Anna Fielder, Going Into Labour: Childbirth in Capitalism, Pluto Press, 2024. Pbk £18.99.
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A substantial literature has emerged over recent years on the issue of 'social reproduction' in capitalism, but within it procreation has received relatively little attention. Equally, while Marx and Engels described the focus of their historical materialism as the ‘production of life, both of one’s own in labour and of fresh life in procreation’, Marx did not devote much attention specifically to procreation itself. Fielder evaluates his contribution and some subsequent developments effectively in a chapter wittily entitled 'Stretch Marx' (and see also pp. 126-8). He noted, as did Engels, the appalling rates of maternal and infant mortality in early industrial Manchester, the inevitable neglect of those infants that did survive as a consequence of the need for men and women alike to work long hours in order to procure the means of subsistence, and the common practice of giving infants concoctions of opiates and treacle such as Godfrey's Cordial (no longer available, I'm afraid) to keep them quiet while their mothers were at work. But these are passing references, so Fielder can justifiably say that 'For all that Marx is known for, his name is not readily associated with the labour of childbirth' (2). It is more surprisingly, perhaps, that for all they are known for, Marxist feminists and contemporary theorists of social reproduction have not paid much attention either to the 'fleshy and messy' aspects of childbearing, or to the social and institutional contexts in which it takes place. Fielder sets out to put that right, starting from the premise that 'analyses of childbearing must grapple with the role of capitalism [as understood by Marx], if they are to account for why calls for change in relation to childbirth often go apparently unheeded' (4). In broad terms, she is concerned with the adverse consequences of neoliberal policy and practice for the bearers of children and workers in the sector, and the potential for challenging them. She brings to the task a solid understanding of Marx, a good grounding in critical international political economy, and her experience as a practising midwife prior to a return to academia: the result is an original and pathbreaking book that should place childbearing – and the midwife - at the centre of work on social reproduction.
The broader background is set out succinctly in the opening pages:
'Over recent decades, academics and activists have attributed responsibility for many of the problems which developed in relation to childbirth to a range of social forces. The rise in caesarean sections and use of heavily routinised care with iatrogenic effects [illness or disease caused by the treatment itself] have been seen as a product of industrialism or industrial society. Patriarchal power structures have also been held to account. It is now widely documented that prior to the eighteenth century, women in Europe as well as North America had given birth largely in their homes supported by other women, friends, relatives and midwives. By various mechanisms, which differed between countries and localities, the influence of males doctors grew. Women were largely excluded from becoming physicians and were prohibited by tradition or other means from wielding instruments such as forceps which doctors increasingly deployed. By the mid-to-late twentieth century, and earlier in many places, childbirth had been constituted as a medical event and was taking place primarily in hospitals: in other words, on the terrain of "medical men". Childbearing has been described as undergoing a process of appropriation by men even well beyond the mid-twentieth century. Yet over recent years, there has been growing acknowledgement that much feminist research carried out on people's experiences of childbearing has centred the experiences of white, often middle-class, cis women. In highlighting the patriarchal character of birth-care-institutions - of their staffing structures and prevalent clinical practices - social and historical forces and determinants of health such as racism and colonisation have often been overlooked' (7).
As this reflects, Fielder does not derive her analysis of childbirth either exclusively or mechanically from Marx. She first addresses childbearing in contemporary societies (Aotearoa-New Zealand, US, and UK) in terms of its own varied history and social logic, and then explores the contribution Marx can make to our understanding of it. She rejects the idea that Marx 'developed an overarching theoretical schema for application in any situation', into which childbirth might be squeezed, drawing instead on his observation that aspects of life that appear immutable or ‘natural’ often do so as an effect of the consolidation of intensely social forces, relations and elements. From this perspective, illustrated by Marx with the idea of the population, 'the concrete is concrete because it is the concentration of many determinations, hence unity of the diverse.' So too with childbirth.
The trick, then, is to identify the 'determinations' that are most significant: Fielder identifies four: obstetric technology, risk, evidence, and choice, addressed successively in chapters 3-6. They are well chosen. First, they are central aspects of contemporary childbirth. Second, they are dynamic categories that capture change over time. And third, the changes that they capture are all shaped by evolving neoliberal policy and practice. The modern application of tools to childbirth can be dated back to the invention of forceps (17th century) and Pinard Horn, or ear trumpet (19th century). Since then, things have moved on considerably. Today, ‘birthing units are filled with a vast array of equipment and technologies: electronic foetal monitors, ultrasound scanners, surgical instruments, syringes, drips, drip-stands, a growing range of pharmaceuticals, electronically adjustable beds, surgical tables, and far more' (16). Obstetric ultrasound was developed from the 1950s (pioneered in Glasgow, from technology originally used to detect weaknesses in the hulls of ships), but made huge advances in the 1980s that have continued to the present. The first commercial electrical foetal monitor dates from 1968 (Hewlett-Packard). The use of medical technologies undoubtedly saves lives (the evidence on behalf of continuous foetal monitoring during birthing is actually weak, but it reaps vast profits for HP, Philips and others, enables whole squads of birthing people to be monitored from one desk, and, apparently, fascinates male partners in particular). But the manner and extent to which technology is used, and over-used, reflects a range of pressures and practices that do not necessarily nor directly address the well-being of the birthing person or the baby. Prominent among these - along with the power and influence of profit-oriented corporations and the need to reassure consumers that you have the latest kit - is the understanding and management of risk. Childbirth is framed as risky, on a sliding scale from low to high, and risk is often assessed through statistical evidence derived from scientific clinical and/or epidemiological research, with the large-scale Randomised Controlled Trial (RCT) emerging as the 'gold standard' from the 1990s on. In turn, these three parameters - technology, risk, and evidence - limit and shape choice in childbirth: 'Be it consumer choice, patient choice, informed choice, women's choice, or other varieties of choice, renditions of choice (and the absence thereof) have become pivotal in defining the quality and character of contemporary birthing care' (16).
There are two related strands to the analysis here – on the one hand the development of the professions associated with childbirth and the institutions and practices that structure their work, and on the other the increasing power of capital, and particularly of large corporations, in the neoliberal period. The two come together in the mechanism of the large-scale Randomised Controlled Trial, illustrated here with the ‘Term Breech Trial’ (114-21), which makes the best point of entry to the logic of the contemporary ‘determinations and relations’ attending childbirth. Situations in which babies are in breech position (butt or bottom first) at full term are very infrequent (maybe 3 per cent of cases). Obstetricians (and midwives) may lack familiarity with them, and delivery anyway involves an increased risk to the baby. A caesarean is therefore an option to be considered. The Term Breech Trial, reported in 2000, involved over 2,000 women in 26 countries and 121 centres, assigned to either a planned caesarean or a planned vaginal birth (planned in order to leave open the option of an emergency caesarean if circumstances required):
‘It was reported that in cases where a caesarean section had been planned, there were significantly lower rates of “perinatal mortality, neonatal mortality, or serious neonatal morbidity” (broadly speaking, complications for the foetuses/neonates) than was the case when a vaginal birth was planned’ (115).
The result was a swift and dramatic shift in medical practice. Rates of planned caesarean birth for breech babies rose sharply, so that now they are ‘reported to be well above 86 per cent in Australia, Scotland, England and Wales. It is even documented that in the UK the caesarean rate for babies who are persistently breech is around 96 per cent. Vaginal breech births have been described as “an exceedingly rare event” in the US’ (118).
All well and good. But RCTs such as this, as large-scale trials with a single dichotomous point of difference, establish a preferred option on a statistical basis for the average case. As Fielder comments, a vaginal breech birth attended by an experienced midwife and delivery team may be much safer than a caesarean in a poorly resourced hospital with inexperienced staff. Significantly, in 2006 ‘a large observation study in France and Belgium found that within that context, neonatal outcomes for term breech babies did not differ significantly whether it had been planned for the infant to be born vaginally or via caesarean section’ (120). But the die was already cast. As a result, obstetricians and midwives alike came to have even less experience of vaginal breech births, so that now: ‘For pregnant people who today do want to plan a vaginal breech birth, it is increasingly difficult for them to find a midwife or doctor who is experienced, skilled and willing to support them in that’ (ibid). At the same time, other considerations hastened a more general move towards caesareans, notably a preference on the part of obstetricians and hospital management (and quite often of the person giving birth) for caesarean sections as ‘routine’, easy to plan and manage, ‘supported by the science’, and therefore less ‘risky’ and less likely to give rise to malpractice suits.
Building up to this focal point, Fielder does a brilliant job of bringing out the key ‘determinations and relations’ of contemporary birthing over the chapters on technology, risk and evidence. This in turn provides the basis for assessing the issue of choice. A crucial aspect of this is the distinctive character of childbearing in the US, where the practice of midwifery was all but eliminated at one point, and high-tech ‘assisted’ births, often involving caesarean delivery, became highly prevalent. In the UK and in Aotearoa New Zealand, in contrast, the profession of midwifery is more normalised, albeit increasingly under strain. Though the contexts differ in this respect, the principal message is the same – in the latter decades of the twentieth century ‘the notion of choice emerged as a pre-eminent principle’ at precisely the same time that choices were increasingly shaped and constrained: ‘celebrations of “choice in childbirth” arose as both a product of and a political response to diverse aspects of an expanding capitalism as it transitioned into the neoliberal era’ (125-6). Fielder draws on Marx’s early work on ‘conscious life activity’ and ‘species being’ to good effect to argue that childbearing people, rather than doctors and clinicians, should do the choosing. She describes a period in the UK in which notions of ‘women’s choice’, ‘informed choice’ and ‘consumer choice’ channelled debate, and deploys these perspectives in discussions of pain relief, elective caesarean, and ‘free birthing’ (choosing to give birth at home without involving a midwife or doctor). Whoever you are, you can’t be sure of getting exactly what you want. But the balance between choice and constraint is heavily weighted by the level of resources and the institutional policies in place, and individual factors of income, class and race. So, for example,
‘In the US, people have been threatened with negative sanctions if they decline epidurals. The researchers of a study in which this was found to be the case explained that although monitoring of a childbearing person is comparatively intensive after an epidural is in place, that monitoring can be performed at regular intervals. In contrast, ‘Caring for an unmedicated woman during birth is arduous, unpredictable, and may take the nurse away from documentation duties for extended periods of time’ (Morris and Schulman 2014: 189).
As the authors report, ‘Among women who did not plan to have an epidural, women of color were more likely to face pressure to accept the epidural by hospital medical staff. Further, among women who received anesthesia (either during vaginal delivery or a C-section), women of color were more likely to experience failure in their pain medication and were less likely to have their pain and anxiety taken seriously by doctors’ (ibid: 188).
And if you are not entitled to free access to the NHS in England by virtue of not being ‘ordinarily resident’ (a complicated issue), ‘free birthing’ may be a forced choice, given an expected minimum fee of around £7,000 for hospital delivery. Such examples could be multiplied, and there are several in the book.
Through these chapters, then, the emphasis is on the varied pressures and constraints that childbearing people face. The conclusion then turns to ‘some of the ways in which childbearing people, birth workers and their supporters have been and continue to be collectively energised to improve the conditions in which people grow babies, birth, labor and live’ (148-9). Here the ‘Lead Maternity Carer’ system in Aotearoa New Zealand is a hopeful precedent, despite the pressures it faces; in the US, the ‘birthing justice movement’ challenges the system, and especially its racialised character, and advocates the greater use of doulas (non-medical trained pregnancy and birth attendants); in the UK, struggles involving strike action have centred on securing adequate funding for services and wages in the National Health Service.
Fielder’s gold standard, in contrast to the regimented hi-tech and drug ‘assisted’ hospital birth (and prospectively a dystopian future in which children are artificially conceived, ‘developed’, and delivered), is one in which the birthing person is supported by a midwife who has accompanied them throughout the pregnancy, and with whom they have developed a relationship of trust; in which supported home birth is an option; and in which well-resourced local hospitals and community birthing facilities are readily available:
‘The very work of midwifery has a relatively low carbon footprint, not least because midwives often provide relatively low-tech, community-based care thereby minimising transport and carbon emissions. A well-supported midwifery workforce can also facilitate the creation of health and well-being (rather than simply the mitigation of risk), and help build and nurture the strength and power of pregnant people, their loved ones and communities as they make birthing safe in ways that matter for them. Such birthing looks very different from services which structurally protect the profits of med-tech companies and of corporations directly investing in fossil fuels’ (157-8).
Midwifery, understood in these terms, can form an integral part of local solidarity economies, and link with a range of movements – such as the International Women’s Strike movement – to advance ‘the power of those whose unpaid and paid work sustains the world’ (Arruzza, Bhattacharya and Fraser, 2019:7, cited p. 159, emphasis original). Midwives, in this perspective, are exemplary providers of care, called to ‘be with’ and support the birthing person, and firmly established as central figures, too often overlooked, in the broader ‘care economy’. So the conclusion opens out the focus to establish childbearing and the way in which it is supported as fundamental to anti-capitalist struggles. Going Into Labour is an original, humane and pathbreaking work.
There is another side to the story of contemporary patterns of childbearing, though - one that Fielder touches on at a couple of points, and that brings in a complementary set of issues concerning its relationship to capitalism in its current manifestation. She notes in the chapter on choice that one aspect of mobilisation around social movements from the 1960s on was that women ‘were demanding to make their own decisions over whether they bore and raised children’ (129); and elsewhere (38-9) she references Jenny Brown’s Birth Strike (2019), which explores, among other things, the complex circumstances in which many women in the United States opt for childlessness or late motherhood. Marx’s focus on the concrete as the concentration of many determinations is equally relevant here. One factor is access – where they are available, and not criminalised - to contraception and safe termination. Another is the steady advance in the access of girls to secondary and higher education – again, where it is not criminalised (the recent closure of nursing and midwifery courses to women in Afghanistan being a shameful recent example). A third is the energy with which the World Bank and other international organisations promote women’s access to ‘good jobs’ in their pursuit of global capitalist development, and the European Commission targets ‘inactive’ women in their zeal to eliminate ‘worklessness’. A fourth is the sheer impossibility of survival, for a working class family, on a single wage, and a fifth is the high cost, particularly in the United States, of childcare. Taken in conjunction with Fielder’s analysis, these points raise with particular force the broader issue of the relationship between childbearing on the one hand, and contemporary capitalism on the other. There is more to be said about this than can be addressed here, but the starting point would be to say that the reproduction of the working class from generation to generation is not simply a matter of ensuring a steady supply of children. There is no evidence that capitalists look that far ahead, if they look at the issue at all; the governments that do are mostly inspired by racist and nationalist concerns, rather than attentive to the future needs of capital; and the relevant international organisations, led again by the World Bank, favour migration as a solution to labour shortages, and focus much more on turning such children and young people as there are into competent and exploitable workers than on increasing the supply of raw human material (Cammack 2022; Cammack and Gimenez 2024). So the relationship between childbearing and capitalism is by no means straightforward. In the UK, the average age for bearing a first child is in the early thirties, suggesting that a very considerable proportion of the total population with the capacity to bear children spends around fifteen years in higher education and work before opting to do so. In most subjects girls do better at A level than boys do; and more women than men go into higher education (aggregate data, please note, is available only in terms of boys and girls, men and women). This has not done away with the gender gap in earnings, but there is some evidence that it might: the UK Office for National Statistics reported in October 2024 that the gender pay gap in the UK as they measured it (‘the difference between average hourly earnings excluding overtime of men and women, as a proportion of men's average hourly earnings excluding overtime … across all jobs in the UK, not … the difference in pay between men and women for doing the same job’) stood at 7 per cent, down from 7.5 per cent the year before. The difference varies across skilled and unskilled and full-time and part-time work, and across sectors, but the most striking pattern is found in measures of the gap by age cohort: 13.5 per cent for workers 60 or over, 12.1 per cent for those 50-59, 9.1 per cent for 40-49, 4.4 per cent for 30-39, 1.3 per cent for 22-29, and negative0.5, so in favour of women, for 18-21 years old. On this evidence, the full picture of the relationship between childbearing and capitalism requires equal attention to those who do bear children, and those who do not. For now, Anna Fielder has provided a groundbreaking analysis of the first group. Let us hope that someone can do as good a job for the second.
References and Further Reading
Arruzza, Cinzia, Tithi Bhattacharya and Nancy Fraser. 2019. Feminism for the 99%, Verso, London.
Brown, Jenny. 2019. Birth Strike: The Hidden Fight over Women's Work, PM Press, Oakland.
Cammack, Paul. 2022. The Politics of Global Competitiveness. Oxford, OUP.
Cammack, Paul, and Martha Gimenez. 2024. ‘The permanent global crisis of working-class social reproduction: ten propositions’, Global Political Economy, early view.
Federici, Silvia. 2004. Caliban and the Witch, Autonomedia, New York.
Firestone, Shulamith. 1971. The Dialectic of Sex: The Case for Feminist Revolution, Bantam.
Fraser, Gertrude J. 1995. ‘Modern Bodies, Modern Minds: Midwifery and Reproductive Change in an African American Community', in Faye Ginsburg and Rayna Rapp, eds, Conceiving the New World Order: The Global Politics of Reproduction, University of California Press, 1995, pp. 42-58.
Gardiner, Jean. 1997. Gender, Care and Economics, Macmillan.
Heagerty, Brooke Victoria. 1990. Class, gender and professionalisation: the struggle for British midwifery 1900-1936, Ph.D, Michigan State University, permalink https://doi.org/doi:10.25335/e3ed-sf19.
Heagerty, Brooke Victoria. 1996. 'Reassessing the Guilty: The Midwives Act and the Control of English Midwives in the Early 20th Century', in Mavis Kirkham, ed, Supervision of Midwives, Books for Midwives Press, Hale, pp. 13-27.
Heagerty, Brooke Victoria. 1997. 'Willing Handmaidens of Science? The Struggle over the New Midwife in Early Twentieth-Century England', in Mavis Kirkham and Elizabeth Perkins, eds, Reflections on Midwifery, Books for Midwives Press, Baillière Tindall, London, pp. 70-95.
Kollontai, Alexandra. 1916. ‘Working Woman and Mother’, available at https://www.marxists.org/archive/kollonta/1916/working-mother.htm
Morris, Theresa, and Mia Shulman. 2014. ‘Race Inequality in Epidural Use and Regional Anesthesia Failure in Labor and Birth: An Examination of Women’s Experience’, Sexual & Reproductive Healthcare, 5, 4, 188-194.
Oakley, Ann. 1976. Wisewoman and Medicine Man: Changes in the Management of Childbirth, in Juliet Mitchell and Ann Oakley, eds, The Rights and Wrongs of Women, Pelican, London, pp. 17-58.
O'Brien, Mary. 1981. The Politics of Reproduction, Routledge & Kegan Paul, Boston, London and Henley.
Office for National Statistics. 2024. Gender pay gap in the UK: 2024, Office for National Statistics, 29 October.
Rothman, Barbara Katz. 1989. Recreating Motherhood: Ideology and Technology in a Patriarchal Society, W.W. Norton and Company, London and New York.
The broader background is set out succinctly in the opening pages:
'Over recent decades, academics and activists have attributed responsibility for many of the problems which developed in relation to childbirth to a range of social forces. The rise in caesarean sections and use of heavily routinised care with iatrogenic effects [illness or disease caused by the treatment itself] have been seen as a product of industrialism or industrial society. Patriarchal power structures have also been held to account. It is now widely documented that prior to the eighteenth century, women in Europe as well as North America had given birth largely in their homes supported by other women, friends, relatives and midwives. By various mechanisms, which differed between countries and localities, the influence of males doctors grew. Women were largely excluded from becoming physicians and were prohibited by tradition or other means from wielding instruments such as forceps which doctors increasingly deployed. By the mid-to-late twentieth century, and earlier in many places, childbirth had been constituted as a medical event and was taking place primarily in hospitals: in other words, on the terrain of "medical men". Childbearing has been described as undergoing a process of appropriation by men even well beyond the mid-twentieth century. Yet over recent years, there has been growing acknowledgement that much feminist research carried out on people's experiences of childbearing has centred the experiences of white, often middle-class, cis women. In highlighting the patriarchal character of birth-care-institutions - of their staffing structures and prevalent clinical practices - social and historical forces and determinants of health such as racism and colonisation have often been overlooked' (7).
As this reflects, Fielder does not derive her analysis of childbirth either exclusively or mechanically from Marx. She first addresses childbearing in contemporary societies (Aotearoa-New Zealand, US, and UK) in terms of its own varied history and social logic, and then explores the contribution Marx can make to our understanding of it. She rejects the idea that Marx 'developed an overarching theoretical schema for application in any situation', into which childbirth might be squeezed, drawing instead on his observation that aspects of life that appear immutable or ‘natural’ often do so as an effect of the consolidation of intensely social forces, relations and elements. From this perspective, illustrated by Marx with the idea of the population, 'the concrete is concrete because it is the concentration of many determinations, hence unity of the diverse.' So too with childbirth.
The trick, then, is to identify the 'determinations' that are most significant: Fielder identifies four: obstetric technology, risk, evidence, and choice, addressed successively in chapters 3-6. They are well chosen. First, they are central aspects of contemporary childbirth. Second, they are dynamic categories that capture change over time. And third, the changes that they capture are all shaped by evolving neoliberal policy and practice. The modern application of tools to childbirth can be dated back to the invention of forceps (17th century) and Pinard Horn, or ear trumpet (19th century). Since then, things have moved on considerably. Today, ‘birthing units are filled with a vast array of equipment and technologies: electronic foetal monitors, ultrasound scanners, surgical instruments, syringes, drips, drip-stands, a growing range of pharmaceuticals, electronically adjustable beds, surgical tables, and far more' (16). Obstetric ultrasound was developed from the 1950s (pioneered in Glasgow, from technology originally used to detect weaknesses in the hulls of ships), but made huge advances in the 1980s that have continued to the present. The first commercial electrical foetal monitor dates from 1968 (Hewlett-Packard). The use of medical technologies undoubtedly saves lives (the evidence on behalf of continuous foetal monitoring during birthing is actually weak, but it reaps vast profits for HP, Philips and others, enables whole squads of birthing people to be monitored from one desk, and, apparently, fascinates male partners in particular). But the manner and extent to which technology is used, and over-used, reflects a range of pressures and practices that do not necessarily nor directly address the well-being of the birthing person or the baby. Prominent among these - along with the power and influence of profit-oriented corporations and the need to reassure consumers that you have the latest kit - is the understanding and management of risk. Childbirth is framed as risky, on a sliding scale from low to high, and risk is often assessed through statistical evidence derived from scientific clinical and/or epidemiological research, with the large-scale Randomised Controlled Trial (RCT) emerging as the 'gold standard' from the 1990s on. In turn, these three parameters - technology, risk, and evidence - limit and shape choice in childbirth: 'Be it consumer choice, patient choice, informed choice, women's choice, or other varieties of choice, renditions of choice (and the absence thereof) have become pivotal in defining the quality and character of contemporary birthing care' (16).
There are two related strands to the analysis here – on the one hand the development of the professions associated with childbirth and the institutions and practices that structure their work, and on the other the increasing power of capital, and particularly of large corporations, in the neoliberal period. The two come together in the mechanism of the large-scale Randomised Controlled Trial, illustrated here with the ‘Term Breech Trial’ (114-21), which makes the best point of entry to the logic of the contemporary ‘determinations and relations’ attending childbirth. Situations in which babies are in breech position (butt or bottom first) at full term are very infrequent (maybe 3 per cent of cases). Obstetricians (and midwives) may lack familiarity with them, and delivery anyway involves an increased risk to the baby. A caesarean is therefore an option to be considered. The Term Breech Trial, reported in 2000, involved over 2,000 women in 26 countries and 121 centres, assigned to either a planned caesarean or a planned vaginal birth (planned in order to leave open the option of an emergency caesarean if circumstances required):
‘It was reported that in cases where a caesarean section had been planned, there were significantly lower rates of “perinatal mortality, neonatal mortality, or serious neonatal morbidity” (broadly speaking, complications for the foetuses/neonates) than was the case when a vaginal birth was planned’ (115).
The result was a swift and dramatic shift in medical practice. Rates of planned caesarean birth for breech babies rose sharply, so that now they are ‘reported to be well above 86 per cent in Australia, Scotland, England and Wales. It is even documented that in the UK the caesarean rate for babies who are persistently breech is around 96 per cent. Vaginal breech births have been described as “an exceedingly rare event” in the US’ (118).
All well and good. But RCTs such as this, as large-scale trials with a single dichotomous point of difference, establish a preferred option on a statistical basis for the average case. As Fielder comments, a vaginal breech birth attended by an experienced midwife and delivery team may be much safer than a caesarean in a poorly resourced hospital with inexperienced staff. Significantly, in 2006 ‘a large observation study in France and Belgium found that within that context, neonatal outcomes for term breech babies did not differ significantly whether it had been planned for the infant to be born vaginally or via caesarean section’ (120). But the die was already cast. As a result, obstetricians and midwives alike came to have even less experience of vaginal breech births, so that now: ‘For pregnant people who today do want to plan a vaginal breech birth, it is increasingly difficult for them to find a midwife or doctor who is experienced, skilled and willing to support them in that’ (ibid). At the same time, other considerations hastened a more general move towards caesareans, notably a preference on the part of obstetricians and hospital management (and quite often of the person giving birth) for caesarean sections as ‘routine’, easy to plan and manage, ‘supported by the science’, and therefore less ‘risky’ and less likely to give rise to malpractice suits.
Building up to this focal point, Fielder does a brilliant job of bringing out the key ‘determinations and relations’ of contemporary birthing over the chapters on technology, risk and evidence. This in turn provides the basis for assessing the issue of choice. A crucial aspect of this is the distinctive character of childbearing in the US, where the practice of midwifery was all but eliminated at one point, and high-tech ‘assisted’ births, often involving caesarean delivery, became highly prevalent. In the UK and in Aotearoa New Zealand, in contrast, the profession of midwifery is more normalised, albeit increasingly under strain. Though the contexts differ in this respect, the principal message is the same – in the latter decades of the twentieth century ‘the notion of choice emerged as a pre-eminent principle’ at precisely the same time that choices were increasingly shaped and constrained: ‘celebrations of “choice in childbirth” arose as both a product of and a political response to diverse aspects of an expanding capitalism as it transitioned into the neoliberal era’ (125-6). Fielder draws on Marx’s early work on ‘conscious life activity’ and ‘species being’ to good effect to argue that childbearing people, rather than doctors and clinicians, should do the choosing. She describes a period in the UK in which notions of ‘women’s choice’, ‘informed choice’ and ‘consumer choice’ channelled debate, and deploys these perspectives in discussions of pain relief, elective caesarean, and ‘free birthing’ (choosing to give birth at home without involving a midwife or doctor). Whoever you are, you can’t be sure of getting exactly what you want. But the balance between choice and constraint is heavily weighted by the level of resources and the institutional policies in place, and individual factors of income, class and race. So, for example,
‘In the US, people have been threatened with negative sanctions if they decline epidurals. The researchers of a study in which this was found to be the case explained that although monitoring of a childbearing person is comparatively intensive after an epidural is in place, that monitoring can be performed at regular intervals. In contrast, ‘Caring for an unmedicated woman during birth is arduous, unpredictable, and may take the nurse away from documentation duties for extended periods of time’ (Morris and Schulman 2014: 189).
As the authors report, ‘Among women who did not plan to have an epidural, women of color were more likely to face pressure to accept the epidural by hospital medical staff. Further, among women who received anesthesia (either during vaginal delivery or a C-section), women of color were more likely to experience failure in their pain medication and were less likely to have their pain and anxiety taken seriously by doctors’ (ibid: 188).
And if you are not entitled to free access to the NHS in England by virtue of not being ‘ordinarily resident’ (a complicated issue), ‘free birthing’ may be a forced choice, given an expected minimum fee of around £7,000 for hospital delivery. Such examples could be multiplied, and there are several in the book.
Through these chapters, then, the emphasis is on the varied pressures and constraints that childbearing people face. The conclusion then turns to ‘some of the ways in which childbearing people, birth workers and their supporters have been and continue to be collectively energised to improve the conditions in which people grow babies, birth, labor and live’ (148-9). Here the ‘Lead Maternity Carer’ system in Aotearoa New Zealand is a hopeful precedent, despite the pressures it faces; in the US, the ‘birthing justice movement’ challenges the system, and especially its racialised character, and advocates the greater use of doulas (non-medical trained pregnancy and birth attendants); in the UK, struggles involving strike action have centred on securing adequate funding for services and wages in the National Health Service.
Fielder’s gold standard, in contrast to the regimented hi-tech and drug ‘assisted’ hospital birth (and prospectively a dystopian future in which children are artificially conceived, ‘developed’, and delivered), is one in which the birthing person is supported by a midwife who has accompanied them throughout the pregnancy, and with whom they have developed a relationship of trust; in which supported home birth is an option; and in which well-resourced local hospitals and community birthing facilities are readily available:
‘The very work of midwifery has a relatively low carbon footprint, not least because midwives often provide relatively low-tech, community-based care thereby minimising transport and carbon emissions. A well-supported midwifery workforce can also facilitate the creation of health and well-being (rather than simply the mitigation of risk), and help build and nurture the strength and power of pregnant people, their loved ones and communities as they make birthing safe in ways that matter for them. Such birthing looks very different from services which structurally protect the profits of med-tech companies and of corporations directly investing in fossil fuels’ (157-8).
Midwifery, understood in these terms, can form an integral part of local solidarity economies, and link with a range of movements – such as the International Women’s Strike movement – to advance ‘the power of those whose unpaid and paid work sustains the world’ (Arruzza, Bhattacharya and Fraser, 2019:7, cited p. 159, emphasis original). Midwives, in this perspective, are exemplary providers of care, called to ‘be with’ and support the birthing person, and firmly established as central figures, too often overlooked, in the broader ‘care economy’. So the conclusion opens out the focus to establish childbearing and the way in which it is supported as fundamental to anti-capitalist struggles. Going Into Labour is an original, humane and pathbreaking work.
There is another side to the story of contemporary patterns of childbearing, though - one that Fielder touches on at a couple of points, and that brings in a complementary set of issues concerning its relationship to capitalism in its current manifestation. She notes in the chapter on choice that one aspect of mobilisation around social movements from the 1960s on was that women ‘were demanding to make their own decisions over whether they bore and raised children’ (129); and elsewhere (38-9) she references Jenny Brown’s Birth Strike (2019), which explores, among other things, the complex circumstances in which many women in the United States opt for childlessness or late motherhood. Marx’s focus on the concrete as the concentration of many determinations is equally relevant here. One factor is access – where they are available, and not criminalised - to contraception and safe termination. Another is the steady advance in the access of girls to secondary and higher education – again, where it is not criminalised (the recent closure of nursing and midwifery courses to women in Afghanistan being a shameful recent example). A third is the energy with which the World Bank and other international organisations promote women’s access to ‘good jobs’ in their pursuit of global capitalist development, and the European Commission targets ‘inactive’ women in their zeal to eliminate ‘worklessness’. A fourth is the sheer impossibility of survival, for a working class family, on a single wage, and a fifth is the high cost, particularly in the United States, of childcare. Taken in conjunction with Fielder’s analysis, these points raise with particular force the broader issue of the relationship between childbearing on the one hand, and contemporary capitalism on the other. There is more to be said about this than can be addressed here, but the starting point would be to say that the reproduction of the working class from generation to generation is not simply a matter of ensuring a steady supply of children. There is no evidence that capitalists look that far ahead, if they look at the issue at all; the governments that do are mostly inspired by racist and nationalist concerns, rather than attentive to the future needs of capital; and the relevant international organisations, led again by the World Bank, favour migration as a solution to labour shortages, and focus much more on turning such children and young people as there are into competent and exploitable workers than on increasing the supply of raw human material (Cammack 2022; Cammack and Gimenez 2024). So the relationship between childbearing and capitalism is by no means straightforward. In the UK, the average age for bearing a first child is in the early thirties, suggesting that a very considerable proportion of the total population with the capacity to bear children spends around fifteen years in higher education and work before opting to do so. In most subjects girls do better at A level than boys do; and more women than men go into higher education (aggregate data, please note, is available only in terms of boys and girls, men and women). This has not done away with the gender gap in earnings, but there is some evidence that it might: the UK Office for National Statistics reported in October 2024 that the gender pay gap in the UK as they measured it (‘the difference between average hourly earnings excluding overtime of men and women, as a proportion of men's average hourly earnings excluding overtime … across all jobs in the UK, not … the difference in pay between men and women for doing the same job’) stood at 7 per cent, down from 7.5 per cent the year before. The difference varies across skilled and unskilled and full-time and part-time work, and across sectors, but the most striking pattern is found in measures of the gap by age cohort: 13.5 per cent for workers 60 or over, 12.1 per cent for those 50-59, 9.1 per cent for 40-49, 4.4 per cent for 30-39, 1.3 per cent for 22-29, and negative0.5, so in favour of women, for 18-21 years old. On this evidence, the full picture of the relationship between childbearing and capitalism requires equal attention to those who do bear children, and those who do not. For now, Anna Fielder has provided a groundbreaking analysis of the first group. Let us hope that someone can do as good a job for the second.
References and Further Reading
Arruzza, Cinzia, Tithi Bhattacharya and Nancy Fraser. 2019. Feminism for the 99%, Verso, London.
Brown, Jenny. 2019. Birth Strike: The Hidden Fight over Women's Work, PM Press, Oakland.
Cammack, Paul. 2022. The Politics of Global Competitiveness. Oxford, OUP.
Cammack, Paul, and Martha Gimenez. 2024. ‘The permanent global crisis of working-class social reproduction: ten propositions’, Global Political Economy, early view.
Federici, Silvia. 2004. Caliban and the Witch, Autonomedia, New York.
Firestone, Shulamith. 1971. The Dialectic of Sex: The Case for Feminist Revolution, Bantam.
Fraser, Gertrude J. 1995. ‘Modern Bodies, Modern Minds: Midwifery and Reproductive Change in an African American Community', in Faye Ginsburg and Rayna Rapp, eds, Conceiving the New World Order: The Global Politics of Reproduction, University of California Press, 1995, pp. 42-58.
Gardiner, Jean. 1997. Gender, Care and Economics, Macmillan.
Heagerty, Brooke Victoria. 1990. Class, gender and professionalisation: the struggle for British midwifery 1900-1936, Ph.D, Michigan State University, permalink https://doi.org/doi:10.25335/e3ed-sf19.
Heagerty, Brooke Victoria. 1996. 'Reassessing the Guilty: The Midwives Act and the Control of English Midwives in the Early 20th Century', in Mavis Kirkham, ed, Supervision of Midwives, Books for Midwives Press, Hale, pp. 13-27.
Heagerty, Brooke Victoria. 1997. 'Willing Handmaidens of Science? The Struggle over the New Midwife in Early Twentieth-Century England', in Mavis Kirkham and Elizabeth Perkins, eds, Reflections on Midwifery, Books for Midwives Press, Baillière Tindall, London, pp. 70-95.
Kollontai, Alexandra. 1916. ‘Working Woman and Mother’, available at https://www.marxists.org/archive/kollonta/1916/working-mother.htm
Morris, Theresa, and Mia Shulman. 2014. ‘Race Inequality in Epidural Use and Regional Anesthesia Failure in Labor and Birth: An Examination of Women’s Experience’, Sexual & Reproductive Healthcare, 5, 4, 188-194.
Oakley, Ann. 1976. Wisewoman and Medicine Man: Changes in the Management of Childbirth, in Juliet Mitchell and Ann Oakley, eds, The Rights and Wrongs of Women, Pelican, London, pp. 17-58.
O'Brien, Mary. 1981. The Politics of Reproduction, Routledge & Kegan Paul, Boston, London and Henley.
Office for National Statistics. 2024. Gender pay gap in the UK: 2024, Office for National Statistics, 29 October.
Rothman, Barbara Katz. 1989. Recreating Motherhood: Ideology and Technology in a Patriarchal Society, W.W. Norton and Company, London and New York.