‘NHS maternity services not good enough’ says a Guardian headline this month. Hardly a shock to those of using and working in UK maternity services today, particularly in urban centres like London. The mainstream media paint a picture of filthy blood-stained wards, heartless midwives and negligent doctors waiting to sully your birth experience. As someone who has worked in maternity care for the last 5 years I find this portrait misleading, hurtful even.
By far the vast majority of frontline staff at NHS hospitals work tirelessly in the face of under-resourcing, as the ‘financial viability’ of NHS services takes precedence and more patients come through the doors as nearby hospitals close. They also find the time to care. It is the fact that health workers do care that keeps services above water – we stay the extra 30 minutes, we work through our breaks, we barely stop for a glass of water sometimes. That is what’s necessary to give adequate care to women in the current system.
But childbearing women do deserve better. And NHS frontline staff deserve better too.
There is a problem with the culture we have around childbirth in the UK and feminists have for decades been fighting for a less medicalized, more women-centred approach to caring for pregnant women. The high caesarean section rate in the UK and other western countries is a cause for concern. Almost 1 in 4 women in England will deliver their baby by Caesarean (23.8% did in 2010) and in some hospitals the rate is as high as 36%. This is compared to the World Health Organisation recommended level of no more than 10-15%. The implication is that many caesareans are clinically unnecessary, increasing risks to both mothers and babies, and over-using precious resources. The phenomenon is widely attributed to ‘the cascade of interventions’ where one intervention by midwives or obstetricians leads to another, on a conveyor belt straight to the operating theatre.
The invention of the obstetric forceps that came into mainstream use in 18th century led to what is perceived to be the masculine (if not male) control of childbirth. Obstetrics has a murky past – early use of forceps and other techniques were experimental and often unsafe. The maternal death rate initially went UP in the 1800s when women began giving birth in hospital, cared for by doctors who had not yet recognised the importance of hand hygiene and aseptic technique. A century of improving standards and safety in obstetrics has brought us to a very low maternal death rate today. This is one of the safest places in the world to give birth. However the profession has had to work hard to raise its status in medicine.
The introduction of new technologies , for example obstetric ultrasound and fetal monitoring technology, has brought great improvements but has also brought with it idea of the fetus as the patient. Concerns about these technologies have been brought to mainstream attention with publications like Naomi Wolf’s ‘Misconceptions ‘, detailing how these technologies subjugate pregnant women and strip them of knowledge and control as decisions are made in the best interests of the baby, favouring operative birth.
Organisations like AIMS (Association for Improvements in Maternity Services), the NCT (National Childbrith Trust) and the Royal College of Midwives campaign to shift the culture of maternity care towards ‘normal birth’ and a reduction in medical intervention. Women themselves report how they are traumatised by birth, feel bullied by health professionals when they are at their most vulnerable and are made to feel like ‘bad mothers’ for disagreeing with professionals.
Birthrights, a campaign recently launched to argue for more control for women in childbirth, focusses on the right to give birth at home supported by a midwife. The campaign asserts home birth as a Human Right and encourages women to pursue legal challenges where these rights are denied by NHS hospitals. Currently in the UK only 2% of women plan a delivery at home. The home birth movement seems to be largely white and middle-class , perhaps explaining the judicial focus of the Birthrights campaign.
I am a heartfelt supporter of homebirth but it is evident that, for the time being, homebirth is the preference of a minority of women and will remain so for as long as the fearful and risk-averse medical culture we have around birth dominates.
What is most often left unaddressed is how we link the fight for a more feminist birth practice to the position and experience of most maternity staff? ‘Women centred care’ was adopted by NHS policy years ago (Changing Childbirth 1993) to encourage staff to work in partnership with women, but without the resources to back it up. Midwives are expected to be advocates for women but building relationships takes time – time midwives often haven’t got. Midwives are currently attempting to facilitate positive birth experiences while the NHS is being dismantled around them.
Feminist activism around birth needs to realise that women and health workers’ interests are the same – we need to fight on the same side. Resisting privitisation and NHS cuts has to be a priority. We do have to fight for greater control for women in childbirth – but we must fight for the NHS, as imperfect as it is, if better birth is to be a reality. ‘Liberalisation’ of the NHS as outlined in the Health and Social Care Act has cleared the way for market forces to take control of our health service. Cuts, closures and increased pressure on frontline staff will surely follow. The quality of maternity care can only worsen in this context.
The principle of a national health service is to ensure equality of access to free, comprehensive, health care. We know migrant women, black or minority ethnic women and poor women are more likely to die in childbirth in this country (CEMACE 2007). We know there is a chronic shortage of midwives – we are overstretched already, facing a rising birth rate, and closures are putting even more pressure on maternity wards that remain. Who is going to feel the consequences of this the most? Poor women, migrant women, and BME women.
Women do deserve a better birth in this country. We deserve to be treated like adults, to be listened to and to be free from unnecessary medical intervention. However, many campaigns focussing on so-called natural birth too often forget the most crucial element in this debate – the right to free, quality maternity care for all women that was established with the NHS in 1948 when universal antenatal care became a reality.
Feminist activism around birth must also take care not to alienate women from the very experience of birth itself. ‘Natural birth’ these days is a consumer product. High-end baby shops selling organic cotton slings, sick mops and bibs also advertise Hypnobirthing tuition, lactation consultants, and independent midwives or doulas. NCT classes at £300 pounds a pop not only support women to make informed choices about birth, but give women the confidence to stand by those choices in the face of pressure by health professionals to follow different recommendations. Middle class women are able to mitigate against the power of obstetrics to subjugate women, to some extent. Where does this leave the rest of us who can’t afford an NCT class? Or can’t afford a lawyer to threaten to sue when a homebirth is denied? And how does this challenge the biggest threat to positive birth experiences: the dismantling of the NHS?
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