The paradox of success ana the challenge of change: Home birth associations of Aotearoa/ New Zealand A thesis submitted for the degree of Doctor of Philosophy in Sociology at the University of Canterbury by Rea Daellenbach University of Canterbury, 1999 ii Abstract This thesis is a social and political analysis of the home birth associations of Aotearoa/ New Zealand. These consumer groups were formed in late 1970s and over the last twenty years have responded to significant changes in the health sector, some of which are the outcome of home birth political activism. Like many other grass roots movements attempting to achieve change, activists have constantly been challenged to re-create Icollective identities' and re-position themselves with respect to various sets of lallies', lopponents', and Ibystanders'. The thesis examines how home birth associations in Aotearoa/ New Zealand have responded in various ways to the radical changes in the professional status of midwifery and the restructuring of the health sector in the 1990s. This analysis draws on theorising about social movements, feminist activism, professionalising strategies and the impact of neoliberal policy projects in the health sector. Home birth association newsletters, the print media, one to one interview, focus group discussion and participant observation are used in this feminist qualitative project. The contradictory positioning of home birth as simultaneously part of and marginalised within New Zealand's state funded maternity service drew home birth advocates into conflicts and compromises with the state. Activists from the home birth associations prioritised a Irights' claim over a home birth advocacy frame and succeeded in effecting significant changes to maternity services as more choices were made available to women. This, however, has not necessarily lead to corresponding changes in the balance of power between consumers and professional experts in policy making and knowledge production. The New Zealand Col/ege of Midwives, which grew out of home birth networks, attempts to address power relations through a discourse of Ipartnership'. However, the 3 0 MAR 2000 iii asymmetrical dependence of home birth associations on midwives to link new members to local networks, and for activists to have a voice in policy making, creates new challenges and strains for home birth activists. A number of home birth associations have attempted to gain contracts with state health funding authorities as a means to exercise more consumer control over home birth services. This raises a new problems for activists as they renegotiate their relationships with state agencies, midwives and women choosing to birth at home. iv Acknowledgements Of all the many people to whom I am grateful for the support, time and energy you have put into this project, I would in particular like to thank the following: All the 'home birthers' who participated in the interviews for this research. All of you who invited me to stay in your homes and contributed in other ways. Rosemary Du Plessis and Geoff Fougere, my supervisors for all your insightful feed back. Mark McEntyre, TUna Vares and Carol Bartle - especially for all your help at the end. Glynette Gainfort and Francine Vella. Tara and Shanti, my daughters. v Table of Contents Abstract ii Acknowledgements iv 1 Introduction: home birth associations at the end of the millennium 1 Confronting the Paradox 1 2 Social movements, political opportunities and social change 8 A home birth movement? 9 Theorising the state? 17 Politics and policies 21 Collective action frames 26 Conclusion 30 3 Constructing reflexivity: an insider! outsider analysis of home birth associations 32 Getting started: biography and topic choice 33 The challenge of insider research 38 Interviewing groups 45 Posing questions 48 Selection of associations and setting up interviews 50 Recording and transcribing 54 Conclusion 56 4 The politics of birthing: an historical overview 57 Regulating Midwives, establishing an occupation 61 In the interests of the nation: the Midwives Registration Act, 1904 69 The hospitalisation of childbirth 72 Maternal mortality 'panics' 74 The hygienic midwife: H.Mt 20 regulations 76 The Department of Health and the Obstetrical Society 80 Pain relief for birthing 84', Consolidating medicalised childbirth 86 The Parents Centre natural childbirth movement 91 vi The regionalisation of maternity services 96 Conclusion 103 5 'New birth'; the emergence of the home birth movement in New Zealand 105 Creating home birth networks 106 Home birth as cultural innovation 111 Home birth collective identity and conflicts 122 A public voice: Home birth in the media 128 Conclusion 136 6 Representing home birth; publicity and politics in the 1980s 138 'Mother and Baby at rtome - The Early Days' 140 Save the midwives 148 Changing organisational structures 151 The professionalisation of midwifery 157 •. Conclusion 164 7 The paradox of success: remaking collective identities in the 1990s 165 The Nurses Amendment Act, 1990 168· Restructuring health and maternity services 178 The unintended outcomes of success: losing political focus 182 New complexities in 'choices for childbirth' 191 Conclusion 195 8 'Women need midwives need women': home birth associations and the New Zealand College of Midwives 197 The structure of the New Zealand College of Midwives 198 Complicating 'partnerships' 202 Rhetorics of partnership and consumer representation 207 Home birth associations and home birth midwives 214 Conclusion 219 9 Negotiating contractual identities 221 The new contractualism: theoretical debates 225 vii Tauranga Home Birth Association 231 Manawatu and Auckland Home Birth Associations 237 Constructing contractual identities? 245 Conclusion 254 10 The challenge of contracts: home birth associations as providers of home birth services 256 The uncertainties of tendering 259 Contracting home birth groups - 'agents of the state'? 261 Contracts with midwives - home birth groups as 'middlewomen' 272 Contracting and community networks 277 Politicising contracting? 281 Conclusion 284 11 Conclusion: standing on a faultline 287 Cultural politics and state politics 288 Contemporary support groups and cultural innovation 293 Diversity, uncertainty and organisational1hedging' 298 Appendix I - The interview groups 302 Appendix II - Interview question guides 315 Appendix III • Media References 322 Bibliography 326 1 1 Introduction: home birth associations at the end of the millennium Confronting the Paradox The home birth associations in New Zealand are in a paradoxical position at the end of the millennium. On the one hand there is much to celebrate - they have achieved some marked successes. Two decades of home birth activism has led to a significant increase in home births, from 0.04% of births in 1974 to approximately 5% in 1998.1 The alliance forged between home birth activists and home birth midwives provided a key impetus for 1 The 1974 figure is cited in Gulbransen, et ai, (1997:88). The 1998 figure is an estimate included in a report on maternity services produced by the National Health Committee (1999:46). In a message to the 1999 Aotearoal New Zealand Home Birth AssociatiQns conference, Karen Guilliland (National Director of the New Zealand College of Midwives) said that New Zealand has the second highest rate of home births of Western nations. She also suggested that the home birth rate might be as high as 7%. Official data is not being collected. 2 midwives to form the New Zealand College of Midwives to represent their professional interests. In recognition of the contribution made by consumer supporters of midwives, consumers are able to be members of the College and are included on the College's governing body. This was a 'first' in the world for a national midwifery professional organisation. Home birth activists' demands on the state to improve the working conditions of domiciliary midwives were realised in 1990, when the law was changed to enable midwives to attend 'normal' births without medical supervision. This change also allowed midwives to claim from the state funded maternity benefit schedule at the same rate as general practitioners (GPs) and to attend clients in hospitals. Direct-entry midwifery courses, campaigned for by home birth activists, were established to enable people to become registered as midwives without first being trained as nurses. On the other hand, these successes pose new challenges for home birth activists. It is these challenges that are examined in this thesis. One consequence of their 'success' is that home birth associations have lost their political focus and activists face new obstacles in having an input into maternity services policy. While in the 1980s, activists demanded the right to birthing choices for all women, in the 1990s, they have encountered many women who now deploy this language of the 'right to choices' to demand different forms of birthing services. In the 1980s consumers who birthed at home and the domiciliary midwives who attended them formed mutually interdependent bonds under the conditions of shared marginalisation. This has become more complicated as midwives lay claim to a new professionalised status. A health restructuring programme initiated a year after midwives were granted 'autonomy' has created new opportunities for home birth associations to reposition themselves as providers of state funded services. Some home birth groups have received contracts to provide antenatal 3 classes or postnatal home help, and