From the May 1986 issue of the Socialist Standard
The profession of obstetrics has received a great deal of public attention as a result of an inquiry which began in February into the professional competence of Wendy Savage, a consultant obstetrician at the London Hospital. Savage was suspended in April of 1985 by her employers, the Tower Hamlets Health Authority, after complaints surrounding her handling of five pregnancies. Following her suspension a campaign was mounted for her reinstatement by local midwives, mothers and GPs.
During the inquiry a number of criticisms were made of the type of approach to childbirth and pregnancy that has come to dominate maternity care in recent years. According to Savage and her supporters the excessive use of high-technology in modern obstetrics has deprived women of the freedom to choose where and how to have their babies. The process of giving birth has become dehumanised because current obstetric practices have succeeded in shifting the focus of interest from the mother to the machine. Women, argue critics, are regarded as mere objects on a conveyor belt. Wendy Savage and her supporters would like to see this depersonalised system of obstetric care replaced by an approach which emphasises both the naturalness of every birth and the individual medical needs of the women concerned.
While socialists sympathise with these objectives we also point out the limitations which present-day society places on their achievement.
First of all, isn't it surprising that the controversy arose within an NHS hospital providing health care to a particularly deprived working-class area in the east end of London? Not at all. Under capitalism there are two quite distinct standards of health care. For the rich — the capitalist class — there are the Harley Street Clinics and the private hospitals which provide the best maternity treatment money can buy. Consequently they suffer none of the degradations associated with current obstetric practices.
For the poor, on the other hand — the working class — there is the NHS.
Contrary to what politicians tell us the NHS is not in the business of providing an all-embracing caring service, free at the point of delivery and run in the interests of everyone. Its real intention is to serve the economic interests of the capitalist class by placing at their disposal a steady supply of fit and healthy wage slaves. In meeting this requirement of the exploiting class, the NHS contributes enormously to the overall profitability of British capitalism. However, it also represents expenditure and as such the provision of its services must be cost-effective to ensure that the capitalist class get value for their money. In economists' jargon this means that resources must be used effectively. services must be rationalised, financial targets must be met, and wages must be minimised — the NHS is big business and it must be run accordingly. Under capitalism even the most basic of our health needs play second fiddle to the managerial and accounting practices associated with production for profit.
So how do these practices relate to the provision of maternity care? The maternity services operate within a context of scarce resources, shortages of expert consultants and midwives and expenditure cuts. Everything possible is done to cheapen the cost of childbirth and this economic fact determines the quality of care and the practices adopted by obstetricians.
In the early years of the twentieth century maternity care was exclusively handled by untrained mid wives, known as "handywomen". Apart from a few difficult cases, which were handled by doctors or GPs. more babies were delivered at home. Today, however, these functions are controlled by professional obstetricians working from maternity units in large district hospitals. Community midwives have been gradually reduced and as a result the number of hospital deliveries has risen from 15 per cent in 1927 to 97 per cent in 1976, with the intention that home delivery be phased out further (Short Report on Perinatal and Neonatal Mortality, 1980).
With the professionalisation and hospitalisation of maternity care there has been an increased reliance on high-tech medicine. One practice which has increased tremendously in recent times is that of inducing labour artificially by using modern technology. Some obstetricians have argued that inductions are carried out only when the life of the baby or mother is threatened but some experts have pointed out that inductions are not always carried out for medical reasons:
Technology is now being used in some hospitals to induce labour routinely, not primarily for the baby's safety or the safety of the mother, but in order to create a production line system where women have their babies by clockwork during daylight hours. (O. Gillie & L. Gillie, Sunday Times. 1974.)
Given the priorities of the NHS it is easy to see why the rate of inductions increased (from 13.7 per cent in 1963 to 38.9 per cent in 1974). Inductions help to speed up the process of childbirth, ensure that hospital beds are used more intensively and shorten the length of time women stay in hospital. Often inductions are laid down as hospital policy — as was the case in the hospital where Wendy Savage worked — in order to meet a planned throughput of births, perhaps 1.000 babies delivered each year. In a study of inductions, A. Cartwright (The Dignity of Labour) reports that more than half the obstetricians questioned said they would recommend inductions where there were staff shortages or a restricted access to anaesthetics. After giving birth by this method, which often has negative psychological and emotional repercussions, women are ushered out of care to be looked after by a much depleted and hard-pressed community midwife service.
Economic considerations can also be observed behind the startling increase in caesarian sections. The use of this method of delivery was central to the case against Wendy Savage. Tower Hamlets Health Authority claimed that she had performed a caesarian "too late", resulting in the death of a baby eight days after delivery by an emergency caesarian. Although the merits of this particular case are unclear, recent figures released by the Office of Population Censuses and Surveys suggest non-medical reasons for this type of operation. The figures show that much depends on how busy the ward is on a particular day. On Fridays, the busiest day for deliveries, there was a 43 per cent increase in the number of elective caesarians (those not performed in an emergency) but on Sundays, the quietest day, elective caesarians were 62 per cent below average. An interesting figure is that the caesarian rate for private hospitals (19.6 per cent) was twice that for NHS hospitals. The explanation here is that most insurance policies cover caesarians, while patients have to pay cash for spontaneous births. Given the choice it is hardly surprising that working class mothers choose the former, less expensive method of payment.
As with all services provided by the NHS for members of the working class, maternity care offers women little choice over the kind of treatment they would prefer. In a study of NHS hospitals in York and London (H. Graham & A. Oakley: Medical & Maternal Perspectives on Pregnancy in Women) most women complained that there were very few areas in which they were allowed any say in their maternity care. They had practically no explanation from the doctors about what was being done to them; they saw too many doctors to receive any kind of personal attention and the whole experience left them feeling like battery hens.
This kind of treatment cannot be blamed entirely on the attitudes of consultants, who are as much victims of the situation as are the pregnant women. Over-worked consultants have little time to discuss alternative options of delivery and for the sake of convenience are likely to make decisions for those in their care. They require a passive rather than a questioning attitude from their patients and this is fostered by the sense of vulnerability and helplessness felt by pregnant women — especially when they are delivered into the hands of experts who, they believe, ought to know best and surrounded by a bewildering array of sophisticated equipment.
So what's the solution? Both the best and the worst aspects of the use of technology are represented in modern obstetrics. On the one hand the risks to mother and child associated with child-birth and pregnancy have fallen dramatically, as evident in the reduction in the perinatal mortality rate (still births and deaths during the first week of birth) from 38.5 per cent in 1948 to 17 per cent in 1977. But on the other hand modern obstetric methods have left women feeling degraded and brutalised. Under capitalism this situation will never be resolved; technological advances can only be used for the enrichment of the tiny few and the consequent enslavement of the vast majority. A truly civilised standard of medical care can flourish only in a truly human society and judging by current obstetric practices, it is perfectly obvious that we clearly do not live in one.
G. Davidson
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