RESTRUCTURING BIRTH: NEOLIBERAL SHIFTS IN MATERNITY CARE, THE ROLE OF NGOS, AND THE IMPACT ON MIDWIVES AND BIRTHPARENTS IN THE PHILADELPHIA COMMUNITY

Abstract

Over the past twelve years, Philadelphia has undergone an unparalleled large scale shift in the way maternity care is provided, accessed, and considered. Key aspects of the changes to the landscape of birth in Philadelphia include: the closure of the majority of hospital-based maternity units, the activities of local women's health non-governmental organizations (NGOs), and the new set of pregnancy care and birth choices that parents navigate. One of the most striking results of the restructuring of Philadelphia's maternity care system is a drastic reduction in the number of hospitals with maternity units. While the birth rate in Philadelphia has remained consistent around 22,000 per year, since 1997 two-thirds of the hospitals in Philadelphia have eliminated their maternity services. During this time, numerous local women's health-oriented NGOs worked to established themselves in Philadelphia. The aim of each NGO has been to respond to inadequacies in the provision of maternity services that develop as hospitals, the dominant resource for maternity care, withdraw from the maternity care business. With only six hospital maternity units remaining and a couple of local nonprofit organizations attempting to supplement the dearth of services, the current system within which parents and health care providers maneuver is both unstable and inadequate for meeting the maternity care needs of the community. In this research project, I explore the processes through which this new maternity care system is being established in Philadelphia with a particular focus on the influence of neoliberalism as an active force in the restructuring process. I examine the outcomes of this restructured system in terms of how lived experiences are influenced by the social, political, and economic reconfiguration of birth. The case of Philadelphia is of particular value as the City's maternity care system has undergone an accelerated restructuring that is unmatched in other areas of the US. While a similar trend in restructuring can now be found in other locations, these changes happened earlier and have continued in a more extreme manner in Philadelphia, marking Philadelphia as a possible canary in a coal mine. Understanding the outcomes of this large scale change in the system of care provides a basis for contending with similar trends elsewhere. My ethnographic work focuses on the experiences of particular individuals as they navigate Philadelphia's new system of maternity care. Within this restructured system of maternity care, the interests of parents and health care practitioners are increasingly devalued or disregarded, particularly for those whose philosophy of birth differs from dominant biomedical maternity care practices. Midwives, whose non-interventionalist methods of care starkly contrast with the biomedical model of care, and parents who wish to have a low-intervention or natural childbirth struggle to achieve their goals within the confines of Philadelphia's maternity care system. Similarly, individuals running local NGOs strain to intervene in the process of restructuring, and often face the dilemma of remaining true to their mission on one hand or preserving financial security by meeting the imperatives of funders on the other hand. Therefore, I have made the stories of midwives and parents seeking alternatives to biomedical care central to my analysis in addition to conducting in-depth fieldwork with three local women's health-oriented NGOs. This project adds to our understanding of how broad political and economic trends in health care translate into select cultural formations which inform the life choices of individuals. In times such as now, when national policy regarding the provision of health care is under scrutiny, it is essential to connect the dots between the circumstances of individuals and the structure of systems of health care. This research project fuses analyses of civil society institutions, the politics of reproduction, national ideology, and local political and economic agenda to present a complex and inclusive assessment of the landscape of birth in the uniquely positioned city of Philadelphia.