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A Neoliberal Quickstep
Contradictions in Australian maternity policy
Kerreen Reiger
La Trobe University, VIC
Abstract
Current Australian maternity policy, while fragmented and uneven, is moving in new directions. Alliances between consumers, sympathetic health professionals and bureaucrats have placed the objectives of improving women's choices, increasing their control over decision-making and providing continuity of care firmly on the agenda. The state arena is a central space for articulating such demands and policy support has been critical to implementing changes in service delivery.
Along with steps forward, though, steps sideways and backwards indicate the contingent character of the late modern state as it responds to social changes at the same time as advancing particular political goals. This paper argues that impediments towards making services more 'women-friendly' lie not only in the historical location of childbirth management in the medically-driven acute sector but in contemporary neoliberal political and economic pressures that both promote and yet constrain change.
Research in selected Victorian hospitals suggests that desirable goals are compromised by working realities in contemporary public hospitals. Political mobilisation in the community and around the state remain necessary to encourage further change in childbirth management, but continuing critical assessment of the structural context and human challenges of maternity reform is also essential.
Keywords
maternity care, Australia, neoliberal health policy, childbirth reform, state
Article Text
Although what Sax (1984) has called a 'strife of interests' shapes Australian health service provision, the historical and political processes involved in maternity care have received little comprehensive attention. In many respects, the social 'design of birth' (De Vries et al 2001) in Australia reflects issues arising in most western health systems - disputes over medical dominance, the relationship between public and private provision, and the role of midwifery and of consumer movements in influencing state policy. While the impact of the neoliberal 'market state' during the 1990s has occasioned considerable debate about health care (eg, Hancock 1999a, Duckett 2003), the implications for maternity care are more mixed than 'gloom and doom' analyses might suggest. There is no national Australian maternity policy framework and exchange of information across institutions, regions and states remains limited, but many changes are under way. New models of maternity care are challenging traditional professional role boundaries (Reiger 2004, Lane 2006 this issue), and consumers' voices are increasingly being heard (Lane 2001, Hirst 2005). Yet formidable historical and contemporary barriers to 'women-friendly' maternity services remain. This article examines some of the complex processes in policy formation and implementation.
The state, medicine and maternity care
The politics of contemporary policy-making take place in the shadow of the past. In particular, the role played by the state has been an important focus of analysis, both in the regulation of the professions in maternity care historically (Witz 1991, Willis 1983, De Vries et al 2001), and with regard to recent changes to professional roles and service provision in Australia and comparable countries (Reiger 1999, Bourgeault et al 2004, Bourgeault 2006). State support for forms of medical dominance of Australian childbirth included subordinating midwifery within nursing (Willis 1983, Reiger 1985), and promotion of specialist obstetric care over that of general practitioners in the late twentieth century (Schofield 1995). Yet as Witz (1991) has argued in terms of Britain, the state has been something of 'a weak link' in the chain of promoting medical interests rather than merely an instrument of professional power. Indeed, in recent years, governments have also been instrumental in 'changing childbirth' to lessen medical control (Department of Health (UK) 1993). Further, in New Zealand and most Canadian provinces, the state has been used effectively by midwives and consumers during the 1990s to institutionalise autonomous midwifery (Tully et al 1998, Bourgeault 2006). In Australia, although governments traditionally promoted medical dominance of birth, recent policy initiatives in several states are encouraging significant change in the mainstream public hospital system (NSW Health 2000, Department of Human Services 2004, Hirst 2005). Full analysis of the complexity of state involvement in maternity care goes beyond the scope of this paper, but I argue that these developments point to the importance of conceptualising the state in late modern capitalist societies as flexible and its power contingent on developments not only within the political domain but in civil society. Although political agendas reflect powerful economic interests, the state is also open to influence from maternity consumers as well as from health professionals. Recent theories of the state, especially those employed by feminists, go beyond traditional Marxian or Weberian approaches which stress class-based power or state political power respectively (Witz 1991: 208-9, Charles 2000). By drawing on more complex interpretations of the relationship between state regulation and processes of change and conflict in civil society, such as those developed by Gramsci and Foucault for example, Showstack Sassoon (1988) and Franzway, Court and Connell (1989) have argued that the state is both a centre for the institutionalisation of power and a site of contestation in which particular players as well as broader structures are implicated. Discussing changes in women's lives and work, Showstack Sassoon (1988: 16-23) observed several years ago that social developments can outstrip the political and the state then has to adjust to social changes which it has also been instrumental in fostering. This dialectical relationship between state and society has also been noted as central to the relationship between women's movements and state agencies. As Nickie Charles puts it, 'feminist social movements engage with the state by confronting it and by working within it; it is experienced as both constraining and open to change' (Charles 2000: 28). For Australian women in particular, the state has been used successfully to increase equity in women's health provision, education and legal status (Broom 1991, Bacchi and Schofield 2005), even though neoliberal political emphasis on individual responsibility and on the traditional family now threatens some of those gains. In Australian maternity care, I argue, contradictory processes are evident within both policy and hospital-based practices. In several states, while policy has encouraged some modification of the traditional obstetric-dominated birthing system, significant impediments towards making services more 'women-friendly' continue to reflect the complex interplay between the agendas advanced by the state and by other social actors. The first section of the article briefly examines the historical processes of contestation through which childbirth became established as medically-managed in the acute health sector. The second section then draws on policy material, direct experience of the field as a consumer advocate as well as researcher and informal interviews at various points with state policy advisers to consider developments in the late 1980s to the mid-1990s. These, I argue, offered major 'steps forward' in reconstituting policy discourse around birth in the light of social changes that gave rise to birth reformers' demands and midwifery professionalising struggles. As women's movements promoted greater autonomy for Australian birthing women (Reiger 2001a) and midwifery professionalisation challenged the established hierarchies of the medical system, state maternity policy became a contested terrain (Schofield 1995, Reiger 1999). Throughout this and a second wave of more recent and significant change since the late 1990s, the political context was also simultaneously shaped by other agendas, most notably those associated with emerging forms of economic rationalism. The final section of the paper then considers how advocacy of 'humanised' birthing by midwives, consumers and some medical and bureaucratic supporters has been increasingly undertaken within a health sector characterised by recurrent organisational restructuring and resource shortages. It draws, albeit briefly, on qualitative research in Victorian public maternity hospitals in 2003-5 including longitudinal studies in both a small rural unit and a large tertiary one, and key informant interviews with unit managers in 5 suburban units. Interviews and focus groups included approximately 90 midwives and 30 doctors across the sites. Interview data was fully transcribed and given back to participants for correction where possible before being thematically coded using NVivo. At least with regard to Victorian public sector maternity care, this data suggests that although state avenues have been an important means of articulating the goals of 'women-centred' care, their achievement in practice remains a compromised political struggle.
Australian maternity provision: the historical legacy of medical power
Even in the many fine accounts of Australian health services, little attention has been paid to maternity care (eg Sax 1984, Daniel 1990, Crichton 1990) and nursing histories neglect midwifery (eg Bessant and Bessant 1991, McCoppin and Gardner 1994). These accounts nonetheless make it clear that the medical profession directly influenced Australian maternity policy, both through using legislation to ensure the subordination of midwifery competition (Willis 1983) and through achieving the power to affect structures of health financing. Australian doctors have had an ambivalent relationship with government since nineteenth century debates over public health provision (Thame 1974). They have nonetheless used the state to support their market position, determined to maintain their freedom and a system of private, fee-for-service practice. While the introduction of the £5 Maternity Allowance or 'baby bonus' in 1912 was initially opposed because doctors wanted the payment to go directly to professional carers rather than to mothers, they accepted the benefit when it included a requirement of medical attendance at birth, thus preventing competition by midwives. The proportion of women attended by a doctor for childbirth then rose nationally from 63 per cent in 1914 to 77 per cent in 1923, with rates in Victoria and South Australia generally higher (Morris 1925).
In subsequent decades, medical power over childbirth became further established as doctors entered the political fray quite overtly in pursuit of their political and economic interests. Their determination to fight a national health scheme and to maintain fee-for-service was especially strategic in a Cold War climate antithetical to 'socialised medicine'. In maternity care, obstetricians' power expanded from the mid-1960s through the 1970s, both within hospitals and within state policy arenas as they became increasingly organized. The specialty, having become an autonomous Australian professional college in 1952, gained in status as public sector maternity care provided a base for obstetric research as well as clinical practice. Schofield (1995) documents the process through which women's needs in childbirth were increasingly defined, by New South Wales health bureaucrats for example, in 'specialist-therapeutic' terms. In this way, she argues the state could be said then to have advanced particular professional interests, not only as a result of direct medical influence but also because medical privilege in general and control over childbirth had become normative. Such normalisation, as Foucault has argued, is a form of disciplinary power that extends 'beyond the limits of the state' which 'can only operate on the basis of other, already existing power relations' (Foucault, in Gordon 1983). As the political and social climate changed in the late twentieth century, both the structures and culture of medical dominance came into question, not least within state policy arenas.
Conclusions: the confusing neoliberal quickstep
Change in contemporary Australian maternity care needs to be understood as a paradoxical phenomenon. In the complex and shifting political, economic and social climate, the historical dominance of Australian maternity policy by doctors has been effectively challenged by midwives and consumers working in alliance with bureaucrats promoting health reform. Several state-auspiced inquiries and policies have facilitated the articulation of women's rights to 'choice, continuity and control' in childbirth. In view of its dialectical relationship with forces in civil society, the state as a nexus of power has been responsive to consumer and professional interests. It has also though, sought to implement reforms based on dominant neoliberal agendas of health service rationalisation and managerial control. The combination of pressures, I argue, has had unexpected and contradictory outcomes. Clinicians and service managers committed to change have found increased philosophical support from state authorities and some funding to trial new arrangements. At the same time, though, other factors both within and outside the purview of the state work continue to limit effective reform. Childbirth management remains in the medically-driven acute health sector and heavily oriented towards private fee-for-service practice. Policy agendas promoting new models of care which diminish medical power are still resisted by some obstetricians (ABC 7.30 Report, August 2005). Background factors also continue to be important, including anxiety around litigation and the impact of powerful corporate interests of insurance, pharmaceutical and technology companies on medical practice and politics (Perkins 2004). The admirable goals of recent maternity policy development also have to be set against workplace realities shaped by staff and resource shortages in the face of increased client demand and new expectations of caregivers. Political mobilisation in the community and around the state remain necessary to encourage further change in childbirth management, but continuing critical assessment of the structural context and human challenges of maternity reform is also essential.
Acknowledgements
Fuller details of the research are available from the author than can be reported here. The 'Constructing collaboration: professional identities and cultures in maternity care' research has been funded by a La Trobe University Faculty grant and collaborative grants between La Trobe University and two hospitals. My thanks go to the many midwives in particular, but also doctors, who have shared their experiences with me, and my research assistants, Elisabeth Speller, Bonnie Simons and Annie Dennis.
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