It’s not self-indulgent to prioritise choice in maternity care

Birth is painful, frightening and unpredictable, and it is also highly politicised.

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I knew I should have waited a little longer before having my third child. According to the Times headline “Pregnant women get £3,000 for private births”. Huh. All I got from my local NHS birthing centre was tea, toast and a shot of Syntometrine. Sure, the staff were lovely and my baby was healthy, but it wasn’t exactly plush. Certainly it was nothing like the Sex and the City-style shopping trip the Times imagines future mothers planning in response to Baroness Cumberledge’s National Maternity Review:

“Home births, acupuncture and hypnobirthing would be offered by companies and midwife co-operatives in exchange for the vouchers as health chiefs aim to use competition to force the NHS to listen to women’s choices”

Way-hey! Bring on the whale music and essential oils! It’s deep, meaningful birthing “experiences” for all, apart from those unfortunate enough to live in a poorly-resourced area and just want your basic, no-frills, safe birth, minus any Primrose Hill bullshit.  

The response to the Cumberledge report, with its proposal that pregnant women in England receive a “personal care budget” of £3,000, has been lukewarm, to say the least. “Can the NHS afford to give pregnant women exactly what they want?” asks ITV News, rather suggesting that given half the chance, they’ll bleed the country dry with their frivolous demands for foot massages and pickled onion ice-cream. “The idea might sound attractive,” concedes the Independent’s Jane Merrick, “but mothers should resist the temptation.” Merrick fears the burden of choice will be too much for mothers and, unlike ITV, she also views it as an attempt to cut costs by increasing the number of home births. The Times leader argues that the report is a “missed opportunity” since “the greatest threat to mothers’ safety is a deep-seated reluctance of some midwives to defer to doctors when necessary” (conveniently failing to mention that the US, where midwife attendance is rare, has a maternal death rate of 28 per 100,000 compared to the UK’s 8).

These are all different criticisms but it is easy to detect a common theme: there is, on the one hand, the medical care of pregnant women – clear, objective, reliable – and then, on the other, we have the haphazard free-for-all that is maternal choice, whereby pregnant women, midwives and doulas prioritise romantic visions over comfort, safety and pragmatism. As Rebecca Schiller, co-chair of Birthrights, writes in the Guardian, there remains a widespread belief that “silly women with their unrealistic and downright irresponsible ideas about birth can’t be the ones who decide what happens to their bodies in pregnancy because it’s just not safe for the baby”. Putting important decisions in their hands doesn’t help anyone, but merely muddies the clear blue waters of research-based care.

I can fully understand resistance to the idea of maternal choice. It smacks, not just of foolish romanticism, but of unchecked privilege. Coming from a family in which not one, but two poorly managed births led to disastrous, life-long consequences, I used to rage at the idea of smug mummies planning their perfect, candlelit home births, conceitedly imagining that nothing bad could ever happen to the likes of them. Women would complain about the need for continuity of care and I’d want to ask them about continuity of oxygen supply to an infant’s brain. I didn’t want choice, I just wanted the baby to be out of me and alive.

But what’s the right way to get a baby out of a body? With forceps? With drugs? With knives? Is it the same for every woman? Is there a way of balancing torn flesh, mental trauma and abandoned autonomy against potential – only ever potential – reductions in risk to one’s future child? I liked to think there was a right answer to all of these questions. It turns out there isn’t, not for any of them. Birth is painful, frightening and unpredictable, and it is also highly politicised. If there is a way in which we romanticise it, it is by convincing ourselves that in avoiding the pitfalls of personal choice women can free themselves from new age mumbo jumbo and enjoy expert-led care that is neutral, evidence-based and measurably safer in all instances.

Cumberledge’s Better Births report promotes a vision of “personalised care” which includes women being able to “choose the provider of there antenatal, intrapartum and postnatal care and be in control of exercising those choices through their own NHS Personal Maternity Care Budget”. There are things that make me very nervous about this. I worry that it brings us one step closer to a privatised model of healthcare. Like Schiller, I fear that the resources to enable women to make these choices are not yet in place and that “there is a risk that the phrase ‘personalised care’ could replace ‘woman-centred care’ as a distractingly shiny bow on a system that’s actually quite the opposite”.

One thing that does not, however, worry me is that pregnant women are not equipped to make the right choices. Because there are no “right” choices. No one else can experience giving birth for you and no one can tell you how your mind and body will respond (in my case, remarkably well to a complete absence of intervention, contrary to everything I’d feared).

Childbirth can be both awesome and terrible. It is a leap into the unknown. That such a leap can come with a price tag may be disconcerting, but that’s no reason not to trust the person who ultimately bears the biggest cost. Pregnant women have to make choices without certain outcomes. Let’s acknowledge and respect that instead of using it as a reason to question their judgment.

Glosswitch is a feminist mother of three who works in publishing.