“Labels” and “birth plans” Euphemized forms of competition in the field of perinatal care

As the number of maternity units continues to fall, through the concentration of technical facilities and the decrease of hospital beds, the organisation of the work of professionals in public and private health facilities is being radically altered. The reduction in average length of stay has led to an intensification of work for staff and a decline in the capacity to receive patients. The sector has also been marked by reports of abusive treatment, denounced as obstetrical violence by women's associations and patients’ groups. In this context of concentration of obstetrical activity, shortage of staff and criticism of professional practices, the main challenge for health establishments is to attract pregnant women to ensure the survival of their wards. Our qualitative survey, based on in-depth interviews with midwives, physicians and patients in public and private maternity wards, highlights the converging effects of the decline in public funding of perinatal care and the development of competitive trends between maternity services: the development of so-called “humanisation of childbirth” practices is intended to respond to social demand for greater attention to be paid to mothers' preferences, but the certification of these practices in the form of “labels” leads us to see them as part of strategies for the expansion and maintenance of clienteles by health establishments. Following social scientists analysing the emergence of health capitalism, we show the instruments and practices by which capital is deployed, not only in the annual budgets of health establishments, but also in the actions, demands and choices of staff and users. We have shown how the competitive space of private maternity hospitals leads professionals to turn ordinary goods into rare commodities, in order to recruit and maintain a clientele of women from the dominant classes. By extending the analysis to public maternity hospitals, we show that the competitive logic does not spare the public sector, and takes on new forms there: differentiation of supply is not sanctioned by the market, but certified by the state, in the form of certification of practices deemed innovative (through “labels”) and the development of institutionalised forms of requesting women's demand (through “birth projects”). The result is a specialisation of maternity services according to their public.