Maternity Services and Policy in an International Context

Risk, Citizenship and Welfare Regimes

Patricia Kennedy, Naonori Kodate

• Publisher: Routledge
• Year: 2015
• Print ISBN: 9780415738941
• eBook ISBN: 9781317812418
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Health Care Delivery
• Index: Politics & International Relations

This book is the first comprehensive international overview of maternity services. Drawing on concepts of risk and social citizenship, it explores the relationship between welfare regimes and health policy by comparing and contrasting provision for childbearing women.

Each substantive chapter focuses on a different country, presenting detailed contextual information on health care provision, maternity interventions and birth outcomes there. They discuss key issues such as birth rates and fertility patterns, the role of patient choice, attitudes to place of birth and maternity entitlements among others, and the countries covered represent diverse welfare regimes, including Ireland, Scotland, Sweden, the Netherlands, Germany, Italy, Japan, the United States, Canada, Australia and New Zealand. An extended introduction and a conclusion draw the book together and place it in the context of the literature on comparative welfare regimes.

It is an important reference for students and academics interested in comparative social policy, health services research, and maternity services and policies.

1 Welfare regimes, health care regimes and maternity services and policy

A comparative perspective

Patricia Kennedy, Naonori Kodate and Nadine Reibling

This chapter locates maternity services and policy within the literature on comparative welfare regimes. It identifies risk and rights as two important concepts that straddle the combined literature on welfare regimes, health regimes and scholarship on maternity policy and practice. It discusses the centrality of the social and medical models of health to the understanding of maternity policy. It strives for a greater understanding of the complexities of maternity policy.

We begin by introducing the comparative literature on welfare regimes that has emerged over the last two decades and explore the scholarship on health regimes and the emerging literature on ‘maternity regimes’. We investigate how childbirth is perceived at the macro-, micro- and meso-levels, a framework developed by De Vries et al. (2001) in Birth by Design: Pregnancy, Maternity Care and Midwifery in North America and Europe. These authors claimed that their goal was ‘to “decenter” the study of maternity care from particular national contexts, to move it analytically in a direction in which any and all contexts are perceived as problematic’ (De Vries et al. 2001: xiii). They questioned how maternity care has been shaped by political systems, state organisations, the organisation of the professions, educational systems, stratification systems and inequality, and attitudes towards and uses of technology. They indicated the lack of a framework for the organisation of comparative studies of maternity care. They offered an analysis of the differences and similarities in the organisation of maternity care in a sample of high-income countries. Using a multi-country, multi-level method, they demonstrated that maternity care has not followed the same evolutionary path in different countries and suggested ‘the social and cultural diversity of societies cannot be separated from the organisational arrangement of maternity care’ (De Vries et al. 2001: xv).

Welfare regimes

The development of modern welfare states is rooted in the motivation and capacity of states to deal with ‘social risks’ (Pierson 2011; Taylor-Gooby 2004). Individual welfare programmes are generally organised around a specific risk, e.g. the risk of illness, disability, unemployment or old age. The welfare regime literature that originated from the seminal work The Three Worlds of Welfare Capitalism (Esping-Andersen 1990) argues that there are distinct ways in which welfare states deal with all these risks. For instance, it was argued that ‘when we focus on the principles embedded in welfare states, we discover distinct regime-clusters, not merely variations of “more” or “less” around a common denominator’ (Esping-Andersen 1990: 32). In his original work, Esping-Andersen identified three distinct welfare regimes: liberal, conservative–corporatist and social democratic welfare capitalism.

A vast scholarship on families of nations and welfare state regimes has developed since that publication (Arts and Gelissen 2010; Ferrera 1996; Huber and Bogliaccini 2010; Peng and Wong 2010). Castles and Mitchell (1993), for instance, suggest the existence of a fourth ‘radical’ world, composed of the Australian and New Zealand welfare states, which combines high-level minimum wage policies and more generous means-tested welfare programmes than the American and British systems. Ferrera (1996) has proposed the Southern European countries as another family of welfare states. Another new category contains the former Communist welfare states in Central and Eastern Europe, which do not fit the standard Esping-Andersen typology. Comparative social policy literature has paid limited attention to former Communist welfare systems, which are generally characterised as ‘authoritarian–paternalist’, including elements of both ‘Continental’ and ‘Nordic’ regimes – e.g. ‘status-reinforcement’ deriving from occupation-based social insurance systems and ‘universality of certain services’ (Kornai 1992). Finally, beyond the Europe–America focus, scholars have pointed out the distinct characteristics of welfare states in East Asia (Peng and Wong 2010), as well as in the developing world (Arts and Gelissen 2010).

Aside from this ongoing debate on the correct number of welfare regimes and the attribution of individual countries to these regimes, a more fundamental critique has been raised about the conceptual outline of Esping-Andersen’s classification (Arts and Gelissen 2010), which excludes important dimensions of welfare policy, most importantly the role of social services and in-kind benefits (Alber 1995; Kautto 2002) and the role of gender or, more generally, how welfare states deal with new social risks.

Both of these lines of critique are directly linked with the ‘risk of childbirth’ and maternity care services because: (1) maternity care consists mostly of services and less of monetary payments; and (2) the way welfare states deal with gender relations and the role of women is crucial for how the transition to motherhood is perceived and enacted by citizens. The gendered analysis of welfare regimes has focused on the institutional organisation of social services for children and the elderly. Depending on whether or not these services are provided by the state, the market, or within families shapes women’s ‘capacity to form and maintain an autonomous household’ by participating in the labour market (Orloff 1993a: 319). Esping-Andersen himself provided a revised typology in 1999 in which he added social services and extended his welfare regime typology by adding the dimension of de-familialisation. Although this work has mostly looked at the role of women and the provision of services in the welfare state globally, in this book our focus is on the time frame surrounding childbirth. Therefore we predominately look at maternity entitlements, while childcare services, which are of central importance later in life, are beyond the scope of this book. Nevertheless, following the welfare regime literature, we expect that the gender values that influence the institutional setup of all welfare programmes (e.g. childcare, elderly care, widows’ pension) will also shape the different ways in which childbirth and the transition to motherhood is organised in the nations that we compare in this book.

Welfare or health care regimes: is health care different?

One of the major critiques of Esping-Andersen’s welfare regimes has been his focus on income maintenance programmes and the omission of social services (Alber 1995) and, most importantly, the fact that health care, one of the most important (and expensive) fields of welfare state provision, was excluded (Bambra 2005). A primary example for this critique has been the UK, which – despite its liberal welfare regime – has a National Health Service that provides free access to health care for all residents.

A number of scholars have provided typologies and classifications of health care systems. Their results reveal both similarities and differences between ‘welfare’ and ‘health care regimes’. The Nordic countries usually form a cluster and the USA is an outlier in all accounts. However, the liberal, conservative and Southern countries show differences in their welfare and health care arrangements. Differences across typologies are often based on their focus on different parts of the health care system

Bambra (2005) uses information on the public–private mix in spending and provision as an indicator of the degree of universality to create a health decommodification index that reveals many similarities with Esping-Andersen’s welfare regimes. However, a number of liberal countries (the UK, Canada and New Zealand) provide a much higher level of decommodification in health care than in their general welfare provision. The typology of Moran (1995) of health care states adds the dimension of governance as the role of the state in the areas of consumption, production and technology. He distinguishes four ideal types: command and control states; supply states; corporatist states; and insecure command and control states. In this mainly conceptual work, individual countries are used to illustrate the types. However, Moran’s analysis is mainly theoretical and so it is not possible to assess the extent to which welfare regimes and health care states overlap and in which cases they are distinct.

In contrast, Wendt (2009) provides an empirically based differentiation of health care systems. Based on a cluster analysis, three types of health care system were constructed: health service provision-oriented type; universal coverage–controlled access type; and low budget–restricted access type. Reibling (2010) develops a typology of health care regimes using indicators of patient access regulations, thereby providing a comparison of various systems from the perspective of service recipients. This classification shows that patient access regulations vary considerably from other aspects of health care systems (e.g. the public–private mix). Thus her results underscore another line of work showing that specific institutional regulations in welfare fields can considerably deviate from identified health care or welfare regimes (Burau and Blank 2006). Welfare and health care regimes can provide a useful framework of reference, but need to be complemented by the analysis of specific institutional arrangements, which is exactly what this book is about.

Aside from the empirical differences in countries’ attachment to certain groups or regimes, there are a number of theoretical arguments about why health care systems can be detached from their general welfare regime. We would like to highlight three of these arguments.

1 Esping-Andersen’s core argument for the formation of different worlds of welfare has been the power resources of the working class (Esping-Andersen 1990). Thus the conflict between capital and labour has played a core role in the formation (and generosity) of income maintenance programmes. Cultural accounts of welfare states have also stressed the variation in ‘deservingness categories’ as causes or results of varying welfare support (van Oorschot 2007). Health care, however, differs both culturally and institutionally from income maintenance programmes. For instance, studies on welfare attitudes repeatedly show an exceptionally high support for health care based on the idea that ill people are seen as highly deserving (Blekesaune und Quadagno 2003). Unlike poverty, illness is perceived less as a person’s own fault, but rather as an unpredictable event. Thus social solidarity with respect to illness seems to be much higher in European countries than other forms of welfare provision. However, in the USA, the only advanced industrialised country without a universal system, public opinion is much less supportive of socialised solutions to individual health problems. Moreover, the fact that lifestyle risks are increasingly identified as major causes for disease has, and may in the future, undermine the high degree of solidarity present for health care in European countries. Nevertheless, the high degree of cross-national consensus around health care makes this field different from other parts of welfare provision. This has been shown empirically as spending on health care is much more stable and convergent in European countries than spending on other social services (Jensen 2008).

2 Another distinct characteristic of health care systems is the important role of the professions. Unlike in other fields of welfare provision, the major line of conflict is not between capital and labour, but between payers (states, companies, sickness funds) and providers (hospitals, doctors) or between providers (professions). The sociology of the professions as well as the institutional analysis of health care reforms have demonstrated the important role of the medical professions in the formation and reform of health care systems (Immergut 1992; Wilsford 1994; Hacker 1998; Tuohy 1999; Hassenteufel and Palier 2007; Kuhlmann et al. 2009; Kodate 2010). This perspective underlines the continuity of health care systems (‘path dependency’) in this predominantly profession-driven policy sector. The medical profession has retained a considerable level of autonomy in its decisions for a long time. The medical profession has also succeeded in extending its field of activity by medicalising a number of physiological changes and social behaviours (e.g. attention-deficit hyperactivity disorder), including childbirth (Conrad 1992). However, in recent years, this autonomy has been challenged from two sides. On the one hand, policy-makers are increasingly concerned about health care costs that conflict with professional autonomy and profit-seeking. On the other hand, the availability of large amounts of data has demonstrated the wide variability of practice, quality and outcomes, resulting in a stronger reliance on ‘evidence’ for medical decision-making (Rosenthal 2008). As a result, although governments are keen to advocate patients’ rights by increasing transparency and collaborating closely with the medical professions, tensions arise between the two actors.

McIntyre et al. (2012), in their paper ‘Primary maternity care reform: whose influence is driving the change?’, explore deve...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of illustrations
• Notes on contributors
• Acknowledgements
• Introduction
• 1 Welfare regimes, health care regimes and maternity services and policy: a comparative perspective
• 2 New Zealand
• 3 Ireland
• 4 United States of America
• 5 Australia
• 6 Scotland
• 7 Canada
• 8 Japan
• 9 Italy
• 10 Germany
• 11 The Netherlands
• 12 Sweden
• Index