UPPSATSER:
Kulturgeografiska institutionen
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No Care for Distance
The (Market) Logic of Regionalizing Maternity Care
ABSTRACT
Westin, M. 2017. No Care for Distance – The (Market) Logic of Regionalizing Maternity Care. Kulturgeografiska institutionen, Uppsatser, Uppsala universitet.
A wave of maternity unit closure is sweeping through the North Atlantic zone, leaving rural communities without the care they crucially need. In its wake resistance grows, mobilizing against closures in the face of a discourse of economic efficiency and neoliberal austerity. To understand the issue, research on maternity care and geography offer useful insights on the particular costs and consequences of losing access to care but is less useful for engaging the causes behind them. Not suffering from a lack of critical engagement, Marxist theory enables the wave to be understood in terms of changing political incentives and the ways these have come about. The present essay brings the two fields together in an effort to aid local resistance in rural communities, concluding that regionalization does not operate on a logic of its own as is otherwise stated but on the logic of markets, imposed on governments by the neoliberalization of the Western world and beyond. The essay aims to provide the political-economic framework needed to confront the logic of markets, neoliberalism, and the capitalist political-economic system that underline the closures..
TABLE OF CONTENT
1. INTRODUCTION ... 4
1.1 Maternity Care Struggles ... 4
1.2 Providing a Framework ... 5
1.3 Literature, Analysis & Applicability ... 6
2. MATERNITY CARE, A MATTER OF DISTANCE ... 8
3. MARXIST NARRATIVES, CONCEPTS AND FRAMEWORKS ... 10
3.1 Social Reproduction & the Keynesian Welfare State ... 10
3.2 Neoliberalism & Market Logic ... 15
3.3 Critical Frameworks ... 20
4. THE ANNIHILATION OF SPACE BY TIME ... 22
5. CONCLUSION ... 27
6. REFERENCES ... 29
6.1 Literature ... 29
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1. INTRODUCTION
1.1 Maternity Care Struggles
In early 2017, struggle over plans to close the maternity unit located in Sollefteå, Sweden, broke out of the local news cycle and into national, as well as international, attention (Branford 2017). The struggle had been ongoing since before more widely-read media begun reporting the events but by the time they did the consequences of the closure had already started to manifest. Since the maternity unit initially closed in February of 2017 three children have been born in vehicles headed for the second closest maternity unit some 100 km away. The fears of the local protest movement had become reality and the previously initiated occupation of the by then closed maternity unit became even more galvanized, receiving messages of solidarity from all over Sweden.
Outside of the media spotlight, other rural communities were caught up in similar struggles. A letter to the editor in a paper local to Karlskoga told of fear experienced by staff at the local maternity over policy-restructuring hinting at the imminent threat of closure (Karlskoga Tidning 2017). Inspired by the reinvigorated debate over maternity unit closures another article was published in the local newspaper in Mora appealing for the reopening of the maternity unit local to Mora, which previously closed in 2009 (Sacrédeus 2017). In parallel, the decisions to close local centers for obstetric and gynecological care for summer have been sparking outrage in both Nynhäshamn and Hudiksvall, geographically separate as they are (Olofsson 2017; Skoglund 2017).
Just a few years earlier, in 2013, the institute of contemporary history at Södertörns Högskola held a witness seminar at the annual Swedish politicians-week in Visby titled: “When did Healthcare Become a Market?” (Abiala 2014). At the seminar, a few select experts from different fields participated in a discussion on the restructuring of healthcare in Sweden in regard to marketization and the adaptation of market logic to its internal workings. In the transcript of the seminar, the pressure of the political climate during the 80s (mentioning Thatcher and Reagan by name) is said to be the catalyst of marketization in Sweden. Furthermore, the Social Democratic Party of Sweden is described as having felt that it had to make a preemptive move to compromise rather than risk losing power to the right-wing parties and their radical neoliberal platform.
The contours of larger historical and geographical processes can be gleaned from the above. A process involving not just a shift of political thought but rather a contest over power and resources involving representatives of established institutions of political power, their would-be challengers and the people subject to their power. Furthermore, the mention of marketized state functions carries the important suggestion that the understanding of state and market as interactive-but-separate spheres is less than optimal. Instead, state and market ought to be seen as parts of the very same political-economic system.
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rather an ongoing thread and a force underlying and driving the actions of actors past and present.
It is easy to get lost in the vivid details of the present at the cost of the historical and geographical context (Farmer 2004). Without a broader view, local struggles remain local, resistance becomes pegged on symptom and accountability stops at the local town hall (or at best the current government). Further so, while overarching relations of power remain in place behind the scenes ever continuing to produce consequences even as the present situation is dealt with. The present essay will try to bring about such a perspective – geographically broad and historically deep – aiming to lift the veil of political discourse, connecting past to present and local struggle to global capitalism.
As a point of departure, the literature on maternity care and geography describe an ongoing wave of closing rural maternity units throughout the western world, causing harm and steep costs to the communities touched by it.
However, the same literature is seemingly reluctant to address the political nature of the wave even as it lays out the consequences. When the writing does address policy decisions its criticism is in regard to insufficient study or lack of planning, going so far as to suggest that politicians are sleeping on the issue and that “It is time for creative solutions (...)” (Sutherns & Bourgeault 2008). However, they do not confront the political framework that the wave of closures is taking place under, nor the motives of the politicians they appeal to. Throughout the articles within the field, there is very little in way of serious engagement with the possibility of a connection between the profound restructuring of public policy in recent time and the sudden scarcity of resources for rural maternity care formerly in operation.
The presumption of a benign political order and the absence of critical engagement with covert assumptions of public discourse severely limit any capacity to uncover the harmful tendencies present throughout the current political-economic system. Free from such limitations the present essay argues that the violence caused to rural people is neither anomaly nor economic fact but the outcome of the inherent contradictions of capitalism.
Further, the essay will argue that a set of connected tendencies inherent to capitalism – its particular shape under neoliberalism, its vagabond nature, and the ever-present drive to accumulate surplus value – are central to explaining and engaging the present wave of maternity unit closure, especially as it applies to rural communities.
1.2 Providing a Framework
The aim of the present essay is to create a political-economic framework from which to understand and engage with the ongoing wave of maternity unit closures in Western contexts. To guide the essay towards its aim, the following questions are sought to be answered:
What is the origin and function of modern maternity care under capitalism?
In which ways have the incentives of governments changed with the rise of neoliberal ideology and how do these align with the needs of rural communities?
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1.3 Literature, Analysis & Applicability
The material of study in the present essay is the literature working in the intersection of maternity care and geography. On the one hand, the literature and its findings provide an understanding of the medical and geographical aspects of maternity care. On the other hand, the skewed political perspective in the very same literature is what the essay needs to break down analytically and replace to fulfill its aim.
Dealing with any material, the task of the researcher is to assert whether the information given is accurate or not (Gilje & Grimen 1992). As this is an essay on social science the assessment of advanced medical literature and the information within has been undertaken through a comparative evaluation of which claims are in consensus and which are in controversy.
Lacking initial knowledge of the field, the present study used the pattern for searching out literature suggested by Alan Bryman (2008). Working from a few estimated keywords an initial batch of literature relevant to the study was found. The review of the first few articles served as a stepping stone for continued reading, hinting at more relevant keywords and staking out a path forward. In the second round of literature collection, attention was given especially to articles referenced throughout the initial sample as these were more likely to be central to the field.
Furthermore, articles already synthesizing health and geography were given priority over articles discussing one or the other. The motivation behind this decision was to avoid having to deal with the complex and perilous process of unifying the two fields without the experience or tools to do so. Models for combining data on geography and health have been suggested (see Mitchell et al. 2002). However, in the present essay expert work has when possible been left to experts as the risk of misconstruing facts and making the wrong connections were deemed to greatly outweigh any gain imagined to be had from building an original understanding.
Returning to the discussion on information contra perspective, Gilje & Grimen (1992) note that the latter is equally an area of engagement for social science as the former. The perspective of interest in the studies on maternity unit closure is the political framework used contextualize the findings. Further, the main undertaking of the essay is basically to analyze and break down the political perspective assumed within in the material it studies and recontextualize the findings within a political-economic perspective more apt at providing useful insights.
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of policy implementation and clinical outcome to critically engage the political-economic system as a whole might be better left for another time.
To continue, it is well established that configurations of space and geography are relevant to Marxist study and Marxist study in turn to discussions of spatial injustice and the capitalist discourse and practice that causes it (Swyngedouw 2000). Marxism provides the tools to ask what is meant by ‘lack of resources’ in the studies of closing maternity units. Further, Marxist studies provide a thorough and compelling historical narrative which offers both a context for and an understanding maternity unit closure. Finally, Marxism, more than anything else, introduces a discussion of relations of power severely missing in the material of the essay.
Two themes developed in Marxist literature are of particular relevance. The first is the Marxist study of the different shapes capitalism has taken (both material and social) over its history. From capitalism's initial form up till the middle of the 20th century, through the era of the Keynesian Welfare State all the way up to its current configuration: Each era has features unique to them equally as they are contingent on their predecessor. An understanding of any one of them hinges on this conclusion. The second theme is the Marxist discussion of social reproduction, underlined and supported by feminist writing. The concept of social reproduction is, in turn, crucial to understanding maternity care and will be discussed accordingly.
The writing on these two themes overlap extensively and ought to be understood as inseparable. Indeed, social reproduction is hard to analyze in Marxist terms outside of historical processes and the historical processes are in turn always underlined by social reproduction, whether explicitly stated or not.
There is, however, a slight mismatch between the Marxist literature on neoliberal capitalism and the study of rural conditions. A large chunk of the relevant literature on neoliberalism is to the point of exclusion focused on urban contexts. Further, the literature that directly addresses neoliberalism in a non-urban context is primarily concerned with agriculture rather than rural life in general. However, the essay still argues that the findings on urban neoliberalism are very much applicable to rural developments.
Essentially, what the literature on neoliberalism describes is how a set of political practices have changed and that following these changes a particular urban configuration has been formed. The cities in which these changes are described, i.e. where the political changes take place, also act as a seat for governments, businesses and other powerful actors. The key to arguing that urban studies of neoliberalism are applicable to rural phenomena is the conclusion that the reach of political power does not end at the city limit. Furthermore, even the idea of a city limit, or where the urban ends and the rural begins, is not exactly clear.
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Further, there are two sources of credibility for the claim that the conclusions in the present essay are relevant for understanding developments in Sweden and any other particular country mentioned in its material.
First, cross-national research on health and medicine is an important and useful tool for developing and understanding policy (Bauer & Ameringer 2010). However, proving the relevance of any particular comparison takes a lot of time, resources and expertise and is therefore impossible within the bounds of most research projects.
To sidestep the need for each and every study to make an argument for its comparison, researchers have taken upon themselves to create general frameworks for cross-national comparative studies. The present essay will use the framework provided by Bauer & Ameringer (ibid.) which is built on sorting countries into clusters by statistical similarity. In the paper, a large number of variables on health found for and comparable between most major countries is presented and analyzed. From the data, six clusters of countries with similar statistics on general health as well as infant and neonatal mortality were found. Although limited to clustering countries by similar outcomes, saying nothing about the causes, the similarities provide a baseline for comparison adequate for the present study.1
Second, for all the differences and particularities of Western countries capitalism and in turn neoliberalism are distinctly universal in their tendencies, expanding and embedding themselves rapidly while shifting capital power beyond the reach of any particular state. And in turn, becoming exceedingly hard to resist for the very same. Case in point, Sweden (the bastion of social democracy) is brought up regularly in Marxist writing as the foremost example of how universalized neoliberalism has become (see Brenner & Theodore 2002; Harvey 2005).
Finally, with the discussion of how the material of the essay has been approached and the applicability of the conclusions made, the chapter on methodology is concluded. Following it, the findings of the literature on maternity care and geography will be conveyed in the next chapter, before in turn moving on to the Marxist literature in the chapter after that.
2. MATERNITY CARE, A MATTER OF DISTANCE
There has been a wave of rural maternity units being closed down in Europe as well as North America and Australia over the last couple of decades (Grzybowski et al. 2011; Pilkington et al. 2008; Tracy et al. 2005). Further, studies carried out with comparisons to the European wave of closures have been carried out in Japan finding many similarities (Koike et al. 2016). Moreover, analogous studies of developments have been carried out in Scandinavian countries such as Finland and Norway (Schmidt et al. 2002; Viisainen et al. 1999).
1 The countries studied in the research material referenced in this essay all belong to the same cluster of
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The foremost conclusion of the literature combining the study of medicine and geography is that distance matters. Lengthy travel to hospital increases the risk of adverse outcome for pregnancies (Grzybowski et al. 2011; Ravelli et al. 2006). The longer distance is also a disincentive to access advanced care, i.e. when given the choice between traveling further and accessing less advance care people choose the latter (Pilkington et al. 2010). It may also cause people to skip prenatal care meetings due to the time and money required to access the care (Sutherns & Bourgeault 2008). Beyond the costs, having to travel far to maternity care increases the risk of unplanned out-of-hospital births (Blondel et al. 2011; Viisainen et al. 1999). And in turn, unplanned out-of-hospital births cause a significantly increased rate of child mortality (Campbell et al. 1984; Bhoopalam & Watkinson 1991). Lastly, studies have found that increased distance to the closest maternity unit, beyond increased risk, causes stress and psychological harm to people in rural communities (Kornelsen et al. 2011).
The medical consideration behind closing small rural maternity units is that better safety can be ensured at large hospitals which are better equipped and have a staff of specialist on hand (Pilkington et al. 2010). The shift from a lot of hospitals serving smaller catchment areas to fewer hospitals serving larger catchment areas is referred to as regionalization. The argument is that although small maternity units might be well equipped to handle low-risk births and common complications during delivery, they cannot guarantee patient safety during more difficult deliveries and when dealing with unusual or particularly difficult complications.
However, there are articles in the field that contest the wisdom and generalizability of the above claim. For example, a prospective study carried out in Norway over two years came to the conclusion that while the claim that larger hospitals provided better care was true for high-risk pregnancies the larger group of low-high-risk pregnancies suffered more increased high-risk from the prolonged travel than they gained from better care (Schmidt et al. 2002). Further, the Norwegian study questions prioritizing extra safety for every child-bearer over accessibility when high-risk births can be anticipated with accuracy during prenatal care. They conclude that the marginal increase in safety for the general population is overshadowed by the risks caused by increased distance. In parallel to the discussion in the Norwegian study Tracy et. al (2005) come to a similar conclusion in their study of Australian maternity closure. Beyond the similar conclusion, the Australian study summarizes knowledge on how hospitals tuned for high-risk pregnancies affect low-risk cases, noting that advanced treatments risk being counterproductive or harmful when imposed uncalled for. 2
Besides the documented effects of increased distance to maternity care, the findings of certain studies questions whether regionalization necessarily leads to an average increased in distance. Pilkington et al. (2008) found that the overall minimum distance to maternal care decreased slightly over the period of 1998 and 2003 when studying regionalization in France. At the same time, they also observed a slight decrease in the number of care facilities within 15 km of people in average. However, the number of people in urban areas and areas moderately affected by closures with a trip of 45 minutes or longer to a care unit decreased
2 Suspicious of clinical literature dismissing wishes and fears of patients on basis of common-sense within the
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over the same period. Further, they note that even in regions heavily affected by closure the travel time to the closest maternity unit stayed about the same even as the distance increased,
Another positive experience with regionalization has been noted in Portugal (Neto 2006). In the study of the Portuguese healthcare system, it was concluded that regionalization has been paralleled by a significant improvement of the healthcare in general. Further, the study mentions that even while closure of local maternity units has been heavily contested there have been resources allocated specifically to mitigate the adverse outcomes of increased distance. The Nationwide Neonatal Transport System, basically an ambulance service specialized in stabilization and transport during or immediately before delivery, is brought up as a particularly successful example of such a measure.
However, even in countries with an overall positive or neutral outcome of regionalization the average change is of little console to the communities negatively affected. Which is to say that although the changes affecting an underserved community can seem to be balanced out statistically by improvements in other regions it is of little help to the people actually losing access to care. Grzybowski et al. (2011), for example, point out that already socioeconomically vulnerable rural people see the harshest consequences of losing local maternity care, a finding backed up by Sutherns & Bourgeault (2008), Kornelsen et al. (2011) as well as Tracy et al. (2005). Therefore improvements to general conditions, combined with a parallel flight from underserved areas, risks hiding the harm still caused to the people left behind.
In conclusion, regionalization has in most cases lead to less accessible maternity care and in turn adverse consequences for people affected by it, whether it be in the form of increased costs or risk. Further, the reasoning behind regionalization has lacked consideration of the risks and gains associated with increasing distance to care. Some examples point to successful attempts at regionalizing maternity care but these have in turn either required specifically allocated resources or been unable to account for particular outcomes. It is for these findings the essay aims to create a new political-economic framework of understanding, beginning in the following chapter with a description of the societal function of maternity care and the origin of the welfare state.
3. MARXIST NARRATIVES, CONCEPTS AND
FRAMEWORKS
3.1 Social Reproduction & the Keynesian Welfare State
Humans, as any organism, have always needed to find ways to reproduce themselves. Reproduction would seem the driving force of life and all but a compulsion for any living being, humans not excluded. However, being born itself does not a human make (Berger & Luckmann 1967). Rather humanness is social quality manifesting through interaction between humans. Essentially, we learn what we ourselves are and what we ought to be through others.
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socialization and is the way that social skills, social practice, norms, culture and all the other tools and preconditions required to be a human being within a particular society are acquired. Throughout the process of reproducing and socializing new human beings, there is a need for the production of material resources to facilitate the aforementioned process. “Resources” is here used as a broad term referring to sustenance, shelter, tools, care for sick and wounded and waste disposal, to name a few. The particular way such resources are used within a society vary. Many societies have made due without our modern form of health care or permanent shelter and still lasted generations on end. Rather than universal or a pre-given, the resources used and considered needed by a society are bound up in its social structure, internal dynamics, and history.
Reproduction then has both material and social aspects that are tangled up with and shaped by each other. To be able to refer to both of these aspects as well as their implied interconnectedness the term “social reproduction” is useful. Marxist scholars have used this term to discuss the ways in which not only humans but specifically the labor force, is reproduced. Bezanson & Luxton (2006), for example, use social reproduction to refer to everything having to do with humans reproducing themselves and the production of the resources they need to do so, both on a daily short-term basis and on an intergenerational long term basis.
To expand the above, Cindi Katz (2001) provides a dual perspective on social reproduction which is helpful for fully visualizing the concept. She tells us that social reproduction is always located in the everyday life of people in complex and distinctly physical ways while also made up of a set of highly structured social practices. That is, social reproduction is on the one hand performed by actual human bodies doing sweaty and dirty work throughout every aspect of their life but is on the other hand structured by norms and institutions within the society that those bodies exist. Doing the dishes for the whole family every night is a toil vividly present in the life of the person scrubbing, but why the task has been put to them in particular and which tools are available for it is decidedly dependent on the society in which they live.
Katz’s double perspective indicates that: Firstly, social reproduction is “life’s work” (Mitchell et al. 2004 in Meehan & Strauss 2015). Even though social reproduction is often seen as non-work, it should not be understood as an adjunct to value producing labor, but rather as co-constitutive of capitalism as a socio-economic system (Meehan & Strauss 2015). Cleaning dishes is work, going to get groceries is work and giving birth to and raising children is work. And while life’s work has markedly seldom been rewarded as such, accumulation of surplus value under capitalism would be untenable without it. Social reproduction is a continual labor taking place in every part of people’s lives, together and in parallel with the wage labor they might otherwise perform. Secondly, while personal, disordered and messy, social reproduction is structured by cultural practice which is both geographically and historically specific (Katz 2001). The norms and specific ways things are done in a certain place, as well as the societal institutions present, shape social reproduction at any given time and place.
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particular to this era and these regions that the essay aim to discuss and analyze. As has been stated above, the function of social reproduction within the capitalist system has in Marxist analysis been formulated as the reproduction of the labor force, the function that ensures that workers turn up at the factory at the beginning of the day (Meehan & Strauss 2015). This is not to say that people would stop having and raising children, let alone securing food or shelter for themselves, were it not for capitalism, but rather that these processes have been appropriated and directed towards the needs of capital within this historically specific context.
While children would have been raised no matter, it is crucial to recognize that children born under capitalism are raised and preconditioned specifically for a life of wage labor or the exploitation of such for profit. Socialization is hinged on social relations and under capitalism, social relations have been turned into material relations.
The material relations between people (alienation), in turn, shape the very form of social reproduction under capitalism. Alienation is, of course, a general feature of capitalist society, affecting the life and relations of humans both within and outside of the sphere of social reproduction. A feature of human society that will remain true as long as a significant portion of society is subjected to commodification alienation will be a factor in human life.
However, alienation has particular effects on functions of social reproduction. Parents selling their children into wage labor is an extreme of such an effect, a particularly brutal expression of the material relation between kin and a view of how social reproduction can be directed toward the generation of profit under capitalism. In reverse, children letting their elderly parents fade away alone due to the pressure of work is another extreme of how social relations have turned into material ones and alienated people from their humanness. At the extremes, we see the processes of social reproduction tearing at the seams, but between them lie a spectrum of subtle and varying effects of alienation in the everyday life of people, effects such as social relations continually being drained by time and energy spent at work and personal well-being forced into subordination to productive performance. Alienation turns workers into naught but anonymous labor power sold for profit and the social reproduction they still perform is for the purposes of capital nothing but the reproduction of equally alienated workers defined not by their humanness but by their labor.
Before moving on from the historical specificness of the capitalist system to the specific and differentiated geographies it creates, it has to be repeated that anywhere we find humans there will be social reproduction in some form or other to sustain them. The resources with and conditions under which they get to do so, however, vary according to climate, culture, and history. That societies and their form of social reproduction vary is certainly not unique to capitalism as a historical system; capitalism does, however, organize the geography over which it reigns in uniquely and radically uneven and unstable ways (Brenner & Theodore 2002).
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differentiation as the social and material practice of any region will continue to be bound up in its culture and history.
However, as capitalism ever expands certain tendencies central to the exploitation of wage labor for profit expand with it. Features of capitalism seemingly have the ability to seep into or force themselves onto any society or culture. For example, the introduction of property and land-ownership laws, the commodification of goods used for social reproduction that follows and in turn wage labor becoming the only feasible and legal way to acquire these goods. And wherever these features become embedded, the particular structures of dominance and exploitation they create follow, whether it is dominance and exploitation between locations or classes. Whatever the specifics, it is the processes of dominance and exploitation as well as the mobile nature of capital that decide which group of people get to live in opulence and stability and which group of people get to live in poverty and precarity.
Intergenerational reproduction in the modern institutionalized form of public maternity care, seen in countries such as Sweden, should be understood as social reproduction specific to both the place and the time it exists. Further, advanced maternity care is not specific simply to capitalism as a historic system, which is apparent from the varying, although distinctly patterned, rates of child mortality around the world (see Bauer & Amering 2010). For its short-term survival, capitalism seemingly has no specific preference for the way its labor force is replenished. As long as the required number of workers are ready and able for work, the child mortality rate and quality of care are all the same to the accumulation of capital in the intermediary. However, the shape of social reproduction is never the product of capitalism alone but rather a complex and contested process with many different factors.
For one there has been a burst of technological development and professionalization during the 20th century, or rather modernity (Giddens 1991). With modernity, among other things, tasks previously performed according to local knowledge and tradition were externalized and turned into systems of structured expert knowledge completely abstracted from their places of origin and the people using the knowledge. The expert systems of modernity made it so that it was no longer experienced women within the community or local midwives who helped deliver children but rather licensed professionals using standardized tools and methods within the walls of established clinical institutions.
Along with the process of modernization came struggle over the benefits brought by technological developments and science. The improved life quality and conditions of social reproduction had to be distributed and the way they were distributed had to be negotiated. To understand this negotiation Bezanson and Luxton (2006) note that responsibility for the provision of different resources and tools used for social reproduction is never locked in place, rather it can fall to a variety of actors and institutions. Historically the responsibility has fallen along patriarchal tradition on the shoulders of women (Fraser 2016). Although, obviously, women are not the only ones participating in social reproduction (Meehan & Strauss 2015).
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War, contrasted with the quality of life modernity enabled for others, causing an uproar among people both within and outside of the working class. It became apparent that the conditions of working men, women and children were so destructive as to threaten to grind the processes of social reproduction to a halt. With the future labor pool under threat, the whole mode of production was at risk. Except by radicals such as Marx and Engels, it was however not formulated as a threat to the capitalist economic system but rather as the ‘destruction of the family’ (Fraser 2016). If nothing else, the struggle and negotiation over social reproduction had been reignited.
Viewed whichever way, the acute tension between exploitation of workers and social reproduction, along with mutually devastating wars and economic stagnation, followed by rampant unemployment, combined to cause an intensification of class conflict during the early 1900s throughout most of the North Atlantic zone. This state of unrest, with the Russian Revolution as a backdrop, paired with growing social movements for the recognition of women's rights and salvation of the working-class family, forced the ruling elites of Western countries to act. A proactive move to appease the discontent masses was seen by the elites as preferable to the discontent masses acting to appease themselves.
The fix to all these problems seemed to lie with the ideas of John Maynard Keynes, and within his writing policymakers found the solution to the stagnating economy. The economy was to be kickstarted by infrastructural projects benefiting large-scale industry and to carry out these projects previously unemployed workers were given work and a wage, which in turn increased domestic demand, securing economic growth for the time being. Further, by improving the conditions of workers the state sought to build an educated and motivated labor force useful for production within the fordist industry, thereby partly removing the tension between social reproduction and capital accumulation.
The ideology behind the new policies came to be known as Keynesianism. They had initially gained popularity during the depression of 1930 but rose to become the new economic paradigm as the leading principle for rebuilding and stabilizing western states after the Second World War (Harvey 2005). This way, from the 1950s onward, Keynesianism came to be implemented in various ways in all advanced industrial countries. However varied, the policy which Keynesianism inspired was signified by social security incomes, public health care, housing projects and standardized education (Painter 2000). The collective goal of these measures was to enable and encourage mass consumption, which in turn would lead to increased turnover of capital (Jessop 1997). Increased employment and increased consumption played into each other and enabled a golden era of industrial growth. These factors, in combination with technological development and the pressure of progressive social movements, enabled larger parts of the western labor force to raise their standard of living to the same standard of the previously relatively small but privileged middle class (Katz 2001).
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al. 2008). A similar shift happened in Finland where 50% of births were taking place at home in 1945 a rate which went down to 1% by 1965 (Viisainen et al. 1999). And another such shift in England and Wales were rates of home births went from 85% in 1927 to 1% by 1982 (Campbell et al. 1984).
The struggle and contest that brought these changes are not unique to the shift from early industrial capitalism to the state-managed capitalism of Keynesianism. Rather, responsibility for social reproduction always changes hands through struggle (Katz 2001). However, the playing field of the struggle over social reproduction is never even. People, rather than states or corporations, will always need to reproduce themselves and when either private or public actors discontinue services supporting or facilitating social reproduction people still have to make due. Responsibility for social reproduction always reverts to the people (ibid.).
In final, a brief summary is called for. First, social reproduction denotes a wide array of processes, each a small part of the continual survival of human society. These processes are constituted by the human labor of biological reproduction, socialization of children as well as material reproduction of food, shelter, and healthcare (Katz 2001; Meehan & Strauss 2015). Second, social reproduction is not unique to any economic system but the essential constitutive process for the survival of any human society. However, the specific shape of social reproduction at any time is heavily influenced by its historical and geographical context and any economic system that reigns within that context. Third, up until the 1970s, responsibility for certain key aspects of social reproduction was held by the state throughout the North Atlantic zone. A particular configuration achieved by a combination of struggle and the drive of capital interests to survive the crises they had previously caused. This particular configuration of state-managed capitalism is referred to as ‘Keynesianism’ and the particular combination of policies it underlined ‘the Keynesian Welfare State’. Fourth, maternity care provided and funded by the state and delivered through professionalized institutions is the particular way that intergenerational social reproduction has come to be constructed in the west over the last century by a combination of technological development, struggle and capitalism's internal dynamic and tendency for crisis. Fifth, social reproduction is always a field for struggle, whether within or between particular societal configurations.
3.2 Neoliberalism & Market Logic
The Keynesian Welfare State was not to last. By the end of the 70s, a combination of factors spelled out that the days of Keynesianism were numbered and that its successor had been chosen. The underlying factors were the unsustainability and tendency for crisis particular to Keynesian capitalism, but the catalyst was a deliberate push by the rich and powerful to restore the previous balance of class power that had been disrupted during the Keynesian period (Harvey 2005). Three main features of this change are of interest to the present discussion: Neoliberalism, the leading ideology of the change, The Schumpeterian Workfare Regime, the present iteration of capitalist society, and entrepreneurialism, the mode government, or rather governance, the change it brought with it.
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reproduction. The concept of neoliberalism is nebulous: it is both an ideology and at the same time a political practice, which do overlap even though they often diverge from each other. Further, both the ideology and the policies that spawn from it are highly adaptable to the circumstances they find themselves in. To clear the confusion and differentiate between the ideology and the political practice, Brenner & Theodore (2002) differentiate between neoliberalism as an ideology and “actually existing neoliberalism” (making them into useful tools for analyzing the current configuration of capitalism).
The ideology is defined by its assertion that there is no better way to create economic growth than through competitive markets free from regulation and near all forms of state intervention (ibid.) Neoliberalism also proposes to extend competitiveness and the logic of markets into the realms of the public as well the social. It has underlined a move away from the collective toward the individual, a shift conceptualized as the realization of the values of human freedom and dignity (Harvey 2005). This extension of market logic has caused profound changes in social relations, societal structure and not least the conditions of social reproduction, a theme which will come to echo throughout every aspect of the following discussion.
The basis for the utopian vision of a market society free from state regulation and the constraints of collective needs was written by economists such as Friedrich Hayek and Milton Friedman in the period following the second world war (ibid.) It was initially field tested in what David Harvey describe as brutal experiments in the periphery, signified by Pinochet's CIA-backed coup in Chile, and was by the late 70s ready for a pragmatic implementation in western contexts. The latter implementation of neoliberal policies was spearheaded by the policies of Thatcher and Reagan and formulated as an aggressive attack against the old program of Keynesianism and everything it stood for. It was portrayed as a reaction to the recession of the past decade, where Keynesianism and the fordist model of industry it underwrote literally ran out of gas3. And as with its introduction, the era of Keynesianism came to an end by economic crisis and the victorious struggle by radically invigorated right-wing groups over social democratic parties and unions who had grown comfortable and weak from half a century of power.
However, neoliberalism didn’t appear overnight to clean the floor and manifest itself in its final form. Indeed, actually existing neoliberalism seems to lack any concrete “end-state” (Brenner & Theodore 2002). Rather the expansion of the real-world policy of neoliberalism is more akin to a process of continual transformation than an organized move toward a defined goal. Therefore, Marxist scholars such as Peck & Tickell (2002) argue that the ideology of neoliberalism should be understood by its real-world operations, neoliberalization, rather than the other way around. They also stress that even though neoliberalism is at work throughout the world it is highly contingent on the context which it finds itself. That is to say that the particular processes of neoliberalization vary according to the state or region it is acting upon. The path that neoliberalization takes is dependent on the path of past and present policy, praxis, and government in any particular location.
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There are however some general features to neoliberalization that are important when trying to understanding the massive restructuring of capitalist society that has taken place throughout the world over the last 30 years. Neoliberalization is often recognized by its drive to roll back the bureaucracy and state functions typical of the Keynesian Welfare State (Jessop 2002). The rolling back usually consists of slimming down bureaucratic structures, cutting down social security programs, privatizing services previously in the hands of the state as well as doing away with regulations seen as holding back the development of business. The way this process of change has been conceptualized is the idealized binary change from a Keynesian welfare state to a Schumpeterian Workfare Regime.
The binary of the Keynesian Welfare State and the Schumpeterian Workfare Regime is proposed in parallel by Bob Jessop and Jamie Peck (both in Painter 2000). The Schumpeterian Workfare Regime emphasizes supply side activities rather than the management of domestic consumer demand which was the typical method of the Keynesian Welfare State. In broad strokes, the Schumpeterian Workfare Regime could be viewed as a concept synonymous to actual existing neoliberalism.
Whichever term is used, the political policy now came to prioritize the needs of producers and their markets over consumers and the social sphere. The basis for providing state aid changed along with the above change of priority. Citizens now started to receive aid on the basis of reciprocity and ability to work rather than entitlement or need. Welfare went from being viewed as essential redistribution of wealth to a dependency that people got stuck in rather than were crucially helped by. The role of the state and its agencies then became to free individuals from this dependency and in return for the emancipation give in to total flexibility and live in complete attentiveness to the needs of the labor market.
However, even while social security was taken away from those less able to pay and privatized, it remained available in commodified form for those with the ability to pay (Fraser 2016). With the withdrawal of state services from the realm of social reproduction, responsibility once again fell back to families and communities. At the same time, the family wage of the previous era had been done away with, realizing women's liberation from economic dependence even as this achievement was subverted by capitalist interests to expand the productive labor force. Women now at an increasing rate went into the wage labor market while still, by and large, responsible for social reproduction within the domestic sphere. But as social reproduction could be commodified just as well as anything else the fix to this discrepancy, for those who could pay, was to outsource the labor to others. For women, outside of the upper moneyed segments of society, however, these changes usually amounted to a total increase in labor rather than socially reproductive labor being traded for value-producing labor.
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money or babysitters needed for trips to the hospital add up to the extent that some women skip or risk having to skip prenatal check-up meetings. Regardless, all of the women in the study, and especially those who cannot afford travel to nonessential check-ups, pay dearly for the distance to the closest maternity ward whether it is with their money, time, health or social life.
Geographical differentiation, as exemplified by the rural-urban divide, is not a feature particular to neoliberal capitalism (Brenner & Theodore 2002). The differentiation has however become exaggerated by the process of neoliberalization. As a part of the destruction of the Keynesian system, the compensatory redistribution between regions it had put in place was increasingly discontinued in the favor of competition and jungle law (Peck & Tickell 1994). While accelerating geographical differentiation the rolling back of equalizing functions and state support was seen in opposite as creating the motivation failing regions needed to seek capital from private investors instead.
Competition became imperative not only between the urban and the rural but on a global, national as well as regional scale. The temporal reduction of competition between cities and local states in the North Atlantic zone during the Keynesian era had come to an end and taking its place was a new regime of entrepreneurialism (Harvey 1989b). Competition had under Keynesianism been held at bay by highly bureaucratic managerial forms of government. The ideology of the time suppressed the need for competition by means of centralized power, bureaucratic norms and the implementation of universal standardizing programs (Painter 2000).
As these equalizing functions were discontinued local governments once again found themselves having to fight for their continued existence, a change which Harvey (1989a) famously has described as the shift from managerialism to entrepreneurialism. With this shift, local governments now needed to both collaborate with and even act as if they were private firms on a market. Cities and municipalities suddenly had to behave in entrepreneurial ways to survive. They had to advertise themselves either directly to potential investors or through events and branding campaigns to attract business. These new activities often had to be carried out in cahoots with local elites and businesses as local governments found their power diminished by the forces of increasingly mobile capital, downscaled state services, and fiscal austerity.
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The re-introduction of competition combined with the commodification of social services brings us back to how market logic has spread through spheres of life and politics previously considered alien to market exposure or commodification. The idea that market and state do and should not blend is canonical to neoliberal ideology which asserts that state and market are polar opposites (Brenner & Theodore 2002). Such an assertion can hardly be taken at face value as state intervention to the benefit of markets and capital has been a regular feature of actually existing neoliberalism throughout its existence. States have time and again come to save neoliberal capitalism from its own crises by for example bailing out financial institutions at the cost of stern austerity for the general population. Even military action in the services of free markets has been a part of global neoliberalization as with the invasion of Iraq and ‘liberation’ of its resources for US interests (Harvey 2005). How separate the spheres of state and markets actually are might come down to semantics as states certainly have adapted to the needs of markets and the practice of the actors on them.
A particularly insidious feature of neoliberalization is that it does not confront existing systems of regulation and policy as an alternative system but rather changes the very rules of regulation and policy (Peck & Tickell 2002). Previous bastions of Keynesianism and social democracy, such as Sweden, were not able to anticipate or resist neoliberalization but rather found themselves playing the very game of the ideology that sought to bring them down. Viewed this way the extension of market logic followed from the introduction of market metrics (i.e. value for money, competitiveness, performance ratings, rather than the other way around). Once regional governments and state services were measured against these metrics, and against private actors already using them. Market logic was bound to follow, creating a new axiom made for a restructuring of previous rationalities, almost without notice.
The axiom of market metrics and the following logic is taken as a given in the literature on maternity unit closure (see for example Blondel et al. 2011; Koike et al 2016; Tracy et al. 2006). The scarcity of resources for hospitals, medical practitioners, and equipment is assumed to be a fact of life rather than the outcome of a particular regime of distribution. The assumption of inherent scarcity then leads down lines of reasoning that concern efficiency rather than need, and output ratings rather than entitlement. In turn, such reasoning coming from seemingly neutral observers of medical practice re-legitimizes the sociospatial differentiation of regions under neoliberalism. Sparsely populated rural regions become constructed as unable to sustain the services needed by the local population, in turn putting strains on social reproduction. Further, these faults are seldom seen as systemic and the blame is instead downloaded to the local government for not succeeding in attaining the industry and population that would have sustained their now failing social service.
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competition, such as the redistributive state function of Keynesian Welfare State, have therefore needed to be discontinued. As these services were discontinued or privatized, responsibility for social reproduction has moved downwards toward local governments, communities, and individuals while the power and resources to carry these responsibilities have moved sideways into the hands of transnational corporations, entrepreneurs and local cabals of capital interests.
3.3 Critical Frameworks
The concepts and the historical background presented in the previous chapters offer a substantive way to reevaluate the findings of the literature on maternity care, making it understandable to us in a new way: not understandable as in explained to us, but understandable as in possible to engage with. With the above-described concepts and background, the essay will come to argue that the heightened risk, downloaded costs and the individual and systemic stress that follow the closing of rural maternity units are neither a political anomaly nor an economic fact but the outcome of the inherent contradictions of capitalism.
In support of such an argument, a number of critical scholars have already provided frameworks and outlines for understanding the phenomenon at hand. The austerity of neoliberalism has already been discussed at length in the previous section but still bears reiterating as it is the overarching historical framework of the current wave of rural maternity unit closures. Further, the vagabond nature of capitalism, conceptualized by Cindi Katz (2001), accounts for why capitalism, supposed to enable equal opportunity for prosperity, in the real world is equally enthusiastic about building wealth at a particular location as it is to carry it away from others when opportunity for quicker profit beckons over the horizon. Further still, Nancy Fraser (2016) states with conviction that the tendency for crisis inherent to capitalism not only applies to the traditional field of economy but equally to the field of social reproduction. Her conclusion is that the functions of capital accumulation are intrinsically at odds with functions of social reproduction. In turn, the contradictions lead to social reproduction being continuously and structurally neglected to the point that it is thrown into such disrepair that total system collapse becomes imminent.
Even as each of these perspectives by themselves can help us understand why rural communities have been, and continually are, exposed to particular strains on social reproduction that urban regions are not, they are held as complementary rather than exclusive for the purpose of this essay. They are different layers of the explanation in full, different pieces of the puzzle. Further, the thesis adds its own explanation to the particularly geographical nature of the cause as well as the consequences of closing rural maternity units, arguing that local governments forced to behave in entrepreneurial ways are caught between the contradictory tendencies of geographical accessibility and economic efficiency.
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To begin, the restructuring of public policy underlined by the logic, language, and practice of neoliberalism is one of the defining historical processes of our current time. Neoliberalism is the reason that the cost efficiency of maternity units is primarily measured in regard to their output of babies rather than the quality life they provide for the communities they serve (see Schmidt et al. 2002; Tracy et al. 2005; Viisainen et al. 1999). Further, neoliberal discourse leads to the acceptance of a lack of resources as fact rather than a result of a certain set of priorities. However, such a sentiment is not unique to neoliberal capitalism; rather the same sentiment would likely have been expressed by politicians typical of the 19th century if anyone were to ask. But as opposed to the events of the present, the conclusion of the sentiment would be that maternity units would remain unbuilt rather than closed down. Therefore, the particular consequences documented in the current literature on maternity unit closures are not the consequences of people lacking access to maternity care but rather of people losing access to maternity care.
This might read as a minor distinction but it is one of the underlying points of Fraser’s (2016) construction of three different historical stages of social reproduction under capitalism. The three stages she outlines are, in chronological order, the pre-20th-century regime of liberal competitive capitalism, the mid-20th-century regime of state-managed capitalism and from the late 20th century forward the globalized financial capitalism of our current time.
In the first of these three stages, state and capital preferred to limit intervention in the life of workers within Europe to disciplinary measures and letting social reproduction have its course without much in the way of support or involvement. Unmediated by state and capital the organization of social life continued along patriarchal lines, anchoring women to the duties of social reproduction, all the while that the impoverishment and precarity of the time stripped from the women the means to carry them out. In this stage, social reproduction and accumulation of capital were explicitly at odds. The fewer provisions afforded workers, the less the cost of labor and the larger the gain from exploitation.
The combination of exploitation and expectation of women and families increasingly generated tension which in turn led to a building crisis of social reproduction which threatened to in extension lead to complete system shutdown. As it turned out, the crisis was avoided through compromise. The demands of organized labor were put in the hands of social democrats to realize and oversee. It was the start of the next historical stage, the era of the Keynesian welfare state.
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Keynesianism, however, had its own internal contradictions, among others an intense need for natural resources and inability to indefinitely expand consumer demand, which eventually came to cause its downfall. Beside of the societal pressure of failing economic growth, the backside of paternalistic bureaucracies started to come into focus of public debate during the late 60s. Keynesianism came under attack from both sides of the political spectrum. On one of the sides, the New Left rose, disillusioned by the social democracy of past decade. Central to the New Left’s criticism of the Keynesian Welfare State was how a lot of the ills it had seemingly fixed had been fixed by diversion to the postcolonial periphery as well as at the expense of racialized and underprivileged workers within the core. On the right, a wave of soon-to-be neoliberal interests was more than eager to pin any and all blame for the troubles of the time to Keynesianism. Embattled from all sides, through political upheaval and backdropped by the final gasps the fordist industry, neoliberalism emerged from the dust victorious and ready to put the torch to any aspect of the Keynesian Welfare State within reach.
Almost 50 years have passed since the process of neoliberalization began, the third historical stage outlined by Fraser. To repeat the assertion of Cindi Katz (2001), social reproduction is always a field for struggle, and just as state welfare was won through struggle it could not easily be taken away without the same. In this way, the remnants of the Keynesian Welfare State are still being fought over, pronouncedly so in previous bastions of Social Democracy such as Sweden. It is an ongoing battle, often unseen, but openly observable when communities come together to contest and openly fight political decisions to close the services on which their communities have come to depend.
4. THE ANNIHILATION OF SPACE BY TIME
If the tension between value production and social reproduction was alleviated in the previous historical stage it is now once again being exaggerated. The internal contradictions of capitalism and the tension they cause is ever a source of class conflict, even, or especially, within the field of social reproduction. However, a unique feature of the current moment is that the people on the bottom of the class hierarchy are fighting with lots to lose rather than everything to gain.
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Furthermore, the task of discipline has become part of health care as denial of service in stagnating regions force people to move to regions where their labor is in need. Needless to say, such disciplinary functions and the new conditional state facsimiles of past social services can hardly be said to be beneficial to rural communities.
For the apostles of neoliberalism, the success stories of rural communities and downtrodden company towns turning their fortune around on their own are preferred to temperance and reluctant concession to the needs of social reproduction. These stories are held up as the ideal for other regions and something they actually could (and therefore should) try to mimic. The idea of a ‘blueprints for success’ has been eagerly promoted. Indeed, it has in the case of the Bilbao Effect – the idea that economic prosperity can be achieved anywhere by building high-profile tourism-oriented cultural institutions – been held up to the point of fetishization (see for example The Economist 2014). However, skepticism is warranted as the promise of prosperity is often naught but the alluring visage of vagabond capitalism; showing a lot in the way of promise and little in the way of commitment (Katz 2001). The point is, that while certain communities might come to flourish, many others will be left in the wake of mobile capital. In the end, sporadic and conditional spatial fixes will neither heal the wounds of communities gutted by neoliberalism nor safeguard them from further pillaging.
With the vagabond movement of capital in mind, the movement of people also needs to be addressed as a further nuance to the discussion of closing rural maternity units. People have moved to cities for work since the beginning of capitalism. Once feudal lords turned into capitalist producers of commodified food the screws on the already strapped farmers tightened under pressure to increase agricultural efficiency. Small plots of land were annexed and farm-work began to be mechanized, enabling it to function with fewer and fewer actual workers. The serf farmers who had previously been able to sustain themselves on the scraps they kept from farming their lord’s land were progressively left without sustenance. Instead, the rural population was forced to turn their eyes to the factories in the cities and try their luck as industrial workers. As rural landowners became able to prosper with a smaller number of workers, cities started to grow rapidly in what came to be known as “urbanization”.
The process of urbanization is still ongoing and to address whether it could be the true reason that services in rural communities are closing a brief look at Harvey’s (1989a) discussion of ‘money as the universal community’ is warranted. In essence, money has brought all of humanity-under-capitalism into the communal fold of the world market. All other ties and connections become secondary to the universal exchange of money as both the means and the end of human endeavors.
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reasons than work itself, these are also necessarily tied to the constraints of the wage-labor market imposed on every other aspect of human life.
Urbanization then does not operate outside of the processes of capitalism and can not be seen as the explanation to why rural maternity services are forced to close. And even if urbanization started off as an analytical description of particular social processes, it has at this point, in the opposite, become understood in public discourse as all but a force of nature. In turn making rural communities less able to mount a resistance against policies potential to further decrease individual ability to choose whether to move or stay.
Just as with the discussion on money, the particular argument contributed by the present essay requires going back to Marx himself. Central to the argument, as to capitalism, is the drive to accumulate surplus value (Harvey 1989a). An important distinction before continuing the discussion on value is that the accumulation of surplus value is the driving force of capitalism rather than the accumulation of money. As mentioned, money has significant effects on the shape of social life under capitalism but is still, in essence, nothing but an abstract representation of value. Value then, in turn, is defined as ‘socially necessary labor time’. Basically, the value of any commodity is defined by the accepted standard minimum time required to produce and bring it to market.
Even as the notion that ‘time is money’ might be slightly off point in its phrasing for the purpose of this essay, time remains crucial for understanding the economic logic and geographic outcome of neoliberal policy, especially as it applies to maternity care. Time, as a measurement of labor input, is in turn of less import to the argument of the essay than time as a pause in the circulation of capital. To explain what is meant by a pause, it must be understood that capital accumulation is a process taking place over time. At the initial stage of a cycle of accumulation, capital is invested in producing a certain commodity. The tools of production, as well as a modicum of recompense for the laborer's time, need to be paid for, so to speak freezing capital invested into the form of a marketable commodity. As long as the commodity remains unsold, either during production, transport to market or the wait for consumer demand, it remains dead (or at least unusable) to the capitalist whose capital was invested. It has yet to yield a surplus, nor can it be invested in the next cycle of accumulation.
As the drive of capitalism is to ever increase the rate of accumulation, the time between the initial stage of investment and the final stage of yielding surplus (the turnover time of capital) must be shortened by any means necessary. Further, the time capital remains frozen in place is not just detrimental to the capitalism itself but is also a site for inter-capitalist competition.
Turnover time can be reduced in a variety of different ways. It can be reduced by enabling mass-production, i.e. producing more of the same commodity over the same amount of time. Furthermore, it can be reduced by decreasing the time commodities are stuck in transport by decreasing the effective distance to market.
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consolidating deliveries previously spread over smaller hospitals (producing less of an output per investment) in larger hospitals able to put its invested capital to more efficient use.
However, time-efficient production is of little use at reducing turnover time if the time it takes to bring the commodity to market stays the same. As the time to market is essentially synonymous with the effective distance to market, it is distance that in turn becomes a barrier to the accumulation of surplus value. For physical commodities, the ways to decrease effective distance are many and has historically involved mobilizing technological developments to increase the speed of travel, the rate of delivery, and the accessibility of commerce. Technological developments exemplified by, among others: railways, electronic communication systems, and massive cargo ships.
Services, although very much possible to commodify, have a harder time of traveling to their corresponding consumers than physical commodities do. Indeed, physical commodities can and do travel with relative ease from their place of production to where the demand is. In opposite, the demand most often has to travel to the service. To then enable accumulation of surplus value from consumption of services, their sites of production have to be in geographical proximity to the consumer. Geographical proximity and accessibility is in the case of services the essential way that the effective distance to market is reduced.
The drive to reduce effective distance, in whichever way, has ever since the conception of capitalism been so effective that people as early as the 19th-century talked about ‘the annihilation of space and time’. An expression of the general wonderment over the rate at which human technologies were able to do away with the previously impervious constraints of time and space. Trying to get at the historical role technological development was playing in reducing effective distance, Marx put the esoteric description of his peers into more concrete terms, changing the wording from ‘the reduction of space and time’ to ‘the annihilation of space by time’ (Harvey 1989a).
Yet the annihilation of space by time – up till present time – has only come so far, especially as it concerns access to maternity care. Faster cars and expanded infrastructure have certainly done their part in increasing the distance consumers of any service can travel at leisure. However, traveling to maternity care after the initial onset of delivery can hardly be said to be done at leisure. Rather, the time available and speed needed to get to the closest maternity unit on time is set by the specific nature of childbirth, as its onset is unpredictable and its progress rapid (Blondel et al. 2011).
