A question of choice

AIMS Journal, 2010, Vol 22 No 4

Avril Nicoll picks her favourite article from the 80s

During the 1980s - the decade that saw me through secondary school, college and my first post as a speech therapist - I had no reason to be aware of AIMS or the politics of birth. But look what I missed! Given the fascinating opportunity to peruse the AIMS Journals of the 1980s, I find the now familiar, gripping mix of the campaigning and the personal, with an added sense of tension over the direction AIMS should take.

The articles show frustration with obstetricians and paternalism, and concern over the large-scale closure of GP units. There is much on nutrition, on Marjorie Tew's statistical analyses, the Wendy Savage case and Michel Odent's approach to childbirth. Women are encouraged to express their choices in writing before labour (although I'm not sure it would be advisable today to put that you are 'practised in the psychoprophylactic technique of preparation for childbirth'.) Reflective stories tell of home birth, hospital birth, miscarriage, stillbirth, cot death and even abortion. Every one adds to the reader's understanding of what it means to be a woman and a mother. They also remind us that:

'The birth of every child is a gift to the world, a new and unique beginning. AIMS seeks to ensure circumstances for every birth that allow it to be a time of celebration.' (Autumn 1981, p.1)

So, which article to choose?

In the 1980s I was - unusually for a Scot - an active supporter of Thatcherism. This was because I believed that every individual should have the freedom to do whatever they choose, as long as it does not impinge on that same right of other individuals. I thought if everyone behaved this way - following their own path but always considering others - the world would be a happier and fairer place. On the question of how to achieve this, choice seemed to be the answer.

However, over the years I have become increasingly aware of how much culture, upbringing, economic and social circumstances, the times we live in, our relationship and connections with other people, language and luck all shape our choices. For some time I have been questioning to what extent we can expect greater choice - even when it is 'informed' - to make things better for all birthing women. Perhaps if I had read Nancy Stewart's thought-provoking editorial 'Choice' is not the answer in the summer of 1982, I would have arrived at this realisation earlier.

Nancy says choice 'is not really a valid priority in improving women's experiences of birth' and that, as a campaigning organisation, AIMS owes it to every woman to 'help her find the way out of the cultural limits, and to embrace her full potential as a woman giving birth.' She argues that, to achieve this, AIMS needs to focus on 'defining the ideal services, and campaigning for their development' rather than promoting the idea of choice.

My experience with the Keep MUM (a maternity unit in Montrose) campaign would bear this out. Women had the choice to go to a midwife-led unit but were increasingly 'choosing' to go to a consultant unit 35 miles away. While our campaign used the defence of choice, the real success came when midwives began to believe in normality and to under stand that it was within their power to make a difference. Now, more than half of all births in the area are in this freestanding unit, over 70 per cent of them in water, and a physiological third stage has become the norm. How much is this down to choice and how much to defining and then offering an ideal service?

While it has become trendy to talk about 'choice architecture' and providing a 'nudge',¹ AIMS has long recognised the need to encourage high aspirations and change through sharing information about good experiences and successful models of maternity care. As Nancy Stewart says, the range of options is always limited', but 'our effectiveness as campaigners is enhanced if we have a platform to work from, an ideal to promote.'

AIMS Journal Late Summer 1985

AIMS Journal Summer 1982

References

1. Thaler, R.H. & Sunstein, C.R. (2009) Nudge. Improving decisions about health, wealth and happiness. London: Penguin Books.