Feminist writer Naomi Wolf’s exposé on US childbirth practices was received with unusual positivity by the UK press. Why did it take a rich and beautiful - if somewhat confused - media personality writing about birth practices in a foreign country to get the message across in the UK?
Anne McCabe reports
One of the biggest challenges in enabling women in the UK to have positive normal birth experiences is in persuading them, their partners, and friends and family that hospital birth is not by definition the safest option; that obstetricians and hospital midwives do not by default offer the best care for women and babies; and that the care offered in women’s own homes and for some Birth Centres can enable birth to be a truly empowering experience and a great way to start a new life.
'Misconceptions' (see review page 20) includes reams of information to persuade women to question their obstetricians, and to consider giving birth away from the risks of the technology-happy units, but will it have an impact?
There are two crucial questions to consider here. Firstly, “Does the author and her book have the credibility in the eyes of UK women to persuade them?” and equally importantly “Will the book reach enough women who are pregnant or planning to have a baby to cause a shift in behaviour?"
The author is American, and gave birth in the US, so not unnaturally she majors on details of the US experience though also includes UK stories and research as a contrast. This both questions her credibility for a UK audience and then reassures a little, and then questions it again when she asserts points such as Birth Centre care is available to all on the NHS or privately in the UK. If only it were true.
Wolf is a renowned feminist who is rejected by other feminists for some of her views. Does this turn some off? She has written about feminism in the past, yet consistently failed to address feminist issues around childbirth and motherhood until after she had children herself. Does this question her motives or, should mothers alone write about motherhood? Or is Ms Wolf simply another example of the dreaded “I’ generation - people unable to understand the issues or empathise with others until they have a particular experience themselves. If the latter is true, how much of a spokesperson for the wider experience of women can Ms Wolf really be?
Some issues raised in the book are equally real and familiar for women in the UK and US. These include the conveyor belt depersonalised antenatal care and dearth of psychological support throughout the pregnancy, birth and postnatal period; women’s body image concerns; the emotional and financial decisions involved in returning to work, or not; postnatal depression, and its demotion to ‘baby blues’ by many in the medical profession. What is more, almost all of the descriptions of ‘ordinary bad birth experiences’ could have been written by British women - indeed some of them were.
The work has a very up-to-date, as well as transatlantic, feel. She quotes from UK events and research even including the ‘too posh to push’ debate triggered at the RCM Conference only months before publishing. This builds her credibility, at least whilst the debate continues.
Credibility is also important for those who are looking at the importance of the work for the future of maternity services in the UK. This would include editors, journalists, and us, among many others. These groups decide what, if anything, to reprint, debate, and what stamp of approval, or disapproval, the work is given.
Tradition has it that what happens in the US today will happen here tomorrow. In the UK we fight the medical model of birth and it’s negative implications for women who don’t need it. The US caesarean section rate is one aspect of US birth our obstetricians appear to be importing at a frightening rate. Our average rate has reached 25 per cent, much higher at some hospitals. Obstetricians with rates less that 20 per cent congratulate themselves despite obstetric research showing that rates greater than 8 per cent bring no benefits.
In the US caesarean sections are performed for around 50 per cent of births, 30 years ago the rate was less than 10 per cent. Fear of litigation is believed to push obstetricians to perform these major operations (a reason given increasingly by UK obstetricians). They are also powerfully driven by the financial benefits of caesarean sections - worth much more to the maternity units than vaginal births. Wolf quotes from a US exposé ‘Open Season’; it estimates that US hospitals would lose $1.1 billion a year if the rate were cut in half. This would have also avoided 142 maternal deaths in the sample of 906,000 caesarean sections considered by the report.
The hospital financial income is not an issue in the UK today. However as private healthcare and NHS/Private pacts grow, are we taking up position at the top of this precipice? What Wolf describes feels at times like an exaggerated version of the UK situation, almost cartoon like, unreal, and frightening at the same time, but then caesarean sections rates over 10 per cent were once described as an epidemic in this country. Could we reach the US caesarean sections rate? If the rate continues to rise at the current speed then yes of course we will.
Another very worthwhile section discusses ma May Gaskin’s ‘Farm’, with its’ 1.8 per cent section rate. This is heart-warming stuff and gives us hope. Wolf admits she would not give birth there herself because of the limited anaesthesia options. Whilst this is disappointing, she does go on to describe a good New York Birth Centre where she would give birth.
Wolf's work does consider important issues for people considering the future of maternity services - provided these individuals and groups are already sufficiently comfortable with the other credibility questions to open the book.
So to the second question, “Will the book reach enough women who are pregnant or planning to have a baby to cause a shift in behaviour?”
Many women devour books of photographs and descriptions of the developing foetus, especially during first pregnancies. The well-known ‘Clare’s Diary’ together with the range of pregnancy magazines and some popular books found on high street shop shelves provides all the printed information many women obtain about pregnancy and childbirth.
In terms of the numbers of pregnant women actually buying and reading the book it’s likely that ‘Misconceptions’ will appeal to a very small percentage. It has already gained a reputation for being frightening, for using graphic and unpleasant language - one pregnant woman writing to a national newspaper comments that the book should come with a ‘health warning’.
It’s likely, that many readers will be those with similar experiences to Wolf's wanting confirmation that their anger is justified and not to be wiped away with platitudes about it all being worthwhile in the end, or looking for ideas to avoid what happened last time they gave birth. Others will be activists already converted to her point of view, or interested to read the detail having read the reviews.
Based on this the book will have a direct impact on only a small proportion of pregnant women, and then, maybe, an indirect impact on their friends and family. More indirect impact is achieved because Naomi Wolf is famous. Her book has attracted significant media coverage. So, whilst she is not the first woman to write about or have published her birth experience, people who would not consider including an extract from an AIMS journal (even though it may be more relevant and more applicable to a wide range of women) for example, will give her words space in their papers and magazines.
The biggest potential benefit of a book of this type for the UK is in terms of impact on people already working to improve maternity services. It warns us of where the UK could be going. It reminds us that, despite decades of AIMS and NCT work, childbirth on the NHS continues to follow an apparently irresistible path towards increased interference, with no increase in benefits for women or babies, and many associated physical and psychological problems.
In doing this Wolf fires our determination and helps us to generate the adrenaline and energy to find routes to first time pregnant women in a way that is acceptable to them. By crusading gently and with credibility among newly pregnant women we can really change the way UK obstetricians practise. When women vote with their feet out of the consultant units into birth centres and hack home the pressure on obstetricians to change will become significantly more irresistible than their current path.
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