Published in July 2022 by the Department of Health and Social Care, the Women’s Health Strategy for England (WHS) acknowledged that women’s health has been long neglected. Following a call for evidence, the report was based on over 11,000 responses from the public, researchers, charities, and organisations and focused on a wide range of priority areas, including reproductive health and fertility treatments, gynaecological conditions, cancer, mental health, and healthy ageing. The respondents highlighted gender health inequalities across the country, the need to improve women’s access to medical services for female-specific illnesses and to address the intersectional disparities that affect women: age, ethnicity, disability and socioeconomic background. Fertility, pregnancy, pregnancy loss and postnatal support was the second most selected topic for inclusion in the WHS, which set out a series of ambitions. These included extending personalised care, and reducing neonatal and maternal deaths and disparities in outcomes and experiences. The importance of women’s voices being heard and responded to in determining future policies was also strongly emphasised throughout the WHS. However, responses to the report, while lauding its goals, have pointed to the apparent absence of funding to deliver the strategy and achieve the report’s ambitions.
Here we focus on maternity care, highlighted by the WHS as falling short in terms of provision and responses to individual women’s needs. Since 1900, numerous initiatives and policy changes have shaped maternity provision, many of which were limited or foiled by failures to improve services and to invest in them. We also highlight the crucial role of women themselves in drawing attention to the poor quality of care and provision in maternity services and the strategies they used to amplify their voices.
Maternity care has been a key priority area for well over a century. At the turn of the twentieth century, interest in women’s health primarily focused on pronatalist objectives and women’s role as mothers. At the time, 156 out of every 1,000 babies born in England and Wales died before their first birthdays. Politicians claimed that declining birth rates alongside relentlessly high infant mortality imperilled the prospects for the British Empire. The Boer Wars and the First World War, which highlighted the poor health and condition of British troops, reinforced these fears. After 1900, the infant welfare movement aimed to reduce infant deaths and led to the establishment of infant welfare centres and schools for mothers. The schools offered mothercraft courses to train mothers in proper hygienic and childrearing practices. Provision varied greatly between local authorities, but overall little material assistance was provided to poor households during pregnancy, childbirth or to contribute to the cost of rearing young children.
As the infant mortality rate began to fall in the decades that followed, largely due to broader environmental improvements, the direction of maternity provision shifted towards the urgent need to reduce maternal deaths, morbidity and suffering; maternal deaths still remained above 40 per 10,000 births in 1937. In the decade 1920-29, 25,000 women in Britain died of childbirth-related causes, chiefly puerperal infections. In 1930, Rochdale, in industrial Lancashire, topped a grim league table as the most dangerous place for mothers to give birth in England, with almost 90 deaths per 10,000 deliveries. From the late 1930s, however, maternal mortality began to fall significantly, mainly due to the introduction of sulphonamide drugs. The Midwives Acts of 1902 and 1936, while criticised for disempowering midwives, tightened up their regulation and secured professional recognition. Midwifery training and the education and regulation of obstetricians improved in the first half of the century, and local authority maternity services became more widespread and extensive.
During the Second World War, pregnant women became a priority when deciding which groups of people were to be evacuated from vulnerable urban areas. By the interwar period, maternity clinics in more progressive towns and boroughs were already providing foodstuffs, such as cod liver oil and cheap milk, and in December 1941, the introduction of the Welfare Foods Scheme extended these benefits to all pregnant women. At their core, these changes were pronatalist and birthing a baby was perceived as the best way for women to contribute to the war effort. However, these ambitions failed to consider the impact of war on women’s emotional and physical wellbeing, and maternity clinics and hospitals in evacuated cities were closed and emergency services overstretched. The heavy, likely deliberate, bombing of hospitals, including maternity wards, and lack of financial and medical support, led to the deaths of many mothers and their new babies during the war. Wartime experience, however, also focused greater attention on maternity care, and in 1948 the NHS ushered in free childbirth services for all.
After the Second World War, an increasing number of births moved from home to hospital, urged by the publication of a series of reports claiming that hospital birth was much safer. By 1954, 64 per cent of babies were delivered in hospital in England and Wales. By 1963, this rose to 68 per cent and by 1972 91 per cent. After 1975, the percentage of women experiencing hospital births never fell below 95 per cent. As this move to the hospital took place, new childbirth technologies and interventions were widely adopted. Newly established organisations, such as the National Childbirth Trust (NCT, 1956), Association for Improvement in the Maternity Services (AIMS, 1960) and Maternity Alliance (1980) questioned these changes. They also began to focus on women’s individual childbirth experiences, agency and choices. While still devoting attention to improving standards of maternity care for all women, these organisations highlighted the overuse of new procedures – including induction, episiotomies and caesarean section – which they saw as potentially harmful to women and their roles as mothers. They also addressed the isolation of mothers in hospitals, who became disempowered and distressed by their birth experiences, and urged women to add their own voices to their campaigns. While increasing numbers of hospitals allowed husbands to attend deliveries, some women described how they were left alone in isolated hospital rooms when experiencing lengthy labours. Though hospital stays might be long, many hospitals also limited visits to new mothers.
Ostensibly, the level of maternity provision achieved by the second half of the twentieth century – free care for all, chiefly in NHS hospitals – appeared to mark the success of government objectives alongside a long campaign by organisations to improve maternity care and outcomes. It also exposed women's long struggle to motivate government and medical officials to listen and respond to reproductivity and maternal health issues. These collective experiences were heard through organisations as diverse as the Women’s Co-operative Guild, the Women’s Institute, and, more recently, the NCT, AIMS and Meet-A-Mum Association (MAMA). Women can be disempowered when reduced to a baby-carrying ‘vessel or incubator’, while the constant prioritising of the baby’s health might also harm women’s health and her bond with her new-born. Yet, historically, women more typically succeeded in improving care when their concerns aligned with pronatalist government objectives, and the health of the baby was prioritised alongside or over that of mothers.
In 1915, Margaret Llewelyn Davies, a British social activist who served as general secretary of the Women's Co-operative Guild, published 160 letters written by working women describing their experiences of pregnancy, childbirth and childrearing. The letters spoke openly about the misery of giving birth in poverty, testifying to the terrible birthing conditions for women, the impact of having many children on women already in poor health, and the absence of birth control advice. They highlighted women’s pleas for government support, financial assistance and improved obstetric and maternity care. In support of the publication and accompanying campaign, Herbert Samuel, MP for Darwin in Lancashire and President of the Local Government Board, argued that action on behalf of women was necessary. Though Davis was a pacifist, she recognised that women might be paid more attention as mothers of the ‘nation’s assets’ –
future workers and soldiers. The outbreak of the First World War had heightened fears of infant mortality, and Samuel asserted that the nation would be weakened without more support for mothers; the ‘waste’ of a large part of the population in birth and infancy would continue. Herbert also noted that the letters were ‘the first time… that the facts ha[d] been stated, not by medical men or social students, but by the sufferers themselves, in their own words’.
Supported by the Guild and Davies, the experiences of previously unheard working women to inform and improve policy began to be listened to. Herbert supported state initiatives to help and teach mothers and improve their infants' care by launching a major expansion of maternity and child welfare centres. He also crucially submitted a comprehensive scheme of financial assistance for mothers during pregnancy, their confinements and to support the care of infants.
The Guild campaign had already contributed to the introduction of maternity benefits in 1911. The Guild also campaigned for the subsequent Maternity and Infant Welfare Act of 1918, which extended pre- and postnatal care. However, the Act was permissive, and services were introduced in a piecemeal fashion by different local authorities (who before the NHS were the principal funders). The Guild campaign was successful in many ways. Yet, it also highlighted how policy changes were directed by the risk that a mother’s health posed to their children, family, and ‘the nation’ rather than the need to listen to and care for women as individuals. Roughly thirty years later, in July 1948, the setting up of the National Health Service was claimed to change women’s lives for the better, particularly women having babies. Its architect William Beveridge assigned women a clear role as wives and mothers with ‘vital work to do ensuring the vital continuance of the British race’. Although now free for women, medical institutions and maternity services still failed to prioritise women as individuals and their choices.
From the outset, the NHS had no clear or universal ideas about what maternity care should consist of, and policies were largely driven by medical opinions and technological developments rather than female patients. Moreover, the medicalisation of pregnancy and childbirth following the introduction of the NHS was not always welcomed. Many obstetricians working in NHS maternity wards themselves highlighted ‘the dehumanisation of obstetrics’ following the move to the hospital. During the 1930s, Dr Grantly Dick-Read had begun to promote his technique of ‘Natural Childbirth’, arguing that proper preparation for childbirth would reduce the need for intervention and pain relief, and result in a more pleasurable experience for mothers. He received thousands of letters from pregnant women and mothers from 1933 until he died in 1959, and when the National Childbirth Trust was founded in 1956, its initial focus was the promotion of Dick-Read’s approach. In 1948, one mother wrote ‘I may say that the knowledge which I gained from your books, & from yourself… stood me in very good stead. At no time was I afraid of anything, and I certainly saved myself a great deal of pain by relaxing.’ Others described less positive experiences. In a letter written to Dick-Read in 1956, a woman who gave birth in hospital explained how her adoption of Dick-Read’s breathing techniques led to a short and successful labour, but had ‘exasperated’ her midwife. The ward sister ‘slapped [her] hand away’ when she tried to play with her new-born baby’s fingers, whereas Dick-Read promoted immediate and close contact with the baby. Following Dick-Read’s advice, she, like many other women, wanted her husband present at any future deliveries, even if this shocked most midwives. Many other mothers feared having ‘unwanted analgesia forced upon [them]’.
As the percentage of hospital births rose dramatically, alongside the increasing use of obstetric technology, many women reported their negative experiences of medicalised births. Consequently, when hospital births became the norm by the 1960s, women began to demand the right to choose to give birth at home. Their voices were raised against the control of obstetricians, the imposition of procedures including induction, episiotomies and caesarean section, the lack of choice on where and how to give birth, and the risk hospital births posed for their physical and mental health.
Since the 1960s, education and employment opportunities, mass media platforms focusing on women’s everyday health and social issues, and the grassroots organisations promoting women’s issues have vastly expanded. Women increasingly voiced their negative childbirth experiences more confidently through the media – even if some authorities refused to listen. These changes dovetailed with the feminist movement and the rise of feminist health campaigns, which amplified women’s right to choose and critiqued the medical dominance of childbirth. For example, Britain’s Women’s Health Movement of the 1970s focused on publicly circulating helpful knowledge on how women’s bodies worked. Doctors had previously ‘monopolised’ this information. While never declaring itself a feminist organisation – with its mantra of functioning as a ‘consumer organisation for childbirth’ – the NCT expressed similar goals to feminist lobbies. By the 1970s, it promoted a woman’s right to choose a home delivery, natural childbirth, and a less accommodating approach to health professionals.
By the late 1970s, childbirth advocates, feminists, and advice columnists – including Sheila Kitzinger, Ann Oakley, Katharina Dalton, and Claire Rayner – researched and published women’s accounts of traumatic hospital births, and how this might result in postnatal depression. In the 1980s, women spoke negatively about ‘factory-line hospitals’ and how they felt like ‘factory-mums’. They saw NHS maternity wards as inhumane ‘conveyor belts’. In 1983, Parents magazine, in collaboration with Maternity Alliance, conducted a large-scale survey on birth experiences. While it was concluded that many improvements had been made in maternity care, one-third of the responding mothers described themselves as ‘unhappy with the way doctors treat them during labour and delivery’ and one-fifth claimed that their wishes were not respected. Half reported some degree of postnatal depression. Some mothers felt they were listened to, but these tended to be privileged women, many of whom had given birth in private clinics. Such women illustrated a further shift towards empowering the ‘consumer’ rather than all mothers. Meanwhile, black and brown women were more subject to particularly poor treatment and ‘pernicious remarks’. Journalist and author Yasmin Alibhai explained how she was told, in 1986, ‘your sort doesn’t get depression’ when she spoke about her acute depression. Her midwife also shouted at Yasmin’s mother for massaging the baby with oil.
The women who resisted the move to the hospital were more likely to be middle-class women, like the members of the NCT. However, women living in poverty sometimes desired a hospital delivery because they anticipated safer, cleaner and more restful environments than their homes. Some women might also challenge ‘natural childbirth’ and wanted access to pain relief, which was not uniformly available through the NHS. Women’s voices were clearly not in unison, but what they all wanted was to be able to make an individual choice.
While the WHS report pointed out that individual respondents were reluctant to discuss mental health, several organisations flagged the need for further improvements to perinatal and postnatal mental health services. Historically, however, women’s voices have been vocal on this subject, particularly those with lived experience of postnatal depression or postpartum psychosis. After the 1970s, women’s accounts, magazines, radio and TV, and organisations like the NCT highlighted the high incidence of postnatal mental illness. This was attributed to numerous factors, including previous psychiatric illness, loneliness and loss of status following birth, the stress of combining work and motherhood, poverty and bad housing, and the poor start to motherhood associated with terrible birth experiences. For example, Ann Oakley, who experienced postnatal depression herself, highlighted the use of obstetric technology, not enjoying labour, followed by isolation, overwork, and segregated marital roles, which created ‘a hazardous start to motherhood’. Both the BBC and ITV featured programmes based on the personal testimonies of women who had suffered postnatal depression and postpartum psychosis. The women explained how when experiencing mental illness, they felt ‘isolated’, ‘ashamed’, ‘miserable’, ‘tense’, or emotionless, and some even thought they were ‘possessed’. Their relationships with their new-born baby, other children, partner, friends and family also suffered.
By the 1970s, there was widespread medical and public recognition of postnatal depression as a common and troubling disorder, affecting around one in ten mothers. Postpartum psychosis was acknowledged to be rarer but more severe, likely to require hospitalisation, and put the lives of women and their babies at risk. Suicide associated with postpartum psychosis remains a major cause of today’s much lower numbers of maternal deaths. Yet many women continued to suffer in silence, sometimes for as long as two years, due to the lack of understanding of maternal mental illness and a shortfall in NHS support. As a result, the media and women took it upon themselves to raise awareness of the illness and the need for accessible support services. MAMA and the NCT both set up postnatal networks to offer peer support to women suffering postnatal depression. Peer support continues to be emphasised as vital in tackling postpartum psychosis, notably through the work of Action on Postpartum Psychosis (APP).
The WHS emphasised that more needed to be done to expand perinatal mental health services. The setting up of a more expansive network of Mother and Baby Units in the twenty-first century to treat women with severe postpartum psychosis has been something of a success story. Women with lived experience of postpartum psychosis played a major role in pressing for this, joining forces with psychiatrists working in perinatal mental health to lobby ministers and shape policy. However, some regions still lack these specialist units, and many women have to travel long distances to access them. In 2016 the Royal College of Obstetricians and Gynaecologists commissioned a report on maternal mental health, in response to feedback that women’s voices often went unheard and unnoticed. Based on a survey of 2300 women, ‘The results present a stark picture of an NHS in which women with poor maternal mental health during pregnancy and after birth experience low rates of onward referral and long waits.’ Meanwhile reporting of anxiety, depression and isolation around birth has risen – notably during the Covid-19 pandemic.
The late twentieth century and the first two decades of the twenty-first are largely a trajectory of improvement for maternal outcomes. However, many issues highlighted a century ago by campaign organisations were addressed afresh in the 2022 WHS where maternity services emerged as a key area requiring attention. This is reflected in a constant stream of media reports, highlighting how mismanaged births led to tragic deaths or injuries, and high levels of litigation, with compensation vastly exceeding research budgets. While, overall, the NHS offers a high level of maternity care, a 2022 report in the Guardian described 39 per cent of maternity units as ‘substandard’. Both midwives and obstetricians continue to not listen to women during pregnancy and childbirth ‘in the way that they should’.
In particular, the WHS report urged the need to have kinder and more personalised births, harking back to debates about the dehumanisation of obstetrics after the Second World War. It also expressed concern about poor outcomes for maternal and neonatal health; and about disparities based on ethnicity and deprivation. Even though the Race Relations Code of Practice in Maternity Services was published by the Commission for Racial Equality in 1995, brown and black women still experience significantly worse childbirth services and outcomes and report that they are not listened to when complications arise.
The reluctance of policymakers to listen to women has led those women who can afford to do so to take ownership of their fertility and childbirth. As a result, increasing numbers of privileged mothers are accessing private fertility services or choosing to have their births in private clinics or employing private midwives outside the saturated and struggling NHS. While this has contributed to a loss of trust in the NHS, most women cannot afford private maternity services and still rely on NHS hospital deliveries. Within the NHS, while some of their requests might be met with resistance from hard-pressed staff and hospitals, women with social and cultural capital are more likely to persist and achieve tailored childbirth experiences. Though some women’s voices are increasingly placed at the centre of obstetric services and care, the voices of those from all social circumstances and ethnicities must be heard and prioritised to achieve the full objectives of the WHS.
This research has been funded by a Wellcome Trust Investigator Award, grant number 221299/Z/20/Z
If you feel affected by any of the issues raised in our article, the following websites and organisations may be able to offer information, help and support.
NHS – Postnatal Depression
Association for Postnatal Illness
MIND – Postnatal Depression and Perinatal Mental Health
National Childbirth Trust
Royal College of Psychiatrists – Postnatal Depression
The Ahmed Iqbal Ullah Race Archives (Manchester), Commission for Racial Equality, Race Relations Code of Practice in Maternity Services (1995).
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