Published by Verso 2005 (new updated edition)
How I wish Allyson Pollock's book had been available when I was a lay member of my local Maternity Services Liaison Committee (MSLC) some years ago. Trying in vain, with my NCT colleague, to be heard by our Health Board and senior practitioners, we argued against the centralisation of maternity services into a yet to be built privately funded hospital on the city outskirts. We had little idea then about the irresistible capitalist forces at work which meant that public 'consultation' would be carried out and ignored, and that the new hospital would inevitably be too small, because, simply put, privately funded initiatives effectively mean a rent rise, with no concurrent rise in income. On top of this, additional profit must be extracted by hook or by crook. The artist's impression of the new PFI hospital, almost looked pretty on the glossy 'consultation' documents, and the obstetric facility was euphemistically described as a 'maternity village'. The reality is a hospital that is too small, looks like Torness nuclear power station, feels like an international airport, and with the best will in the world, functions like a factory where intervention rates are high and rising. We are all (public and practitioners alike) now paying the price as it closes its doors to labouring women on an all too frequent basis, and women inside its doors often do not have one-to-one care even in labour, and staff frantically attempt to bridge a yawning care gap.
Allyson Pollock's book would have given me a much deeper understanding about the driving forces behind this apparently progressive, and inevitable move to centralise, rationalise and privatise. It would have helped me understand why this was indeed inevitable, and what the consequences might be. It may well have helped some practitioners understand that in supporting these moves, they were contributing to a reduction in their own clinical autonomy, undermining the laudable principles of the NHS beyond retrieval, and capping their own resources and staffing levels to such an extent that their stress levels would in many cases become untenable, and they would feel forced to disengage from those very people they had wanted to serve, in order to survive the system. This book would have helped me appreciate the lengths to which organisations will go in order to achieve their objectives and silence resistance. It makes the examples I saw of secrecy and subterfuge look like nothing in comparison to what happens nationally. On one famous occasion when I suggested looking at maternity services in the Netherlands, a Dutch obstetrician who completely disagreed with the Dutch system was invited to 'tell us' about Dutch maternity services1,2. Needless to say, this model of care never appeared on the MSLC agenda again. One example highlighted by Allyson Pollock was the 'muzzling' of the Glasgow Herald newspaper when it persistently criticised plans to build the PFI Hospital in Edinburgh. It was told to stop, or lose a large income generating employment advertising contract for Scottish Office posts.
The author describes how the NHS principles of 'universality, comprehensiveness and equality' pursued from 1948 to 1980 gradually reduced previous inequalities, but that this changed rapidly after the conservative Government came to power in 1979, when 'the focus shifted away from the reduction of social inequalities' and towards market values.
This book is a tour de force. It is a meticulous expose of the political moves particularly from the time of Margaret Thatcher to the current Government, to privatise our health service, (along with every other aspect of life), to the detriment of the public. It is based on sound analysis and concrete examples, which make it extremely accessible and readable - and all the more chilling. While some of the examples were already in the public domain (though not easily accessible), many were not, and as Allyson Pollock argues, the public has thus been largely unaware of the silent but persistent drive towards the privatisation of health care. This is often couched in Government policies in terms of choice, diversity and efficiency, but democratic consultation has been spectacularly lacking throughout this process.
This is not a Britain only phenomenon - this is happening across the Globe. The author points out that health care systems all over the world are being dismantled (if they existed), and privatised, so that health care everywhere is not so slowly, but surely becoming a 'commodity to be bought' - in fact, a commodity that MUST be bought, or done without, rather than a right.
What does this mean? Put starkly, it means that all those managing and practising within health care systems must 'conform to an essentially business culture.' It means that multinational organisations are entering health care provision, relentlessly draining resources, closing hospitals, merging services, reducing staff, mopping up profits, and reducing the quality and quantity of services across Britain, so that as 'hospitals compete for trade they trade away care.' Those who speak out are accused of 'corporate disloyalty', ignored, or got rid of (as in the case of Community Health Councils, that were sometimes extremely successful at mounting public campaigns to resist closures and mergers of hospitals and services).
Allyson Pollock points to an unethical partnership between Government and business, enabling business men to influence Government thinking and policy and enabling Government officials to move very readily into health care businesses and gain from their profits. Publicly owned land and property is then easily sold off by Governments, in short term efforts to make ends meet and pay multinational companies. The new business structures now underpinning the NHS (plc) lack accountability and services are so fragmented that it is impossible to track how money is spent, or measure the quality of services. Local health needs do not feature, and: 'The emphasis is now on "decentralisation" and choice, but there are no mechanisms for providing democratic local control', and choice is an illusion when the reality is of 'over diagnosis and over-treatment of some, and neglect and under-treatment of others.' She dispels the myth that public services are necessarily wasteful, mediocre and old-fashioned and that private services are efficient, high quality and modern.
Powerful, corporate organisations and multinational companies are redefining our ability to make decisions about all of our social care services, including health, as services that exist for the good of all rather than to profit a few. They are defining them as economic services that can and should be floated in the market, where wealthy, unethical companies based in rich countries make large profits and poorer people and nations provide cheap labour and cannot afford health care. As Allyson Pollock says: 'What is at stake here is whether we want to break up one of the key bonds that makes our society more fair, more civil and more gentle than that of the USA. The NHS was an effort to remove health care, and so the risk of ill health, from both the political and the market arena, to make the right to health as equal as the right to vote.'
What does all this mean for those of us involved in maternity services and other areas of health? The reality is that while there are some exciting and exemplary midwifery initiatives in different parts of the country, they are few and far between and often under threat. In many areas we have gone back to baby factories, where intervention rates are higher than ever, women and babies are traumatised, there are fewer home births than are wanted, hospital stays are short, postnatal support is reduced and there is too little support for women breastfeeding. Many of our new families are left shell shocked, floundering and alone. These families desperately need more support and resources, not less.
Yet, changes do occur. While globalisation is often hugely oppressive and serves the whims of multinationals, there are examples of people working collectively using current information technology for successful change. As Faye Ginsburg and Rayna Rapp3 observe, 'Global interconnections may thus generate positive possibilities as well as negative consequences.' They talk about 'a "politics of hope" that seeks ... to identify the space in which new imaginaries are emerging out of people's daily lives.' Ordinary people are creating profound change through their persistence and passion. While there is unremitting pressure on social models of maternity care, during her talk, 'Stroppy Women', Mavis Kirkham told us at the Sheffield Home Birth Conference in March, that the campaign to keep open the small Birth Centre at Darley Dale in Derbyshire was won against all the odds. She quoted Helen Griffiths of the Darley MOMS campaign as saying, 'Many thought it couldn't be done. Isn't it a good job we didn't listen to them.'
Not only do we need to build on, and campaign for more of the kind of exemplary midwifery services that we have available, but as Allyson Pollock suggests, we need to look at what is happening to the NHS and our health services overall: 'what is required now is not reform but revolution - a quiet, collective and reflective revolution of the sort that brought the NHS into being in the first place.' This book is a fine place to develop a deeper understanding about the structures at work that are dismantling our health care, and to begin or develop quiet, revolutionary activity.
Andrea O'Reilly is a leading authority in the academic study of mothering. She designed and taught the first academic course on motherhood in Canada and has edited and contributed to at least nine books on the subject. She is founder and director of the Association for Research on Mothering, the first feminist research association on mothering-motherhood. Now she has founded Demeter Press, the first feminist press on motherhood, and the publisher of Rocking the Cradle, a collection of O'Reilly's essays written over a number of years.
The book has much that is interesting, provocative and important. As O'Reilly points out, this is an under researched area of feminist thought where there is much to be written. Much early feminist writing was suspicious of, if not downright hostile to, mothers and had little to say about what feminist mothering might look like. O'Reilly has been working hard for many years to fill some of these gaps through her own research and through encouraging others to publish. It is therefore a huge pity that this book suffers from some serious flaws. First much of it is written in dense academic jargon which will exhaust the patience of all but the most motivated or specialised reader. It reads as work written by an academic for a narrow group of academics and, really, the material is too valuable to be limited like that.
Secondly, it is a very loosely themed work without enough of a driving argument to connect the diverse material. The introduction makes a brave attempt to set an over-arching theme, albeit a loose one. O'Reilly outlines the distinction first drawn by Adrienne Rich between motherhood and mothering. Motherhood is used to mean 'the patriarchal institution... which is maledefined and controlled and is deeply oppressive to women', while mothering is 'women's experiences of mothering which are female-defined and centred and potentially empowering to women'. The essays that follow cannot really carry this substantial theme. They dart from birth to African-American mothering to autobiographical accounts of academic mothering with none of the ideas taken far enough to be satisfying, and with quite a lot of repetition that in a more coherent collection would have been edited out. It would have been preferable to present the book as what it is: a series of essays written at different times and for different purposes whose only real connection is that they have a common author.
These shortcomings are frustrating because, though hard work, the book is worth battling with. There are a number of chapters which deserve more space. For example there is an intriguing discussion of the language of natural birth which O'Reilly argues has limited the movement to defining itself in opposition to the medical model rather than setting its own agenda. O'Reilly's inclusion of autobiographical material to make her points is also an appealing approach which contrasts with the inaccessibility of her more abstract writing. (She has promised a purely autobiographical work as a future project.)
O'Reilly's account of attachment parenting or 'sensitive mothering' is particularly valuable. As someone who has followed this style of parenting, I found it salutary and a little uncomfortable to be challenged about the extent to which 'natural' parenting is in fact specific to a particular historic time, racial group or social class. O'Reilly points out the need for wariness in promoting any 'right' way of mothering. She has written more elsewhere about the ways in which motherhood has been used to contain women and neglect their needs. Here, she draws attention to the way that the rise in 'sensitive mothering', with its demand for the mother's intensive presence, has coincided with, and directly challenges, significant recent progress by women in the work place and beyond the home.
In the final chapter, O'Reilly draws on her own experience of 'feminist mothering' to ponder why there has been so little written about what empowered mothering might look like. She wonders if 'this absence is due in part to our inability to define what we mean, or more particularly what we want or expect to achieve in, through and from feminist mothering.' Is it about how our children will be brought up, or about empowering ourselves as mothers, or about both? There is no doubt that O'Reilly will continue to develop her answers to these questions. They are crucial discussions and I hope that Demeter Press's future plans can include a developed account of them which is accessible to intelligent educated women and not merely a narrow academic audience.
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