Controlling birth? Relationships between midwives, women, and the medical profession in England, 1960-1992.
Introduction
This paper will explore the changing nature of relationships between midwives and women in urban England between 1960 and 1992, and is part of a larger study on the history of maternity in twentieth century England. The paper uses interviews with midwives and members of maternity consumer groups, as well as contemporary documents, to argue that two developments over the period had a significant impact on the ability of midwives to relate to the women in their care. Each was seen particularly in urban areas, and was in response to the demands of an urban ‘elite’. The first was the push by specialist obstetricians for the use of hospitals for birth, and for the use of technology for diagnostic and therapeutic purposes. The second was the foundation of consumer groups which focused on the experience of the childbearing woman. Both developments were predicated on the belief that the prevailing system of maternity care was flawed and potentially dangerous, and both sought vigorously to change the experience of pregnant and birthing women. Furthermore, the development of consumer groups, often as a direct result of the perceived impact of the medicalization of birth, eroded the relationship between women and midwives by implying that they were working towards different goals. Evidence suggests that midwives attempted to neutralise, or even come alongside women in these debates. Ultimately, however, the voice of the urban consumer and the medical elite had a decisive impact not only on how midwives came to describe their work but also on the rhetoric and policy of government in the area of maternity services.
Background
In the late 1950s the maternal death rate in England was 3.2/10,000 (dropping to 0.81/1000 by 1990) births and although this was a much improved figure on that of the immediate pre-war period, obstetricians increasingly used the rhetoric of danger when discussing birth (Macfarlane et al 2000). There were a variety of reasons for this; some of them altruistic, some less so. A tripartite system of maternity care in England had been created following the development of the National Health Service in 1948. This meant that general practitioners [GPs], local health authorities (who employed district midwives) and hospital based obstetricians all had involvement in the care of pregnant women. At the same time the birth rate was rising (Macfarlane et al 2000). The conclusions of a Government report looking at the structure of the maternity services in 1959, demonstrates the influence that obstetricians wielded over national policy (Ministry of Health 1959; ‘Cranbrook’ Report). Although the Report defended ‘the advantages of home confinement for the apparently normal case…’ it urged that beds should be available for 70 per cent of women to have hospital births. It also agreed that most GPs did not have the skills to be involved in any aspect of maternity care. In many ways, the Report was just confirming what was already occurring, with an average of 65 percent of births in England already taking place in hospital settings. By 1970 the influential Peel Report, another Government publication, was arguing that enough beds should be available to allow all women to deliver in hospitals, and that all care should be given under the auspices of hospitals, rather than being devolved to local authorities or GPs (Department of Health 1970 ). Again, the recommendation signalled what was already happening, with 81 per cent of all births occurring in hospital in the late 1960s. At no stage was home birth actually outlawed, although the Short Report, came close to this with its argument that childbirth should be seen as analogous to intensive care and should take place in a similar environment (Department of Health 1980). As one consultant put it at the time: ‘A lifetime in obstetrics convinces me that no baby should be born at home unless circumstances prevent hospital admission’ (Davis, The Times, 21.05.1980)
The question of safety was at the heart of many of the debates and much of the rhetoric around birth in the post-War period. The majority of obstetricians believed that there was a direct causal link between hospital births and reduced maternal and perinatal mortality. Alongside the place of birth, the development of technology in pregnancy and birth was seen as a way of reducing the risk of mortality and morbidity (Shorter 1983). This included the use of ultrasound scans for visualising the foetus, sonar waves for amplifying the foetal heart rate, epidurals for pain relief, caesareans and inductions of labour (Butler and Bonham 1963). Inevitably this deployment of technology could only occur in hospitals; and in large urban teaching hospitals. As one obstetric consultant from St Mary’s in London argued ‘To suggest that we should go back to the days of “home confinement” is like asking a modern surgeon to remove an appendix on the kitchen table.’ (Beard, The Times, 06.09.1974) and six years later, Davis was arguing that ‘the hazards of delivery are too many and too serious to subject both patient and midwife to the risks inherent in the obvious lack of medical facilities in the home.’ (The Times, 21.05.1980)
The path of maternity care in England between the 1960s and 1980s therefore seems clear. Hospital births outstripped home births, and maternal and perinatal mortality rates fell; obstetricians, and through them government documents, suggested a direct causal link. This is not the paper to discuss the merits of this argument; much work has been done by researchers suggesting that home births were never more risky than hospital births, and also that supposed links between hospital deliveries and mortality rates are coincidental at best (Tew, 1990). This paper will, however, explore the striking impact that women – as service consumers – had on the way arguments were framed, and ultimately on government policy. The language they used was not only very different, but increasingly influential. In the vanguard of this revolution in the debate about birth were well -off women living in urban areas; arguably, from a public health point of view, the group who had least medical need of specialist services.
The development of a consumer voice in maternity services
Feminist critiques of the history of birth have tended to suggest an oppositional relationship between (male) doctors and (female) service users in the post-war period with doctors using the language of risk and safety to coerce women into accepting high technology institutional births (Donnison 1988; Oakley 1980; 1984). Birth in hospital was led and controlled by doctors, with writers such as Oakley arguing that women were more or less tricked into giving up their hegemony over their experience. However, the evidence demonstrates that this was never the whole story. In urban areas, including Nottingham, Birmingham, Sheffield and parts of London, demand for hospital births by women always outstripped the availability of beds (McIntosh 2012). Midwives in Sheffield and London recommended women to book their hospital bed for birth within the first few weeks of pregnancy. Similarly in Nottingham and Derby the local health authority fought a rear guard action to remind women of the advantages of home birth over hospital birth, to little avail (McIntosh 2014). In 1960, there was a debate in London about whether all women should have access to hospital beds; this was not for medical reasons but because women increasingly felt that they were ‘entitled’ to a hospital bed. The argument was made that women should be allowed to have their babies at home, but not forced to if they preferred hospital, and it was noted that these women tended to be ‘highly intelligent and provident women’ (TheTimes 12.2.1960). Looking back on the period, Jean Robinson, a campaigner for women’s rights in childbirth, argued that it was the ‘articulate middle class’ who got hospital beds even in times of shortage, because they booked early and believed the rhetoric about safety, and had the confidence to ask for what they wanted (interview with the author).
It was these same ‘articulate middle classes’ who were the driving force behind two influential health consumer groups which were set up in the late 1950s and early 1960s to promulgate specific views of the birth experience and are still in existence today; the National Childbirth Trust [NCT] and the Association for Improvements in Maternity Services [AIMS]. The NCT (formed in 1956 as the Natural Childbirth Trust) had been originally organised in order to help women to work with the system; in particular early NCT classes advocated relaxation and controlled breathing as superior to appearing out of control and in need of analgesia. The original aims of the Trust were clearly based round hospital care, and included the requirement that husbands should be present if desired, that analgesia should not be forced upon women and that they should be humanely treated. AIMs, set up in 1960, had at its beginnings in more polemical and strident fashion, when its founder Sally Willington wrote a letter to the Guardian newspaper saying:
In hospital, mothers put up with loneliness, lack of sympathy, lack of privacy, lack of consideration, poor food, unlikely visiting hours, callousness, regimentation, lack of instruction, lack of rest, deprivation of the new baby, stupidly rigid routines, rudeness, a complete disregard of mental care of the personality of the mother’. (The Guardian 01.04.1960)
She initially tried to call her group ‘the Society for the Prevention of Cruelty to Pregnant Women’, although was soon persuaded to change this for something with less negative connotations.
Both Willington, and Patricia Briance who set up NCT, had personal experience of hospital maternity care, both came from comfortable intellectual middle class backgrounds, and were comfortable using the language of ‘rights’. Briance later argued that ‘You cannot possibly imagine what it was like back then in fifties, we knew nothing about having a baby and there was no one to tell us; no books or magazines that told you what to expect’ (The Independent 26.04.1996). No mention of midwives or of doctors; she offered a view that was not only stark but that reflected a particular agenda. A woman would expect to get information herself, not rely on professionals; both AIMs and NCT developed the concept of women not as patients but as consumers of the maternity services. From the beginning, AIMs in particular was adept at harnessing the power of argument whether through letters to MPs, evidence to local committees, or talks to women’s groups. It boasted as members school teacher and welfare workers as well as consultants, surgeons and psychologists, and was granted an audience at the House of Commons just a year after coming into being (The Times 06.02.1961). Similarly, the NCT was good at making and using its contacts. In 1963, an interview with Betty Parsons, a teacher with the NCT commented on the ‘cordial relationship she has built up within the medical profession’ and a book she wrote on antenatal exercises had a ‘very complimentary’ Forward by John Peel, the President of Royal College of Obstetricians and Gynaecologists (who was later to Chair the committee calling for hospital beds to be available to all women) (The Times 01.04.1963). As Sheila Kitzinger – another childbirth campaigner and wife of an Oxford Don – remarked in interview, it was the relationships with Doctors that meant things got done (interview with the author). She commented very favourably on relations between herself and the obstetricians at the John Radcliffe Hospital in Oxford. Jean Robinson, who campaigned against unnecessary inductions of labour in the 1970s through AIMs, also spoke of her contacts; consultants in both London and Oxford. Clearly socially these women were on the same level as the doctors and politicians they dealt with and contacts could be informal and non-threatening. This gave them influence and power in developing and selling their view of childbirth.
The same often applied to the women who joined the NCT and AIMs or who used their services. One of the primary functions of the NCT was to run ante-natal classes in relaxation and childbirth preparation for women and their partners. As Betty Parsons commented, many of the lessons she gave were private one-to-one lessons; even the group sessions cost money. Nearly twenty years later Janet Balaskas, who had started off as an NCT teacher but now ran her own Active Birth movement in North London agreed that the women she dealt with belonged to a privileged group (interview with the author). However she argued that ‘Women like us can help effect changes for other women who don’t have our opportunities.’ Choosing to take lessons in natural or active birth was a huge commitment for women not just in terms of money, but time as well. One commentator explained in 1964 that a course of classes usually consisted of eight two hour sessions, plus daily practice, in order to be properly ‘trained’ (The Times 06.04.1964). This clearly was out of the reach of many women. The same commentator explained, rather scathingly, that although some classes were beginning to be offered on the NHS, a couple of sessions were not going to replicate the intensity needed to achieve success.
The issue of power and control is also clear during the early years of both AIMs and NCT. Women were only allowed to attend NCT classes if they had the permission of their doctor. The career of Janet Balaskas in many ways sums up some of these issues. She was radicalised by her own experiences of pregnancy and birth; shocked by what she felt was the medicalization of the English system she was in a position to return to her native South Africa to deliver. Even there, she asked permission of the doctor to have a natural birth. On her return, she trained as an NCT teacher, but was disillusioned with their continued acceptance that women should passive in labour and lie on their backs to deliver. In response she turned to yoga and began to develop what she described as ‘active birth’; encouraging women to stand and move for labour and squat for delivery. At this point she parted company with NCT because they considered her work ‘unproven’ and too ‘radical’ – in her words. In interview she talked about organising a rally in 1982 to protest at the refusal of the Royal Free Hospital in north London to allow women to have active births. She estimated that about 5000 people attended (Kitzinger suggested about 2500); including the wife of a member of Pink Floyd who donated stage and speakers, and the newsreader Anna Ford. At this point only two hospitals, both in well-heeled west London, and independent midwives offered active birth. Balaskas talked about change being incremental and word of mouth which only works in a tight geographical area; her classes still run in the same area of North London.
In interview Sheila Kitzinger used the language of control to describe the types of women attending NCT classes – ‘Mostly educated women. Women who were concerned about taking control of their lives and often it wasn’t just childbirth but other areas too that they were concerned with.’ The NCT and AIMS both developed a more radical agenda in the 1970s and 1980s, they increasingly argued against the use of technology. Although safety was always central to the rhetoric of the maternity services, and was particularly used to promote hospital birth and the use of technology, certain groups of women began to use different criteria to inform their experience of pregnancy and birth. This was partly based on personal experiences of technologically mediated birth. The language of feminism seems also to have been significant to many women in terms of the rights and control that they demanded over their own bodies. Equally important was the drive by some women for birth to be seen a psychological event as much as a physical one.
Kitzinger described the process of engagement with policy; radicalisation of women through demonstrations was one thing, real progress came through the media and through Government. She described learning to ‘…manage the media is a bit strong but learning to communicate with the media and express yourself with the media is a specific skill…’ She also talked about putting pressure on Parliament, and getting questioned of MPs and by MPs. These were all particular class and social skills, and Kitzinger and others argued that the work they did made a difference to all women. As Balaskas commented, birthing pools and space to practice active birth are now encouraged in NHS facilities and supported by midwives; this could be seen as the positive impact of the work of an elite. However, it could also be seen as at best an irrelevance; women from low income backgrounds and ethnic minorities continued to have the highest rates of perinatal and maternal morbidity and mortality; birthing balls and pools made little impact on their needs for responsive care (Confidential Enquiry Reports).
The impact of the consumer voice on relations with health professionals
Relationships between midwives, doctors and women were complex, and the stories told about maternity care from each perspective do not always tally. To women, midwives and doctors could be cold and bossy, or deeply warm and caring. To the midwife, women could be unnecessarily demanding or laughably ignorant. Both groups used shorthand and concepts of heroic attitudes or behaviour to describe characteristics of the other, in a way that made sense and made a complex and symbiotic relationship more manageable.
Certainly there were groups of midwives who were instrumental in developing a radical language and in working alongside women, in particular the Association of Radical Midwives which was formed in 1976 by a group of student midwives, who themselves felt oppressed by the system under which they worked. In terms of change, however, their efforts were dismissed by some of the consumer campaigners; Kitzinger argued that they were not a major influence on changes in maternity care, although Balaskas said that she would always support the right kind of midwife; one not driven by fear or policy.
However, midwives were often seen by women as being part of a discredited system, and this impacted on the relationship between mother and midwife. Jean Robinson who worked for AIMs remarked that, ‘midwives sold women down the river’ because they were seen as part of the medical establishment, rather than being ‘with woman’ as the name ‘midwife’ suggested they should be. She argued that AIMs and other consumer groups ‘were hampered not just by the arrogance of the medical profession and their entrenched and undeniable power, but by the weakness of the midwives…they are not fighters and they do not think strategically.’
It is certainly true that many midwives were excited by the possibilities of technology, and embraced its cutting edge nature enthusiastically. One who worked in Manchester described how in 1967 their hospital was the first one in England to have an electronic fetal heart monitor – ‘of course it was exciting, we’d never seen a foetal heart monitor before… I thought everyone should have the benefit of technology’ (Stella; interview with author). This seems to have been particularly true of hospital midwives. For Kitzinger, however, it was more about a state of mind:
Well many midwives were very authoritarian and thought that it was a sort of games mistress approach almost, that you had to behave yourself as if you were on a hockey field and obeyed the rules, otherwise everything would go to pot.
There was also a pride among midwives that they were professionals and did know best; one midwife who worked in Manchester in the 1970s felt that many women had their expectations of pregnancy and birth raised by consumer groups, and that any resource to technology or assistance constituted ‘failure’. There was also pride among midwives who worked in rural communities that they knew ‘their’ women well, and the relationship was an individual one rather than needing to be mediated through the language of ‘control’ or ‘rights.’
One midwife, Jenny, who worked in Nottingham in the 1970s and 1980s said that she felt relationships between women and midwives were good in the 1970s because ‘They didn’t have the expectations that they have now, and trusted you I think probably.’ The move from ‘patient’ to ‘consumer’ affected midwives because they felt their professional status was being eroded. Littleford described the impact that this had on their work and on their professional standing; ‘I think the women’s and families expectations were far greater than we could ever provide.’ This she attributed to Government policy and to the demands of women, but also the squeeze between expectations and the ability of the service to cope. This included not just lack of staff and equipment, but lack of respect by doctors, particularly in the large teaching hospitals, for the work that midwives did. Littleford felt midwives were regarded as pliable handmaidens both by doctors and increasingly by some women; and that their demands could be incompatible.
Within the rhetoric of urban consumer groups and radical midwives there was no attempt to include the voices or needs of non-middle class members of the community such as women from low income families, refugees, teenage mothers or single mothers. Mavis Kirkham, who worked as a hospital midwife in Sheffield in the 1970s, described consciously deploying ‘nice middle class’ couples to pioneer partners being present in theatre for elective caesareans. Within her work, she spoke of ‘misfits’ coming together; not just midwives who did not fit the system but women as well. Again, she argued that change came incrementally; through individuals attending antenatal classes, or booking with a certain community midwife. In many ways these were still an elite self-selected group; women who were articulate and well-read and confident enough to demand a particular kind of care. In contrast, Oakley’s work on the experience of first time pregnancy and motherhood, conducted between 1975-6, demonstrates that women continued to be accepting of the system as it was (Oakley 1981; see also Cartwright 1979). This was not to say they were always happy with it, but they had no language for criticising the system, and no sense that they could change it. McIntosh (1989), in a study of motherhood on urban Glasgow, found that women did not invest the act of birth with huge significance; it was only a tiny part of the larger experience of motherhood. These were ordinary women living in an urban environment; not people with the confidence to right to MPs or the money to buy into a philosophy such as active birth.
Conclusion
The consumer movement in maternity really developed from the 1960s onwards, and had a significant impact on the language and beliefs around birth by both policy makers and professionals. The evidence suggests that urban elites who developed consumer groups in maternity had an influence on the discourse around pregnancy and birth beyond their numbers. This included debates around the types of care offered; hospital birth, the use of technology and the development of active and low tech births. Although the arguments around active birth have been foregrounded in this paper, some women also campaigned for greater access to induction of labour and the provision of epidurals. The consumer voice was always complex and multifaceted. Similarly successive governments, taking their cue from obstetricians, had used medical concepts of ‘safety’ and ‘risk’ to frame policy since the early 1960s. However from the 1990s policy makers began to use phrases such as ‘choice’ and ‘control’ in relation to maternity which consumer groups had been using for twenty years. Arguably women did begin to take control of childbirth across the period, but in a way which spoke to a small, elite, cross-section of society. Although some midwives developed their own radical agenda around birth, for others the voice of the consumer represented a threat to their sense of professional identity and confidence. The move to hospital birth and demands for different kinds of birth marginalised the role of midwives, leaving them sandwiched between doctors and women.
Dr. Tania McIntosh, Principal Lecturer, School of Health Sciences
References
All oral quotes are from interviews with author
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