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Social Science & Medicine 71 (2010) 475e481

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Social Science & Medicine

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Medical dominance and neoliberalisation in maternal care provision: Theevidence from Canada and Australia

Cecilia Benoit a,*, Maria Zadoroznyj b, Helga Hallgrimsdottir a, Adrienne Treloar a, Kara Taylor a

aDepartment of Sociology, University of Victoria, Victoria, BC, CanadabUniversity of Queensland, Brisbane, Australia

a r t i c l e i n f o

Article history:Available online 29 April 2010

Keywords:CanadaMedical dominanceMaternity care provisionAustraliaNeoliberalisationMedicalisation

* Corresponding author.E-mail address: cbenoit@uvic.ca (C. Benoit).

0277-9536/$ e see front matter Crown Copyright � 2doi:10.1016/j.socscimed.2010.04.005

a b s t r a c t

Since the 1970s, governments in many high-income countries have implemented a series of reforms intheir health care systems to improve efficiency and effectiveness. Many of these reforms have been ofa market-oriented character, involving the deregulation of key services, the creation of competitivemarkets, and the privatization of health and social care. Some scholars have argued that these“neoliberal” reforms have unseated the historical structural embeddedness of medicine, and in somecases even resulted in the proletarianisation of physicians. Other scholars have challenged this view,maintaining that medical hegemony continues to shape health care provision in most high-incomecountries. In this paper we examine how policy reforms may have altered medical dominance overmaternity care in two comparatively similar countries e Canada and Australia. Our findings indicate thatneoliberal reforms in these two countries have not substantially changed the historically hegemonic rolemedicine has played in maternity care provision. We discuss the implications of this outcome for theincreased medicalisation of human reproduction.

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Introduction

Theconceptofmedical or “physician”dominance canbe traced tothe beginning of the 1970s to the writings of Eliot Freidson (1970a,1970b). A profession is an elite category of occupation that hasassumed a dominant position in a division of labour. Freidsondefined “professional dominance” as the way in which certainprofessions control the content of their work (autonomy), definelimits of the work of others (authority), and act as state-supportedexperts regarding the public’s health (altruism) (Freidson, 1970b).According to Freidson,medical professionals have achieved a specialelite status among politicians, government bureaucrats and thegeneral public, who have become convinced of medicine’s superiorexpertise and the trustworthiness of its members.

Professional medical dominance of decision-making aboutmaternity care predates the development of the modern welfarestate. Two distinct but concurrent processes facilitated this medicalhegemony of maternity care in earlier stages of industrial capitalism.First, pregnancy and childbirth became defined as an illness eventthat required frequent medical supervision and technological inter-vention (Donegan, 1978; Oakley, 1984). Second, there was a shift in

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birthplace fromthehome,where thebirth attendantswerevisitorsofthe pregnant woman, her family and extended kin, to the hospital,where the pregnantwomanwas now the ‘guest’ andwas expected tofollow ‘house rules’ established by physicians and hospital adminis-trators (Sullivan & Weitz, 1988). Further to this, hospital-based careallowed for the utilization of new scientific techniques, technologicalaids, and pain-relieving drugs, as well as the provision of social carefollowing childbirth (McCalman, 1998; Walzer Leavitt, 1986). Bymeans of a lengthy public health campaign, women becameincreasingly convinced of the need to have their pregnancies moni-toredbyphysicians (Barker,1998). These phenomena suggest that themedicalisation of human reproduction is perhaps more prominentthan that of any other health event (Kent, 2000).

The medicalisation of childbirth has been criticised for its nega-tive effects on women’s satisfaction with the birth experience(Declerq, Sakala, Corry, & Applebaum, 2006), as well as othernegative psychological and social consequences, including dis-empowering birthing women (Bourgeault, Benoit, & Davis-Floyd,2004; DeVries, Benoit, Van Teijlingen, & Wrede, 2001; VanTeijlingen, Lowis, McCaffrey, & Porter, 2000), and subordinatinga rangeof other, primarily female, birth attendants such asmidwives(Oakley, 1976; Sandall, 1995; Willis, 1983). In addition, the medi-calisation of childbirth has been argued to increase inequities inaccess and quality of maternity care, in particular for women of

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Aboriginal background1 and other ethnicminority groups, aswell asthose residing in rural and remote areas and the inner city, wheretraditionalmaternity care systemswere undermined but physicianswere reluctant to set up practices (Benoit, Carroll, & Chaudhry 2003;Benoit, Carroll, & Westfall, 2007; Bourgeault et al., 2004; O’Neil &Kaufert, 1996).

Willis (1989) put the ‘golden age’ of medical dominance overpregnancy, childbirth and other health events roughly between the1920s and 1970s; this was when the medical profession in Anglo-American societies enjoyed unchallenged state patronage andsupport (Willis, 2006). During this period, themedical profession incountries such as Canada and Australia governed the health divi-sion of labour, including other maternity care providers, by actingas a state within a state, or government-by-proxy (Kettl, 1988;Salamon, 1981). Because medical dominance of health systemgovernance was more technocratic than democratic, it providedlittle opportunity for public participation.

Medical dominance and the consumer challenge

The cultural milieu of advanced industrial capitalist societies inthe late 1960s and early 1970s was marked by a general lessening oftrust in professional authority, an unprecedented decline in respectfor medicine, and a growing recognition of the emotional, socialand spiritual components of life and healing. This shift foundexpression in, among other things, a birthing consumer movement,which promoted birth as a natural biological process, questionedthe need for physician attendance at all births, and made the casefor different approaches to childbirth. Some came to believe thatchildbirth should ideally occur at home without medical inter-vention, and be celebrated as a woman’s achievement, with herpartner, close family and friends.

Beginning in the early 1970s, governments in a number of high-income countries, including Britain, Canada, New Zealand andAustralia, also began taking an increasingly active role to controlthe influence of medicine. The interests of competing professionalgroups such as nurses and midwives were supported by ministriesof health and other governmental bodies, often in vocal oppositionfrom physicians (Bourgeault et al., 2004; Brodie & Barclay, 2001;Tracy, Barclay, & Brodie, 2000). At the same time, governments inthese countries made opportunities available for patients (nowreferred to as ‘health consumers’) to become formidable players inthe negotiation of their health care (Bury, 2004). In short, pregnantwomen could no longer be easily dismissed as ‘passive recipients’of doctors’ services. They had become ‘reflexive consumers’(Zadoroznyj, 2001) and many even developed activist roles basedon their past childbearing experiences.

Medical dominance and neoliberalization

This re-examination of medicalisedmaternity care practices andthe concurrent shift in thinking about medical dominance overmaternity care was nested within governments’ larger economicand political projects to reform their country’s private and publicsectors. This strategy has come to be referred to as neoliberalism,which “denotes a politically guided intensification of market ruleand commodification” (Brenner, Peck, & Theodore, 2010, p. 3).

1 Aboriginal or Aborigine refers to indigenous peoples around the world.Australian Aborigines/Australians are a group of people who are identified byAustralian law as being members of a race indigenous to the Australian continent.Aboriginal peoples is a term used by the Canadian government to refer to three sub-groups: First Nations, Inuit, and Métis. In this paper we use the term “Aboriginal” torefer to the indigenous peoples of both Australia and Canada.

Among other things, neoliberalism involved the change froma Fordist to a post-Fordist economy, that is, one characterised byflexible production designed to respond to diverse consumerdemands and fragmented markets spread across the globe (Harvey,2005; Williams, 1994). Post-Fordism entailed a series of labour-market reforms that while initially deployed in unionised labourmarkets were eventually applied to reform professional labourmarkets as well, including public health management (Coburn,2006; Willis, 2006).

However, we have to be careful not to view neoliberalism ina monolithic fashion. Rather, it involves heterogeneous forms of“neoliberalisation” that emerge and take shape through their collisionwith diverse institutions located in different geographical socio-political landscapes (Brenner et al., 2010). Neoliberalisation processesare closely linked to processes of ‘regulatory restructuring’e i.e., “therecalibration of institutionalised, collectively binding modes ofgovernance and, more generally, state-economy relations, to impose,extend or consolidate marketised, commodified forms of social life”(Brenner, Peck,&Theodore, inpress, p. 4). In thispaperweexamine thelink between processes of neoliberalisation and medical hegemonyover maternity care provision across different welfare states. Specifi-cally, we ask whether neoliberalisation places countervailing orcomplementary pressures on the medicalisation of childbirth in twohigh-incomecountrieseCanadaandAustralia.Bothof thesecountrieshave highly medicalised maternity care systems, and face similarchallenges regarding equity in maternity care provision due to theircolonial heritage and the geographical dispersion of their respectivepopulations; as a result, culturally-inappropriate andmal-distributedmaternity services for Aboriginal and rural and remote women areprevalent in both countries (Benoit, Carroll et al., 2007;Department ofHealth and Aging, 2008, 2009). In addition, both countries haveundertaken extensive neoliberal health reforms in recent decades,albeit of differing forms. In either case, the ostensible aim has been toincrease efficiency and effectiveness and at the same time expandingpublic choice and democratizing health care governance.

These similarities between the Canadian and Australian mater-nitycare systemsprovide anopportunity for the authors to reflectonthe relationship betweenmedical dominance andneoliberal reform.Some Australian researchers argue that the medical profession hasretained its dominance in the health division of labour despiteneoliberal reforms to health policies in that country (Willis, 2006).Canadian researchers demonstrate more differentiated impacts onmedical dominance: some argue that physicians have become pro-letarianised (i.e., its empowered status and professional dominancehavebeen eroded) by thenewmanagerialismespoused byCanadiangovernments (Coburn, 2006), while others highlight a continuedembeddedness of medical dominance in primary health care inCanada (Bourgeault & Mulvale, 2006). This division in the Canadianmaternity care literature suggests the need for more comparativeresearch between countries with a broadly similar background inregard to a history ofmedical dominance and experimentationwithneoliberalism (Willis, 2006).

With this in mind, we discuss below how the “moving map” ofneoliberalisation (Harvey, 2005, p. 88) has played out for theorganization of maternity care in Canada and Australia. While thereare a number of distinct dimensions of the neoliberalisation process(Brenner & Theodore, 2005) below we focus only on the one that ishighly relevant to our analysis e regulatory experimentation.

Neoliberalisation and regulatory experimentation inmaternity care

In recent years, Canadian and Australian governments havebeen involved in regulatory experimentation in maternity care indifferent ways. We examine these developments in turn.

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Medical dominance of maternity care in Canada, while signifi-cantly predating the welfare state, became enshrined and solidifiedwithin the package of policies and regulations that accompanied theadoptionofuniversal health care, knownas ‘Medicare’, implementedand formally adopted in 1972 (Badgley & Wolfe, 1967). While oftenreferred toas a singlehealth care system, in fact, funding anddeliveryof insured services are provincial/territorialmatters.Most physicianswork inprivate practice, with their services paid from theprovincial/territorial insurance plans. Funding for the insurance plans comesfrom the general revenues of the provinces/territories, with addi-tional transfer payments from the federal government through the1995 Canada Health and Social Transfer Act (Bill C-76).

It is crucial to note that, though initially resistant to the imple-mentation of a ‘socialised’ health care system for Canada (therewaseven a doctors’ strike to protest the government Medicare plan),physicians across the country eventually gained much by this newwelfare state policy (Naylor, 1986). First of all, their services werereimbursed through the public purse, thereby virtually guaran-teeing them economic security. Secondly, Medicare solidifiedphysicians’ dominance over maternity care services, granting thema monopoly over the provision of the country’s care of pregnantwomen, which was reinforced by the reimbursement of physiciansbut not midwives (or nurse practitioners) for services rendered,limiting women’s choices regarding style and place of care. Thirdly,physicians retained their right to remain private entrepreneurs,establishing their practices wherever they deemed appropriate,where they would provide a range of medical services to womenthat physicians themselves, not the women, decided upon asnecessary. This point is notable, as it did nothing to alleviate thepre-existing disparity in the availability of physician servicesbetween rural and urban areas. Finally, the hospitalization ofchildbirth had long been a goal of Canadian medical professions.Medicare solidified the medically dominated hospital as thelinchpin to the entire maternity care system (Bourgeault et al.,2004; Benoit, Carroll et al., 2007).

Provincial and territorial governments throughout the 1970sinto the 1980s experimented with a number of cost-controlinitiatives to counter continuing economic escalation, includingglobal hospital budgets and aggregate caps on physician salariesthrough negotiations with provincial medical associations.However, such initiatives did not have a fundamental impact on therising health care costs (Barer & Stoddart, 1991). Some provincialand territorial governments challenged the restricted professionallabour market by passing legislation to either widen the role ofother care providers (e.g., nurse practitioners) or, in the Canadiancase, certify a brand new competitive healer e the midwife.

Legislative changes for the inclusion of midwives as primarymaternity care providers in Canada began in the early 1990s.However, these changes did not occur synchronously across thecountry since each province/territory has jurisdiction over its ownhealth care services. Where midwifery has become regulated,a new type of midwife e the certified midwife e has emerged.Currently, six provinces and one territory have certificationprocedures in place for midwives (Bourgeault et al., 2004) andmostof these jurisdictions fund midwifery services through provincialand territorial health insurance plans. Midwifery services are notpublicly covered elsewhere in the country; instead, pregnantwomen and their families have to pay for their care out of pocket(Canadian Institute for Health Information, 2004a).

Pay structures for midwifery care also vary across regions. InQuebec, certified midwives are largely salaried practitionersworking in birthing centres, and home birth attendance is notcovered under current legislation (Vadeboncoeur, 2004). Bycontrast, in Ontario and British Columbia, certified midwives arepaid per client course of care, and are permitted to attend births

either in clients’ homes or in hospital. Midwives in both Ontario andBritishColumbiahaveadopted a ‘woman-centred care’modelwhichemphasizes: continuity of care (with the same midwife or team ofmidwives caring for the woman throughout her course of care);informed choice (whereby the woman is given the information sheneeds to make decisions regarding diagnostic tests, interventionsand procedures); and choice of birth place (home or hospital, forthose who qualify for home birth on the basis of their obstetricalhistory, health, and other criteria). Midwives working in these twojurisdictions tend to work in independent group practices of two,three and as many as eight midwives as part of a team, similar togroup practice arrangements among Canadian physicians. In Man-itoba, midwives are regulated, enjoy both hospital and home birthprivileges, are, paid by salary and directly employed by provincialhealth authorities. Discussions are currently underway with ruralhealth authorities to expand into First Nations communities there.

While seen by many as a major achievement for pregnantwomen in Canada in that midwifery care is now a choice in manyregions and services reimbursed through the public purse, theimpact of this change to date has been small, with less than fivepercent of births attended by a certified midwife (CanadianInstitute for Health Information, 2004b). Some estimate that asmany as 40 percent of women who want to see a midwife inOntario are currently unable to find one, and other provinces arealso experiencing a situation where demand far outstrips supply(Association of Ontario Midwives, 2007).

In an effort to improve health equity and accessibility of healthservices for its vulnerable populations, the federal governmentinvested funds in the recent decade towards the development ofprimary health care teams (PHCT) in various provinces. In Canada,maternity care is one of the key areas targeted for primary carereform. Multidisciplinary Collaborative Primary Maternity CareProject (MCPMCP), 2005; Multidisciplinary Collaborative PrimaryMaternity Care Project, 2006. The South Community BirthProgram, which opened its doors in Vancouver in 2004, is a case inpoint. The program provides multidisciplinary collaborative care tolow-risk childbearing women. Yet, as Bourgeault and Mulvale(2006) note, such teams have not changed the structuralembeddedness of medical dominance, and their availability andsustainability over the long run remains an issue.

While there has been a trend in Canada to deregulate maternitycare services by providing public funds for the services of certifiedmidwives working autonomously, the Australian case providesa number of points of contrast. Australia’s universal health caresystem, also known as Medicare, has been in place since 1984.Australia’s medical practitioners are, for the most part, privately orself-employed and are able to set their own fees without govern-ment restriction. Medicare provides a fixed subsidy for differenttypes of medical services and procedures, and patients areresponsible for paying any charges levied by providers above thissubsidy out of their ownpockets. In the case of obstetrician led care,these charges can be large, as discussed below (Van Gool, 2009).

Another distinctive feature of the Australian health care systemis its parallel private health insurance sector, resulting in a two-tiered health care system, with many of the associated problems ofinefficiency and inequity (Gray, 1998). In maternity care, the privatesector provides an important alternative to publicly available care,with more than one third of Australian women giving birth inprivate hospitals under the care of a private obstetrician(Department of Health and Aging, 2008; Laws, Abeywardana,Walker, & Sullivan, 2007; Segal, 2004).

Private health insurance declined significantly following theintroduction of Medicare in Australia (Colombo & Tapay, 2003, pp.9e10). From 1996, various measures were taken by the conserva-tive-leaning government to arrest and reverse this trend. These

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policies, and their impact on medical dominance and the provisionof maternity care are the main focus of our analysis.

Measures to boost private health insurance (PHI) includeda substantial subsidy in the form of a non-means tested, 30 percentrebate to residents on the purchase of PHI (Duckett, 2005a; Hurley,Vaithianathen, Crossley, & Cobb-Clark, 2002), a tax rebate forresidents who bought PHI, and a range of financial penalties onthose who did not take out PHI (Butler, 2002). As a result,membership of PHI rose substantially, from 30.1 percent in 1998 to43 percent in 2000, with the level remaining steady since then.(Hurley et al., 2002, p.8; Walker, Percival, Thurecht, & Pearse, 2005;Australian Institute of Health and Welfare, 2008).

The policies to boost PHI membership have undermined theefficiency and equity of the Australian health care system (Segal,2004), and have not reduced waiting lists in public hospitals(Duckett, 2005b). Rather, they have provided substantial publicsubsidies to the wealthiest quintile of Australians, the group mostlikely to purchase PHI, while the impact of the reforms for thepoorest 40 percent has been minimal (Walker et al., 2005). Hence,the reforms have done little to improve accessibility or equity inhealth care. The reforms have increased access to obstetricians inprivate practice, but primarily for high-income women. Asmentioned earlier, the out of pocket (OOP) fees for private obstetricservices can be substantial, and Australia has one of the highestrates of per-capita out of pocket expenditures (Van Gool, Savage,Buchmeuller, Haas, & Anderson, 2006, 2009b).

The government’s response to the increasing rate of OOPpayments was the introduction in 2004 of a suite of policiescollectively known as Medicare Plus. Of particular relevance is the‘Extended Medicare Safety Net’ (EMSN), which limits consumers’out of pocket expenses (currently set at $1000 Australian dollars[AUD], or half that for low-income earners) in a calendar year.Whilethe EMSN policy was originally designed to provide a safety netagainst catastrophic medical expenses, the policy’s outcomes havebeenmost substantial inmaternity and reproductive care (Van Goolet al., 2006, 2009b). Following negotiations between medical orga-nizations and the government, the EMSNwas introduced in tandemwith a new Medicare item for the planning and management ofa pregnancy, hence making these services subject to the EMSN‘safety net’ provisions (Glasson, 2004). As a consequence, obstetri-cians in private practice have been able to substantially increasetheir charges for the management of pregnancy: between 2006 and2007 alone, the average fees for the planning and management ofa pregnancy rose 16.2 percent, and Medicare payouts for obstetricservices increased by 100 percent in the first three years of thescheme (Dunlevy, 2007, p. 1). The increased charges have beenabsorbed by the public purse. By 2007, safety net payments forobstetric services cost $98.6 million AUD, making up 31 percent oftotal safety net expenditures (Department of Health and Aging,2008), and accounting for the single largest category of safety netpayment. Furthermore, safety net payments have been shown to belarger in areas with relatively highmedian family income and lowerhealth care needs (Van Gool et al., 2007), revealing importantregional and socio-economic inequities in the scheme.

In a two-tiered health care system such as Australia’s, theparallel private sector must offer advantages over the public sectorin order tomaintain viability (Gray, 1998, p. 910). Having PHI allowswomen the choice of private obstetrician, generally offers conti-nuity of carer throughout pregnancy and childbirth, longer post-partum hospital stay if desired and often superior hospitalaccommodation in a private room. However, current health policyin Australia makes access to these advantages inequitable; instead,policy channels public funds to private obstetric services (Van Goolet al., 2006, p. 11), perpetuates the dominance of medicine anddecreases the efficiency of the maternity sector by utilizing highly

trained obstetricians as primary birth attendants for womenregardless of their obstetric risk.

Australian women giving birth in the public health care systemhave fewer opportunities for choice of maternity care provider andlittlepossibilityof receivingcontinuityof careduring the childbearingperiod. A reviewofmaternity services conducted in Australia in 2008highlighted the limited choices available to Australian women inrelation to pregnancy and birthing care; to the extent that suchchoices exist, theyare typically limited to lowriskwomenwhoqualifyfor midwife-led care in a birthing unit that is part of a larger hospital(Department of Health and Aging, 2008, 2009).

While there has been a trend in Canada to publicly fund theservices of certified midwives working autonomously, Australianmaternity services have moved in the opposite direction andbecome increasingly controlled by physicians, in particular obste-tricians. The only exception to this trend was a policy implementedin 2006 allowing for antenatal services in rural and remote areas tobe delivered by “appropriately trained and qualified midwives,nurses and registered Aboriginal Health Workers, on behalf ofmedical practitioners” (Department of Health and Aging 2008, p. 9).Otherwise, Australian midwives are not eligible for reimbursementfrom Medicare for their services, and are not able to prescribemedications or order the relevant tests that Canadian midwivesroutinely do (Homer & Passant, 2005). Although Australianmidwives are currently the focus of a federal government review ofmaternity services, there is little opportunity and negligible publicfinancing for them to work as independent practitioners(Department of Health andAging, 2008).Mostmidwives are insteademployed by hospitals or medical clinics and their practice isdetermined by organizational imperatives or by the medical prac-titioners for whom they work. Despite the establishment of somemidwife-led birthing centres within some hospitals, these devel-opments havebeen relatively small in scale and sometimes tenuous.

Unlike their Canadian counterparts, who attend a substantial,albeit decreasing, proportion of births (Canadian Institute for HealthInformation, 2007), general practitioners play a relatively small anddecreasing role in the provision of obstetric services in Australia(Weaver, Clark, & Vernon, 2005). Instead, obstetricians, especiallythose in private practices, are playing an increasing role in the provi-sion of maternity care. Within the maternity workforce, obstetricianshave been the main beneficiaries of government policies promotingPHI. Between 1998 and 2003 the numbers of specialists qualified inobstetrics and gynecology grew by 10.6 percent (Australian MedicalWorkforce Advisory Committee, 2004). This growth defied earlierpredictions of a projected decline of this medical specialty, based onexpected retirements, and unattractive features of the specialty, suchas long and unpredictable working hours and the comparatively highcost of medical indemnity (Weaver et al., 2005, p. 436; MacLennan &Spencer, 2002). In addition to this growth in absolute numbers ofobstetricians, their ratio to women over the age of 15 years hasincreased (AustralianMedicalWorkforce Advisory Committee, 2004).Of thisworkforce, themost commonpractice type is solo private,withan additional one-fifth working in a combination of solo privatepractice and public hospital work. Only 11 percent of all obstetricianswork solely in the public system (Australian Medical WorkforceAdvisory Committee, 2004, pp. 43e46).

In sum, the current situation in Australia, with governmentadvocacy for PHI and little support for primary maternity healthcare, has cemented obstetricians’ dominance and increased themedicalisation of childbirth.

Neoliberalisation and the intensification of medicalisation

The data presented above show that recent neoliberal reformsundertaken by Canadian and Australian governments have not

Table 2Maternity outcomes for Canadian and Australian women by hospital sector, 2005.

Delivery method Australian private Australian public Canadian

Spontaneous vaginal 44.6 63.1 60.2C-section 40.3 27.1 26.3Forceps 5.1 3.0 3.7Vacuum extraction 9.7 6.4 9.8

Sources: Australia: Australian Institute of Health and Welfare, 2005; CanadianInstitute for Health Information, 2007; Laws et al., 2007.

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substantially altered the historically hegemonic role medicine hasplayed in maternity care provision. In fact, available evidencesuggests that increased medicalisation of pregnancy and childbirthhas taken place (Conrad & Leiter, 2004; Van Teijlingen, 2005).

While Canadian family physicians are still the most commonproviders of prenatal care and the primary attendants at childbirth,their portion of service provision has declined over the decades. Inaddition, they are less likely to deliver multiple births or performcaesarean sections. Instead, more costly obstetricians, the vastmajority who work in urban areas, are increasingly working asprimary care attendants to birthing women (Table 1).

These various changes in maternity human resources haveresulted in increased medicalisation of childbirth, despite thereintroduction of midwifery in the recent period. The proportion ofwomenwho delivered by caesarean section, for example, increasedfrom approximately 5% to nearly 20% in Canada between the late1960s and the early 1980s. The caesarean delivery rate decreasedfrom 18.2% of deliveries in 1991e1992 to 17.5% in 1994e1995, andthen increased steadily to 21.2% in 2000e2001 (Table 2), whilerecent data show the rate has increased further to 26.3% in2005e2006.

Caesarean rates are not uniform across social groups andgeographical areas. While there is a clear social gradient incaesarean rates e i.e., controlling for age, rates are significantlyhigher for women in low-income neighbourhoods than women inhigh-income neighbourhoods (Leeb, Baibergenova, Wen, Webster,& Zelmer, 2005), caesarean rates also vary among the country’sprovinces and territories (in 2000e2001 from a low of 8.1% inNunavut to a high of 25.8% in New Brunswick) and even amonghealth authorities in the same province (Canadian PerinatalSurveillance System, 2003). At the same time, maternal hospitalreadmission rates after a caesarean have also been increasing, ashas the national epidural rate.

These findings point to the continued medicalisation of labourand delivery. A recent cross-national study conducted by the PublicHealth Agency of Canada (PHAC) (2009) polling women regardingtheir childbearing period also supports this thesis. Despite the lackof evidence for certain medical interventions preceding birth (suchas the practice of shaving a woman’s pubic hair or giving her anenema), of the Canadian women surveyed 19% reported beingshaved and 5% reported receiving an enema prior to birth, eventhoughmost Canadian hospitals have a policy not to adhere to suchpractices (PHAC, 2009 p. 12). Moreover, 21% of women surveyedreceived an episiotomy (PHAC, 2009, p. 13).

Australian women who gave birth in private hospitals were 50%more likely to undergo caesarean section (Van Gool, 2009), and hadhigher rates of forceps deliveries, vacuum extractions, and C-sections (Laws et al., 2007, p. 39). Comparison of the patterns ofintervention in the two countries, shown in Table 2 revealremarkably similar maternal outcomes for the Canadian andAustralian public sectors, and a striking difference in maternityoutcomes for Australian women in the private sector.

The strong association betweenprivate health status in Australiaand the likelihood of a C-section cannot be explained by differences

Table 1Maternity care providers, population and estimated births, Canada 1996e2005.

Primary attendants at vaginal births

1996 2000e2001 2005

Ob/Gyn 56% 61%GPs/family physicians who

practice obstetrics44% 39%

Certified midwives n/a <1% 3%

Source: CIHI. 2004.

in risk profiles or birthing complications attributable to the women(Roberts, Tracy, & Peat, 2000; Shorten & Shorten, 2004). Multivar-iate studies demonstrate that the rise in PHI status is associatedwith a rise in the likelihood of an operative delivery in privatehospitals. An increase in private hospital births occurred from2000,when the full impact of changes to PHI incentives took effect.Additionally, there was a 61 percent increase in elective C-sectionrates for primiparous women in private hospitals between 1997and 2001, compared with a 27 percent increase for primiparouswomen in public hospitals. In other words, the likelihood of anoperative delivery was 2.25 times greater for primiparous womenin private hospitals than those in public hospitals (Shorten &Shorten, 2004, p. 33). Furthermore, “[a]mong low risk women,regardless of parity, private patients ha[ve] higher age adjustedrates of instrumental delivery, especially after epidural. Thesehigher rates of intervention are not associated with improvedperinatal outcomes, but are associated with increased risk formothers” (Roberts et al., 2000, pp. 139e140).

Discussion and conclusion

As we have noted above, there is no static concept of neo-liberalisation; it is a process that encompasses variegation;“systemic geoinstitutional differentiationdas one of its essential,enduring features” (Brenner et al., 2010, in press, p. 3). In otherwords, processes of neoliberalisation are dependent on a variety offactors, develop unevenly, and therefore create geoinstitutionaldifferentiation. Neoliberalisation is thus, like globalization,a ‘syndrome’ that encompasses heterogeneous forms of that existand come into being through their collision with diverse institu-tionalizations based on different geographical socio-politicallandscapes (Brenner et al., 2010). Although the basic tenets ofneoliberalisation are similar in form, the content and its applica-tions differ in time and space. Furthermore, the path-dependencyof neoliberalisation is always partial; it can be solidified in differentways within institutions but it cannot itself as a mode or concept bepinned down. It is patterned and cumulative; a ‘moving map’ ofregulatory institutionalised practices (Harvey, 2005, p. 88).

Because the pathways of neoliberalism are dependent on locationandhistory, it is important to examinenationally specific pathways ofneoliberalisation, which are not merely sustained differently withinnational borders, but includepathways that allowvariegated forms tomove across spatial and national borders. Processes of neo-liberalisation therefore, no matter how they differ, link us.

The cases of the organisation of maternity care in Canada andAustralia illustrate this phenomenon. The importance of suchcomparative work reaches beyond the borders of maternity careand pushes the theory that neoliberalisation theorists set the stagefor. This paper contributes empirically to these types of analyses byoutlining the ways in which neoliberalisation path-dependencyoccurs in contexts that are shaped by pre-existing inequitiesaround professional status as well as gender and other structuralissues. In Canada, regulatory change has involved attempts toundermine physician professional privilege by challenging theirtraditional gatekeeper role in the health care division of labour

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(Coburn, 1993). In Australia, regulatory experimentation hasfocused on bolstering the private health insurance sector anddecreasing the risk of catastrophic health care costs for consumers.As elaborated above, the net effect of both has boosted medicaldominance over maternity care provision, despite a current reviewof maternity services aiming to improve choice and availability ofmodels of care provision (Van Gool, 2009).

Moreover, the resilience of medical dominance inmaternity careillustrates its structural embeddedness (Bourgeault & Mulvale,2006), which is linked to the market-mentality of the processesof neoliberalisation. As we have outlined, Australia is a goodexample in which larger regulatory practices inherent to neoliberalreform lay the groundwork for the continuation of institutionalisedmedical dominance (Willis, 2006). State concepts of market rela-tions contribute to commodifying labour and birth through initia-tives that maintain an obstetrical monopoly over childbearing,enhancing rather than presenting alternatives to medicaldominance.

This is one example of the collaborative nature of medicaldominance and neoliberalisation that presents a challenge for theimplementation of choice and the provision of equitable maternitycare (Sandall et al., 2009). Although Canada is a different story dueto the regulation of midwifery, the low rates of midwifery utiliza-tion remain a problem. Choice itself as a concept is problematic dueto the uneven distribution of maternity care resources based onrural/urban and Aboriginal/non-Aboriginal divides (Benoit, Carrollet al., 2007). Further choice of maternity care provider and placeof birth is not equitable across the country, while the provinces/territories lack cohesion in terms of midwifery regulation, fundingand legal standing. The consequences of inequality in maternitycare, and the challenges to rectifying these problems, presenta difficult situation for childbearing women and their families. Theimportance of choice and autonomy in the birthing process is welldocumented, as are the consequences in terms of maternal post-partum health (Benoit, Westfall, Treloar, Phillips, & Jansson, 2007).By fleshing out the relationship between neoliberalisation andmedical dominance through comparative analyses of countries thatare similar in structure, we take an important step in evaluatingpossible solutions to the implementation of true choice and equi-table maternity care.

In conclusion, neoliberalisation is neither monolithic, norhistorically inevitable; more importantly, it is not necessarilycounter opposed to medical dominance. In fact, at least for our caseexamples, there is evidence of an elective affinity between the two,hidden beneath principles of ‘choice’, ‘reflexivity’ and ‘patientcharters.’ This neoliberal rhetoric of consumerism provides thejustification for the continuing hegemony of medicine over mater-nity care in Canada and Australia. It would be beneficial to investi-gate the recent history of medicalisation of maternity care in otherhigh-income countries using our analytical perspective, aswell as toexplore counter-neoliberalizing forms of regulatory restructuring inthese countries and their impact on medical hegemony.

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