A neoliberal quickstep: contradictions in Australian maternity policy.

ABSTRACT

Current Australian maternity policy, while fragmented and uneven, is moving in new directions. Alliances between consumers, sympathetic health professionals and bureaucrats have placed the objectives of improving women's choices, increasing their control over decision-making and providing continuity of care firmly on the agenda. The state arena is a central space for articulating such demands and policy support has been critical to implementing changes in service delivery. Along with steps forward, though, steps sideways and backwards indicate the contingent character of the late modern state as it responds to social changes at the same time as advancing particular political goals. This paper argues that impediments towards making services more 'women-friendly' lie not only in the historical location of childbirth management in the medically-driven acute sector but in contemporary neoliberal political and economic pressures that both promote and yet constrain change. Research in selected Victorian hospitals suggests that desirable goals are compromised by working realities in contemporary public hospitals. Political mobilisation in the community and around the state remain necessary to encourage further change in childbirth management, but continuing critical assessment of the structural context and human challenges of maternity reform is also essential.

KEY WORDS

Maternity care, Australia, neoliberal health policy, childbirth reform, state

Although what Sax (1984) has called a 'strife of interests' shapes Australian health service provision, the historical and political processes involved in maternity care have received little comprehensive attention. In many respects, the social 'design of birth' (De Vries et al. 2001) in Australia reflects issues arising in most western health systems--disputes over medical dominance, the relationship between public and private provision, and the role of midwifery and of consumer movements in influencing state policy. While the impact of the neoliberal 'market state' during the 1990s has occasioned considerable debate about health care (e.g., Hancock 1999a, Duckett 2003), the implications for maternity care are more mixed than 'gloom and doom' analyses might suggest. There is no national Australian maternity policy framework and exchange of information across institutions, regions and states remains limited, but many changes are under way. New models of maternity care are challenging traditional professional role boundaries (Reiger 2004, Lane 2006 this issue), and consumers' voices are increasingly being heard (Lane 2001, Hirst 2005). Yet formidable historical and contemporary barriers to 'women-friendly' maternity services remain. This article examines some of the complex processes in policy formation and implementation.

The state, medicine and maternity care

The politics of contemporary policy-making take place in the shadow of the past. In particular, the role played by the state has been an important focus of analysis, both in the regulation of the professions in maternity care historically (Witz 1991, Willis 1983, De Vries et al. 2001), and with regard to recent changes to professional roles and service provision in Australia and comparable countries (Reiger 1999, Bourgeault et al 2004, Bourgeault 2006). State support for forms of medical dominance of Australian childbirth included subordinating midwifery within nursing (Willis 1983, Reiger 1985), and promotion of specialist obstetric care over that of general practitioners in the late twentieth century (Schofield 1995). Yet as Witz (1991) has argued in terms of Britain, the state has been something of 'a weak link' in the chain of promoting medical interests rather than merely an instrument of professional power. Indeed, in recent years, governments have also been instrumental in 'changing childbirth' to lessen medical control (Department of Health (UK) 1993). Further, in New Zealand and most Canadian provinces, the state has been used effectively by midwives and consumers during the 1990s to institutionalise autonomous midwifery (Tully et al. 1998, Bourgeault 2006). In Australia, although governments traditionally promoted medical dominance of birth, recent policy initiatives in several states are encouraging significant change in the mainstream public hospital system (NSW Health 2000, Department of Human Services 2004, Hirst 2005). Full analysis of the complexity of state involvement in maternity care goes beyond the scope of this paper, but I argue that these developments point to the importance of conceptualising the state in late modern capitalist societies as flexible and its power contingent on developments not only within the political domain but in civil society. Although political agendas reflect powerful economic interests, the state is also open to influence from maternity consumers as well as from health professionals. Recent theories of the state, especially those employed by feminists, go beyond traditional Marxian or Weberian approaches which stress class-based power or state political power respectively (Witz 1991: 208-9, Charles 2000). By drawing on more complex interpretations of the relationship between state regulation and processes of change and conflict in civil society, such as those developed by Gramsci and Foucault for example, Showstack Sassoon (1988) and Franzway, Court and Connell (1989) have argued that the state is both a centre for the institutionalisation of power and a site of contestation in which particular players as well as broader structures are implicated. Discussing changes in women's lives and work, Showstack Sassoon (1988: 16-23) observed several years ago that social developments can outstrip the political and the state then has to adjust to social changes which it has also been instrumental in fostering. This dialectical relationship between state and society has also been noted as central to the relationship between women's movements and state agencies. As Nickie Charles puts it, 'feminist social movements engage with the state by confronting it and by working within it: it is experienced as both constraining and open to change' (Charles 2000: 28). For Australian women in particular, the state has been used successfully to increase equity in women's health provision, education and legal status (Broom 1991, Bacchi and Schofield 2005), even though neoliberal political emphasis on individual responsibility and on the traditional family now threatens some of those gains. In Australian maternity care, I argue, contradictory processes are evident within both policy and hospital-based practices. In several states, while policy has encouraged some modification of the traditional obstetric-dominated birthing system, significant impediments towards ...