Hi-tech births (1986)

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

Castles in the air (1986)

Illustration by George Meddemmen

From the April 1986 issue of the Socialist Standard

Under capitalism the housing problem has been a constant feature of working-class life. Although consecutive British governments have enacted numerous reforms, overcrowding. shortages, slum-living and homelessness persist. The present government's 1980 Housing Act sought to broaden the scope of home-ownership by allowing council tenants the "right to buy" local authority-owned housing, in the belief that a shift of tenure offered the best solution. So what have been the results so far?

There is a popular image of owner-occupiers as a privileged minority enjoying a number of advantages denied to tenants of rented accommodation, such as freedom of choice, independence, security of tenure, high-quality housing and asset growth. In addition, the financial carrot of tax subsidies such as mortgage interest relief helped make owner-occupation a seemingly attractive proposition.

The remarkable growth of the owner-occupied sector — from 54.7 per cent in 1983 to 60.2 per cent in 1985 and a projected 67.9 per cent in 1991 — seemed to justify the Conservatives' policy on council house sales, which was popular with the electorate. Political pundits have in fact pinpointed the 1980 Act as a major factor in the Conservatives' electoral successes in recent years and Labour traditionally the party of council housing has taken note of this and reversed its policy.

Despite its apparent popularity, however, the growth of owner-occupation has not been accompanied by an easing of workers housing problems. In fact for many working-class households owner-occupation has created more problems than it has solved. Entry into the owner-occupied sector is no guarantee against squalor and the responsibilities of maintenance and repair, coupled with the pressures of regular mortgage repayments. place an enormous burden on those dependent exclusively on wages and salaries for the upkeep of their house. In this context security of tenure is an illusion and the threat of eviction and homelessness is ever present.

Contrary to popular belief, most owner-occupiers do not actually own their houses. Their right of tenure is secured only through loans which they have to repay with interest to the lending institution — usually a building society but increasingly since the 1980 Act to local authorities. The title deeds to the property are held by the lending authority until the mortgage has been fully repaid, which means that over the life-time of the mortgage — which can be as long as 30 years the owner-occupier's status is akin to that of a tenant but also bearing all the responsibilities of repair and maintenance.

If owner-occupiers get too much into arrears the loan-making body can apply for a court order to gain possession of the property. A recent report in the National Westminster Bank Quarterly Review shows that as owner-occupation grows so too does the problem of mortgage arrears and repossession. It points out that "although increasing numbers of people are entering owner-occupation. increasing numbers are being forced out" (August 1985). The 1980 edition of Judicial Statistics showed that there were 27,105 mortgage possession actions in County Courts in England and Wales. By 1983 this figure had reached 43,274, an increase of 61 per cent. This nevertheless tends to underestimate the problem of mortgage default because most of those in arrears do not figure in possession actions. Many people resolve the problem in other ways: some borrow money to pay off the arrears (even though this only delays the date of court action); others sell their house to meet their debts and either move down market or into rented accommodation, while some simply hand over the key of the property to the mortgagees.

Those forced to give up their houses either voluntarily or as a result of a court order often face difficulties in securing other accommodation. A move to cheaper housing invariably means a move to a poorer area, with all the repercussions that may have for changing jobs (if this is possible) and schools and severing family and social connections. The move to rented accommodation is not, however, as easy as it appears. As the local authority housing stock dwindles the chances of ex-owner-occupiers being rehoused are slim — a problem which is aggravated by the rules many local authorities have which effectively exclude owner-occupiers from access to council houses and place them in low priority categories for rehousing. And as for the privately rented sector, this has shrunk so much that offers of accommodation are exceedingly rare or far too expensive for those priced out of owner-occupation.

So what are the causes of mortgage difficulty? Building societies grant mortgages on the basis of the size and stability of household income, and for members of the working class this means the wage or salary derived from the sale of their mental and physical energies to the capitalist class. The conditions of capitalist production determine both the amount and the availability of workers' incomes — if the capitalist class isn't trying to cut workers' wages to the absolute minimum in order to maximise profits then it is making workers unemployed to minimise losses. Ether way workers cannot win, a fact mirrored in the insecurity of their position as owner-occupiers.

The Building Society Fact Book (1985) attributes the upsurge in arrears and possessions to the sharp increase in unemployment and the consequent fall in wages and salaries. Two major reports — the National Consumer's Behind with the Mortgage and the Building Societies Associations Mortgage Repayments Difficulties — show that owner-occupation becomes unsustainable for those households which suffer an unexpected and long-term cut in earnings. This can be brought about by factors other than unemployment, such as sickness, pregnancy. industrial disputes, marital breakdown and death.

It follows, therefore, that owner-occupiers who want to maintain their homes and stave off the bailiffs must not get sick, pregnant, go on strike, get a divorce, be made redundant or die — a tall order for any member of the working class. In the circumstances of rising unemployment the pressure on owner-occupiers is enormous, but for low wage earners it is especially acute. Workers on low wages are highly vulnerable to sharp increases in housing costs or any reduction in their income, and even the slightest rise in mortgage rates can cause severe problems.

To encourage as many households as possible to take up owner-occupation, the government has also wielded the axe to council house expenditure programmes. This has meant that council house rents have risen sharply over the past few years while tax subsidies to owner-occupiers and various other incentive schemes (shared ownership, homesteading, mortgage guarantees and council house sales with large discounts on market values) have helped to cheapen the cost of house purchase. Given the choice between slum or near slum council housing and the seemingly lucrative financial incentives of house-buying, it is hardly surprising that opinion surveys indicate a huge demand for owner-occupation.

In recent years the concept of home-ownership has been sold to workers so relentlessly that the shabby reality of owner-occupation has been submerged beneath a barrage of misinformation. Workers should not accept the well-worn fallacy that there is something fundamentally different between rented and mortgage accommodation — that council housing is somehow "socialist" and owner-occupation "capitalist". The provision of both is determined by the conditions under which those who own the means of producing houses, the land, building materials and capital, can realise a profit. These people do not care whether their capital is used to produce council houses for rent or houses for sale in the private sector. Their goal is profit and nothing else.

Under capitalism the housing market determines both the quality and quantity of accommodation within the price range of the working class. Consequently, there is very little difference in house standards between owner-occupied housing and council accommodation — in fact, owner-occupiers are marginally worse off than council tenants in this sense. The recently published Duke of Edinburgh Inquiry into British Housing reveals that the state of repair of the average owner-occupied sector has fallen below that of the average council house. The former has, on average, a higher percentage of dwellings which are officially classified as unfit (4.7 per cent); lacking basic amenities such as an inside toilet (3.3 per cent); and requiring repairs of £7.000 or more (5.3 per cent) and £2,500 or more (21.3 per cent). Many workers simply cannot afford to carry out the maintenance and repairs required on their homes, a situation which has been exacerbated by the recent cuts in home-improvement grants. In some cases workers are sent on an endless trip to nowhere for what is basically a slum house; or worse still, making mortgage repayments on a house that has been demolished as a result of structural faults or subsidence. Their homes may have been lost or fallen into an uninhabitable state but their mortgages remain the same.

In the nineteenth century Engels made the following remarks about the housing problem:

 As long as a capitalist mode of production continues to exist it is folly to hope for an isolated settlement of the housing question or of any other social question affecting the lot of workers. The solution lies in the abolition of the capitalist mode of production and the appropriation of all the means of subsistence and instruments of labour by the working class itself

(The Housing Question)

During Engels’ time very few members of the working class could be described as owner-occupiers: the majority lived in rented accommodation. At present owner-occupation is the major form of house-tenure in Britain but the problems to which Engels was referring in The Housing Question are still with us. Homelessness rose by 6 per cent last year and the government is at present carrying out a full national survey which, experts believe, will reveal the true extent of the housing "crisis".

As long as profit takes precedence over human need the problem of housing will remain as an ineradicable feature of working-class life. The solution, therefore, lies in the abolition of capitalism nothing more, nothing less.

G. Davidson