Under capitalism’s reach, every aspect of human life – including childbirth – is shaped by its logic. Yet, compared to other areas of health and care, the impact of capitalism on birthing practices remains underexplored. In this interview, sociologist and former midwife Anna Fielder, author of Going Into Labour, examines how capitalism influences labor and childbirth, and how these spaces have also become sites of resistance.
People’s Health Dispatch: What led you to write this book?
Anna Fielder: I guess this started quite a long time ago. My mother was a midwife, so I grew up in a family where birth was always part of life and conversation. Later, I became a midwife in England, and as I trained and worked in the field, I became involved in the politics of midwifery.
I found that there was already a strong focus, in discussions on birth care, about the effects of patriarchy – that was and remains important. Over time, especially in the past couple of decades, there has been growing recognition that systemic racism is deeply embedded in what we call maternity services. And I say “so-called” maternity services because not everyone who gives birth identifies as a mother, so the term itself carries assumptions that do not reflect everyone’s experience. In addition to that, I often question whether these services actually support mothers in the ways they should.
There is incredible work being done today, for example, by Māori scholars in Aotearoa New Zealand, where I currently live, and by Indigenous people around the world – on childbirth within Indigenous communities. There is also important research on how cis-heteronormativity shapes health services, including so-called maternity care.
But what is often missing from discussions about the so-called maternity services, is reference to capitalism. While we sometimes talk about the commodification of birth or the influence of profit motives in healthcare, there is rarely a direct analysis of capitalism itself in relation to childbirth. Capitalism is not just an external influence; it is a vast, expanding system – a totality, as Marx described it – within which people live their lives, work and also birth babies. And yet, when I looked at the literature on birth, capitalism was barely mentioned. In the birth politics spaces I was involved in, the word capitalism was almost never used, and Marx was referenced even less.
At the same time, in left-wing political circles, where I’ve been involved since my late teens and early 20s, there was plenty of discussion about labor – but never about the labor of childbirth. Labor was always framed in a different, although incredibly important, sense – through the lens of wage work, industrial production, and economic exploitation. It seemed to me that these two worlds – birth politics and Marxist thought – never seemed to meet.
But when I looked at the problems in childbirth and maternity services, it appeared to me that we cannot fully understand these issues without addressing capitalism. Many of the efforts to improve maternity care, eradicate coercion, and make birth safer, feel painfully slow to take effect and hit up against vast challenges. Part of the reason, I sense, is that we need to really grapple with the role capitalism plays in shaping these conditions.
This project started as a thesis but then became a book, because I was determined to bring these two worlds together. I wanted to understand and articulate the multiple ways capitalism shapes the problems that continue to haunt so-called maternity services today.
PHD: So how, in your view, does capitalism shape contemporary birthing practices?
AF: In many ways, and it varies from place to place. Few health services today, whether they are commercial enterprises, public services or others in the not-for-profit sector, are immune to capitalist-type pressures, such as to keep costs as low as possible while pushing workforce “productivity” to the maximum. This can really take its toll on health workers, who are incredibly committed to the wellbeing of patients and already work over-and-above to provide care. It’s also important to remember that even public sector health services are stocked with pharmaceuticals and equipment that have been produced for profit. Such pressures influence childbirth in different ways.
One dynamic I want to draw attention to is discussed in a 2016 article in The Lancet by Professor Suellen Miller and colleagues, titled Beyond Too Little, Too Late and Too Much, Too Soon. Their argument highlights an imbalance in maternity care, where some people receive too little, too late, while others are subjected to too much, too soon.
“Too little, too late” refers to a lack of well-resourced maternity care – care that is withheld, unavailable, or not evidence-based. This leads to high rates of maternal mortality and morbidity. It is particularly associated with the Global South, but it also exists within wealthier countries. For instance, there are “maternity care deserts” even in the USA.
On the other hand, “too much, too soon” is associated with the Global North – though it is apparent in middle-income countries as well and areas of the Global South more generally. This refers to the overuse of medical interventions that are not medically necessary – for example, unnecessary cesarean sections or inductions of labor that do not improve health outcomes. These interventions can cause harm, leading to complications and sometimes long-term health risks.
This juxtaposition of extremes – some people being denied essential care, while others are subjected to excessive, sometimes harmful interventions – reveals systemic inequities. I have come to the conclusion – and this is where I would extend on the argument made by Miller and colleagues – that such inequities are actively generated and exacerbated by capitalism. Mistakes happen in birth care, and there may always be times when interventions are needed but don’t actually happen for different reasons; or when they are used if not really needed. Those issues need addressing, but what’s being emphasized here is not so much individual errors – it’s the structural logic driving patterns of use. This is not simply about individual decisions, but about structural forces shaping pregnancy and birth care.
The “too little, too late” / “too much, too soon” framework is, as I see it, a reflection of how capitalism influences and shapes maternity care. On the one hand resources are withheld in some contexts (particularly when they are not deemed to be cost effective, or when they will not generate profit). On the other hand, they are expanded especially where profit can be made. It’s not as simple as that – there are other dynamics operating – but there is a very real danger in capitalism that profit rather than people, is prioritized.
Capitalism is also shaped by colonial and racial dynamics. The World Health Organization (WHO) reports that in 2020 nearly 95% of maternal deaths associated with pregnancy happened in countries categorized as low and lower middle-income. In the US, the maternal death rate of Black women is about 3 times that of white women. Other countries have similar devastating inequities, there are similar things happening across the world.
The fetishization of technology in childbirth
PHD: One of the chapters in your book explores the concept of commodity fetishism and how it applies to medical technology in childbirth. Could you explain how this concept operates in the birthing context? How has the increasing reliance on medical technology shaped childbirth in recent decades?
AF: In the chapter, I explore the concept of fetishism in different ways. It’s a term with multiple interpretations.
From a Marxist perspective, commodity fetishism refers to how an object – a commodity – appears as a thing with mystical powers and value in its own right because the social relations through which it was created are not seen; the labor of the many people across the world who were part of its production – who brought it to life, so to speak – are rendered invisible. Closely related to this is the idea that certain objects are imbued with almost magical powers they don’t inherently possess. There are also psychoanalytic interpretations of fetishism, but for the purposes of childbirth, I focus on how these concepts apply to medical technology.
A prevailing assumption in capitalist society is that technology will eliminate uncertainty in birth, inherently making it safer and more predictable. This is a form of technological fetishism – the belief that the mere presence of medical technology automatically improves outcomes, that it has this sort of magical power to make birth safe for us.
To be clear, the correct use of some technologies can save lives. A well-timed cesarean section, for example, can be crucial. I am incredibly grateful for safe access to cesarean surgery when needed. But we are also witnessing a rise in the routine use of medical technologies in birth, including cesarean sections performed in instances where they are not medically necessary and may not even be wanted by the birthing person. WHO notes that experts used to suggest an optimal cesarean rate of around 10-15%. In many countries now, well over 40% of all births – sometimes over 50% – happen by cesarean. This raises serious concerns. When major abdominal surgery is performed without need, it exposes the patient to risks such as wound infection, complications in future pregnancies, and potential uterine rupture during a future labor that could be avoided.
To be clear, I am not opposed to technology in childbirth. Neither does capitalism have a monopoly on birth technologies – people have always used tools, herbal remedies, birthing stools, and other aids that may well be considered technologies – to support pregnancy and labor. But what interests me is how today many obstetric technologies have been imbued with this near-mystical status, as if they alone can solve the challenges of childbirth.
This brings us back to the Marxist understanding of fetishism. What are the social relations under capitalism that have given medical technologies this elevated status, where their use is often assumed to be inherently superior? Is it simply that people pushing babies out of their own bodies makes less profit for multi-national medical tech and/or pharmaceutical companies? There is certainly money to be made as these devices, technologies and equipment are produced, sold and used. Insurance company policies – including rates of payment for different procedures – may also influence cesarean rates, and the WHO has noted that there may be a role for more research around insurance reforms. But there’s more to it than that, and it’s not just – as is commonly assumed – that some women do want to have cesareans, although that is the case.
Let me give you an example of what I’m getting at, and there are many more from across the world. A 2018 study carried out in Delhi, India, noted that there is a notably higher rate of cesarean sections in private sector, rather than public, hospitals. It suggested that commercial interests indirectly influence this trend. Private obstetricians may be juggling high patient loads with limited staff support. One obstetrician quoted in the study put it like this: “One normal delivery costs me at least a night, sometimes two nights. If I do 10–15 normal deliveries in a month I hardly ever sleep at home. If I do 15 cesareans I’m not home late for coffee.” There are similar things happening in different countries.
In some settings, cesareans might be used for hospital resource management. If bed shortages in a labor ward create pressure to clear space, it may become easier or more convenient to perform a cesarean rather than wait for labor to progress in its own time. This is not to say that cesareans are performed carelessly, but rather that systemic pressures influence decision-making in ways that do not always align with person-centered care.
To return to the idea of technological fetishism, I am keen that we don’t just talk about there being too many (or too few) cesarean sections or inductions of labor. I am keen that we talk about – make visible – the pressures, relationships and dynamics that are of an overtly capitalist nature, that are influencing these patterns.
The same applies when there is insufficient access to, for instance, safe cesareans. Let’s start talking about the dynamics and relations of capitalism that contribute to the closure of maternity units, or failure to open units, in areas where they cannot operate at a profit but nonetheless fulfil a human need. Let’s not fetishize the technology, the equipment, as if it acts on its own.
PHD: In the same chapter, you also discuss how the introduction of active management of labor as well as the increased use of cesarean sections have reshaped the structure of childbirth. How has this shift impacted who gets to speak, who has authority in the birthing space, and who interacts most with the person giving birth?
AF: The active management of labor was a protocol developed by Dublin obstetrician Kieran O’Driscoll at the National Maternity Hospital in Dublin. This strict approach involved medical confirmation of labor, charting cervical dilation, breaking the waters if dilation was not progressing as expected, administering synthetic oxytocin to speed up labor in certain cases, and performing a cesarean section if birth was not imminent within 12 hours.
While this method was framed as the active management of labor in the sense of childbirth, it was also about controlling the work of birth workers. In many ways, it mirrored Taylorist principles of labor management – hierarchical divisions of labor and breaking tasks into strictly timed processes to increase productivity.
O’Driscoll himself acknowledged an economic aspect to his work. In his book, he wrote that after introducing active management where he worked, the “unit cost of production” – the number of babies born per salaries paid to nurses – was three times higher in other hospitals compared to the unit he worked at. However, he noted that the wages of nurses remained the same.
This reveals how labor in the birth ward was being optimized for efficiency, rather than for better care. Elements of active management of labor are still used today, though not always in O’Driscoll’s exact form. However, we now see a similar emphasis on short-term efficiency through the increasing use of cesarean sections. It’s also interesting that a part of O’Driscoll’s early active management of labor protocol was that the woman in labor had one-to-one care – a nurse, for example, present with them in the room throughout labor. That is an aspect of his work that is seldom remembered today, as birthing units are often so busy that midwives and nurses may be caring for a number of people at a time.
The electronic fetal monitor – another piece of medical equipment – is particularly interesting in terms of technological fetishism. It is widely acknowledged that once the monitor is in use, attention in the birth room tends to shift toward the screen and what is happening there rather than toward the person giving birth. The birthing individual is rendered almost invisible, while the technology takes center stage.
Yet, what we know from research is that positive birth outcomes are strongly linked to relationships of care. Supportive, continuous relationships – for example, between a birthing person and a trusted midwife – reduce cesarean and other medical intervention rates, and improve health outcomes. Strong, nurturing relationships that instill confidence in the birthing person are incredibly important. But they take time to build and nurture, and that requires investment in the labor of birth workers (and those birth workers are often women) which is not always readily forthcoming in the current climate.
Birth, choice, and risk
PHD: Childbirth today is often framed within a discourse of risk management. Of course, birth always carries an element of uncertainty, as you’ve discussed, but the way risk is emphasized now seems to be something different. How does this focus on risk management in birth connect to capitalist approaches to labor and productivity?
AF: Yes, risk is very much linked to uncertainty, as you pointed out. Childbirth has always carried an element of uncertainty, but different societies have framed this in different ways – sometimes in terms of danger, fate, divine will, or chance perhaps. Today, however, the dominant discourse is one of risk.
Risk analysis is a concept I often associate more with the financial sector and insurance companies than with other areas of capitalism. It involves the constant evaluation of probabilities – the likelihood that an unwanted event might occur – and the implementation of mechanisms to minimize potential loss.
But managing risk is not the same as creating health. That distinction is critical. Some argue that the risk-based framework does not belong in birthing rooms at all, as it fundamentally alters the experience of pregnancy and labor in particular ways. Yet, it is difficult to imagine contemporary childbirth without this discourse of risk woven into every aspect of care.
I’ll read you a passage from my book to illustrate:
Today, phenomena as diverse as emotional stress, a pre-existing medical condition, being pregnant with twins or triplets, eating particular foods, drinking alcohol, conceiving within months of a previous pregnancy, conceiving many years after a previous pregnancy, specific emotional states, being ‘too young’, being ‘too old’, being ‘too thin’, being ‘too short’, being ‘too large’, having a particular postal code, eating liquorice, and much more besides, have been gauged to increase risk (of one thing or another) within pregnancy.
Almost everything related to pregnancy is now seen as risky in one way or another. Pregnancies are often categorized as either low risk or high risk – but never as “no risk.” Birth workers, in turn, are expected to constantly mitigate risk – not only in terms of health outcomes for the childbearing person or baby, but also in terms of legal risk. The fear of litigation is a significant factor, as healthcare providers worry about being sued, and institutions seek to minimize liability.
This also connects back to technological fetishism. In contemporary capitalist birth care, one of the primary ways of managing risk is through the increasing use of medical technologies – technologies that are commodified and produced for profit. However, many of these technologies come with risks of their own. In response, new technologies are introduced to manage the risks created by previous interventions, creating a continuous cycle of intervention and technological expansion.
This cycle is not just about safety – it is also about the expansion of markets. New risk designations generate demand for new products, procedures, and pharmaceuticals, supporting the growth of an ever-expanding industry around birth. Whether or not this actually makes birth safer is a different question altogether. Many now acknowledge that the relentless focus on risk can itself create anxiety for birthing people – becoming a risk factor in its own right.
PHD: The remaining two key themes in your book are evidence and choice. I’d love to focus more on choice because it often comes up as a central issue in discussions about women’s health, and health in general. Could you walk me through how you approach it in your book and why choice is so important in birthing practices today?
AF: I think choice is incredibly important in birth, but I think I would prefer the language of decision-making or even self-determination over “choice.”
I first encountered the discourse of “choice in childbirth” in the late 1970s and early 1980s when my mother was involved in activism around the issue. We often talk about choice in relation to abortion, and that’s incredibly important, but the idea of choice in childbirth is often overlooked. What amazes me is that many of us fight for a childbearing person’s right to decide whether to continue a pregnancy, while not always recognizing that if a person chooses to do that, they should also be able to choose what they want in terms of birth care.
Being able to determine what happens during labor – such as whether this or that is done, or not – is a huge determinant of birthing well-being. When people are denied that possibility, rates of birth trauma increase significantly. However, when birth activists started campaigning for choice in childbirth, the conversation merged with the language of consumer choice, reflecting the rise of neoliberalism. This created a false assumption – that you can simply “pick” a particular birth, like selecting a brand of baked beans at the supermarket. And birth doesn’t work like that.
It’s so important for people to have control over the conditions in which they give birth, but we cannot always control the outcomes. It’s also rarely acknowledged that not everyone is even given choices – a lot of people are given very few, if any choice, in relation to birth – and the divisions in who gets to decide and who doesn’t, or between the understanding of right and wrong choices, are deeply shaped by capitalism.
Additionally, there’s also the fact that choice was sometimes framed as an argument against interventions – “I choose not to have intervention X or Y.” While opting out can be important, we have to ask ourselves why do people need to opt out in the first place? For me, the issue here becomes how can we improve quality of care for everyone rather than simply emphasizing individual choice to have something different.
We also need to recognize that making choices in labor is often harder than at other times in life. That’s why we need strong, trusting relationships between birth workers and those giving birth (as well as their support people); relations that have been developed and nurtured well before labor starts, ensuring that birthing people have the support they need to make these decisions.
PHD: Unfortunately, birth workers – like many healthcare workers – have faced severe problems in recent decades due to austerity and similar processes. However, many are also leading campaigns for both their own working conditions and better care for their patients. How do you see birth workers organizing today, and how can they work with the broader community to fight against the commodification of childbirth?
AF: It’s already happening. One consequence of a system that actively generates technological fetishism is that while we over-emphasize technology, we don’t have enough birth workers. This is a global issue – many areas even in the Global North lack basic maternity facilities, and there’s a severe midwife shortage.
For example, in New Zealand, the last time I checked, there was a 40% relative workforce deficit in midwifery. The system needs 40% of midwives that it doesn’t have, just to be properly staffed. Midwives are working under excessive caseloads, stretched beyond capacity, and we’ve seen them going on strike in various countries. Midwives don’t strike easily, but when they strike, it’s because things have hit rock bottom.
That’s why it’s so encouraging to see babies, families joining picket lines, recognizing that the conditions in which midwives work are the conditions in which people give birth, and vice versa. That’s a real space for solidarity, for connection, for shared understandings to develop and flourish, and it goes beyond midwifery. Investment in birth workers more generally – doulas and nurses, for instance – is critical. I don’t love the word “investment” because it’s capitalist terminology, but living in a capitalist society, we cannot entirely avoid it right now.
In practical terms, we need funding and resources to ensure birth workers can work without burnout. This is especially crucial so they can work one-to-one with pregnant people, and for community-based birth workers who provide continuity of care for childbearing people. Continuity of care means that people give birth with a birth worker they know and trust, rather than feeling like they’re on a hospital conveyor belt staffed by workers they’ve never met before.
That relationship-building really helps people. If somebody knows and trusts the health professional who is present during their labor, it prevents the experience from feeling like a conveyor belt process – a common issue in perinatal care, sometimes referred to as “baby factory” conditions. If you’ve got a trusting relationship between the person who is giving birth and the birth worker, people feel a lot safer; and when people feel safe, labor works better, physiology works better. I won’t go into the physiological mechanisms by which that happens, but they are fascinating.
This is why an emphasis on continuity of midwifery care is so important. Not only should we protect existing models of this kind of care, but we must also expand them – ensuring they exist in conditions where midwives are not burdened with unmanageable caseloads. It is critical that midwives’ workloads become sustainable.
Resisting further privatization of maternity and reproductive health services is also essential. And there is a direct link between access to abortion and access to safe pregnancy, birth, and postnatal care – these issues cannot be treated in isolation. When abortion access is restricted, maternal mortality rates rise, making it clear that these are not separate concerns but deeply interconnected aspects of health. Recognizing and addressing these connections is fundamental to creating a healthcare system that truly supports childbearing people and future generations.
This is why it’s critical to build connections between different struggles – between campaigns for safe birth care, for access to safe abortion care, movements against obstetric violence, and broader efforts to challenge capitalism as a system. Many of these struggles may appear disparate or disconnected at first glance, but they are fundamentally linked through the structures that shape our world.
People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch. For more articles and to subscribe to People’s Health Dispatch, click here.
