judgment in today’s terms, in the context of analgesia (in this case the analgesia was whiskey) for after-pains (the name for uterine contractions following birth), and a cough. Nurse Power relays, “I was filled with gratitude; she’d untied my hands” (Donoghue, 2020, p. 103). In that transaction, Nurse Powers is in effect advocating for a higher quality, and safer level of patient care by exercising her elevated agency. By viewing safety in birthing as an interpretive act (Smythe, 2010) and interpreting women’s perceptions of emotional safety in the delivery room (Nilsson, 2014) there are possibilities to Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 10 contextualize practices and attitudes over time. Indeed, the hermeneutic notion of historical tradition acknowledges the influence of history in our current milieu without objectifying history as an irrelevant theoretical abstraction (Grondin, 2003). As Kay et al. (2017) suggest, there are generational divides regarding what women view as acceptable experience in childbirth, recognizing that narratives of “safety” for women in the 1970’s and 1980’s, are replaced with notions of “choice” in the new millennium. The interpretive act that comprises safe care during childbirth (Nilson, 2014; Smythe, 2010) also summons paradoxical possibilities for caregivers to cause harm under the guise of safe practice. In many health care settings (including, but not exclusive to maternity settings) there are contradictory safety expectations for nurses to follow doctor’s orders, while simultaneously establishing agency for excellent nursing practice. The horizons for shared visions of safe care struggle in this context to fuse harmoniously. Blue In a more severe case, the brown might be followed by lavender in the lips. Cheeks and ears and even fingertips can become quite blue as the patient’s starved of air… (Donoghue, 2020, p. 48) Examining Privacy and Dignity Gadamer (1996, p. 138) emphasizes the significance of attending to the particular situation, and the enlisting the practical wisdom (phronesis) to respond to the situation holistically. These tenets guide the following interpretations of privacy and dignity. The fundamentals of privacy in 1918 bear examination when considering the environment of birthing depicted in the ward under the care of Nurse Powers, and especially in the progression of illness. Patients in that small setting are housed together, separated only by a makeshift curtain or screen. A patient’s deterioration to an anoxic state and beyond is unveiled for all, and often constitutes unavoidable intrusion into another’s tragedy. Donoghue’s (2020) depiction conjures the context of privacy, and a sense of indignity, with pointed verisimilitude: Mrs. Garratt’s passed a comfortable night,’ said Sister Luke. Comfortable! The word made Delia Garrett cough into the back of her hand. In this pokey cubby on a backbreaking camp bed with people dying left, and right? (p. 20) Historicity once again inserts itself into the address. In this instance, understandings that surround views of privacy and dignity unravel in Donoghue’s account. The texts of other literature featured in this discussion, leaving us to contemplate the temporal dimensions of the work, and the task of establishing fresh understanding (Moules et al, 2015). A lack of privacy and consideration of a woman’s dignity during birthing continue as concerns from a global perspective, more recently framed as obstetrical violence or reproductive injustice (World Health Organization, 2015). A side-narrative in Donoghue’s novel concerns Bridey’s upbringing in one of the notorious Irish church-sanctioned mother and baby institutions. That narrative exposes the Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 11 shame and violence that took place for women who became pregnant outside of marriage, highlighting the indignity and injustice suffered by unmarried women in the context of birthing. Interpretations of birth in the 1970s as being “shrouded in mystery” but allowing the mystery to “take its course” while being “on the conveyer belt of care” (Kay et al., 2017, p. 6). These authors bring into view an image wherein women surrender their birthing experience to accommodate systemic expectations. The promise for interpreting such discourses are provocative, involving the address of paternalism, prudery, and misplaced authority over the intimate act of birthing – all the while entangled with narratives of privacy and dignity. The crisscrossing of these various possibilities gives rise to inquiry into the meaning of the historically situated instance, perhaps informing attitudinal sensitivities of the current birthing context. The loss of dignity may look different today, involving a woman’s relationship to the caregiver, if there is a perception of not being understood or taken seriously (Nilsson, 2014). Black I’ve seen it darken to violet, purple, until they’re quite black in the face. (Donoghue, 2020, p. 40) Blame, Shame, and Guilt Donoghue (2020) alludes to a societal impulse to assign blame, and addresses the stigmas associated with both succumbing to influenza and caring for someone succumbing to influenza. These societal impulses are recognizable today, creating significant societal binaries where various factions take up health guidelines in confrontational ways. Donoghue (2020) infuses the text of her storytelling with the following communique: Would they be dead if they stayed in bed? Infection culls only the weakest of the herd (p. 257) Donoghue (2020) depicts a physician, Dr. Kathleen Lynn (the only character in the book who is based on a historic individual). Dr. Lynn discusses the notion of blame with Nurse Powers, and in doing so, provides something of a “gut-punch” for the reader. That is, the inevitability of human powerlessness, the forbearance that persists despite the powerlessness, and the repetitive nature of influenza moves the reader towards what Caputo (1987) refers to as an “actuality (which) must be continually produced, brought forth anew again and again” (p. 17). Dr. Lynn says: We could always blame the stars. I beg your pardon, doctor? That’s what influenza means, she said. Influenza delle stelle-the influence of the stars. Medieval Italians thought the illness proved that the heavens were governing their fates, that people were quite literally star-crossed. I pictured that, the celestial bodies trying to fly us like upside-down kites. Or perhaps just yanking on us for their obscure amusement” (Donoghue, 2020, p. 147). Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 12 The power of the title, The Pull of the Stars, is thus exposed. This revelation, in and of itself, lends a certain humility to the perspective of our being-in-the world. When contemplating the persistent mysteries of the universe, it seems that humans accept its influence over existence – our Dasein - and the infinite implications associated with human being and time. When contemplating the works of Heidegger, then, we return repeatedly to the notion of our temporal Being as enacted by Dasein, and the many influences that encompass existence, in order to present the ultimate hermeneutic opportunity for understanding. We engage in the paradoxical possibilities involved in the hermeneutic address of what darkness could mean alongside a light-filled hope of a new life. These questions, and so many others, permeate the parts and the whole of the inquiry. The Fecundity of Elizabeth’s Case Jardine, in his 1992 classic article, refers to the “true fecundity of the instance” (p. 55) that comes into play. Jardine also cautions that there should be limits associated with explicating implications of meaning. We believe the following narrative intimates parallels with much of the previous analysis in this work. However, we invite readers to elicit understanding for themselves. The account explores the lived experience of first author (Humphries) daughter, who delivered her first infant in July of 2020 in London, England, at the early height of COVID-19, when much was not yet known about transmission, health impacts and outcomes, treatment, and prevention: Ironically, my daughter described the first three weeks following the birth as a ‘black time,’ prompting me to tell her story, with her permission, since her description aligns with the colour- based trajectories of Donoghue’s novel. When I spoke with Elizabeth about these black days surrounding her birthing, she discussed many impressions. One of the first memories she shared with me was that during three difficult days of induction, health care providers stood at the doorway and did not enter the room to make physical contact unless absolutely necessary. She said, ‘it wasn’t until I started to scream during my contractions that one of the nurses finally came in and held my hand. For the first time in three days, I actually felt that someone was taking care of me, and that I felt truly looked after.’ Because of COVID restrictions in the hospital where Elizabeth gave birth, her partner, Stuart, was not allowed to be with her for much of the prodromal and first stage 3of labour, prompting feelings of isolation and fear during a difficult labour. Before her transfer to the labour/delivery unit, however, Elizabeth was very aware of the other women in the room, even though she was unable to contain her vocalizations. She imagined the trauma that her screams would elicit for other expectant women on the ante-partum ward. She described that experience as one where she felt alienated, frustrated, and abandoned. In the postpartum period, most of the midwife visits took place over the phone, rather than the usual practice of having the midwife come to the home. The much-needed hands-on breastfeeding support was not available to her. The inability for assessment by a health care professional effectively positioned this new mom and her partner with the responsibility for medically assessing any of the inevitable concerns that arose. Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 13 For my part, as an experienced clinician and researcher of the perinatal experience, a brand- new grandmother, I was desperately trying to glean what was transpiring from thousands of miles away, and offer what I could in the way of guidance and support. The meaning of the pandemic for Elizabeth’s nuclear family in Canada has meant that we were unable to travel to England to support the new family, and to be with a treasured grandchild and nephew during a very special time in our family history. Hermeneutic Circling Grondin (2003) asks “can the interpretative-the hermeneutic-really be overcome?” (p. 12). His question is thought provoking, for it implies that interpretation occupies a very basic aspect of human approach to truth. In Heideggerian terms, it seems that in the fullness of Dasein, we are unable to avoid interpreting the facticity into which we are “thrown” in the world-that-is-already- there. In other words, the everyday realities of our circumstances will always provide the backdrop for our inevitable interpretations. Perinatal nurses will be tasked, for some time, to interpret the long-term effects for new families, many of whom accessed poor levels of support during the birthing experience. Important questions surface about the implications of giving birth during pandemic. For those who experienced birth we wonder how the experience will influence parenting and overall maternal well-being – both at the time of birthing and beyond. Reingold et al. (2020), for example, suggest that violation of WHO’s respectful care framework constitutes a violation of human rights. These authors, and others, researched the negative experiences of maternity patients during COVID-19. The harmful practices include a loss of person-to-person contact with caregivers in pre-and post- natal contexts, reliance on digital health, restrictions on birth companions, inadequate information about policies (Reingold et al., 2020), lack of continuity of care (Rudrum, 2021), and the feeling of “doing it alone” (Wilson et al., 2021). The research resonates with Elizabeth’s experience, the discourse surrounding dignity, and Gadamer’s notion of “genuine freedom” (1996, p. 23). Gadamer underscores the significance of Dasein by equating Heidegger’s conception of the hermeneutic circle as derived from its temporality (Grondin, 2003). For the millions of women who have given birth during the pandemic, the temporality of understanding is exquisitely highlighted. It seems that a certain universality to understanding-in-language (Moules et al., 2015) is also at play, given the significance of Donoghue’s text, and the texts of others in our analysis, which offer unending potential for continued interpretation. Understanding, in the context of our discussion, unfolds with the interplay that circumnavigates the part and the whole of understanding, and the always-present underpinning of Dasein. Our interactions are resplendent with expanding understandings of the connectedness of each (Moules et al., 2014; Gadamer, 1960/2004). For perinatal nurses, the taken-for-granted “knowing” about care has been interrupted by a pandemic. The parts and the whole communicate with fluidity. Discussion Humphries & Marcellus Journal of Applied Hermeneutics 2023 Article 6 14 We are moved by the depiction of strength, courage, knowledge and skills of Nurse Powers as she navigates what is a somewhat typical four-day stretch in her work schedule, albeit a stretch that provokes lasting consequences for her life. We contemplate her strength and courage, and that of those who give birth under her care. We wonder about the name, “Nurse Powers,” and speculate that the choice of name intimates the potential for profound influence that nurses hold. We muse about the similar and dissimilar aspects of political discourse that shapes both that pandemic and the current one. The questions and wonderings spiral, long after the initial reading. The image of the celestial bodies yanking on us for their obscure amusement interjects, alongside circuitous fascination about historical understandings regarding the influence of the stars, and the predictable and cyclical nature of infectious disease. The power of such an image has implications for the conceptualization of Dasein, perhaps elucidating the futile quest for autonomy within one’s existence. As Jardine (1992) said, “a ‘good’ interpretation then, is not definitive and final, but is one that keeps open the possibility and the responsibility of returning (authors parenthesis), for the very next instance (author’s parenthesis) might demand of us that we understand anew.” (p.57). Jardine thus exposes the ongoing opportunity for further interpretation, creating what Caputo (1987, p. 5) described as an “opening,” rather than a resolution. The quest for understanding is underpinned throughout this analysis by acknowledging Dasein, with its implied finitude, historical situatedness, and a sense of “being-toward-death” (Caputo, 1989, p.199). The projection of the finitude of Dasein that we contemplate as a result of Donoghue’s work indeed represent a “penetrating glimpse into the radical temporality and angst of human existence” (Grondin, 2003, p. 145). The context of a century between pandemics, and the unique experiences that shape the existence of those who occupy that century give pause. From pandemic to pandemic, the contemplation of Dasein in the perinatal context is sobering. References Akrich, M., & Pasveer, B. (2004). Embodiment and disembodiment in childbirth narratives. Body and Society, 10, 63-84. https://doi.org/10.1177/1357034X04042935 American College of Obstetricians and Gynecologists (2022). 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Statement on the prevention and elimination of disrespect and abuse during facility-based child-birth https://apps.who.int/iris/bitstream/handle/10665/134588/WHO_RHR_14.23_eng.pdf 1 Throughout this article we primarily use the term woman to reflect the language of the times used in both the novel and journal. We acknowledge that definitions and understandings of gender and inclusiveness evolve and vary over time and context. Thus, we also integrate inclusive and gender-neutral language as described in the American College of Obstetricians and Gynecologists policy statement on inclusive language (2022). 2 Puerperal fever, or childbed fever, was common prior to the discovery of germ theory. Routine handwashing is still not yet a standard of practice globally. 3 Prodromal labour is defined as a type of false labour contraction that takes place in the third trimester, with no changes in the cervix yet taking place. The first stage of labour, also called the latent phase of labour, is defined as when the cervix begins to soften and dilate and persistent contractions begin to be experienced.