Two-tier? Too right

// 3 January 2012

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Pregnancy bump.jpg

A guest post from Chrissy D looking at the arguably already two-tiered system of antenatal provision for mothers-to-be that currently exists in the UK

I’m hearing a lot lately about the threat of a two-tier healthcare system, since the government’s announcement that NHS trust hospitals could earn up to 49% of their funding from private treatments. Let’s just be clear: any illusion that a multi-tier health care system doesn’t already exist, particularly where mothers and their children are concerned, is not only naïve, but entirely irresponsible.

Leviathan, from The Economist blog, speaks the obvious on this “somewhat ritual denouncement which shies away from the fact that the real NHS is multi-tiered already, with doctors mixing private and public practice”, although from a woman’s perspective the multi-tiers begin even earlier than in the consulting room; they begin at conception.

For a start, there is no denying the two-tiered system of antenatal provision for mothers-to-be that currently exists in the UK. Here there are two distinct levels: the NHS and the NCT. Sure, the NHS provides (in my area) a half-day birth class and three evening classes about what to do when your baby comes; these mainly focus on the physical process of birth and the practicalities of life with a newborn. If you are giving birth at a hospital, you can go look around the maternity unit beforehand for a sneak peek. If you have a bit of money to spare, however, you can hop on the next tier of antenatal care, otherwise known as the NCT. NCT antenatal courses focus on achieving birth they birth they desire and informing parents about what to expect from labour, delivery and beyond, as well as creating local networks of new mums, and providing members’ babies with ready-made friends for they traverse the birth canal. The former tier is free, the latter costs up to £16.95 per course session and annual membership of £40 (with concessions available). Unsurprisingly, the latter is more often the preferred domain of the middle-class mother to be. The former – on a good day – is populated by the rest of us. The latter’s aims are noble and delivery (pardon the pun) effective, but both show a stunning lack of proper state provision for the health and care of expectant and new mothers.

Further to these existing tiers, the proposed availability of c-section to anyone who wants it is likely to create yet greater disparity.

The first possibility is that if caesarean without medical necessity is to be available to purchase, we risk a division such as middle class parents able to pay for a caesarean, while working class mothers must ‘suffer’ the labour pains with less availability of pain relief and clinical attention during labour (while the obs and midwives are occupied in theatre).

However, the second possibility is that the chasm that currently exists may be widened even further, with middle class mothers striving for a ‘natural’ delivery, comfortably informed by their NCT antenatal teachers, and working class mothers opting – with little or no information offered to them on the matter – for the seemingly easier choice of having their children surgically removed. This would result in the detainment (for recovery) of working class mothers in their homes during the postnatal period and limit their access to community breastfeeding and personal support at the most pivotal time.

The tiers of postnatal healthcare (including babycare) are a little more complex, having been created more through the government’s failure to effectively regulate aggressive marketing of infant formulas by global pharmaceutical brands, under the insulting pretense of helping new mothers find their way, thus causing potential ill effects to new mothers and their infants.

Baby feeding (and NHS professionals) offers a choice between two tiers, almost always dependent on class – to breastfeed or not. Those who breastfeed are predominantly middle class, thus have access to the best education on the matter and are more likely to attend breastfeeding support groups (community run and attended primarily by (in my experience) middle-class mothers). Working class mothers are vulnerable to the relentless marketing by formula milk companies, to the point of being left with less choice; then, the very multi-tiered system that throws them to the hounds of pharmaceutical consumerism judges them on their choices and celebrates those who have the best information and opportunities for support. So the new mothers with the least money are encouraged to spend the most on feeding their infants.

What working class mothers aren’t paying for ante- and post-natal healthcare, they are encouraged to fork out on formula milk and other aggressively-marketed baby healthcare products. They are neglected by the free system set up to ensure their wellbeing and left as carrion for companies who make money out of new parents’ instinct to (spend money and) nurture their child.

The problem with Andrew Lansley’s proposed changes to the private-funding cap isn’t that it will create the greatly feared two-tier system; it’s that the crevasse will be forced even wider. That said, who didn’t see it coming?

Close-up of a pregnancy bump by Emery Co Photo, shared under a creative commons licence

Comments From You

saramcthingy // Posted 3 January 2012 at 5:55 pm

You’re confusing antenatal care with antenatal classes, and by the way the NCT offer discounts of up to 90% for people with lower incomes.

There’s no ‘proposed availability of c-section to anyone who wants it’ – if you actually read the Nice guidance, it says no such thing.

And, er…are you confusing working class with stupid by any chance? (working class mothers are more vulnerable to relentless marketing?)

Chrissy D // Posted 3 January 2012 at 10:32 pm

I’m aware the NCT offer a discount – and I also became a member after my son was born, when I was struggling a lot. I have no complaint against NCT itself, but with what is lacking in the NHS’s care provision (including but not limited to antenatal classes).

I use the term ‘working class’ in the sociological sense, and am not suggesting that anyone working class is stupid, of course that would be a particularly stupid thing to insinuate. i am suggesting that those for whom comprehensive information is not as easily available are inevitably made more vulnerable, and the service provided by the NCT shoudl be well within the remit of the NHS.

Anni // Posted 5 January 2012 at 10:55 am

While I cannot stand AL and know his move to make the NHS PHE is going to cause more trouble and pressure for all people, I can’t get on board with some of the information in this blog post.

Certainly not this- ‘Baby feeding (and NHS professionals) offers a choice between two tiers, almost always dependent on class – to breastfeed or not.’

Breastfeeding and advocating it has *nothing* to do with class. I’ve just confirmed this with a friend of mine who is a health visitor. I find this very wrong of you to say. The NHS is notorious pro everyone breastfeeding to the point of superseding women’s rights and trying to force it on people.

In every hospital women are pressured into it and the midwives literally push you into making your baby latch on and make you feel terribly guilty if you have difficulties. They do not ever advocate formula feeding- in fact if you want to do that you get made to feel like you are a terrible mother. I’ve seen enough of my working class friends pressured into it including my sister. All were overloaded with information and pressured into breastfeeding.

Such treatment is extremely common and has been highlighted in many ways- including blog posts here and readers comments. Added to that visits and support by health visitors are free, they are the ones who are involved with pushing and supporting breastfeeding and I can assure you they are for all. My health visitor friend is predominantly the mother and baby visitor for a very poor area of london and all the women there come from working class or sole-benefit-support areas.

If you don’t agree with these experiences and this information i’d suggest posting a link to this idea to ‘baby and bump’, mumsnet and netmums to see other mothers experiences. I think you’d be surprised when it comes to advocating breastfeeding and trying to help mums after.

The only tangent I can agree with you about this on is those mothers with more money can pay for private health visitors and obviously since they are paying for them they’d have access when they want. But that’s an intrinsic problem with the NHS now anyway, private paying people always get better then those on the NHS. It’s not a new thing and while it needs challenging, it should be highlighted as an ongoing problem, not one that will/can be widened, because it’s already as wide as it can go in terms of mothers and babies, but one that has been there and will until everything is standardised to the same level. Which didn’t happen when we had NHS and won’t happen with PHE. Different name, same crap.

Also RE, the middle class opting for natural, working for C-section- actually you’d find people state the untrue term of ‘too posh to push’ because it’s the middle class they believe having C-sections but actually the NHS doesn’t advocate having em because the cost is far far higher (20k for a C-section!). Instead it ruthlessly pushes the idea of natural childbirth and makes you feel pretty low for suggesting painkilling drugs and epidural etc. They want the less the better 1) because they believe it’s better for babies and 2) because they want to lower costs. People who can pay for elective C-sections are likely to get them (i.e middle class) because they can pay. Those on low/er wages cannot.

But people rarely elect c-sections due to class. Most are an emergency or due to an overdue baby, phobia or date neccessity, such as a doctor only being available on that day. (Some military wives get to elect due to their partners not being around a long time at the end of their pregnancy.)

Chrissy D // Posted 7 January 2012 at 11:49 am

Anni, thank you for your comments. I agree with much of what you say, actually. I do believe women are judged by NHS professionals for formula feeding. I had experience with this myself the first time I even suggested to my health visitor that I would combination feed (breast and formula feed). Yes, everyone is encouraged into (coaxed into, in my opinion, which is a poor approach) breastfeeding. I am a huge fan of breastfeeding, but I respect anyone’s decision not to do so. What I can question, however, is whether it really is their decision, or whether formula marketing (marketing to do with babies in general) is so aggressive that that ‘choice’ is only an illusion.

What I am saying is that it’s an unfair playing field. We get free support from health visitors, but to say that everyone – regardless of class – has equal access to information and resources, is (in my opinion) irresponsible. I feel that most of the excellent services offered by the NCT should be within the remit of the NHS. I feel it’s a battle between the health visitors and the formula companies (or their parent companies), with the result that the health professionals come across as militant in their approach, while the formula companies hide behind the pretty semiotics of their packaging.

In some ways, The Feminist Breeer sums up my argument re: breastfeeding more eloquently than I did: http://thefeministbreeder.com/you-think-women-arent-vulnerable-to-marketing-check-your-privilege/

Her post was in response to a post from another feminist blogger, and a friend suggested I check this out. I can see both sides of the argument, but my opinions and experiences are more akin to those of TFB.

Of course, her whole argument doesn’t apply here, because we have different healthcare systems, but worth a look for interest.

Further, I don’t suggest that someone’s class (for want of a better word) will directly determine their decision to opt for c-section or not, but I do believe it determines their access to information, which is likely to affect their decision. My suggestions are speculation, and I am delighted to have further dialogue about this.

Thanks again for your comments – these are interesting indeed.

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