Pregnancy and childbirth can be a magical but often complex time for women and birthing people. Drawing on her PhD research, Dr Georgia Clancy, from Warwick’s Department of Sociology, explores women’s most popular childbirth choices and the barriers preventing their realisation.
For the last 30 years, the concept of ‘choice’ has been a key part of NHS England’s agenda for maternity care. Policies have included Changing Childbirth in 1993, Maternity Matters in 2007, and most recently Better Births (2016), which offered a renewed commitment to ‘genuine choice’ for women. However, the similarity in the language and goals of the last three NHS policies, as well as numerous Government inquiries into maternity care, demonstrates the difficulty of putting policy into practice.
In England, most women and birthing people will expect to take part in decisions about their maternity care. As an extension of their human rights, “every woman and birthing person is free to make choices about their own pregnancy and childbirth, even if their caregivers do not agree with them” (BirthRights, 2021). Despite the right to autonomy, in practice, decisions about pregnancy and childbirth are not straightforward and are often complicated by different approaches to childbirth, discussions of risk and notions of ‘good’ motherhood.
People can decide on the how and where
One of the most important decisions for people to make during this time is how and where to give birth. Although childbirth in the Western world has been medicalised over the past century, there is a range of birth options to choose from in England: labour ward, alongside maternity unit, freestanding maternity unit, and home birth.
I have looked into women’s childbirth choices at different points in their maternity journey. From forming personal preferences, to making a decision (i.e. a birth plan, usually with a maternity care professional) to the actual outcome of how and where they gave birth.
My research has shown 49% of women would prefer to give birth in the alongside maternity unit (a birth centre attached to a hospital), making it the most popular childbirth preference in this study. This was because, for the majority of women, the alongside maternity unit represented a compromise in which no unnecessary risks were taken, but the prevention of (bio)medical risk also did not put at risk the possibility for ‘normal’ childbirth to occur. However, I also found that women’s childbirth preferences were often not realised in their decisions and outcomes, but rather medicalised as they progressed through their maternity journeys.
When it came to women making decisions, usually in the form of a birth plan, the popularity of the alongside maternity unit dropped to 29%. It was replaced by the labour ward as women’s most popular birthplace decision, with 45% of women deciding to give birth there. For the women who had given birth at the time of their participation, there was further medicalisation in their childbirth outcomes.
Structural barriers stop people realising their choices
I found that women’s childbirth preferences, decisions and outcomes were not aligned, and women’s preference for ‘normal’, low-technology birth was often medicalised in their decisions and outcomes. In trying to understand these findings, three overarching structural barriers to the fulfilment of women’s childbirth choices were identified.
Firstly, there is a tension between the promise of ‘genuine choice’ in Better Births and the notion that more women need ‘increasingly complex care’ in pregnancy and birth. The concept of ‘increasing complexity’ refers to women giving birth later in life, and the growing prevalence of conditions such as diabetes. These factors are used to assign women to a ‘risk category’ which often limits both the choices available to them and the amount of decision-making power they have, whilst supporting the need for medical observation, examination and treatment.
The second barrier to realising women’s choices was found to be limited resources. Participants reported that in their experience certain birth services were being stopped, facilities closed, or there was not enough staff available to fulfil women’s birth preferences and decisions in reality. A consequence of the shortage of midwives, in particular, was the lack of continuity of carer that women received. This not only created less fulfilling maternity experiences for women, but it also meant that women’s birth decisions could be overridden by unknown staff at the next appointment or once in labour.
Finally, various aspects of professional culture were found to affect the realisation of women’s choices. In particular, I found variation in the childbirth ideologies of professionals working in different maternity settings, which affected their professional practice, perceptions of risk and communication with women. In addition, professional culture was identified in relation to the ethnic stereotyping of women and growing medical negligence culture which could constrain women’s choice and limit provider’s practices.
Having choices and making decisions about birth is important not just because it is women and birthing people’s right, but also because agency in birth has been found to have psychological and physical benefits for the mother and baby. Knowing what births women want and why, provides evidence to support the proper resourcing of these services, primarily alongside maternity units. In turn, identifying barriers to the realisation of women’s choices tells us where structural change needs to happen in order to deliver genuine childbirth choice for all women.
 Continuity of carer is when antenatal, intrapartum and postnatal care is provided by the same small team of known midwives or clinicians.
Join the free online ESRC Festival of Social Science event:
Sharing childbirth experiences: choices, challenges and conversation.
Thursday 25th November 12:30 - 1:30 pm
Pregnancy is a magical but often complex time for many women. Join Warwick's Georgia Clancy to explore the experiences, choices and challenges of pregnancy faced by women and NHS staff today. Starting with a thought-provoking performance and followed by a discussion via a panel of experts, this event will highlight the work that individuals and organisations are doing to create change and improve maternity experiences. Discover where women and birthing people can seek help and support during this important time in their lives. We aim to empower women and childbearing people with knowledge about the type of care they should expect and the support available to them.
22 November 2021
Dr Georgia Clancy is a researcher in the Department of Sociology at the University of Warwick, concentrating on different ideas of risk and policy making in the area of maternity care. She holds an ESRC IAA Postdoctoral Innovation Fellowship in the Department of Sociology.
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