Mary Dejevsky: When the middle classes flee

In the face of such hostility, is it any wonder that women will pay for a birth that is, as far as possible, on their terms?

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The Independent Online

Childbirth is a one-off – something that no one, but especially not middle-class mothers, wants to get wrong. Pretty much everything else in life can be remedied with a little time, money or pain, even a poor choice of school and an unsuitable career. But a bad experience in the maternity ward cannot be undone, even if both mother and child emerge healthy.

This may be one reason why many more middle-class women, who would otherwise see themselves as stalwart supporters, in principle and practice, of the National Health Service, are choosing private maternity care. Whether it is antenatal classes, one or more private midwives, a "doula", a maternity nurse or the whole lot at a private clinic, more women are shelling out for a service that they are entitled to, entirely free, on the NHS.

There will be those who say, in so many words, good riddance. After all, if fewer women make use of NHS maternity services, there should be less pressure on facilities for the rest. But if middle-class women – beyond those who are privately insured – are opting out of state provision in noticeable numbers, this suggests there is a problem. And if there is, it is one that should concern both the NHS and any government committed to preserving a universal health service.

The middle classes, as has long been observed, are adept at applying their "sharp elbows" to their children's schooling, and they play the health system in much the same way. They know – and if they don't know, they know how to find out – who the better GPs are, where to find the better hospital departments and the better consultants for their condition.

In a widely reported blog post, the social commentator and former Labour Party adviser, Matthew Taylor, recently took this a stage further. He concluded, from the experience of several friends, that well-educated, but not necessarily well-off, individuals had better life chances than others, even in the face of a terminal cancer diagnosis. They questioned the initial judgement, sought information on the internet, tracked down the best specialists – and enjoyed a better qualify of life for longer than they had initially been led to believe. This was, Taylor argued, another, particularly striking, example of middle-class advantage. He proposed that all cancer patients would benefit from a personal "advocate" to fight their corner.

So what is going so wrong for middle-class women and NHS maternity services? One explanation might be that nothing is really going wrong as such, it is simply that this generation of educated women is more aware – through friends, colleagues and the internet – that there are alternatives, and they have enough of their own money to pay. After all, many will be aware that the cost of having a child in a good maternity unit in the United States could be upwards of $20,000, so that the £8,000 or so it costs here might seem a bargain – especially given the cost of university tuition (rising to £9,000 a year) or private schooling (£10,000 or so a term).

But I doubt this is the whole story. After all, £8,000 is a tidy sum. I also doubt whether the trend is entirely – as some would have it – a consequence of the various natural and home birth movements that dangle the prospect of idyllic, unmedicated births in intimate surroundings, followed by a celebratory glass of champagne. This may be the ideal many aspire to, but most women are surely realistic enough to understand that anything that falls short of this perfection does not have to be a nightmare.

Of course, the internet and social media mean that one mother's bad experience can now go a very long way. More pertinent, however, may be how much those bad experiences, as they are told and retold, seem to have in common. And it goes beyond the now, alas, almost routine complaints about ward hygiene and hassled nurses.

One common complaint relates to the shortage of specialised staff – midwives and consultants – either all the time or specifically at night and weekends. This is the standard NHS management problem, that refuses to recognise hospitals as 24/7 services. Another relates to the lack of privacy. Yet another – and in some ways the most shocking – is the way that some nurses and midwives appear to scorn especially middle-class women for being oversensitive, pain-averse and, essentially, unworthy of childbirth. This contempt from the female of the species is matched by the male species of consultant that wants to deny women the choice of a Caesarean. Both seem to be saying that women should suffer in giving birth.

In the face of such hostility, neither sharp elbows nor abject cries for help are much use. Is it any wonder then that women will pay for a birth that is, so far as possible, on their terms?

Yet there are risks here. The smaller risk is that more midwives will leave for a burgeoning private sector, leaving NHS wards with even fewer qualified staff, and training unable to keep pace. The much bigger risk is that the flight of the middle class from NHS maternity services will accelerate and spread to other parts of the NHS, reproducing the dire effects – for the less privileged – that segregation by money and class has had on Britain's schools.