“The Birth System is Broken”: Healthcare Providers and the Marginalization of Pregnant People’s Birth Preferences

• In Event: Sociology of Reproduction

Abstract

People planning to give birth face a range of choices, framed by competing discourses about nature, control, and safety. The available choices, and knowledge of them, are shaped by the structure of healthcare, including provider beliefs, practice-level policies, and insurance policies.This paper uses interview data from both pregnant people and healthcare professionals to examine how professionals operate within the healthcare structure in the San Francisco Bay Area to either facilitate or constrain patient preferences. I ask: how do healthcare professionals navigate pregnant people’s birthing preferences? I primarily use interview data from 21 professionals: twelve midwives (three of whom worked outside of a hospital), seven doctors, and two nurses. I also supplement these data with interviews from 29 people who had recently given birth for the first time. Interview data with professionals granted insight into the “behind-the-scenes” realities that were usually opaque to pregnant participants.
Building on the sociology of birth (e.g. Armstrong 2000; Morris 2013; Simonds, Katz Rothman, and Meltzer Norman 2006), I argue that limited time, insurance restrictions, and fear of legal liability contribute to a practice structure that prioritizes efficiency and consistency, marginalizing patient preferences, which, in this sample, were overwhelmingly for low- or no- intervention births. Influenced by institutional limitations, providers typically viewed birth preferences as inconvenient or harmful unless they remain flexible and within the practice norms of the institution. Pregnant people, in turn, must walk the thin line between being knowledgeable advocates and respectful, “good” patients, a path made more fraught by inequitable care (Johnson and Simon 2021). Professionals advise pregnant people to “shop around” for a provider who is a good fit for their preferences; however, people’s ability to receive care from an ideal provider is limited. This paper shows how the healthcare structure, even in a relatively well-funded region of the US, shapes birth decision-making.

Author

• Meghan Olivia Warner, Stanford