Original Article

Regime change in Australian maternity hospitals Karen Lanea,* and Kerreen Reigerb a

School of Heritage, History and Society, Deakin University, Victoria, Australia. E-mail: [email protected] b School of Social Sciences, La Trobe University, Victoria 3086, Australia. E-mail: [email protected] *Corresponding author.

Abstract Contemporary attempts to ‘organise’ risk and manage uncertainty are remaking many ‘industrial-era’ institutions – including maternity hospitals. Health policies are encouraging a shift away from hierarchical, medically dominated structures towards new governance systems and ‘women-centred’ care, often led by midwives. To understand the resulting contestation, in this article we argue for a wider conceptual frame than a focus on neo-liberal state regulation of the professions. We utilise theories of the ‘second modernity’, in particular those concerning socio-cultural changes associated with shifts in risk regimes, to interpret findings from qualitative research studies undertaken in Australian maternity hospitals. Whereas analysis confined to macro or institutional levels emphasises stability and hegemony, we demonstrate that when cultural and interactional levels are examined, considerable fluidity and uncertainty in the identification and negotiation of risk is evident, resulting in new work practices with inevitable shifts in professional identities and allegiances. Social Theory & Health (2013) 11, 407–427. doi:10.1057/sth.2013.7; published online 8 May 2013 Keywords: managing risk; midwifery; maternity organisations; risk regimes; obstetrics

Introduction Changes under way in Australian maternity hospital structures and workplaces have occasioned personal angst and heated public controversy, especially in the context of the recent National Australian Review of Maternity Services (Commonwealth of Australia, 2009; Lane, 2012a, b). Related struggles over women’s human rights and interpretations of risk, safety and professional practices in maternity care are evident internationally – for example, the closure © 2013 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health www.palgrave-journals.com/sth/

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of the widely esteemed Albany midwifery practice in South London (Edwards and Davey, 2010) and the imprisonment of Hungarian obstetrician and midwife Ágnes Geréb for attending homebirths and the subsequent case at the European Court of Human Rights (Hill, 2012). The management of maternity care offers a window into significant social changes, and indictments of the established maternity system as an inhumane ‘industrial model of childbirth’ inappropriate to the twenty-first century (for example, Kitzinger, 2005) thus warrant serious attention. As a result of such critiques, major changes have been under way in many jurisdictions. In this article, we consider efforts towards reform or ‘regime change’ in Australian maternity care in light of theoretical debates on the institutional and cultural changes associated with the ‘second modernity’, especially those on shifting constructions of risk. These developments, we argue, produce greater destabilisation in institutional forms and professional allegiances than is accounted for by previous analyses.

Background In contemporary advanced economies, attempts to ‘organise’ risk and manage uncertainty are remaking many ‘industrial-era’ institutions, and this includes the hospitals in which most new members of society are born. Policy directions in health services reflect new public management and marketisation strategies aimed at replacing traditional, medically dominated hospital hierarchies with new ‘post-bureaucratic’ institutions. These are based largely on private sector models, including increased managerial authority (Exworthy and Halford, 1999; Degeling et al, 2003; Iedema, 2003). In analysing these developments in health care and other fields, sociologists have focused primarily on the relationship between neo-liberal states and the professions, especially medicine (Fournier, 2000; Dent and Whitehead, 2002; Reiger, 2006; Leicht et al, 2009). Building on earlier comparative work (De Vries et al, 2001), Benoit et al (2005) and Sandall et al (2009) provide a detailed analysis of comparative maternity care systems along these lines. They argue that the emergence of varying forms of professionalism reflects the historical legacy and particular reform processes of distinctive national welfare states. Following the lead of Brenner et al’s (2010) argument that neo-liberal regulatory restructuring is ‘variegated’ rather than uniform, Benoit et al (2010) more recently traced comparative developments in maternity care in Canada and Australia. In spite of differences in health systems and in some outcomes, they point to similar trends – most notably that medical dominance has remained resilient due to its ‘structural embeddedness’ in the market in health services and its degree of state support, especially in Australia (Benoit et al, 2010, p. 480). Like many other health-care analysts (for example, 408

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Dent and Whitehead, 2002), their primary frame of reference concerns the impact of neo-liberal political–economic policies on traditional and emergent forms of professionalism. This focus, in our view, tends to neglect both the influence of wider socio-cultural processes and the resulting local ferment as institutional practices are contested. When we commenced pilot interviews and informal observations in five maternity units in Victoria, Australia in 2003, and subsequently in four case study sites, managers in each reported that major systemic reorganisation into new networks had disturbed the traditional relativities of the sector, those associated with hierarchies of location, hospital and professional status, and levels of care. Under the aegis of neo-liberal state policies ‘rationalising’ the Australian health system in the late 1990s, state health authorities and senior executives promoted both restructuring and a more entrepreneurial, competitive culture rather than the traditional public service orientation (Hancock, 1999). In changes towards what Iedema (2003) and others (for example, Josserand et al, 2006) describe as ‘post-bureaucratic’ organisational forms, staffing and management arrangements, workplace practices, and identities and allegiances in these public maternity hospitals were all being reshaped. The key objective advanced by policymakers and managers, and supported by consumer and midwifery organisations, was to increase the range of care options and the choices given to women (Reiger, 2006), but enhanced effectiveness and efficiency, and in some cases increased social equity, were also sought. A common strategy involved implementation of flatter organisational structures to replace older-style hierarchical regimes dominated by medicine. In a changing socio-cultural and political environment, administrators and professionals found themselves operating within an increasingly dominant organisational as well as professional discourse of ‘managing risk’. Using new midwifery or interdisciplinary teams, the care of women at ‘low’ and ‘high’ risk of obstetric complications became more delineated, yet managing the perceived risks of childbirth remains hotly disputed (Lane, 1995, 2012a, b; Scamell, 2011; Reiger and Morton, 2012). Although struggles over administration, resource allocation and professional power are as common as in other sectors, in childbirth they are all exacerbated by deeply held and emotionally laden philosophical disagreements over knowledge and clinical practice (Lane, 1995, 2012b; Reiger, 2008). Several scholars have recently suggested that debates on the social construction of perceived risks are therefore central to understanding the pregnant body and contemporary maternity care (Lupton, 1999; Possamai-Inesedy, 2006; Weir, 2006; Bryers and van Teijlingen, 2010; Scamell, 2011). Although they explicate the significance of ‘risk debates’ for understanding women’s expectations, maternity policy and professional practice, our focus in this article is on the local, institutionally specific dynamics of hospital work places. We will first © 2013 Macmillan Publishers Ltd. 1477-8211

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introduce the research studies, and then elaborate on a conceptual framework concerning risk and organisational change with which to explore the empirical evidence of challenges in what we have termed ‘regime change’. Many of our findings concerning professional role conflicts are consistent with those reported in similar countries, but using a ‘risk’ perspective or lens in an organisational context casts them in new light. As participant observers/consumer activists as well as formal researchers, we have become very aware of the excitement and frustration, and indeed confusing turmoil, evident not only in these hospital sites but also in professional and political contexts in the last decade (Reiger, 2006; Lane, 2012a). We argue therefore for further consideration of the impact on health care of the diverse changes associated with the ‘second modernity’ – the wider socio-cultural context of heightened anxiety about risk, and how ‘encounters with risk’ (Hutter and Power, 2005) actually operate in specific sites. Whereas analysis confined to macro or institutional levels emphasises stability and hegemony, when cultural and interactional levels are examined, we find evidence of considerable fluidity and uncertainty in the identification and negotiation of risk, which results in new work practices with inevitable shifts in professional identities and allegiances.

Investigating Australian Maternity Hospitals During our research into midwifery professionalisation (Lane, 2000; Reiger, 2006), we became interested in processes of change not only within the profession at large, but also in how changes were being played out in markedly different ways within various hospital cultures. The major findings on interprofessional conflict and collaboration have been reported elsewhere (Reiger, 2008; Reiger and Lane, 2009), and here we extend our analysis by considering this complex data further in light of developing political and theoretical debates and by drawing on more recent work. In 2002, our background in maternity consumer organisations during the 1990s and work with midwives led to our interest in the discourse of inter-professional collaboration and in the practical reality of working relationships in ‘changing regimes’ of maternity care. In view of the institutional, professional and spatial patterns being remodelled as a result of several new state and local initiatives (Reiger, 2006), one author (KR) undertook pilot interviews in five suburban hospitals with several midwifery and medical managers as key informants. These provided the basis for discussions with managers in other units, leading to invitations to work with hospital managers to investigate change processes. Our jointly developed research proposals were supported by our respective universities and approved by university and hospital ethics committees. 410

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The hospitals included (i) a rural maternity unit (Rural [KR]) that was introducing a new midwifery team in collaboration with local General Practioners; (ii) a large tertiary unit (City [KR]) in the midst of changing its structure into a framework in which new midwifery teams would be responsible for ‘low-risk’ women and medically led teams for complex care; (iii) a regional unit (Regional [KL]) and (iv) a suburban site (Suburban [KL]), both of which were also introducing new forms of midwifery teams. In total, following publicity about the project and approaching various work groups, 65 obstetricians, 17 managers and 150 midwives were interviewed for anywhere between 30 and 90 min, usually individually but some in small groups, sometimes opportunistically and sometimes more than once. These semi-structured but often free flowing interviews were recorded and then transcribed. In the main case study sites, but not in the pilot interviews, transcripts were returned for checking to indicate what could be explicitly quoted as against used as background. Using a common coding system developed with NVivo qualitative data analysis software, data were thematically analysed, focusing on professional knowledge and identity, role conflicts, management, work practices and organisational processes – issues emerging from the data but also widely reported in international literature on changes in health care (Dopson and Fitzgerald, 2005; Halford and Leonard, 2006). Regular ethnographic observation was also important in identifying key issues and players in the tertiary setting and, on occasion, in the rural setting. This article is also informed, though less directly, by preliminary analysis of a further 30 interviews with midwifery and obstetric leaders subsequently conducted by one author (KL) in new ‘caseload’ models of care across Australia (Lane, 2012a). As a process of knowledge exchange, our reports were made available to these hospitals to encourage further critical reflection on managing change processes and professional relationships. As others point out (Dopson and Fitzgerald, 2005), each hospital brings its own history and culture to the changes associated with neo-liberal health reform. Space here precludes discussion of the considerable differences across the sites, but most interviewees were caught up in similar processes of organisational change driven by professional agendas and specific government policies encouraging moves from obstetric-led to more midwifery-led and collaborative care across the sector. The sites demonstrated the complexity and depth of some of the resulting conflicts and their local cultural manifestations in ways that were sometimes depressing for managers keen for organisational innovations to succeed. Through a collaborative research process in which the hospitals strongly supported our work (though not always all our findings), we gained insight not only into particular interviewees’ accounts of local changes but also into complex interpersonal, inter-professional and institutional processes that © 2013 Macmillan Publishers Ltd. 1477-8211

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seemed to require analysis extending beyond accounts focused on issues of professionalism (Lane, 2006; Reiger, 2008).

From Industrial Birth to Managing Risk in Reflexive, Post-Bureaucratic Organisations Several strands of theorising about late or second modernity proved germane to our study. All stress the political and cultural, as well as economic, implications of globalisation, and point to major social changes shaping institutions, professional relationships and personal identities (Appadurai, 1996; Caddas-Coulthard and Iedema, 2008; Beck, 1992). Rather than the hierarchical bureaucracies of the earlier twentieth century, hospitals like other institutions are increasingly characterised by horizontal dispersion, networking and team management, and driven ‘reflexively’ by emphasis on auditing, continuous innovation and internal processes of ‘risk management’ (Power, 1999; Reed, 2006). According to many analysts, these developments have reshaped not only work processes, but also impacted upon workers’ identities. Organisational demands for increased measurement and accountability extend to intensified self-regulation (Iedema, 2003; Caddas-Coulthard and Iedema, 2008). Instead of direct managerial controls, what Rose and Miller (1992) termed the indirect ‘voluntary self-regulation’ of subjects is part of a broader reconstruction of self and identity across the population. This is also identified by Giddens (1990) and Beck and BeckGernsheim (2002) as ‘individualisation’ – the imperative for individuals to ‘live a life of one’s own’, and to ‘plan, understand, design themselves and act as individuals’ in carving out their lives’ (Beck and Beck-Gernsheim, 2002, pp. 3–4). In pointing to the fluidity, reflexivity and complexity of late modern life, these sociological accounts have suggested that changes in perception and indeed construction of risk are central to emerging social forms. Although risk as such is not new – all societies have faced and managed external risks through cultural and religious beliefs – in late modern societies, claim Beck (2009) and Giddens (1990), we now also grapple with internal risks, the ‘manufactured risks’ that occur as a consequence of human interventions in natural and social environments. In the resulting ‘social dispersion of risk’ in late modernity, instead of a single locus of risk or a risk object, competing groups, including policymakers, insurers and health professionals, shape how they receive and interpret knowledge, regulations and risk. Social theorists commonly argue against the scientific–technical emphasis on risk as objectively ‘real’, claiming instead that objects, events or practices are actually created as risky through sociocultural processes (Douglas and Wildavsky, 1982). Yet they differ on how to interpret historical differences in constructions of risk (Dean, 1999; Tulloch and 412

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Lupton, 2003). Following Zinn (2008), we can distinguish between an early Beckian tradition which stresses a ‘grand narrative’ in which ‘risk society’ constitutes an emergent form of modernisation – one reflecting especially the impact of globalisation – and a post-modernist ‘cultural turn’. This draws from Foucault’s analysis of ‘governmentality’ concerning the shifting practices or techniques through which power pervades social as well as political life. Although all these provide insights into the context of contemporary health care, broad theoretical interpretations of risk have been criticised for neglect of the structural dimensions of social life and of everyday practices (Tulloch, 2008, pp. 142–144). Empirical studies of ‘risky’ endeavours have included accounts of ‘edgework’ – those choosing extreme or dangerous leisure pursuits – and studies of some health-care practices, including those of pregnant women (Weir, 1996; Possamai-Inesedy, 2006; Jones, 2007). These studies demonstrate how childbearing women increasingly have to negotiate the ‘extreme anxieties’ being constructed within contemporary risk culture (Lupton, 1999). Yet it seems to us that the picture remains more complicated than focusing on risk culture suggests, not only for women but also for health professionals themselves (Scamell, 2011). Instead of a wholly new ‘regime’, multiple sets of expectations and practices are simultaneously in play, from old-style paternalistic authority and rules reflecting structurally based hierarchies of class and gender to various forms of self-management and critique. We have turned then to Crook’s (1999, pp. 160–185) argument that different social ‘dreams of order’ underlie the risk orderings or ‘regimes’ evident in different forms of governance and social practice in contemporary Western societies. Although arising from different historical contexts, what he terms ‘modernist’, ‘hyper-reflexive’ and ‘neotraditional’ regimes can coexist and are never fully realised. In maternity care as elsewhere, they are always contested and in process – their advocates jostle not only for cultural dominance but also for material resources like space and equipment, and to maintain or attain the structural positions that enable the exercise of power (Lane, 2012a). In what follows, we apply Crook’s concept to maternity care in general and then employ it as the lens through which we interpret our hospital data. Maternity care in a modernist risk regime Until recently the dominant model of hospital-based provision of maternity care was that established in the early to middle years of the twentieth century in Western industrial or ‘Fordist’ societies. In common with factory production processes, it relied on notions of a standardised birthing body – one where labour and birth were characterised by predictable, mechanical processes (Martin, 1987). By the 1970s, the standardisation of obstetric-led care was best exemplified by obstetricians’ adherence to ‘active management of labour’ principles © 2013 Macmillan Publishers Ltd. 1477-8211

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(Murphy-Lawless, 1998). Pre-determined rates were (and are) set for women’s progress in labour and intervention practices used to ensure ‘routinised production’. Seeing ‘risk’ as residing in ‘frail’ women’s bodies, which were always in danger of malfunctioning (Murphy-Lawless, 1995, 1998), obstetricians claimed to be able to predict and manage ‘objective’ risks posed by infection and haemorrhage. These could be controlled through using modern science spatialised in hospitals organised on industrial principles. Doctors legitimised themselves as defenders of the scientific faith, casting midwifery knowledge (spatialised via birth at home) as unscientific, unreliable, and therefore even dangerous. In Australia, as in many other countries, midwives were seen as needing medical supervision through training primarily as obstetric nurses (Reiger, 1985; Murphy-Lawless, 1998; Lane, 2012a, b). They worked in traditional (modernist) hospitals, which, in accordance with Weber’s (1922/1978) classic analysis, reflected an orderly, bureaucratic hierarchy – medical specialists (mostly male), female nurse-midwives and administrators (medical and the female head or ‘matron’) all ‘knew their place’ and the rules; so did the women in their care. They received routinised perineal shaving, enemas and analgesia and had little voice in how they gave birth (Reiger, 2001; Rothman, 2007). Hospital space was clearly demarcated and assigned rank: labour ward and operating theatre placed above post-natal wards, with antenatal and community-based services still lower in status. At the symbolic level, although not always and everywhere in practice, the perceived mortality and morbidity risks of childbirth were increasingly managed through culturally constructing it as a medical event requiring specialist professional management.

A hyper-reflexive risk regime in childbirth These historical patterns have been disrupted in recent decades. In common with other organisations in neo-liberal market-oriented systems, maternity hospitals now face ongoing struggles and tensions according to how they interpret, where they locate risk and what practices should be adopted to minimise it. Risk has been redefined – rather than being a scientific property located in the fragile female body, ‘risk’ has become multiplied and seen as increasingly pervasive, arising from social conditions like family violence as well as located within the ‘risky’ maternal body itself (Bryers and van Teijlingen, 2010). As in other areas of health care, networks of international experts use social and behavioural norms to compare individuals and position those that deviate as at risk (Lupton, 1999). Antenatal surveillance is now predicated on reflexivity; that is, it involves a myriad of tests and monitoring of diet as well as drug, nicotine and alcohol consumption, on the basis of which the pregnant woman is expected to modify her own behaviour (Bryers and van Teijlingen, 2010). 414

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These developments take place within ‘post-bureaucratic’ maternity hospitals characterised by more egalitarian governance and by greater engagement with consumer activists and the wider community (Reiger, 2006). More flexible spatial and staffing arrangements are emerging. Rather than a pyramid reflecting idiosyncratic medical authority, multidisciplinary teams include midwives (who are no longer necessarily nurses) obstetricians, ultra-sonographers, paediatricians, anaesthetists, social workers. Reflecting what can be seen as a new hyperreflexive risk regime, managers and professionals in these health organisations construct and manage institutional risk by drawing on auditing and accountability techniques from the corporate sector. They are expected to use evidencebased medical and technological practices to manage the intensified demands for accountability common to neo-liberal regimes (Hutter and Power, 2005). A plethora of self-monitoring and quality improvement techniques – professional performance indicators, clinical practice guidelines, individualised health plans, patient satisfaction surveys and consumer participation strategies – now dominate their work and impact on their subjectivities. At the same time, these standardising techniques are challenged by an alternative discourse, one that promotes women-centred care and normal, physiological birth (Reiger and Morton, 2012). Midwives, for example, professionalise around the concept of managing ‘the normal’ and espousing woman-centred care but their practice is nonetheless governed by the institutionalisation of health surveillance and ‘risk amplification’ (Scamell, 2011, p. 991). Measures to humanise birth environments, encourage family involvement and establish midwifery-led, communitybased care have been strongly promoted by consumer organisations such as the Maternity Coalition (Reiger, 2006) and received support from Australian policymakers and midwifery organisations. Rather than hierarchical relationships, professionals are expected to work in partnership with women to minimise ever-present risk and maintain the seemingly precarious normality of childbirth. Neo-traditional orderings of risk Most of these developments outlined above remain contentious, not only at public inquiries and in the mass media, but also within hospital workplaces. These contests give rise to what Crook (1999) designates as ‘neo-traditional orderings’ or what Lash (2002) calls ‘risk communities’: emergent groups that are held together by shared values, beliefs and cultural tastes. In maternity care, international and local professional networks promote change yet resistance continues, notably in Eastern Europe. In the Australian institutional sites studied, resistant communities echo traditional status hierarchies but also bridge them in the interest of a shared response to the new ‘risky’ environment. At Suburban, City, Regional and Rural hospitals, ‘old’ allegiances still reflected class, gender and ethnic divisions, whereas new alliances emerged based on resistance to © 2013 Macmillan Publishers Ltd. 1477-8211

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change in organisational and work patterns and in identities. Although the balance has been shifting from a modernist to hyper-reflexive risk regime, the result therefore remains fluid and uncertain.

Changing Regimes in Maternity Care In what follows, we focus on two major themes, both of which are theoretically derived and evident in our data. Both concern contested social practices and relationships – first, the challenge posed by changes in work organisation, including skill sets and the use of space, and, second, the redefining of identities and relationships. We argue that a recurrent paradox runs throughout – that along with excitement and promise, the scale and pace of maternity care regime change generated not merely overt resistance but led to heightened anxiety. In some cases, this threatened the trust relations necessary to organisational stability and professional collaboration in health care (Gilson, 2003; Calnan and Rowe, 2007) and hence the stability of the new order.

Re-Organising Work In the late 1990s, widespread upheaval in health administration reflected the Victorian state government’s neo-liberal philosophies (Hancock, 1999) but the destabilisation offered new opportunities too. Reform-minded clinicians and service managers found increased philosophical support and some funding under a ‘Maternity Enhancement’ Strategy (later Programme) to trial new staffing arrangements (Reiger, 2006). The old system of organising midwifery work was seen as too rigid and neither economic nor efficient. As one manager explained: We were having a fully staffed birth unit and a fully staffed maternity [postnatal] ward, and nobody ever crossed over. Or you could have a frantic maternity ward and 4 or 5 midwives sitting in the birth unit, because that was their area … (Manager Pilot study Outer Suburban) The new systems, sometimes introduced as a result of institutional amalgamations, were no longer primarily based on traditional ‘antenatal, labour and postnatal’ wards, although these remained in more limited form. Instead, antenatal intake interviews and ongoing surveillance, facilitated by technology such as ultrasound, electronic monitoring and foetal blood sampling, allowed both midwives and doctors to distinguish the care of women deemed ‘low risk’ from those seen at ‘high risk’ of obstetric problems. Using protocols to establish 416

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women’s risk categorisation, midwives’ work was often now organised around regular ‘teams’ rather than rosters. Designated as the appropriate carers for ‘lowrisk’ women across the reproductive continuum, they referred to designated doctors for medical care. Yet both the management of childbearing women and the work of staff caring for them remained contentious due to philosophical differences in evaluating risks. In most sites, the use of ‘high and low’ risk to categorise women as the basis of midwifery staff organisation was eventually rejected for various philosophical and practical reasons. But alternative or subsequent moves to geographically based teams also involved many changes – new systems of staffing, renaming and modifying use of space and equipment, and redesign of record-keeping processes for women’s admission, care, discharge and home follow-up. The new midwifery-oriented system thus challenged traditional obstetric hegemony by relabelling birth from being seen as always a (potentially) high-risk event under medical control to a normal physiological process, at least for women designated as ‘low risk’ who could thus stay, if provisionally, under midwifery management. Standardised antenatal care policies and professional referral guidelines determined if and when doctors (as ‘high-risk’ practitioners) were to be involved in a woman’s care, and new hospital protocols and codes of professional practice regulated transfers from midwifery to medical care. In most units, it was reported that senior midwifery managers now held positions of increased authority in less hierarchical structures. They became adept at using restructuring opportunities to advance their professional agenda and commitment to greater continuity and personalised care for women. However, they had to convince midwives to move from the traditional system – working regular rostered shifts primarily in one area (antenatal/labour ward or post-natal) depending on hospital size – to take on the internationally recognised ‘full scope’ of midwifery professional practice, that is, to be prepared and able to care for women in pregnancy, birth and post-natally. As a result, midwives were increasingly subjected to the new ‘individualising’ expectations – more flexible work, greater autonomy and more responsibility accompanied by heightened accountability and self-monitoring.

New skills and work patterns Both doctors and midwives faced new technologies and increased reporting requirements associated with funding based on specific medical procedures along with intensified quality assurance demands. It was changing ideas about what the work of a ‘real’ midwife was now that was most contentious though. Some midwives relished the idea of accruing more skills, responsibilities and power. As one young graduate at Regional pointed out, midwives themselves © 2013 Macmillan Publishers Ltd. 1477-8211

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had to change in order to work more as equals with medical colleagues: they had to have the skills and credentials but also the attitude. [Doctors] now know I’m not subservient and acculturated to being the handmaiden to the doctor. [H]ow can we get doctors to have respect for what midwives do as a profession … if we midwives don’t take ourselves seriously as autonomous practitioners? (Midwife Regional) Implementing the new system of caring across the childbearing period involved a major learning curve for many midwives who needed to up-skill in order to practise what were previously seen as medical tasks, such as suturing. Skill problems were mostly mentioned with regard to birth suite requirements, but antenatal work also required new skills in which many midwives felt deficient. For others, being expected to leave the comparative safety of the hospital to undertake community-based care was a scary prospect (what if I get lost or attacked?), yet a City Midwife expressed her anxiety about moving from mostly post-natal domiciliary visits back into the hurly burly of the main organisation. Whereas some, even if anxious, welcomed the opportunities now offered, others felt excluded by and resisted the new developments. With the introduction of the team model at Rural, the ward-based midwives who felt their family responsibilities or experience precluded them from joining the team grappled with potential marginalisation and deskilling: one said she ‘felt very sad because it’s something I love doing, and I felt a little bit like I’ll be in no man’s land’. At the other case study sites, overt resistance often reflected past experiences. Some midwives at City said that they chose to work permanent night shifts in postnatal care to give ‘real’ care when it was quiet, but also to escape increasing managerial demands. They also pointed out that in previous years some of them had been excluded from prestigious labour ward work, and they now resented being told they should reskill to do it. One Suburban midwife, though herself grudgingly supportive of the new system, said that several of her colleagues ‘didn’t want to do everything … they weren’t skilled enough to change … and they didn’t want to change’. Others at City too also had little commitment to the new learning expected, including its political agenda: as one said of her reluctant colleagues: [T]hey want to come to work. Do a shift. Do the best they can in that shift umm, yeah, and then get paid and go home. They don’t want to change the world for women having babies. It’s all a bit much … (City Midwife) The actual work of assisting with birth was also changing. Increased support for physiological childbirth meant greater dexterity in using a variety of positions, along with use of warm water and physical movement for pain relief instead of 418

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drugs. More physically arduous care, for example supporting births on the floor or in a pool, was often challenging and rewarding. It could also be a significant source of anxiety. The move to organise the staffing of women’s care according to differences in their perceived ‘risk’ status included reorganising space. At several hospitals we heard that many doctors expressed concern that their routines had been unsettled by their having to adjust to attending births run by midwives in ‘blue/ red/green’ (or similar) teams, each with its own ‘birth suite’ and being told to ‘follow the woman’ rather than always going to the same labour ward. As the work of more midwives became organised into teams with their own locations, names, visual signifiers and clientele, stories of squabbles over beds, desks and who should answer which buzzers emerged. A group of midwifery students reported that in birth suite one day ‘everyone was fighting over’ which ‘low-risk’ women from certain areas belonged to which team: said one, ‘I’m just like, this is ridiculous. Here are these women trying to give birth!’ Space often signified power differences of course: in one hospital, comments about ‘upstairs and downstairs’ referred to assumed status differences between the ‘high’- and ‘low’risk units and in another ‘across the corridor’ signified persistent tensions between family birth unit staff and those in the mainstream labour ward. The sense of implementing a new regime, reflected in redecorated corridors and rebadged units, was also signified by everyday practices and by symbolic shifts – by midwives and obstetricians increasingly addressing each other on a first name basis and by old ‘nursing’ uniforms and status markers replaced by more informal clothing. Past practices and symbolism continue in common use yet they are now challenged by new language and embodied expression. Old and new anxieties It was in the management of time in particular that new patterns of work gave rise to intensified anxiety. The major changes in maternity care, notably new forms of team work, were introduced into a health system still demoralised by the workforce casualisation encouraged by neo-liberal policies during the 1990s (Hancock, 1999; Reiger, 2006). For the majority of midwives who had trained in a care-giving model based on nursing – in which working according to rosters and knowing the predictable nature of each day’s work was taken for granted – moving to more flexible work practices required a new orientation and much greater commitment. Yet industrial requirements perpetuated the traditional hierarchical rostered system of nursing. Some of the midwives who actively resisted taking more professional responsibility sought the support of those in the Australian Nurses’ Federation, the union that has historically controlled midwifery industrial bargaining in Australia. Many in the union were reluctant to countenance non-rostered conditions and higher pay rates for more © 2013 Macmillan Publishers Ltd. 1477-8211

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out-of-hospital-work, fearful that alternative working and salary arrangements would undermine employees’ conditions in the wider sector. Eventually, with much persistence and emotional effort involved in negotiations, managers achieved new forms of annualised salaries. Considerable anxiety about the lack of experienced, competent midwifery staff, at least at times, was reported in most units. Indeed at Rural, it was a primary motivation for moving to a new model of care. The established roster was about ‘to fall over’, according to the Senior Manager, for want of local midwives who were prepared to work both as nurses and as midwives, as in the traditional system. In the urban units, not only managers but also many midwives expressed concern about the challenge of introducing new systems without enough committed, permanent staff. One commented about the ‘nasty catch-22’ she faced, especially when trying to support new practices like women walking when in labour: And the workload is dangerous and I’m left in a vulnerable, dangerous position because I shouldn’t be looking after that many women and that new baby and having a possibility of having two or three women walking in labour. It is dangerous here sometimes and that worries me, because that makes me vulnerable and because I’m compassionate and I want to do the best I can, yeah I pick up extra work when legally I should say no … (Midwife Suburban) In view of their sense of heightened risk, some midwives also expressed a fear more commonly raised by doctors – that of being sued for adverse outcomes. Although midwives traditionally felt protected by working within the traditional hierarchical medical system, there was growing awareness that their ‘new’ professional autonomy carried ‘scary’ responsibility. To manage this fear, one said she always wrote incidents down: ‘because when there is something wrong you can look back, because if you don’t write it down, you don’t know which day, which patient you are looking after or what happened’. Doctors also expressed considerable anxiety, especially about midwifery skill levels, but also fears of litigation in a cultural climate in which, as they put it, the ‘doctor as God’ idea was no longer accepted. For many obstetricians, more autonomy for midwives merely ramped up their sense of necessary vigilance. At City and Regional, some resented feeling ‘locked out’ of birth rooms by midwives keen to ‘protect’ women from medical intervention. One obstetrician at Regional made explicit the widespread perception that ‘it always falls back to the person who is the end of the line … and even if midwives independently practice we are still the end of the line’. In spite of such reiterations of traditional medical authority, in the changing regime, the medical practitioners, like managers and midwives, were developing new work and organisational patterns. Most 420

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importantly, they were also renegotiating professional relationships and sometimes reinventing themselves.

Negotiating Identities and Allegiances: Risk Communities and Neo-Traditional Orderings In these complex hospital workplaces, identities and relationships appeared to be fluid and uncertain. They were often characterised not only by considerable excitement and enthusiasm but also by anxiety and unresolved conflicts. Participants themselves compared this ‘hyper-reflexive regime’ with the traditional order of modernist hospitals. They commonly described this as ‘pyramidal’, as the major responsibility for institutional risk management lay with the (male) Medical Director and the (female) Matron at the top of a clear ‘pecking order’. Many interviewees expressed awareness of differences not only between the specific local cultures of maternity hospitals but also of a shared ‘old order’ that was now waning. They described professional and personal identities that were closely linked, constructed over time through collective training and within specific hospital cultures and spaces. Most importantly, in traditional regimes, these appeared stable and thus could be taken for granted, deeply imbued as they also were with gender, class and ethnic distinctions. They directly shaped personal experience and relationships. A doctor from an immigrant background, for example, commented on always being aware of not having what is often termed cultural and economic capital – for example, private schooling and the contacts and self-confidence it gave: [S]o life was a bit harder, and so right from then you feel that you are not quite … you are sort of there by default … yeah I think … there is still the [immigrant] boy come-good sort of thing that you, you know, that you’ve got into this position somehow, not born into it as most of my colleagues are or were. (Regional doctor) Established personal and group identities reflected traditional social status and power. In particular, as Pringle (1998) and others (for example, Halford and Leonard, 2006) have demonstrated, hospital life includes remnants of patriarchal medical culture. As one female consultant commented, it lingered in her hospital’s ‘ether’. Yet it appeared that the traditional class-based and patriarchal legacy of obstetrics is now less secure and is challenged on a daily basis: as one doctor put it, there is a ‘generational shift’. In meetings observed during fieldwork at City, a prestigious teaching hospital, it was apparent that several senior ‘White men’, especially professors of obstetrics, still exerted overt power and the authority to dominate discussions. However, the impact of the © 2013 Macmillan Publishers Ltd. 1477-8211

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‘revolution’ of evidence-based medicine during the 1990s unsettled many assumptions and established behaviours, even if not all practitioners really changed practices. The presence of many younger female doctors and greater ethnic diversity among obstetricians, along with the higher educational level and greater feminist consciousness of midwives, has generated new forms of critique and uncertainty. As a doctor at Suburban observed, in medicine, the highest social status traditionally accrued to the tertiary centres in the capital cities, whereas ethnic ‘others’ were largely relegated to regional or suburban hospitals. Yet medical shortages meant that overseas-trained doctors were increasingly employed, and, like women, were being appointed to new salaried positions in which they were expected to exert authority even over private sector peers. Some reported heightened anxiety in doing so, and, like the doctor quoted above as seen to be there by ‘default’, they could not take their legitimacy for granted. Interviews and observation in the case study sites indicated the emergence of what Lash (2000, p. 60) calls ‘risk cultures’ – communities of affect bonded through mutual affection and commitment to common causes in the face of late modernity’s ‘chronic uncertainty’. Crook (1999) would refer to these as neotraditional orderings and, certainly, the new alliances emerging across professional boundaries, especially in the larger units, reflected the organisational restructuring of risk and allocation of work responsibility accordingly. Whereas some allegiances reflected developments such as new midwifery teams and new spatial locations, others were informal and remained unstable in composition. Within both professional specialties, new intra- and inter-professional groupings formed and reformed in the context of contested knowledge claims, such as over interpretations of evidence-based medicine. New anxieties about professional statuses arose alongside established rivalries between public and private sector doctors, and between midwives and obstetricians. At the Regional and City units, Family Birth Centre midwives comprised distinct professional communities, often set against Birth Suite (labour ward) midwives, whose power derived from their traditional status as highly skilled, technologically oriented clinicians respected by doctors. In newer midwifery teams, collective identity involved not only defining yourself against those in another group, but also in terms of midwifery identity associated with working in ‘low’, ‘high’ or ‘mixed’ risk work areas, and in relation to continued adherence to, or distance from, their previous nursing identity. Some traditionalist midwives, notably those still based in birth suites and identifying as ‘high-risk’ practitioners, consciously set themselves against the changes in administrative systems and organisational culture promoting greater midwifery autonomy. Seeing themselves as highly skilled and experienced ‘old-timers’, they took pride in their expertise and found allies in doctors who shared their anxiety about the possible deskilling of birth suite midwives once they also worked in other areas. 422

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By contrast, midwives choosing to work to the full scope of practice, such as in family birth centres and in newly emerging team and caseload systems, actively constructed identities as innovators. Expressing excitement about new opportunities, they sought to partner with women such as through more communitybased work. In many units they found their medical allies primarily among obstetricians committed to working within the public system in the interest of social equity. To an extent, in these sites it appears that traditional professional categories had become, as Giddens (2002) suggests, ‘relics’ of traditionalism or what Beck (2002, p. 209) calls empty ‘zombie’ categories, ones contradicted by alternative values, practices and identities. Although most of these professionals were negotiating identities and allegiances in new ways, it seems, somewhat predictably, that obstetricians, especially those in private practice, have remained fairly resilient with regard to both identity and control over their work. As they still tend to see themselves as being ‘where the buck stops’, as holding the final legal responsibility for adverse outcomes, they continue to assert authority over seemingly ‘low-risk’ care in spite of midwifery claims to be experts in ‘the normal’. Yet, like many midwives, they also spoke of anxiety at becoming embroiled in conflicts over women’s management, many of which were fuelled by differences in perception of risk. In busy units there is little chance to negotiate differences, to debrief and restore collegial relationships. Working in these post-bureaucratic hospitals increasingly requires, as Iedema (2003, p. 176) argues, ‘a self-steering performance of self’. This takes a toll, which not only some managers but others too, conveyed to us through their evident distress in interviews when they recounted conflicts and what felt like assaults on their integrity. A senior doctor reported her personal hurt and frustration with a midwifery manager who refused to acknowledge her in the corridor out of distrust towards all obstetricians and a midwife reported that after a major argument with a doctor about a women’s management, she was ‘so shaken up’ that even months later she still ‘couldn’t look him in the face properly. … It just really hurt, like he was, he attacked me so, …. He really made me feel like I was an unprofessional nincompoop’. Such evidence suggests that in these hospitals traditional ways of being an obstetrician or a midwife no longer ‘work’ optimally for many of those interviewed, although old patterns die hard. While new managerial strategies and emerging norms of inter-professional collaboration are reconstructing work processes and social relations, a modernist risk regime, in which medical veto of midwifery autonomy and practice continues, often runs alongside or underlies new reflexive systems of risk organisation. As several other organisational and political theorists have argued (Josserand et al, 2006; Brenner et al, 2010), changes in professional and organisational forms reflect political economic as well as cultural pressures, © 2013 Macmillan Publishers Ltd. 1477-8211

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including in maternity care (Dent and Whitehead, 2002; Benoit et al, 2010; Sandall et al, 2009). However, in line with Crook’s (1999) delineation of the complex social processes involved, and in contrast to accounts stressing a simple reproduction of medical hierarchies over time, our case study data suggests considerable instability. Risk regimes and ordering practices are always in a state of play – they are never completed projects.

Conclusion In this article, we have argued that theoretical debates on the ‘second modernity’, especially shifting orderings of risk, provide a fruitful lens through which to interpret the often ‘angst-ridden’ impact of a wave of change in Australian maternity hospitals. As evident from the 2009–2010 Maternity Services Review and from earlier reform initiatives (Reiger, 2006; Lane, 2012a, b), policy commitments to improved choice for women have encouraged structural and cultural changes in the Australian maternity care system. Further research is required in other locations and especially by engaging childbearing women themselves, in order to explore the implications of the patterns and turmoil we have identified. Our research in several public maternity units suggests that these hospitals are reconfiguring care provision based on women’s perceived risk status. Accordingly, all key social actors become responsible for both identifying and managing diverse kinds of risk. Yet we have argued that the changes in these public maternity hospitals should not be interpreted in terms of a sweeping process of ‘epochal’ change from the modernist risk regime of industrialised birth to a ‘hyper-reflexive’ regime. Rather, we find that uneven, contested and indeed contradictory processes are at work. In the case study sites, ongoing tensions reflect a recurrent underlying paradox – whereas on the one hand, the use of risk discourse in the new regime facilitates allocation of childbearing women to distinct ‘low’- and ‘high’-risk groups and assigning caregivers on this basis, on the other it encourages heightened anxiety of both women and professionals. In the face of inevitable uncertainty – the unknowable character of each and every birth – collegial trust rather than routinised auditing is essential. Professional tensions can diminish the possibility of offering the highly individualised, humane care that is an objective of policy reform, and undermine the complex psychological and physiological processes essential to healthy birthing and to women’s well-being (Reiger and Morton, 2012). Within both midwifery and medicine, though, along with reluctance to leave ‘comfort zones’, we also found evidence of professional alliances and innovation in identity formation within changing institutional regimes. As these health professionals manage their everyday work practices 424

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and reconstitute their professional selves, they do so not only in the context of neo-liberal forms of regulating the health professions but also in the context of cultural pressures arising from the social uncertainty and instability of a hyperreflexive risk regime. Perhaps then it is unsurprising that considerable confusion and tensions remain, especially over where to locate and how to define and manage, the ‘risk’ increasingly associated with childbirth.

Acknowledgements The research for this article was funded by Deakin University Arts Faculty and by collaborative grants between La Trobe University and the tertiary and rural hospitals. We have appreciated the support of our research assistants, notably Bonnie Simons, and feedback from colleagues at conferences and reviewers’ suggestions for refining the argument developed here.

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