The Politics of Maternity

Rosemary Mander, Jo Murphy-Lawless

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136737077
• Edition: 1
• Topic: Medicine
• Subtopic: Gynecology, Obstetrics & Midwifery

The evidence surrounding the skills and approaches to support good birth has grown exponentially over the last two decades, but so too have the obstacles facing women and midwives who strive to achieve good birth.

This new book critically explores the complex issues surrounding contemporary childbirth practices in a climate which is ever more medicalised amidst greater insecurity at broad social and political levels. The authors offer a rigorous, and thought-provoking, analysis of current clinical, managerial and policy-making environments, and how they have prevented sustaining the kind of progress we need. The Politics of Maternity explores the most hopeful developments such as the abundant evidence for one-to-one care for women, and sets these accounts against the background of changes in health service organisation and provision that block these approaches from becoming an everyday occurrence for women giving birth. The book sets out the case for renewed attention to the politics of childbirth and what this politics must entail if we are to give birth back to women.

Designed to help professionals cope with the transition from education to the reality of the system within which they learn and practise, this inspiring book will help to assist them to function and care effectively in a changing health care environment.

1 Introduction

Homage and legacy

I learned about maternity politics and its significance from a number of midwives whose politicking reached the level of an art form. These midwives honed their political skills in clinical, managerial, policy-making, educational and academic arenas; they manoeuvred and manipulated situations and people with a deft sleight of hand invisible to anyone not looking out for it. Since that initiation, I have come to appreciate others' political dexterity in wider arenas. As well as learning from such experts, there is another source which I am proud to acknowledge. In some ways, this book represents a form of homage to a classic volume, which is familiar to and loved by generations of readers. Because of the dynamism of the subject area, few books on maternity or childbearing politics achieve the status of ‘classics’. The book which has indubitably achieved this status is the one edited by Jo Garcia and her colleagues, published in 1990 (see also Chapter 6). Its multidisciplinary scholarship brought a new depth and breadth of academic work to maternity politics. Its continuing use, not to mention its regular disappearance from library shelves, testifies to its ongoing importance and relevance in the rapidly-changing world of maternity scholarship. The legacy of this book, ‘The Politics of Maternity Care: Services for Childbearing Women in Twentieth-Century Britain’, is apparent in many publications, in addition to virtually every thesis and dissertation, on maternity or midwifery topics. This legacy clearly makes the book by Jo Garcia and her colleagues a hard act to follow.

With this legacy in mind I set out to produce a new book on the politics of maternity. While not an edited book like its eminent predecessor, the present volume seeks to emulate the academic standard set in 1990. There are also other differences. In this book I aim to develop a definition of politics which is relevant to women in addition to the multiplicity of disciplines who practise in maternity, with their even more various agendas. Because ‘The Politics of Maternity Care’ was an edited volume, developing and applying such a definition would have been difficult. This may have had the effect of making more subtle, or possibly diluting, the focus on politics. Any such effect, however, was more than compensated by the breadth, variety and academic scholarship of the contributed chapters.

While Jo Garcia and her colleagues' book continues to be used and useful, I recognise that the relevance of some of the material has decreased with the passage of time. This is largely due, again, to the dynamic nature of maternity care. It is also necessary to consider whether the changing context of maternity care has reduced the relevance of ‘The Politics of Maternity Care’. In order to contextualise the maternity environment, it may be helpful at the outset to reflect on the changes which the maternity services have encountered since Jo Garcia and her colleagues published their ground-breaking book.

Significant developments in the maternity services since 1990

In the decades since ‘The Politics of Maternity Care’ was published, changes have occurred on all fronts but, for the sake of convenience, I address changes in policy and practice.

Policy developments affecting maternity services

The nature of the National Health Service (NHS) as a ‘political football’ became most evident during the Thatcher era (UK Prime Minister 1979–90). Partly due to her government's attempts at reorganisation and partly due to longstanding under-funding, the NHS Review was undertaken in 1988. The outcome was the government White Paper Working for Patients (1989), which introduced an internal market in health care; this constituted a system of contracting for services between purchasers and providers. This system came into operation in April 1991, making Health Authorities and general practitioners (GPs) responsible for assessing population needs and purchasing services from hospitals and other units of service. At the time of writing, this system has largely been dismantled, but changes in funding and providers are in the forefront of plans by the present coalition government.

Changes in NHS funding are nowhere more apparent since the mid-1990s than in Public Private Partnership (PPP) and Private Finance Initiative (PFI) contracting arrangements (see also Chapter 6). These private sector bodies, in the form of partnerships or consortia, have been used to provide capital investment for both hospital and community developments. A typical PFI project will be owned by a company set up specially to run the scheme and will comprise a consortium of a building firm, bank and facilities management company. While possibly structured differently, PFI projects usually feature four key elements: Design, Finance, Build and Operate. The key difference between PFI and conventional ways of providing public/health services is that the public sector does not actually own the asset, ie the property. The health authority effectively leases the property, making an annual payment, like a mortgage, to the private company who provides the building and services. This arrangement continues for the duration of the contract (25–30 years), which may be extended more or less indefinitely through renegotiation. PFI is now used for a large majority of capital schemes, such as hospital building projects (Liebe and Pollock 2009).

Since 1999, the much sought-after political devolution within the United Kingdom has, effectively, given rise to four different NHSs (Connolly et al 2010). Although devolution has, to date, had limited impact in Northern Ireland, people who use the health services in Scotland and Wales are well aware of their relatively privileged position. While there are a number of policy differences, the impact to date on maternity services is more difficult to assess. There are certainly proud reports of exciting developments in the devolved nations (Kirkman and Ferguson 2007; Reid 2011a). It is appropriate to question, though, whether devolution stimulated the development or just the report of the development.

A progressive policy which should have affected the childbearing woman is the increasing focus on client/consumer input into decisions at all levels of health care. This increasing focus is reflected in the document ‘Patient Focus Public Involvement’ (SEHD 2001). Publications like this seek to operationalise the principle of ‘Nothing About Us Without Us’, adopted by disability activists in the late twentieth century. The achievement of such lofty ideals, however, requires a change in the culture of health care. This would be facilitated by investment in communication systems, genuine consumer/client information and involvement and universal responsiveness among health care personnel. At the time of writing, it remains to be seen whether sufficient priority is accorded to client input to achieve such an outcome.

The political significance of the inequities and inequalities of the health care system were demonstrated most forcefully, not to say notoriously, by the Black Report (DHSS 1980). Although rates of, for example, life expectancy and infant mortality appear to have improved since 1990, the gap between the most and the least affluent has not; in fact that gap is actually increasing (Mackenbach 2011).

The policy developments envisaged by the Winterton Report (1992) and ‘Changing Childbirth’ (1993), and their equivalents in the three devolved UK countries, brought seemingly infinite promise for the childbearing woman and her midwifery attendants. Such promise was encapsulated in the cliché ‘woman-centred care’ (Reid 2011b: 190). By default, though, obstetric and other medical practitioners in the maternity area would be variably affected. These effects, together with the financial implications of such momentous changes, proved insurmountable for managers and policy makers (Rothwell 1996), leaving women's and midwives' aspirations for control, choice and continuity yet to be realised.

Developments affecting practice in maternity

The usual perception of a lack of newly qualified midwives to maintain the workforce had begun to change by 1990; this led to recognition of the difficulty of newly qualified midwives finding employment (Mander 1987). This finding was supported by Penny Curtis and her colleagues, who investigated the midwifery workforce in England (Curtis 2006). These researchers identified the 38.26 per cent of midwives with effective registrations who do not practise, but gave scant attention to the woefully deficient establishments. Thus, the connection failed to be made between perceptions of shortage in clinical areas and budgetary priorities.

The chapter in ‘The Politics of Maternity Care’ by Rona Campbell and Alison Macfarlane on place of birth was written in the long shadow of the Peel Report, when the homebirth rate was at an all-time low. Since then, perhaps in association with policy developments mentioned already, but also influenced by women's activism, the number of out-of-hospital births has generally risen. As I discuss in Chapter 8, the fledgling midwife-led facilities in freestanding and alongside settings face many challenges (Hatem et al 2008) and the homebirth rate has increased only patchily.

The rise in some areas of the homebirth rate may be linked to enthusiasm for independent midwifery services. Such enthusiasm, however, was not shared by members of the Royal College of Midwives (RCM); when invited in 1993 to ballot on supporting their independent co-professionals, the members voted to withdraw their indemnity insurance (Warren 1994). Since then the statutory regulatory body and the European Union have further threatened independent midwifery (HPC 2009) by requiring exorbitantly-priced professional indemnity insurance as a requirement for practice (see Chapter 7).

The increasing escalation, between 1994 and 2004, of the long-term rise in caesareans has carried serious implications for midwives, childbearing women and maternity services (Mander 2007). The recent levelling off of the caesarean rate in some countries suggests that medical personnel have finally recognised the iatrogenic nature of what they have for too long regarded as the ultimate rescue operation.

The publication of the twin volumes of ‘Effective Care in Pregnancy and Childbirth’ in 1989 by Iain Chalmers and his co-editors sounded a clarion call to their obstetrician colleagues to put their practice on to a research-based footing. Little did they foresee the Pandora's box of evidence-based practice (EBP) which would be opened on an unwitting world of health care. Not unconnected to the intrusion of EBP is the increasingly litigation-oriented and defensive practice which is currently required of a range of practitioners.

Another innovation which has influenced practice since ‘The Politics of Maternity Care’ was published is the Baby Friendly Hospital Initiative, launched in 1991. Altruistically, this project's prime focus is on the establishment of breast feeding by preventing interventions which interfere with the physiological initiation of lactation. The extent to which the benefits to babies outweigh the tyranny for mothers and staff is, however, difficult to assess (Mander 2008a).

As well as the possibility of midwives returning to their roots in the form of facilitating breast feeding, a similarly ‘radical’ approach has emerged through what may be known in this commodified climate as a ‘unique selling point’ (USP). The concept of ‘normality’, originally allocated to midwives by medical practitioners for whom such humdrum practice held little lucrative incentive (Donnison 1988), has been grasped avidly. The fact that the concept is poorly defined and equally poorly understood has proved no deterrent. In Scotland, government policy has supported this development in the form of ‘Keeping Childbirth Natural and Dynamic’ (KCND 2009).

An aspect of maternity attracting less attention is the changing pattern of maternal mortality. While the number of maternal deaths in developed countries such as the United Kingdom is nearing the irreducible minimum, their causes have changed markedly. No longer are the obstetric accidents, such as haemorrhage, major factors. Increasingly significant are the problems of women with complex needs, including lack of basic maternity and psychosocial care. Thus, the medical contribution to the prevention of deaths of women, who for various reasons are alienated from the health care system, is becoming less and less relevant.

A changing picture

This brief overview of some of the developments in maternity care since ‘The Politics of Maternity Care’ was published has shown that political issues are becoming more, rather than less, significant. Equally, these issues are likely to affect an ever wider range of personnel. These developments demonstrate all too clearly the need for a new book to assist practitioners and others negotiating labyrinthine maternity politics.

Terms and meanings

Jo Garcia and her colleagues gave little attention to the nature of politics. Although the contributed chapters in their book addressed issues which were implicitly political, politics was rarely mentioned as such. The exception to this observation is found, perhaps unsurprisingly, rounding off Robert Kilpatrick's interview with Wendy Savage (1990: 340). In this interview Savage's thoughts on the meaning of maternity politics become abundantly clear as a combination of party, medical and gender issues.

Before encountering the complexities of the political maelstrom of maternity care, though, exploring the breadth and limitations of the nature of politics will make this encounter more manageable. My exploration provides, as well as food for thought, an indication of this book's orientation.

Politics

Widely used, with little thought to its meaning beyond negative complexity, politics is a term which deserves to be teased apart.

A definition, which has long been a favourite, comes from my well-thumbed dictionary and emphasises politics' interpersonal and organisational aspects:

astutely contriving, manoeuvring or intriguing.

(Macdonald 1977: 1036)

This definition is wide enough to permit an approach sufficiently eclectic to include a number of aspects relevant to clinicians and practitioners. It has been pointed out to me by an anonymous reviewer, though, that this definition neglects crucial aspects of politics, such as power and control. So I undertook a search for a more inclusive definition, which produced helpful additions:

(a) ‘the activities involved in getting and using power in public life, and being able to influence decisions that affect a country or a society’

This definition constitutes ‘Party Politics’ which, while possibly connected to maternity politics, are subtly different. Party Politics are generally more predictable, with a rigidity of philosophy and infrastructure not found in other forms of politics.

(b) ‘a person's political...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• 1 Introduction
• 2 Interpersonal politics
• 3 Interoccupational politics
• 4 The politics of maternity beyond the western world
• 5 Politics of practice philosophies
• 6 The state, governmentality and our maternity services
• 7 Musts to avoid: How not to do statutory regulation
• 8 Promising practices: How it can be done
• 9 Conclusion
• References
• Index