Centralization of Obstetric Units: (Austerity) Challenges to Maternity Care

By Marita Vyrgioti

Last week, the President of the Royal College of Obstetricians and Gynaecologists, Dr David Richmond, made quite a controversial proposal, one that would create a “public and political furore”, in his own words[1]. The British National Health System (NHS) has been dealing with a serious shortage of middle-grade obstetricians and therefore has suffered a general drop in the quality of maternity services offered, due to exhausting shifts and antisocial-hours of work, and to doctors’ burnout. In his recent interview in Guardian, Dr Richmond suggested a merger of the current 147 obstetric units into 118; a reduction of 20%. He supported his view saying that the concentration of obstetric experts in central units can result in high-quality maternity care and 24/7 consultancy, which would be impossible otherwise. The centralization of obstetric units will be combined with the boosting of midwife-led units, suitable for women who have a low-risk pregnancy.

There is nothing new in the claims of an ailing national health system. According to a survey conducted by the Japan Medical Association in 2008, UK obstetricians and gynaecologists are indeed hyper-productive, delivering the highest number of births among their fellow professionals across 15 countries: 468.1 births per doctor, a figure almost double than that in Canada, the second in terms of numbers of births[2]. The same report reveals that the UK maternity system is highly dependent on the support of 31,186 full-time midwives to 1,600 obstetricians and gynaecologists. A similar shortage is highlighted in a 2011 OECD report on the health workforce, which shows that between 2000 and 2009, there were 22.1 gynaecologists/ obstetricians per 100,000 females; with an OECD average of 26.8[3].

Five years and a Tory government later, these figures indicate that perhaps some of NHS’s weaknesses are structural: there is a long-term shortage of obstetricians and a significant reliance on midwives for childbirth. However, a question seems to emerge; ‘Do arguments about merging and centralizing obstetric units actually deal with the current problem or merely attempt to institutionalise it’?

Published almost four years ago, MaMSIE’s special issue on ‘Austerity Parenting’ seems particularly pertinent to these emerging questions. In the editorial note, the guest editors Tracey Jensen and Imogen Tyler argue that changes in the welfare system affect first and foremost mothers; rendering them one of the most vulnerable and precarious social groups. They also trace the so-called ‘interpellations of impossibility’ that inform parenthood in austerity regimes: ‘to be at once held more responsible than ever before for the future successes (and failures) of your children and yet at the same time to be increasingly vulnerable (through the retreat of state support, public services and welfare benefits) to the conditionalities and precarities of late capitalism’[4]. In a sense, Jensen and Tyler claim that policies or measures advanced to deal with austerity, make parents more precarious through a twofold process: less welfare support and more personal, individual responsibility. In other words, such policies render parenthood a strictly personal matter. So, does the same happen with childbirth as well?

Having said this, how can we—academics and researchers working on the maternal, mothers or future-mothers—evaluate the Dr Richmond’s proposals, through the lens of ‘Austerity Parenthood’? For instance, closing down 29 maternity units appears as a promise to pregnant women and future parents in general: to purge a malfunctioning, wasteful and inefficient system. However, at the same time, this narrative conceals the multiple implications mothers will have to deal with: traveling further to give birth, squeezing themselves into fewer maternity units, or resorting to private clinics, just to name a few. Moreover, what seems to be at stake in establishing segregation between an ‘expert-led centralized clinic’ and a ‘local midwife- unit’?

Perhaps, Dr Richmond was right in one thing: these proposals should, indeed, create a ‘public and political debate’ (and not a furore) on the current inadequacies of NHS’ Maternity Services and open-up a dialogue on the possible ways to deal with them, beyond, austerity solutions.

[1] Denis Campbell, ‘Doctor’s chief calls for string of maternity unit closures’, The Guardian, 21 January 2016, http://www.theguardian.com/society/2016/jan/21/dozens-of-maternity-units-should-be-closed-down-says-doctors-chief

[2] Narumi Eguchi, ‘Do We Have Enough Obstetricians?–A survey by the Japan Medical Association in 15 countries’, JMAJ, 52:3 (2009), 150-157.

[3] OECD, Gynaecologists and obstetricians per 100,000 females, 2009 and change between 2000 and 2009, Health at a Glance (2011), http://goo.gl/d8bLB9.

[4] Tracey Jensen, Imogen Tyler, ‘Austerity Parenting: new economies of parent-citizenship’, Studies in the Maternal, 4:2 (2012), http://doi.org/10.16995/sim.34

Marita Vyrgioti is a Ph.D student in the Department of Psychosocial Studies and an Anniversary Scholarship Holder from the School of Social Sciences, History and Philosophy, at Birkbeck University, London. She currently works under the supervision of Professor Stephen Frosh, on a thesis titled: ‘Devouring: a Psychosocial Critique of Sovereignty’. Before joining MaMSIE as an intern, she worked as an Editorial Assistant at Common Ground Publishing and as a Researcher in Educational Programs at the European Public Law Organization (EPLO).

Writing Maternal Ambivalence (and How we Love to Hate it…)

By Rosalind Howell

I’m not the only one who, since having children, has had an urge to write about the experience. There are many blogs, as well as memoirs and whole parenting magazines often written by mothers, for mothers. Amongst this body of writing there can be very distinct tones; one is the confessional style memoir which tries to capture the difficult thoughts and feelings that assail the author in early motherhood, such as Rachel Cusk’s 2001 book, A Life’s Work. Another is the ‘how-to’ article which shares with the reader a particular parenting secret or skill that the author has recently become convinced of and wishes for us to join her in. I received one of these recently from the Huffington Post, `The blog` initially assured me that its aim was to ‘soothe my frazzled parent brain’, the title of the article then screaming warningly at me, “The single most important parenting action we can take today!” Both of these popular styles of writing originate in some way from the writers’ own rich and complex lived experience of being a mother and/or mothering. Yet, what ends up on the page can often be perceived as either excessively shocking and provocative or excessively bossy and tyrannical. Both in their own way perhaps also wish, anxiously, to seek reassurance.

Despite praise for A Life’s Work, Cusk has said there have been times when she wishes she had never written it. Her story of the bewilderment, loss and rage she felt on becoming a new mother provoked in some readers a corresponding rage. She became the mother that other mothers loved to hate. One Mum­netter (not alone in her strength of feeling) described with relish, how she ‘wakes up most days feeling like slapping her’. Cusk mentioned she has been stopped in the street whilst with her children and shouted at by other outraged mothers with children. Whilst there is something in Cusk’s outpouring of feeling that can feel rather relentless to read, I was also struck, as I read it for the first time recently, by her vulnerability, the sensitivity of her observations of her daughter, and her tenderness for her. Why then were such excessive feelings of hate and rage stirred up in Cusk’s female readers?

“Nothing”, according to psychoanalyst Adam Phillips “makes people more excessive than when talking about excess”. He suggests a child will tantrum in order to find out if his parents are robust enough to withstand his hatred, rage and frustration. Likewise, as adults, our intense, overwhelming feelings and extreme reactions can leave us fearful of being rejected by others for being ‘too much’ for them. Our reactions to other people’s excess then, can give us a clue about our own fears, longings and internal conflicts. Phillips goes on to say that, our knee jerk reaction to someone else’s perceived excessiveness is often because of a wish to punish them, “and often excessively”. Certainly such violent reactions, as from the mums­netter above do seem to have put Cusk’s detractors into the role of sadistic and punitive parents.

But what of the intensity and extremity of feeling that mothers feel for their own children? Rozsika Parker has suggested in her book Torn in Two, that there can be a collusion among women to deny maternal ambivalence. Ambivalence in this Freudian sense describes the coexistence of opposing feelings of love and hate. These come from a common source within us and are independent of the object of our attention. Mixed feelings, rather, are a more realistic weighing up of an external situation, and are therefore much less emotionally charged. Love and hate (or ambivalence) are interdependent feelings; they inform one another and can be a good indicator of what is important to us. We are ambivalent about those things that matter most to us. D.W Winnicott said famously that the acknowledgement of maternal ambivalence is necessary for an infant’s emotional development. In a seminal, and now much quoted paper, “Hate in the countertransference” he suggests that the mother’s acceptance of her own complexity of feeling has a pivotal role in helping the baby learn to tolerate her own hate, loss and disappointment in relationships. What Parker does is to reverse this idea and focus on the mother’s experience. She says, maternal ambivalence, ‘if remaining manageable’, can increase a mother’s creative capacity for thought and therefore aid her development and growth. So, being able to bear and then perhaps put words to the complex mix of feelings involved in being a mother, and mothering, could be good for everyone.

But theory like this might soothe the woman in the mother but not the baby in her. Before having children I have read Winnicott in a smug, rather envious way. Winnicott describes the mother baby relationship from the point of view of the baby, and emphasises that a ‘good enough’ mother creates an environment (or not) from which the baby can grow and thrive. The deprived baby part of me was certainly drawn to this Winnicottian view, pre­having children anyway. As Lisa Baraitser has said in a talk on feminist interpretations of psychoanalysis we read Winnicott when we are in a good mood and for me it felt good to read when I was a potentially, more­than­good­enough­mother but not so good immediately afterwards when faced with the complexity and vulnerability of being in the position of mother as well as that of needy baby. Rachel Cusk’s book put some people in a very bad mood partly because the bad or the difficult was perceived as outweighing the ‘good enough’. Perhaps too, there was a more general difficulty in hearing the story of mother’s experience as part of a complex picture, and not simply experiencing it as a further attack on our wounded baby selves ­ many of Cusk’s critics , for example, were angry on behalf of her children.

I didn’t read A Life’s Work earlier in my mothering career partly I think, because I feared my own ‘excess’ of feelings would be stirred up uncontrollably and interfere with my being able to cope with life as a new mum. Although my new mother feelings are now not so raw, I seem to revisit them again and again in different guises. My very dissatisfactory experience of breastfeeding, for example, overwhelms me at times now when I experience my children as insatiable in their demands from me for food, time, love or energy. When my daughter recently started a new school, a part of me suddenly felt engulfed with fears that the world was hostile, unsafe and rejecting, much like the reaction I had as a new mum to some midwives, health visitors and other mothers of newborns. Like Cusk, my anxieties made it difficult for me to find solidarity with other women, simply because they were in the same boat (with a newborn). This perceived lack of support and connection to other mothers is not, I would suggest, something that we find it easy to read about. Perhaps it’s as hard to accept that mothers are ambivalent about each other as it is to accept that mothers are ambivalent about their children.

On the other hand, Naomi Stadlen in her book What Mothers Do, challenges the idea of maternal ambivalence in both Winnicott and Parker. She says it is unfounded presumption by these theorists that all mothers are ambivalent about their children, and suggests that the Winnicott paper on this subject has been taken on as a truth despite containing no actual evidence. Her experience of talking to groups of mothers over many years has left her with the sense that it is the love and joy within motherhood that is somehow not allowed a voice in our culture, not the difficult feelings that get plenty of air­time from published writers. These women, who are prevented from writing by the demands of motherhood, she suggests, may experience higher than average levels of resentment. In some ways it feels like Stadlen can’t tolerate the expressions of overwhelming feeling in writers such as Cusk. That she too, finds it all a bit excessive. She may also be hinting though, that there’s an opportunity here for a different kind of writing.

So one question might be, in what other ways could maternal experience be put into words? And, what other kinds of conversations about being a mother/and or mothering that felt more satisfying and more complex, could then be opened up rather than shut down? What are some of the effects of mothers writing about mothering? For example, did the process of writing helps to render, in Parker’s terms, maternal ambivalence manageable for Cusk? Did it have the same effect for some of her readers? Perhaps others simply felt that, she evacuated her difficult feelings into them via the page, and left them feeling angry and hopeless.

There may be a cultural presumption that there is something inherently excessive about autobiographical writing, as if it is necessarily unchecked, unrestrained and undigested. The popularity of the parenting blog attests how we can be used to a very edited, polished and censored form of writing where difficult feelings are omitted and easy answers given. Those difficult feelings may not just be omitted from the writing but possibly even from the mind, emerging only as bullying imperatives for other mothers (The single most important parenting action we can take today!)

Where then does the messiness go? The excessive mess of overwhelming feeling, unarticulated thoughts, bodily felt experiences and violent and guilty resentments. One cultural place that acts as a dustbin for these disavowed feelings is the car­crash stories of celebrity parental failure that we love to hate. And Cusk’s story was partly read like this, (“at least my hateful feelings aren’t as bad as hers!”)

In Stadlen’s story our culture has rendered the pleasures of motherhood a guilty secret. In Cusk’s, those same pleasures are often hijacked into a bullying agenda from mother to mother to ‘Be Happy’. Parker, though suggests there is an episodic nature in these difficult and joyful experiences of motherhood. Both pleasure and pain can be acute and intense, less likely to be consistently one thing or the other. In order to understand this more, we may have to read and write maternal experience rather differently. If, as Parker has suggested, maternal ambivalence can be born and digested within individual women to produce creativity and growth, maybe the writing of it can benefit a wider group of mothers and even influence the cultural representations of motherhood that exert such pressure on women. Our own maternal ambivalence being of course inextricably entwined with societies deeply ambivalent relationship to mothers and what they represent .

Finding words for those intense experiences of motherhood, often which start out so raw and un­articulated, and are such sources of pleasure and pain, does, i think have the potential to offer alternative stories to mothers that are infinitely more digestible and altogether more hopeful. More than soothe or reassure they may, to paraphrase Jacqueline Rose, in her article ‘Mothers’, help make the writing, reading and living of maternal experience, more than worth it.


Cusk, R.( 2008) A Life’s Work. Faber and Faber

Parker, R (2005) Torn in Two: The Experience of Maternal Ambivalence. Virago.

Phillips, A (2011) On Balance. Penguin

Rose, J. Mothers (2014) In: The London Review of Books, Vol. 36, no. 12

Stadlen, N (2004) What Mothers Do: Especially when it Looks like Nothing. Piatkus

Winnicott D.W (1958) Hate in the Countertransference. In Collected Papers: Through Paediatrics to Psychoanalysis. Karnac.



youtube.com The Maternal in Contemporary Psychoanalysis and Feminist Thought

Rosalind Howell is a trained Movement Psychotherapist. She currently facilitates workshops for staff teams who wish to develop their reflective skills. She also holds quarterly women’s talking circles at her home. Since giving birth to her three children she has also given birth in herself a passionate desire to express her ideas in writing. Her articles have appeared in E-Motion journal and Juno magazine.