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Birth and the `reflexive consumer': trust, risk and medical dominance in obstetric encounters.

Introduction

For some decades now, the so-called `consumer' movement in health care has grown in Australia and overseas and become increasingly significant in a range of areas of health care provision including obstetrics (Bastian, 1991; Consumers' Health Forum, 1992, 1996; Grace, 1994). Not only has the development of this movement been seen to have an impact at the `macro' level of health policy, but also at the `micro' level of doctor-patient interactions which, some have argued, have the potential to disrupt the dominance of medicine (Gabe et al., 1994; Haug, 1979; Haug and Lavin, 1981; Little, 1995; Wiles and Higgins, 1996). At the `macro' level, there is little conceptual difficulty with the organization of actual or would-be `consumers' into pressure/lobby groups. However, the extent to which doctor-patient interactions themselves can be reconstructed and recast as simply the exchange of services between a provider and a `consumer' in a market for services is of course debatable, and despite some proponents of this view (e.g., Logan et al., 1989) it is a contentious one (Germov, 1995; Lloyd et al., 1991; Lupton, 1997a).

There are many reasons for this. Some of the most notable particularities of the doctor-patient relationship identified by Talcott Parsons nearly half a century ago still pertain today: the asymmetry in knowledge and hence power is of course still significant, though, some claim, the gulf between consumer and provider has been reduced in important ways. These include the rise in general educational level, in self-help groups which develop an extensive knowledge base about coping with particular conditions, and in the use of alternative medicines and information age technology that allow individuals to access alternative sources of information about, and approaches to, health conditions (Easthope, 1998; Haug, 1979; Haug and Lavin, 1981; Kelleher, 1994; Saks, 1994). Nor is the asymmetry simply between two parties; much has been made of the changing employment patterns of many medical practitioners rendering them employees of sometimes large organizations (Starr, 1982), and of the constraints that can be imposed on medical practice by not only employer organizations but also by insurance companies providing medical malpractice insurance (Cook and Easthope, 1996; Hay, 1992). Despite these developments, fundamentally the asymmetry in knowledge and power between doctors and their patients remains tilted in the favour of the doctors.

Many other characteristics of the doctor-patient relationship render it, at best, a rather particular case of a `consumer/provider' relationship. It is often anxiety and distress which bring people to medical encounters; Parsons referred to this as the patient's `vulnerable and emotional state', an important feature which differentiates this encounter from most others in the marketplace. Patients seek medical encounters on the basis of need more than on the basis of want, as in the case with simply market exchange, and this to Parsons was another feature of the doctor-patient relationship which differentiated it from business relationships (Bury, 1997; Parsons, 1951). In addition, many have noted the `confessional' characteristics of the therapeutic encounter which can involve laying bare the soul and often the body (Foucault, 1973; Gerhardt, 1987).

So, consumerism in health is clearly an important phenomenon of the contemporary era, but its impact, significance and meaning for the doctor-patient relationship is obviously quite complex. Indeed, in recent years a number of analysts have argued that constructing the patient qua consumer has gone too far (Germov, 1995; Lupton, 1997a), and that Parsons' insight from psychoanalytic theory, that the adoption of a dependent, passive patient stance has therapeutic value, is one that ought to be maintained in considerations regarding consumerism in health (Lupton, 1997a, 1997b).

The research reported in this article makes some contribution to the debate regarding the significance and meaning of the phenomenon of consumerism in health. It takes as its particular focus the provision of maternity services in obstetric encounters, and examines the character and extent of the consumerist behaviour and attitudes of a sample of birthing women through an analysis of their birthing narratives.

Childbirth is an extremely important example of a particular type of medical encounter which has rarely been examined in this light. Childbirth is an experience which most contemporary women will go or have gone through. It is the single most important reason for the hospitalization of younger women (Australian Institute of Health and Welfare, 1998) and is without doubt the major site of young women's sustained contact with the medical domain (Zadoroznyj, 1999b). Sociologically, it is a very rich arena in which to analyse women's behaviour, as `consumers' or otherwise, for a number of reasons. First, it is an arena where for some time now a variety of discursive constructions of the meaning and management of birth have been in competition. In other words, childbirth is a discursive domain characterized by lack of an `authoritative truth'. Although dominated by a `risk/technocratic' discourse propagated largely within the medical arena (Davis-Floyd, 1994), this has been challenged by `natural' childbirth advocates (Dick-Read, 1951; Kitzinger, 1986; Le Boyer, 1977), by feminists including liberals and poststructuralists (Annandale and Clark, 1996; Martin, 1992; Oakley, 1980) by consumerist discourses (Bastian, 1991), as well as by politicized midwives who offer maternity services constructed around `consumer' desire for safe and satisfying birthing (Sandall, 1995). Of course, this is precisely the kind of situation which both Giddens (1990, 1991) and Beck (1992) argue lends itself to the `reflexivity' typical of social actors in `high modernity', where uncertainty, risk and lack of foundational truths require the reflexive remaking of `self'. This reflexive making of self is, of course, congruent with `consumerist' behaviour (Lupton, 1997a; Zadoroznyj, 1999a), and can be readily evidenced in the provision of maternity services. In giving birth, women can choose between different discursive constructions of childbirth, each with different conceptions of risk, different implications for how childbirth should be managed, as well as different implications for the extent of the involvement of birthing women themselves in the management of their births. As Lane (1995: 89) has argued: `obstetrics is not immune from general and growing consumer criticism which is itself substantially reflexive'.

Childbirth is also an arena rich for an analysis of this kind because the pressure of competition in the market for the provision of services is strong, given that a substantial proportion of maternity services are provided in the private hospital sector (Australian Bureau of Statistics, 1995; Cunningham, 1993) so that having to make choices is almost structured into the experience of giving birth for many women. The recent resurgence in the significance of midwife-led maternity services (Rowley et al., 1995; Shields et al., 1998) adds another dimension to the complexity of choices which surround birthing women.

The analyses reported in this article will focus particularly on the identification and character of consumerist attitudes and behaviour among the women interviewed in this study. The article will also explore the extent to which the `consumerism' is related to conceptions of risk, and is congruent with reflexivity and self-identity, and will examine its implications for medical dominance.

Methods and study design

Stage 1

The analyses reported here are part of a larger study concerned with women's choice of maternity services in a particular region of a major Australian city. In part, the study was prompted by concerns that only a minority of women (29 percent) from the regional public hospital catchment area (as defined by postcode) gave birth at that hospital; another 35 percent went to other public hospitals and 36 percent gave birth at private hospitals in and near the region. The women from the region who chose not to give birth at their local maternity hospital were identified as the study population. Most of them (95 percent) gave birth at one of seven hospitals, and each of the hospitals was approached about participation in the research project. Four of the hospitals agreed to participate in the research, accounting for 70.2 percent of all women from the region who did not give birth at the local hospital (South Australian Health Commission Pregnancy Outcome Unit, personal communication). The three that declined were all private hospitals. Data on the proportional distribution of births to women from the region at each of the four hospitals participating in the study were used by the Epidemiology Unit of the Health Commission to calculate the appropriate sample size from each hospital. Effectively, this produced a simple random sample of women from the catchment area who had given birth to a live infant at one of the four hospitals in 1991.

The Pregnancy Outcome Unit then provided the unit record numbers of sampled women. Hospital computer programs were used to match the numbers with names and addresses, and a reply-paid mailed questionnaire was sent to the women under the auspices of the Health Commission. One reminder was sent to non-respondents after two to three weeks. The questionnaire was sent to 866 women between October 1992 and January 1993. Responses were obtained from 519 women for an overall response rate of 61.7 percent.

Stage 2

Respondents to the survey were asked whether they would be willing to participate in further research; 64 percent of respondents indicated that they would, and provided telephone numbers. A list of these numbers was used to select a random sample of women to be contacted for a followup interview. Fifty open-ended, in-depth interviews were conducted as the second stage of the research project.

The interviews took the form of birthing narratives which inquired into women's constructions of their ideal births and their actual experiences. This approach, like all narratives, frames events in a temporal and causal sequence and as such constructs a particular type of `account' (Robinson, 1990: 1173). The narrative approach allows respondents to tell their story in ways that `make sense' to them and hence brings into view their reflexivity as well as highlighting shifts in their subjective and lived identity.

The birth narratives in this study were constructed through a semi-structured, in-depth interview that allowed participants to `build up, document and order preceding events, findings and circumstances which together constitute a clear trajectory' (Robinson, 1990: 1173). Once the narratives were complete, demographic information including highest educational attainment, respondent's occupation, husband's occupation and family income were obtained; these demographic indicators were used to categorize the women. The sample of women interviewed was obviously too small to utilize a gradational concept of social class; however, it was found that a categorical distinction could be made between those women who were employed in primarily blue-collar occupations, with relatively low educational qualifications (secondary school or lower), and a relatively low earning capacity, and their well-educated, professional/managerial sisters with a much higher earning capacity. Husband's occupation and family income were also taken into account when categorizing the women, and interestingly relatively little ambiguity emerged; the various indicators used tended to not be contradictory, and there was a high degree of homogamy within couples.

As with other small scale, childbirth focused research (Martin, 1992; Nelson, 1983) the women in this study were categorized as either working class or middle class. This categorization is broadly indicative of differences in the women's objective, material circumstances as well as in the differential `habitus', cultural orientation and practice of middle-class and working-class women (Bourdieu, 1986; Williams, 1995). Of the women in this study, 28 were classified as middle class, and 22 as working class. The differences in material circumstances of the two groups have some predictable yet pronounced implications for birthing choices. Social class had a major impact on health insurance status and hence over possible choices regarding birthing options. Of the middle-class women, 23 (82 percent) had private health insurance for all their pregnancies and births. In Australia, private insurance enables the choice of private practitioner (specialist obstetrician or general practitioner) and the choice of either a public or private hospital, and approximately 41 percent of all women of childbearing age had private health insurance (Australian Bureau of Statistics, 1995). Of the working-class women, only three (13 percent) had private health insurance cover for all pregnancies. It is of course possible to purchase care from a private practitioner in a private hospital without private health insurance, but the costs are generally prohibitive. The working-class women in this study could select from one of three public hospitals within or just outside the region, and could also opt for midwife-led birthing services or conventional care from an obstetric team.

This article will focus primarily on the interview part of the study. The analyses are discussed in terms of whether or not they refer to a woman's first pregnancy and birth, whether or not the woman is privately insured, and in terms of the women's material, social and cultural capital, which will be referred to as their social class.

Findings

The analyses are presented first in terms of women's views, attitudes and/or behaviour in their first birth. The results show that, for first birth, approximately half of the women exhibited a clearly `consumerist' approach toward the selection of their provider of maternity care and the setting in which they chose to have that care. In Australia, childbirth has been virtually completely medicalized, so that `seeing a doctor' about being pregnant is almost universal. This sample of women held no exceptions; all went to their GP in the first instance. However, many of them exhibited strong `consumerist' behaviour in so far as they made deliberate efforts to identify and select maternity services that would suit them. Their comments reveal that they weighed up options, discussed maternity services with friends, relatives and acquaintances, and then made decisions. A number of the women had even selected their specialist obstetrician, and/or hospital before they even went to the GP, whom they used purely for the purposes of obtaining a referral. For example, a privately insured nurse married to a manager, recounted that she
   ... knew of [some] obstetricians ... at the time I worked in a consulting
   rooms and the girls down the front worked for obstetricians so I asked them
   who they would recommend.

   So you went to your GP and asked to be referred to this person recommended
   by your friends at the front of the office?

   My friends, yes (laughs). (I 9, p. 1)


Her case also illustrates a further dimension of consumerism in so far as her interactions with the doctor of her choice were such that she was able, indeed encouraged, to be an active participant in the management of her pregnancy and birth. When asked her opinion about her doctor she said:
   I mean I found him really good. He said to me, you know, what did I want,
   what did I expect, and I said to him what I thought I'd like and he said
   `If that's what we can do, then we will'. (I 9, p. 2)

   Another woman chose her first doctor through

   ... a friend of Mum's who'd worked with the doctor that was there ... she'd
   worked with him and said that he was really good, so that's how I actually
   contacted him ... I'd heard there was [another] gynae there, but I'd heard
   a few bad reports about him (laughs) that he sort of loved doing Caesars
   and that sort of thing. So I guess it was just hearsay that I didn't go to
   him, and that was virtually the only option there was in a small country
   town. (I 3, p. 2; privately insured sales assistant married to a mechanic)


Others went to a GP with `selection criteria' in mind, but not necessarily the name of a specific person. The criteria used were quite variable. For some women, they reflected quite pragmatic concerns about the location of a doctor and the ease with which they could get to appointments (especially as many of the women were in the paid labour force during their first pregnancies). Quite a common pattern among women with private health insurance was that their GP would suggest a few names of specialists, and leave the final decision up to the woman according to what was important to her. For example, one woman said:
   [My] GP ... referred me.... Well, eventually referred me on to, or gave me
   a list of gynaes ... and then I chose one because the gynae was close to
   where I worked and so it was easier for those visits [and] I went with a
   woman ... [which] I felt initially would be [important]. (I 23, p. 1)


The theme of wanting to have a woman doctor was echoed by a number of women in the study; for example a teacher said:
   The only thing I knew I wanted was a female obstetrician, which I had ... I
   just knew I wanted a woman -- a bit closer to home. (I 36, p. 1)


For other women, the selection criteria used were less pragmatic and more informed by the women's social values, views about birth, and desire for particular types of relationships with their providers. Some of these women articulated particularly nuanced and detailed `selection criteria'. In all cases these were middle-class women, those with cultural and material capital, and were therefore well placed in their ability to exercise maximum choice, and with the knowledge and language to inform and implement their choice. This group of women were very clear -- some even before any obstetrical encounters -- about what was important to them about the character of the relationship they wanted to develop with the provider of their maternity services. They stipulated quite precisely criteria which involved the social characteristics and social values of the doctors. For example, a tertiary educated industry training officer said:
   [The GP] gave about four names -- and she made me decide. I asked her for
   one that wasn't sexist and, you know, somebody that was in the know I
   suppose, and that wouldn't push on to me any other interventions, medical
   interventions. I wanted to see a woman but there was only one private one
   -- and she was booked. (I 25, p. 1)


Others subscribed to a non-technocratic construction of childbirth, and took the view that pregnancy was not an illness. They sought a particular kind of relationship with the doctor or midwife, and rejected the passive/ dependent patient model of relationship in favour of one involving mutuality and shared responsibility. Thus one of the women, a tertiary educated radiographer married to a businessman said:
   I'd want to know that the staff sort of have a modern view of deliveries
   and give you the independence that you need and will work with you ...
   treat you like a person having a baby that sort of needs support rather
   than a patient. (I 29, p. 13; emphasis added)


This woman's selection of a doctor was based on the fact that:
   ... he was very matter of fact, not condescending as a lot of [them are]
   ... [He] always had plenty of time to answer any questions, didn't keep you
   there, didn't have to wait too long ... always took the time to answer any
   questions, didn't make a drama of anything if anything was going wrong....
   He was just pleasant. (I 29, p. 2)


Many of the women's comments revealed a sense of choice, but not surprisingly they were mostly women with private health insurance. One exception was a middle-class woman who did not have private health insurance, and had weighed up her options accordingly. A tertiary educated woman, working as a rehabilitation counsellor, she talked to family who had had babies recently, had made contact with two public hospitals in her area about visiting them, and on that basis had made a decision about which hospital she would go to for the birth of her child. Her recollection is as follows:
   Well I did a home test first and then I went to the GP to have that
   confirmed. At that surgery there was a [GP] obstetrician and I decided to
   go for a share care arrangement and that obstetrician took me through the
   share care.

   Why did you choose the share care option?

   Basically I think because I thought I'd get more personal attention from my
   GP than perhaps waiting in line for hours perhaps. I didn't really know
   what to expect but I thought perhaps it might be like a casualty area of a
   public hospital where I might be waiting for a long time. And I was still
   working full time so I couldn't afford to have long ... visits ... in the
   public hospital. (I 45, p. 1)


A small group of five women chose care from a midwife rather than a doctor for their first birth. Their choice was largely determined by the fact that they subscribed to non-technocratic views of childbirth: two were midwives themselves, one a self-described `hippie' who wanted a natural home birth, and the remaining two chose birthing units at a local community hospital which they could access without private health insurance.

An illustration of yet another type of `consumerism' evident in these women's first births are two cases of `doctor shoppers' in the sample. One, a tertiary educated teacher, found the visits to the specialist she had originally been referred to frustrating because she had to wait too long (so long that she received a parking ticket on one occasion), and because the doctor did not give out his after hours telephone number (I 2, pp. 2-4). She went back to her GP and asked for a referral to a particular specialist recommended by a friend of hers. In another case, the possibility of genetic problems was an issue of particular concern to the couple, who were referred to a specialist. The couple didn't like the specialist; the woman recounted:
   I just think he was arrogant. You know, like he wasn't friendly at all and
   he didn't seem to be very sensitive to what was happening. (I 11, p. 2)


The couple changed to another doctor, again by going back to their GP and asking for a referral to a particular specialist they had heard of. The description of him was quite different:
   I thought he was a really nice person, and he was open. He listened to what
   you want, you know, not what he wanted to do. (I 11, p. 3; emphases added)


These examples are indicative of a group of `consumerist' approaches to first birth which account for almost half of the women in this study. They clearly demonstrate that women's discursive constructions of childbirth are important determinants of maternity service provider and the character of the relationship sought with providers. In all, 18 of the 28 middle-class women in this sample, and three of the 22 working-class women talked about their selection of maternity services in ways which quite clearly exhibited a `consumerist' orientation. The remainder were much more likely to simply be guided by a GP's recommendations, whether as a public or a privately insured patient. The most extreme examples of the opposite of the `consumerist' approach came from working-class women, many of whom didn't have private health insurance and articulated their sense of constraint, or lack of choice, very clearly. For one, a woman with three years of secondary education, employed as a sales assistant:
   I didn't get a choice.... He was really dreadful, especially for a first
   baby. (I 41, p. 2)


Another, a clerk who hadn't completed secondary school, articulated the structural constraints as follows:
   Well I didn't really have much choice.

   Did you go to your GP?

   Yes, but I was a public patient so I didn't have much choice of where to
   go. (I 17, p. 1)


Similarly, in an expression of constraints and fatalism, a nurse aide with four years of secondary schooling said:
   I was under the impression that being a public patient, well you really
   don't have much choice. You've got to go and do what you're told to do, and
   I'm not really a very assertive person so I just did what I was told to do.
   (I 13, p. 2)


This kind of fatalistic attitude probably reflects some of the material, structural and cultural constraints experienced by many women, and has been documented elsewhere (Martin, 1992; Nelson, 1983; Zadoroznyj, 1999a).

However, it is important to further examine the character of the `consumerism' exhibited by many of the other women in this study. While their behaviour and attitudes were `consumerist' in so far as they made conscious choices and selections, sought out particular kinds of care which suited their needs, and `shopped around' for providers that suited them, their narratives also revealed something far more complex. The women involved in this study articulated a number of elements important to them in their position as patient/consumer of maternity services. The most important which emerged from the women's narratives concerned the strongly interwoven elements of talk, time and trust. These three elements were frequently talked about together by the women in an interdependent way. Furthermore, noteworthy differences in the conceptualization, and attitudes toward trust by middle- and working-class women were also apparent in their first pregnancies.

Talk, time and trust

More than simply shopping around for doctors or midwives, it became clear from these women's birthing narratives, especially when talking about their subsequent births or about their choices for future births, that their `consumerism' was such that trust featured fairly significantly, and was intrinsically related to (or built on) having time to talk with maternity service providers. For the women, the encounter between them and their midwife or doctor was not simply about an exchange of services, but an exchange of services between people where their social personhood was absolutely central: their identity as women, middle or working class, articulate or not, young or otherwise, and their feelings, which included fear, vulnerability, curiosity, concern and confidence, were critical to both the subjective evaluation of the obstetric encounter, and to the women's subsequent actions, behaviour and choices.

Trust and `facework'

For middle-class women (most of whom had private health insurance), trust was discussed as something that developed through talk and with time. References to `talk' and `time' were made frequently by many of the women when discussing their care from maternity providers. For example, a tertiary educated teacher, married to a public servant said:
   I wanted someone who I was going to establish a relationship with and go
   and visit regularly throughout the nine months. (p. 1)

   I went back to him for the second time, so yes, he was good. (p. 2)

   What did you like?

   Probably that he had time to talk, he answered all the questions, and he
   was available even when I called him, and I called him many times about
   little things. He was very good in that way, so I found him to be
   understanding and caring. (I 35, p. 2)


Generally, the middle-class women identified very specific social attributes and values which they saw as desirable in a doctor. These included being non-sexist, not condescending, answering questions, and very importantly, taking the time to talk (and listen). For these women trust wasn't given nor assumed simply because of a person's status as a doctor. Rather, trusting a doctor could only develop in a relationship with them. For the middle-class women in particular, the relationship had strong elements of mutuality in it, such as asking questions and having them answered, and being involved in the management of pregnancy and birth, as opposed to simply being a passive patient.

For these women, who generally chose their doctor carefully and deliberately, trust, in the language of symbolic interactionists, had to then be subsequently accomplished, to be built in a process of interaction (Emerson, 1970; Mead, 1962). Thus, for example, articulating why she wouldn't have wanted to be a public patient one of the women said:
   You can't develop a relationship.... I was a little bit scared of
   childbirth, and it was very important to me to make sure that I developed a
   relationship with somebody that I trusted. Not to just go in off the street
   and `Oh yes, here's your doctor'. (I 6, p. 9; emphases added).


Another articulated the same point; in her case, trust had been built over the course of treatment prior to becoming pregnant. For this reason, the woman said:
   I had a lot of confidence in my gynaecologist. I had private cover so I had
   that continuity of doctor, who I had also seen about my gynaecological
   problems before ... so I had that confidence thinking he wouldn't do things
   either unnecessarily, or he'd guide me.... I felt he would guide me into
   what I'd need. (I 26, p. 1)


In a similar case, a tertiary educated woman married to an accountant, told us that she had sought out a specialist when having fertility problems, and had gone to one recommended by her sister. She went on with seeing him when she became pregnant, saying:
   He was so good that I decided `Well I don't want anyone else'. (I 21, p. 1)


On the basis of the relationship developed with this doctor over time, she came to trust his decision making and was comfortable following his advice about the management of her first (and any future) labour:
   ... my doctor suggested [an episiotomy] ... he thought it would be easier
   to sew up than a big split or whatever.... I trusted him there. (p. 3)

   ... [in future] I would tend to go with whatever my doctor suggested
   actually because I really trusted him.... So if he was to say `This is the
   way you go', I would go that way. (I 21, p. 8)


One of the few working-class women to have private health insurance for all her pregnancies talked in a similar way about developing confidence and trust in a doctor.
   ... as far as being able to choose my own doctor. That was important to me
   too, to know who I was going to have.

   What was important about it?

   I guess it's just to build up a relationship with a doctor, and just to
   know that he's the one that's going to be there when the time comes. (I 3,
   p. 4)


Giddens (1991) draws on the work of both Luhmann (who distinguishes between confidence and trust, and risk as the element that defines the distinction) and of Goffman's analysis of everyday encounters, all of which involve `facework', the adoption of a particular image of self in part determined by others' response to it (Goffman, 1969). For Giddens, trust can be understood in two quite distinct ways. One is based on the notion of the interaction between self and other; which he calls `facework commitment', and defines as the `trust relations which are sustained by or expressed in social connections established in circumstances of copresence' (Giddens, 1990: 80). This notion of facework commitment resonates strongly with the way that predominantly middle-class women in this study talked about trust in the patient-provider relationship: as something that particular individuals could (but did not necessarily) develop through talk and with time.

Faceless commitment: trust/faith in `abstract systems'

An alternative approach to trust is not as something that is accomplished in interaction, but as something that is based on faith in symbolic tokens or abstract systems, such as in this case, credentialled professionals such as doctors or midwives. This kind of trust is what Giddens refers to as `faceless commitment' (1990: 84). It resonates with Parsons' analysis which argued that in order for the relationship of asymmetry between doctors and patients to `function', patients and doctors `need to orientate themselves towards each other in a trustful manner ... and this trust has to be based on abstract codes of conduct' (Bury, 1997: 84). While this kind of trust is rarely referred to by the educated, middle-class, highly consumerist women in the sample, it is evidenced much more often and more clearly among the working-class women. For example, a secondary educated sales assistant with private health insurance for her first pregnancy, and married to a storeman said:
   They know better than me. I've never done this before ... so I went in with
   an open mind and left it to the experts. (I 33, p. 2)


This faith in abstract systems was articulated by a secondary educated, casual receptionist married to a greengrocer when describing her attitudes in her first pregnancy towards undifferentiated `experts'. She said:
   I was just going to ... leave a lot of the decision making ... to the
   people that knew all about it, like the nursing staff and doctors ... I
   mean, I didn't really know what to look for in an obstetrician ... I
   thought [at the time] `Oh well, one doctor's as good as another'. (I 4, p.
   2)


In the case of a woman referred to a specialist by a GP, trust was talked about in the following way with respect to her first experience of maternity services:
   As long as everything went well ... I put my trust in the doctor I think. I
   didn't know a lot about it. (I 1, p. 1)


Apart from the GP's recommendation, this woman didn't have any knowledge of or familiarity with the specialist. Her experience with the specialist was less than satisfying. She described the following:
   ... the doctor I didn't like. He was very old fashioned, and never
   remembered my name, and I was just a number and I really felt annoyed
   because I was paying private health just to be treated like a number and it
   didn't impress me at all....

   He just used to brush [my concerns] aside. He just treated me like he was a
   man, I was a woman.... `Don't you worry, I'll take care of everything' kind
   of attitude. (p. 2)

   He said `What do you know about having a birth?' and I said `Oh, I know it
   hurts a lot'. He said `I wouldn't say that. I'd just say it was a bit
   uncomfortable'. (I 1, p. 7)


This woman's faith in abstract systems evaporated rapidly in light of being patronized in this way, even though she stayed with the obstetrician throughout her first pregnancy and birth. However, like the majority of women interviewed, this woman took active steps with her subsequent birth to manage it in ways that suited her better. Thus with her second pregnancy, she dropped private health insurance, and went to a public hospital clinic, where she found doctors more responsive and communicative:
   The doctors that I did see, they were good -- they used to talk to me a
   lot.... The only thing of course is you wait two hours in the waiting room.
   (p. 7)


In this case, as with many others, faith in abstract systems dissipated when challenged by negative experiences, whereupon the quality of the interaction and relationship with the maternity service provider became central, rather than simply the status of the provider as `expert'. In this particular case, talk -- being listened and responded to -- was central to defining a satisfactory relationship. The strength of the relationship between talk, time and trust is also seen very clearly in the cases where trust never developed between a woman and her maternity provider(s). There were a number of women, all of them working class, for whom this was the case. One, a sales assistant with three years of secondary schooling, was a public patient in a country hospital for her first birth when she was referred to a specialist because of complications. Her narrative is especially interesting to examine because of the language she uses. In talking about the doctor she says:
   ... he had a bit of an arrogant bedside manner. He treated me like a lump
   of meat. (I 41, p. 2)


Her description of her labour is as follows:
   ... the specialist decided that because I was so young that I should have
   an epidural and he tried to give me one. I kept telling him that I didn't
   want one and he'd shove this needle in my back. Eventually I must have made
   enough noise for them to leave me alone and so he just said `Well, suffer
   girlie'. I just remember that distinctly -- `Well, suffer girlie'. So it
   was truly distressing. It was amazing that I ever had any more (laughs). (I
   41, p. 3)


In her subsequent three births (in the city rather than a country regional centre), she took control basically by delaying seeing an obstetrician until late in her pregnancies. We asked:
   Did you see your GP instead?

   I didn't see anybody for the first few months. I decided not to see
anybody.

   Were you ever offered the option of share care with your GP?

   No. No, I haven't been able to find a GP that I like and can trust.

   What haven't you liked about them?

   Just because they're arrogant and treat me like I don't understand anything
   and they treat me like a real kid. (I 41, p. 11)


This woman's language reiterates in a number of ways her feelings of being stripped of her social identity as a person; she refers variously to being treated like a `lump of meat', a `girlie', a `real kid', or `like I don't understand anything'. In one of the cases discussed earlier, an unsatisfactory relationship with a doctor was in part about the doctor never remembering her name, treating her like a number, not dealing with her concerns seriously and giving her trite, if not dishonest responses (regarding the pain of childbirth). Similarly, for many of the other women the character of the dialogue between doctor and patient symbolized the character of the relationship. There are many possible barriers to constructive and fruitful dialogue: differences in social class, in language and cultural orientation, age and gender. However, `talk', when done well, can overcome some of these barriers as the excerpt below, from a young woman describing her contact with a doctor in her first pregnancy, demonstrates:
   I didn't like him the first visit.... But the second visit was fine.

   What didn't you like about him the first time?

   He was old -- he was an older man. Just the way he was. Didn't appeal to me
   the first time.

   What did you then come to like about him?

   Well he talked to me about everything. You now, he didn't push me aside and
   say that I was stupid. (I 16, p. 2)


While there are significant differences in the way that middle-class and working-class women articulate what they are seeking in the doctor-patient relationship, particularly before they have a first birth, it is also clear that for all women, irrespective of social class, a relationship of trust is predicated on providers taking the time to talk -- and listen -- to them. In talk involving dialogue and adequate time -- the prerequisites to quality `talk' -- there is clearly an affirmation of the self for the parties involved. This confirms the status of the birthing woman as person, rather than as object (the lump of meat, or the number). Many women articulated their need to be listened to, to have someone be responsive to their concerns, provide answers to questions, and provide reassurance. Through this, talk becomes a central component of the therapeutic encounter. The dialogue in the talk means that certainly mutuality, and sometimes dependence will be present in the relationship. The mutuality derives from the exchange being between persons. They are not of course equals in the sense that age, social class, gender, and of course credentials and expert knowledge can serve to differentiate them. However, maintaining a shared status as persons opens up the possibility of and allows for trust to be established and built, and this may, in terms of practical action, mean trust to allow the other to do what they consider necessary (ie, the episiotomy, or other intervention). So, in very real ways, consumerism (in the sense of looking for and finding the right kind of provider and person), the development of mutuality through talk, and hence the development of trust, can lead to either or both passive or active subject positions. They are by no means mutually exclusive, but rather coexist through the relationship of trust developed through talk which makes women willing to allow providers to advise and sometimes determine how pregnancy and labour will be managed. The importance of maintaining the integrity of personhood was clearly articulated when one of the women said:
   Even when there was a problem they ... didn't forget that you were up the
   other end. You know, they were still talking to you while things were going
   funny down the other way. (I 30, pp. 14-15)


As has been shown in other research, in this study too it would seem that `talk' and developing a satisfactory relationship of trust is easier for women already in the possession of cultural, social and/or material capital (Blaxter, 1990). For these kinds of `middle-class' women, there is less `social distance' in terms of language and cultural style between them and their doctors. In this study there were a number of cases, all with working-class women, where patient-provider `talk' wasn't ever `done well', and even more unfortunately some of these women blamed themselves. For example, a secondary educated woman on a supporting parents' benefit had this to say:
   Were you able to discuss with this doctor what you wanted at the birth?

   Well I didn't really relate to him very well. I must be a person that
   doesn't hit it off with doctors.... I find it very hard to build a
   relationship with a doctor.

   So you didn't particularly like this chap you saw?

   No.

   What didn't you like about him?

   Oh I just couldn't ... I mean, he was an older man, a much older man, and I
   couldn't really converse with him, so to speak. I probably couldn't
   communicate with him. (I 13, p. 2)


Talk and the mediation of embarrassment

Another aspect of the obstetric encounter which makes it a particularly sensitive one for many women is the involvement of not only `private' but also sexualized parts of the body. Given this particularly significant dimension of the encounter, it is interesting that the process of talking with a provider is one which is seen by many women as easing them through procedures such as internal examinations which many women felt apprehensive about. For example:
   What did you like [about the doctor]?

   He made you feel very, very relaxed. I can't stand having pap smears or
   anything like that. I know they're important and I always feel
   uncomfortable. But he had to do one and he just kept me talking the whole
   time -- I didn't even know I had it done. I thought `Well, that's amazing'.
   He was just brilliant. (I 21, p. 2)


In this case, `casual' talk was used as a means of being distracted from a situation that might otherwise be embarrassing and/or uncomfortable. What was accomplished in the interaction between patient and doctor was the construction of a situation as non-threatening, non-sexual, safe and completely comfortable -- indeed, almost as though it hadn't happened. In other interactions, talk was used as the mechanism through which women's discomfort and embarrassment were broached and handled gently yet directly. For example, a secondary educated legal secretary, when asked what she liked about her obstetrician, said:
   I was trying to think actually, because I know other people have talked
   about their gynae and said `Oh he's young' or `He's attractive'. Well he's
   not young. He's just a real.... Not even a father figure, but he's just got
   a wonderful manner. He makes you feel at ease. I mean it's not an easy
   thing to go along and talk about, especially to someone you don't know, but
   from the word go I just felt at ease with him. He's never too rushed to see
   you, you know what I mean.... He just sort of had lovely qualities and made
   me feel at ease. (I 26, p. 2)


Talk and technical competence

One of the more surprising findings of the analyses of women's views about their doctors and midwives, was how few of them indicated the technical competence of their provider as an element that distinguished that provider's care. While a number of women mentioned technical competence in terms such as he/she `knew what he was doing'; `didn't make a drama of things', or was `extremely competent', this was never cited as the only or main reason for being positive about a doctor or midwife; rather, when it was mentioned, it was always in the context of how talk was conducted. Thus, for example:
   Well he knew exactly what he was doing, and first time around you have no
   idea and I was really quite nervous ... and he sat and explained everything
   to me the whole time. I wouldn't be nervous to ask him anything I wanted to
   know. (I 10, p. 2)


In another case, a woman switched from a private obstetrician to a midwife clinic at a public hospital for her second pregnancy and birth. She was extremely positive about the latter, referring to the quality of the technical component of her care in the context of the quality of the discussions she had with the midwives and the time which was given to this part of the provider-patient relationship:
   Yes, I loved the clinic service -- I thought they were great. The midwife
   that I was assigned to, she was terrific, and I have no complaints at all
   about the clinic.

   What made her terrific?

   Again that air of efficiency but not the cold unfriendliness. She was very
   friendly and she was helpful. You could tell she knew what she was doing.
   She always made sure that if I had any queries ... I mean she didn't just
   talk at me and then tick me out of the office. She always made sure if I
   had any concerns that I told her so that she could answer them. (I 48, p.
   9)


Birth, risk and the `reflexive consumer'

It is interesting that, given the strength of the `risk discourse' in the arena of childbirth, the emphasis on technical competence is as minimal as it is for women who have already given birth. Part of the explanation for this would seem to be that the embodied experience of giving birth not only gave an experiential knowledge but also confidence in the self. Many of the women talked about this in terms of their willingness to consider providers such as midwives for subsequent births, and in terms of a decreased concern about risk in subsequent pregnancy and birth. Most of the women became more confident about giving birth once they had been through the experience. This confidence reduces the salience of an abstract conception of risk, with clear implications for choice of provider in subsequent pregnancies as the following case indicates:
   The first time I wanted a specialist there because I was very nervous.
   Actually my doctor didn't get there [for] the first birth ... he got there
   about two minutes after it -- so it was the midwives that did everything in
   the hospital.... And the same for the second one.... It was the midwives
   that worked with me all night. So for sure they're very, very experienced
   women and I wouldn't hesitate to use the birthing unit and the midwife
   clinic if I was to consider having another one, which we are at the moment.
   (I 10, p. 7)


There are many other ways in which the women's narratives indicated consumerism and reflexivity in their attitudes and behaviour regarding subsequent or future pregnancies. As indicated, the majority of the women interviewed took active steps to control the management of subsequent births, and this was especially strong among the working-class women, many of whom were somewhat fatalistic about their first births, but became far more activist in their subsequent births (Zadoroznyj, 1999a). This change represents a fundamental shift in identity made possible through the embodied experience of birth. For these women, there is clear evidence of reflexivity and consumerism. One of the women, not entirely happy with the `talk' with her first obstetrician, had already `shopped around' by talking to friends, and said:
   I would definitely have a different specialist. I mean I was happy with him
   but there were things that I wasn't happy with, and I would have the
   specialist that I could discuss ... everything ... [with.] (p. 14)

   Since then I've listened to different friends, and I've sort of already
   made up my own mind who I would pick. (I 47, p. 14; Year 11 legal
   secretary)


Another of the women identified the reflexive shift in her own identity (in terms of her self-confidence) when she said:
   I guess I've just become more confident in myself really.... [Learnt] how
   to stand up for [myself] really. I find you do tend to be bossed around a
   bit by the obstetrician.... If you don't stand up for yourself, you know,
   they sort of like to do it their way. (I 3, p. 8; Year 12 sales assistant,
   married to a mechanic, private insurance)


One of the women who had very strong beliefs about birthing, and had found a compliant obstetrician for her first two births, had to find someone else before her third baby, as her first obstetrician had `rudely retired' (I 30, p. 1). She did this by talking extensively to friends who'd all had babies in the last few years. Three spoke very highly of a particular specialist:
   ... so he was the obvious choice, so I went and met him. I mean if I hadn't
   liked him I would have changed again, but he was lovely ... easy and happy
   to do whatever you want to do ... I don't like anybody who's really
   regimented about anything. (I 30, p. 9)


Another woman said she would probably `shop around' for the next pregnancy; speaking of the obstetrician who had delivered her first baby she said:
   He was alright but I don't really [know] ... I've heard other ones are
   really good; I've heard other ones are bad. I might just talk to ... like I
   know a lot of people who have had babies in the last three years. So I
   might [ask around a bit]. I mean I don't feel like he spent heaps of time
   with me or gave me a lot of information, especially for a first time, do
   you know what I mean? Like probably he gave the service that could have
   been okay to a second time mother, not to a first time mother that didn't
   know a lot about what was happening. Because you don't -- you don't know a
   thing. (I 31, pp. 5-6; tertiary educated waitress married to a salesman)


Conclusion

In terms of evaluating the impact of consumerism on doctor-patient relationships, the analysis of childbirth is particularly instructive, especially in an era that has witnessed a number of sustained challenges to the medical appropriation of pregnancy and birth. Despite the medicalization of birth and the dominance of a discourse of risk, medical discourse is not entirely hegemonic and this has very real consequences for birthing women who can, and do, choose alternatives. Even within a predominantly `risk' framework, the notion of birthing women having some say in the management of their births has become quite prevalent, so that women's views about a variety of matters are often sought. This is more than simply `interior decorating' obstetrics (Rothman, 1982), but can involve decisions over many aspects of birthing including pain management, position, the willingness to consider `interventions' and whether the birth will be midwife or obstetrician led. At this level, there is certainly strong evidence of consumerism with important implications for medical dominance. In terms of the selection of a provider, there is certainly evidence of consumerism among the women involved in this study.

The exercise of `choice' with regard to first birth was largely informed by structural and cultural elements -- particularly the possession of cultural and material capital, and having private health insurance. These factors primarily accounted for the differences between the women in this study in their attitudes and behaviour as either `consumerist' or `passive patient', especially in terms of orientation to their first birth. With regard to subsequent births, the majority of women became activist, suggesting a reflexivity developed through the experience of giving birth. There were undoubtedly strong elements of consumerism in this reflexivity, and they involved changes in self-identity for some of the women.

Just as the `consumerist' behaviour evident in women's first birth is shaped by social class or the `habitus' derived from the possession of cultural and material capital, so too are attitudes of trust in professionals. In their first pregnancies, middle-class women were less likely than working-class women to trust providers simply because of their credentials. These differences were reduced quite substantially by the experience of pregnancy and birth, particularly in the sense that working-class women were less likely to subscribe to the `faceless commitment' of faith in abstract systems, and more likely to recognize the importance of developing trust through a personal relationship based on `talk' and time. While there is undoubtedly a strong emotional component in relationships organized around maternity care, this doesn't necessarily mean dependence in the sense of being a passive patient. Rather, these women's narratives suggest very clearly that most women want and can be involved in decisions about the management of their maternity care. Their narratives indicate that women's feelings in pregnancy and birth (for example fear or embarrassment) can be therapeutically `managed' through talk which is predicated on full recognition of birthing women's social personhood; this implies that, at one level at least, provider and patient are equals. Operating from this basis, trust can be developed even in the context of the asymmetry in knowledge, expertise and power regarding the provision of maternity care. When trust can be established through open discussion and communication which takes into account women's feelings and wishes, and of course takes time, then the technical management of birthing will rarely trouble the women, and nor will they be likely to seek out a different provider for subsequent maternity care. Consumerism is then, an important though complex phenomenon in childbirth, and has significant implications for the provision of maternity care and for the selection of maternity care providers. This, like many other recent developments, suggests yet another constraint on how medicine is practised, and hence presents another small but significant challenge to medical dominance.

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MARIA ZADOROZNYJ is Senior Lecturer in Sociology at the Flinders University of South Australia. Her teaching and research interests include the sociology of health and illness, with special interests in gender and health and the sociology of childbirth. She is a co-author of the text Society and Health (Sydney: Longman, 1996).
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