Framing the maternal body: neo-liberalism, dualism and sexed difference
This is the transcript of the paper I gave at the Open University GCRN this week (7th June). It's slightly packed in because I was on a panel with my lovely friend Rose, and a really interesting doctoral candidate from Oz, Amy Mowle. This is the basis of my thesis, and my approach to my doula work. The system isn't currently working for anyone - mothers, midwives or medics - and we need more than pithy patches to make meaningful change. We need to shift our paradign and begin to think about how we value mothers and maternity in an entirely different way. It's deep, Babes, but read on (and very happy to answer Qs by email)
Thanks for inviting me to present my research. This paper summarises my recently completed MRes at the Centre for Women’s Studies at the University of York, interrogating how birth plans are written and deployed.
Birth plans have become a rite of passage in many pregnancies in the UK. Birth plans are now recommended by a wide range of antenatal and peri-natal specialists and educators, from NCT To NHS. They are considered to be the method by which mothers can exercise choice and retain control.
However, there is an inconsistency here, that suggest the purpose, role and value of the birth plan is misunderstood, and is the starting point for my research. While birth plans are recommended, they are also maligned as being unrealistic, and the refrain ‘… it all goes out the window once labour starts…’ is a common one.
In both research and experience we find that birth plans are not aligned with outcomes – writing a birth plan can’t determine how your birth happens. This gulf between the stated preferences of mothers and birth outcomes is a cause of friction. Mothers who write them may be constructed as being wilful and hubristic, presumed to influence a process that is culturally synonymous with loss of control. There is evidence to suggest that the presentation of a birth plan is associated with tensions between mothers and their care providers
Birth plans are both popular and problematic. While they are recommended in line with both strategic health policies and feminist approaches to birth which foreground woman centred care, choice and control, they are clearly an adjunct to standardised clinical care protocols which are determined within national clinical guidelines, which themselves can be characterised as risk averse & defensive.
Birth plans are an intriguing aspect of the British maternity experience for a number of reasons, not least because they are totemic of many of the issues within the NHS maternity care system, which include the tensions between physiological and managed birth, hierarchical power dynamics and the siting of authoritative knowledge, which in turn informs the complex and sometimes irascible discourse between Mothers, midwives and medics, often referred to as the Birth Wars.
In light of this, my research question was: what do mothers seek to achieve when they write their birth plan .
For those of you without a personal, professional or political association with maternity care, I’d like to offer some context to my research. The maternity care system is in crisis, and this isn’t new. Maternity services (in the UK) have been dysfunctional and problematic for mothers and midwives for generations.
Despite research evidencing the physical and emotional health benefits of physiological birth to the maternal dyad, and core strategies and guidelines intended to create the conditions that support it, intervention rates continue to increase. 2019/20 data shows c-section rates in England up 4.7% in the 5yrs since 2014. This rate was under 10% in the year I was born, 1976, and now at approx.. 34.5%. That this is variable by region and Trust indicates that this outcome is driven by something other than female physiology.
Having completed her report into failures practice at the Shrewsbury & Telford Trust, Donna Ockenden has now been appointed to review failings in the Nottingham University Hospitals NHS Trust. Last year the investigation into failings at the Morecambe Bay Trust was published, and we await an investigation into practice failures in East Kent.
At the end of last month the charity Birthrights released its independent report ‘Systemic Racism, not Broken Bodies’, identifying the risks women face when ‘Birthing while black’ as activist Mars Lord describes it.
My research was undertaken in the shadow of the pandemic, and a 28 month period where women were subject to limitations to intrapartum support and services, and while many still are.
It’s not only mothers who are not being adequately served by maternity services. A decade of budget cuts has resulted in workforce shortages, cuts to CPD, strictures on the conditions required to provide care, low morale and burnout. The current 31% attrition rate for newly qualified midwives is indicative of the significant stress and pressure they are under. All this suggests a lack of political will to improve conditions in a service which is not in fact a niche concern: 84% of women will have a baby by the time they are 45, and 100% of us are born.
The picture in the UK is one in which women and babies are surviving, but the potential for joy in what is ultimately a human experience is significantly debased.
I approach this research not solely as an academic but also as a doula, having observed the process of birth in various environments and varying levels of risk and complexity. This research is intended to have meaning that will inform adaptation & improvement to services and improve mothers experiences.
In qualitative, semi-structured interviews undertaken with multiparous mothers and experienced midwives in 7 different Trusts across the UK, I was able to identify 5 themes that characterised the impetus to write a birth plan.
· Firstly, mothers do complex and situational planning that covers the complete perinatal period.
· Secondly the birth plan is an attempt to circumvent the fragmentary system that rarely offers individualised care mothers prefer
· Thirdly, mothers aggregate and synthesize information gathered during their own childbirth career
· Fourthly, mothers prefer certainty over choice and control and are prepared to flex and compromise in order to gain confidence in the forms of care they’ll receive
· Finally, a key driver for mothers in the writing of their birth plan is to avoid bureaucratic care, which they are concerned will increase their risk of sustaining iatrogenic harm, both physical and psychological.
So contrary to presumptions, mothers do not write birth plans with the intention of over-riding medical expertise. They seek appropriate, relational, safe care and the birth plan is a tool they use as they attempt to access this.
I’m afraid to say these are not a particularly ground-breaking research outcomes, and reflects much existing research, including Changing Childbirth in 1993, International Conference on the Humanization of Childbirth in Brazil in 2000, to Better Births in 2016,
What’s more interesting is why these consistent findings have not been effectively applied to maternity strategy. Moira Gatens described the structures of social behaviour running ‘below the threshold of conscious decision making’ – so in order to draw meaningful conclusions from my research I have sought to identify the contextual factors which have contributed to this failure.
While mothers may always have planned for the perinatal period, the birth plan itself is a modern construct. An understanding of the historical milieu that birth plans arose from give us empathy for the progenitors of what has become a somewhat controversial document, helps to clarify the foundational motivations and allows us to identify where broader conditions have disordered it’s adoption.
Over three centuries, from the Enlightenment onwards, there was a transfer of authoritative knowledge from female to male spheres. Ownership of credible knowledge about pregnancy and birth moved from the tacit, intuitive female communities of midwifes, who understood birth as a normal human process to the paternalistic medical model which conceives birth as high-risk event requiring active management. The establishment of the NHS in the 1947 sealed the wholesale transfer of birth away from women and families and into the institution with the 1971 Peel Report recommending the facilities should be provided for 100% of births to happen in hospital.
Simultaneously, there was push-back against institutional and state control of women’s health, with the establishment in the UK of the NCT in 1956, and AIMS in 1960, in alignment with the liberatory women’s health movement in the US. So, when Simkin and Reinke published their pamphlet ‘Planning your baby’s birth’ in the US in 1980, it was in the context of a concerted and determined effort by women to recover lost knowledge about their own bodies and participation in their bodily processes. This is not quite the same as seeking control over the process of birth.
Since then birth planning as envisaged by Simkin and Reinke has been appropriated and usurped by the very partriarchal institutions it was intended to wrest control from.
This appropriation of the birth plan has been possible because some of its characteristics and the demands of the feminist health movement for women’s independent personhood and bodily control, mirrored themes central to neo-liberalism, which was simultaneously gaining purchase in the West. The superficial parallels provided a measure of common ground from which ‘choice and control’ were defined as factors that would offer mothers access to the highest quality care and the best outcomes.
On this basis – and under a succession of British Governments since the 1980s which conceptualised mothers as rational decision-making consumers located within a free market of health and maternity care – the birth plan was modelled by health care providers (within the NHS as well as private practitioners) as a mutually acceptable tool via which to access this logic of choice.
Through the neo-liberal lens, the birth plan is understood as an aid to mothers. When healthcare is rationalised in terms of economic dynamics the consumer, in this case mothers, must be free to exert considered and fore-sighted choice. This is the recognizable characteristic of the birth plan – a form of modular planning, akin to LEGO™. If the mothers instructions are followed, and the pieces chosen and placed in the correct way, they can be relied on to lead inexorably towards the best outcome.
It should be noted that perhaps one reason that choice and control via the birth plan was as acceptable a solution to Government policy-makers as it was to birth activists, was that it offers the side benefit of circumventing and making more efficient the lengthy, high time- and cost- investment of antenatal education and relational care, in line with the neo-liberal desire to roll back the state
In this way, the uniquely human and embodied experience of birth is framed as a straightforward form of production, subject to the same pressures and forces as the free market of products and services
However, this insistence on unmediated agency and control makes mothers unduly responsible in a process which is – in truth - a communal endeavour rather than an individual pursuit, and gives ground for both maternal guilt and cultural judgement if a ‘best’ outcome is not achieved. Simultaneously this focus on personal responsibility and individual choice turns attention away from the systemic and structural issues which affect the practice of maternity care.
While there are parallels between this logic of choice as realised in maternity care and some feminist demands for bodily control, the neo-liberal correlation between ‘good’ or ‘sensible’ choices and a totemic healthy body echoes the disaggregation of the mind / body in the Cartesian proposition. This heralds a fundamental mismatch between the neuro-hormonal, psycho-social realities of the birth room and the theoretically rational navigation of a free market of health care.
Susan Bordo sees this dualism as the basis of Western Philosophy, which she describes as a ‘project of disembodiment’ (cited in McHugh, 2007, p. 29), a neat encapsulation of the aspiration to slough off the unruly body in order to attain the cool, rational objectivity of the mind.
This dualism is both androcentric and the conceptual sub-structure for scientific modes of analysing, considering and interpreting the world (Tiles, 2011; Hekman, 2008) within which maternity care is contained, and to which maternal choice and control is opposed.
This dualist model in which female is constructed as corporeal, mechanistic and autonomic while male is allied with capacity for reason and judgement both forms and justifies medical and cultural biases which pathologise female bodies in such a way that they are not conceptualised in their own right or even as the dimorphic other, but judged against the male body and found wanting.
The way that female bodies function in birth is an overt contradiction of philosophically contrived norms and standards of behaviour. female bodies are a disruption from the norm – the healthy functioning of the female body is a problem simply because it is not what men’s bodies do (Schiebinger, 2017; Shildrick 1997) and are indicative of a problem to be solved, to be cured and restored.
Birth represents the most confronting example of this, where the ‘leaky boundaries’ that Shildrick referred to in 2017 to are not just conceptual, they are actual. The presence of blood, amniotic fluid, urine, faeces, tears and milk present a combination of taboos which force focus on the power of female sexuality, the opportunities and risks of reproduction. These are taboos which function to codify female bodies potentially dangerous (Brochmann and Stokken Dahl, 2017; Dammery, 2015). Pregnancy can be understood to be a particularly affronting paradox, a chimeric state where the body is neither one nor two, where rights overlap, and where questions about humanity & individual purpose coincide with existential anxiety about our mortality (Shildrick and Price, 2017).
So neo-liberalism offers a rationale for how maternal choice and control came to be co-opted by paternalistic institutions and used in a way which is unhelpful to mothers.
Dualist theories of the mind, body and sexual difference gives context for how maternal bodies are used to rationalise constructions of mothers are ignorant and their bodies as pathological.
Neither in themselves are adequate to explain how this perpetuates.
I propose that Irigaray’s theory of sexed difference is valuable here, in which she proposes our existence in the world is informed in part by the materiality of our sexual difference and further by the subtly varied psychic perspectives on and interactions with the world that sexual difference provides. I’m going to lean particularly on Jane Clare Jones in 2014, Laura Green in 2012 and Margaret Whitford in 1986 to illuminate the point.
Particularly relevant to my thesis is Irigaray’s assertion that the surface the infant sees itself reflected in in Lacan’s psychoanalytic theory of development, and against which he realises himself as an independent, sovereign being, is not in fact an inanimate mirror, but an entirely relational, foundational and interactive mother (Jones, 2014).
Jones and Green both identify that in order to attain this aspiration for sovereign independence it is necessary to erase the connection with the mother, what Green describes as ‘severing dependence on the ‘dangerous, engulfing and overpowering’ maternal body’ (Green, 2012).
So female bodies, particularly reproductive ones, come to represent a disruption to the entire male imaginary. Both Jones (2014) and Green (2012) identify this expunging of the maternal as a continuing symptom of dominant patriarchy.
Here we can draw together a number of strands; the male body as the standard; the Cartesian disaggregation of mind/body; the association of the female with autonomic corporeality (and the male with rational judgement); the Western philosophical disembodiment described by Bordo; and the rationalism exhorted by neo-liberalism. It is in this light that mothers can be constructed as ignorant, able to hear their bodies but not interpret them, and that mothers perinatal needs can be positioned as secondary to paternalistic models and metrics of care. In this way maternal intentions to write and enact a birth plan can be constructed as wilful and hubristic.
I contend that it is a significant factor in the cultural, intellectual and physical incursion of the male imaginary into what is judiciously a female sphere, and its disruptive insertion into cultures of birth which would otherwise vertically connect generations of women. I propose that a phallogocentric imaginary holds authority over and controls birth, but cannot conceive of what is necessary to accommodate this normal human process salutogenically, nor to encompass the relational care that mothers repeatedly define as important to them.
As I did a run through this morning it occurred to me that it’s worth noting why I chose the two images on this slide. The intent here is not to draw attention to outcomes (e.g., that one type of birth is better than another). This is to fall into what Green calls the ‘phallic binary’. Rather to witness the potential for mothers to be disembodied, de-centred and dehumanised when birth happens within the male imaginary.
Recognition of the implications of these epistemological sex-difference stereotypes are central to understanding the biases against female bodies which underpin how science and medicine conceptualise, construct and anticipate female bodies.
These prejudices against the healthy functioning female body create biases which underpin practices which prevent mothers from accessing the modalities of care they want, regardless of the autonomy, choice and control the neo-liberal birth plan promises.
These are the systemic and structural biases which make maternal choice and control illusory and relational care largely unattainable. Instead we have fostered a maternity care system which is largely in opposition to the physiological and emotional needs of mothers in birth, in its fragmentation, bureaucratisation and overwhelming focus on measurable outcomes rather than experience. It is notable that in the last month the Ockenden Report has failed to identify the systemic issues which underpin the problematic practice, and is making recommendations that perpetuate the paternalism of the last 40 years.
In light of this I conclude that while the neo-liberal birth plan may be framed as reflecting feminist values – particularly those that relate to bodily autonomy and control – in fact it mischaracterises the form of dynamic, safe and relational support and control that mothers desire. Further in turning away from the effects of systemic and structural influences on birth experience, and making mothers responsible for their own destiny, it can be considered to be a particular challenge to women’s health and well-being.
Image credit : ‘The Delivery (Oh my baby! Oh! My baby!’)
© Amanda Greavette