When midwife continuity of carer is the policy proposal, what is the problem of perinatal health inequalities represented to be?

Abstract

Midwife continuity of carer (MCOC) is widely recommended to protect birthing people against disrespectful care and mitigate effects of social adversity. In the UK, this is reflected in the Core20PLUS5 framework, which identifies maternity and, specifically, MCOC as one of five national priorities for reducing healthcare inequalities. Within health policy networks, the prevailing view of the policy process is that the task of government is to find solutions to existing policy problems. A critical policy approach, in contrast, considers how any policy proposal represents a problem in a particular way, shaping what is perceived as possible or desirable. Adopting this approach, I suggest that the promise of MCOC (and, specifically, intrapartum continuity) has been overstated, given the context of extreme social inequality, chronic underfunding of the NHS, the impact of austerity and the denial of structural racism in the UK. MCOC has been found to improve access, experience, and outcomes for disadvantaged and racially minoritized people by offering more personalized care. When MCOC is the policy proposal, however, the problem of inequalities in perinatal health tends to be represented in terms of fragmented maternity care, limiting policy discussion of the drivers of health inequality. This enables elected officials to appear to address health inequality by relying on midwives to adopt more flexible working practices. Representing the problem as a matter of health justice, in contrast, not only requires that personalized care is informed by structural competency and cultural safety but demands that policymakers address structural drivers beyond the healthcare system.