Maternity is one of the key tests of any health care provision. And maternity care in England and Wales is said to be struggling to cope with rising fertility, more ‘high-risk’ pregnancies – due, in part, to a growing number of obese women and over-40s having babies – and tighter budgets. The focus is very much on hospital maternity units’ performance.
However there has always been more to maternity care than hospital beds and specialist equipment. Historian Angela Davis of the University of Warwick has studied the trends over the last century or so. She notes that maternity care was much more varied in the past, and has always involved balancing the possible need for medical intervention against the wellbeing of mothers, babies and their families.
The decades before the 1940s were notable for conflicting trends in childbirth – a reduction in infant mortality but increasing maternal mortality. Early feminists, Dr Davis says, campaigned for women to be able to go to hospital rather than remain at home – not only to mitigate the risk to their health but also to offer recuperation after giving birth.
However many women did not have insurance cover for hospital care, as insurance was generally linked to paid employment. Hospital capacity was also restricted in many areas. So hospital births were usually limited to women who could afford to pay or were deemed to be in special need.
The creation of the National Health Service in 1948 removed that insurance obstacle, and accelerated moves towards more hospital care. New specialist technologies – such as those for inducing birth or caring for premature babies – increased the momentum. The Peel report of 1970, led by a consultant obstetrician, “implied that hospital birth was safest,” says Angela Davis. And, though “it was later criticised for a lack of evidence to support this”, it contributed to a “dramatic shift from home to hospital birth”. From the mid-1970s, over 95 per cent of births were in hospital. The old infrastructure supporting home births, symbolised by nostalgic TV portrayals in Call the Midwife, disappeared.
Yet maternity-related rows didn’t disappear with it. Feminists now began to ask whether the ‘medicalisation’ of childbirth was overriding women’s choice. Campaigning groups such as the National Childbirth Trust suggested that fathers be allowed to attend. Traditionalists didn’t always welcome their interventions. Says Davis: “Initially the organisation tried to work with the medical profession, but increasingly found itself in opposition to it.”
More evidence emerged too about risk in childbirth, countering the assumption that all women were potentially vulnerable. In the mid-1980s, the consultant Wendy Savage caused much debate when she advocated less medical intervention during childbirth. She was suspended from her London hospital post for alleged incompetence but then reinstated after an official enquiry.
Once, everyone had deferred to the ‘men in white coats’; now, more were listening to how women felt about the care they received. Angela Davis has interviewed a number of mothers from different generations for her research. What emerged was a feeling among many that “despite receiving good medical care, emotional care was lacking”.
Advocates of home birth continued to argue that this most favoured mothers’ wellbeing. Others believed that more sensitive hospital care was the answer – using GP maternity units, for example, less impersonal places where mothers were cared for by familiar staff.
So while the argument over where to give birth appeared to have been settled by the shift towards hospitals, the broader debate over maternity care has remained unresolved. Anxiety about risk and access to technology has competed with the desire for the best childbirth experience and, as Dr Davis puts it, “good communication and durable relationships between women and their birth attendants”.
The number of home births remains low. But in maternity, as in other areas of health care, the big question now is whether the hospital should retain its dominance.
Chris Bowlby is a presenter on BBC radio, specialising in history.