HEALTH | UNITED KINGDOM | ADVOCACY & POLICY | CULTURE
Too Posh to Push?
WORDS BY CHARLOTTE SWAINSTON | C.SWAINS@THEIWI.ORG | 2 SEPTEMBER 2024
'Too posh to push' - a phrase that echoed around the NHS, neonatal groups and mother's associations at the turn of the 21st century (i). Striking where it hurts most, at the class anxieties omnipresent British culture, it insinuates this notion that richer mothers seek to minimise their birthing experience to a relaxing day out by seeking a caesarean. Further than this petty social observation, however, is the pejorative assumption that a 'natural' and non-medicalised birth is inherently 'better' than one requiring a large amount of medical intervention.
This idea of the importance of a 'natural birth' above all else is one that has been widely disproved in the medical community. Despite old wives’ tales of restless babies born after epidurals, a Bristol study in May 2024 has suggested that having an epidural during labour is associated with a marked reduction in serious complications in the early days after birth (ii). Caesarean births, more commonly known as C-sections, drastically improved infant and mother mortality rates when introduced with proper anaesthetic and antiseptic (iii). The World Health Organisation had previously recommended a quota – 10-15% - of births to be delivered by C-section but dropped this recommendation in 2010, stating that 'there is no empirical evidence for an optimum percentage' and emphasised that the most important thing is that 'all women who need Caesarean sections receive them (iv).' Yet despite medical innovation seemingly being at the forefront of the modern maternity experience, there is an increasing political movement towards 'natural' unmedicalized births in exactly the community derided in the 'too posh to push' trope - the middle, educated, classes.
This is a trend that appears worldwide. A study was undertaken in Brazil to understand the impact of the government’s 'humanization' initiative in childbirth (v0. C-sections in Brazil had reached a rate of 85% - an exceptionally high rate even though the WHO ‘quota’ recommendation had been rescinded. The public health system tried to reduce this by instituting a system of 'humanized' care, with a focus on promoting individualised birth plans to fight a ‘one size fits all’ approach. An interesting finding from this study was the discrepancy between the desires of middle-class affluent women, and their working-class counterparts. Middle-class women associated a ‘humanized’ birth with a natural, non-medicated birth – no C-sections, and little to no pain relief. Researchers noticed that middle-class women also were the most interested and engaged with learning about natural birthing techniques they saw as innovative that would aid the experience, such as squatting to deliver their child. This humanization initiative, therefore, was interpreted as a ‘naturalisation’ initiative by the richer expectant mothers, whilst less affluent mothers, it was noted, were uninterested the ‘natural’ aspects for the sake of them, but appreciated an individualised approach to choice of medications and procedures.
This conflation of individual care with natural approaches is systematically evident in UK birthing culture, an overall more affluent country. Recent major exposés of birth trauma suggest a culture in the NHS that promotes ‘natural’ over all else, to the point of damaging mother and/or baby. Women who have pushed for medical interventions or even investigations, because of symptoms or a gut feeling of concern, have systematically been dismissed. These findings were published in the 2024 inquiry by the All-Party Parliamentary Group on Birth Trauma, who described this culture as one which had a ‘failure to listen’ and ‘a lack of informed consent.’ Women were pressured to breastfeed, as ‘natural’ was considered best, but often not given help to do so (vi). Yet this should all be prevented in the UK, where the espoused direction of maternity care is towards a system that promotes personal empowerment. Women’s right to choose their birth – C-section or vaginal – is enshrined in public policy. So, where is this cultural disconnect?
Outside of the NHS this culture of ‘natural as best’ perversely prevails, especially amongst the middle classes previously mocked for their medicated approach. The Green Party, in the recent general election, promoted a natural birthing ethic, stating ‘We will work to reduce the number of interventions in childbirth, and change the culture of the NHS so that birth is treated as a normal and non-medical event (vii).’ There was outrage about this un-scientific policy from both inside and outside a party which specifically prides itself on promoting expert-backed policies. This glaring deviation from their political norm represents how the topic of maternity care has become increasingly untethered from scientific evidence in contemporary culture. Natural birth has become a spiritual doctrine, moving rapidly away from scientific realities.
Reflecting on this policy, the NHS’ failings in the Birth Trauma Inquiry, and on the Brazilian study, a pattern begins to emerge. Like the study suggested, amongst more affluent groups and nations, personalised maternity care is becoming synonymous with ‘natural’ maternity care. No longer are women ‘too posh to push’, but mothers, healthcare providers, and public leaders alike are instead too ‘natural’ to follow scientific evidence and nuance. Childbirth has become a complexly interwoven dialogue of the emotional and the intellectual, and this is resulting in a real imprecision in discussions of maternity care. These imprecisions have real-life impacts for mothers and babies. The world, and the UK particularly, needs to reckon with its class and status anxieties which are directly creating trauma and pain for expectant mothers.
i. https://www.theo-clarke.org.uk/sites/www.theo-clarke.org.uk/files/2024-05/Birth%20Trauma%20Inquiry%20Report%20for%20Publication_May13_2024.pdf
ii. https://www.theguardian.com/commentisfree/article/2024/jun/07/women-birth-green-party-natural-c-sections-too-posh-to-push
iii. https://www.theguardian.com/lifeandstyle/2001/jun/14/healthandwellbeing.health
iv. https://www.bristol.ac.uk/news/2024/may/epidural-study.html
v. https://iris.who.int/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf
vi. International caesarean section rates: the rising tide. https://doi.org/10.1016/S2214-109X(15)70111-7
vii. https://www.jstor.org/stable/26965049