This week, I am sharing this beautiful, if alarming, text by Rebecca Mack – who writes the newsletter ‘This Woman’s Work’.

The impetus behind the Fifth Wave Institute came partly as a result of my reading ‘Of Woman Born: Motherhood as Experience and Institution’, by Adrienne Rich, sitting on the steps of the Bodleian Library during my last few days in Oxford.

Reading that book, and diving into the world of thought that subsequently revealed itself to me, was probably one of the single richest intellectual experiences I’d had up until that point. In it, drawing on extensive research as well as her personal experience in her first heterosexual marriage and then as a lesbian mother, Rich picks apart how the figure of the mother – imagined, fantasised, imposed, enforced, all but defined by its actual embodied experience – has for millennia been a central tool of the subjugation of women.

In the below, Rebecca writes of her experience as a midwife in the UK’s NHS, and the systemic failures that ultimately led her to seek a different way to care for women. I’m sharing it here (it has been slightly edited) because it deeply resonates with the Institute’s vision for a different, care-centered world. It also feels appropriate as C-section rates have recently surpassed those of vaginal births in England.

Both this essay and ‘Of Woman Born’ exemplify two of our deeply held beliefs: our systems are broken, and they can be rebuilt. “The fields need to be radically dug up and new ones sown”, as Rebecca puts it – in midwifery as in all other spheres of human activity that involve people taking care of each other.

As Rich writes in her 1977 essay of the same name,

“We need to imagine a world in which every woman is the presiding genius of her own body. In such a world, women will truly create life, bring forth not only children (if we choose) but the visions, and the thinking necessary to sustain, console, and alter human existence—a new relationship to the universe. Sexuality, politics, intelligence, power, motherhood, work, community, intimacy, will develop new meanings; thinking itself will be transformed.

This is where we have to begin.”

I came late to midwifery. I was twenty-seven, earning 25K a year as Personal Assistant to a group of corporate directors. Free gym, nice offices, lovely boss. It wasn’t enough. I had a calling. Possibly a catholic or middle daughter thing, I don’t know – I just knew I wanted to help people.

Midwifery looked like the perfect job: women-centred, empowering work and oodles of babies to cuddle. Whilst training, I did a two-week placement on a special care baby unit where my main job was to sit, skin-to-skin-cuddling preemie babies in my cleavage. After the two weeks ended, they practically had to escort me off the ward. It was joyous.

I knew instantly at my university interview that this was the career – or rather, the place for me. Not long after, I was called back to the office of the midwifery lecturer who had just interviewed me. She sat at her desk, swinging on her chair, shoes off, chatting animatedly to her colleague who was curled up on the sofa. ‘I’m home’, I thought. ‘I want to stay in this world forever.’

The training lasted 3 years and was hard going from the start. We spent half the week working on the wards and the other half studying in classrooms. There were no long holidays like other students and if you missed a shift, even due to illness, you were required to make up the hours in your own time – meaning most ‘holidays’ were spent back on the wards. We were paid a small bursary (not meant for anyone to live on) which has since been terminated for new cohorts. The real payment came in the satisfaction of learning and experiencing the craft you loved.

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Lovestruck I was. Many a time, I walked on air as I bounced home, remembering the beautiful newborn that had just been miraculously pushed into my hands. But as time progressed, I missed – or ignored – the emerging red flags.

The wards were permanently short staffed. By the second year, I found myself being used as ‘staff’ instead of ‘student’ in low-risk areas. ‘Breaks’ on an eight- or twelve-hour shift were a luxury, not an essential. A quick dash to the loo whilst running in between patients and finding sustenance from the ‘thank you’ chocolates left in reception became the norm.

Shifts never ended on time – typically due to a lack of staff to hand over to. The fear of litigation loomed large, and practice often felt more ‘defensive’ than ‘responsive’. The constant requirement for documentation interrupted the flow of organic relationship building and care providing.

As students, we were shielded to an extent from the negative sides of midwifery. Kind mentors would insist we take a break or encourage us to go home before our legs gave way. Unqualified, we were free from the threat of losing our registration, and we could spend time building relationships with our women and their families instead of documenting our every breath. Alas, we would not remain students forever.

With the thrill of qualification came the terrifying removal of the protective mentor’s shield. Caring for women and their families was still the ultimate high for me; but unfortunately, the anxiety around their safety – and my sanity – became the ultimate low. The system wore me down, not the people I cared for. The lack of staff, the overcrowded wards, the constant life-threatening juggling act. I was permanently anxious. I would frequently leave a shift exhausted, back literally breaking, bladder bursting and spirit just a tiny bit more broken.

The unpredictability of each shift terrified me. I can remember starting a night shift on the postnatal ward, being moved to the antenatal ward – while still caring for my postnatal charges – and then delivering one of my antenatal women on labour ward. After 14 long hours with no break, I emerged from the delivery room with a fresh newborn wrapped around my neck, begging to go home to my own children.

Yet barely through the door home, I was back on the phone. ‘Has that baby in bed 3 fed yet?’, ‘Can someone check the CTG on the woman in bed 6?’. My husband removed my shoes, I drank a longed-for cup of tea, then another, and then another.

This was not the exception but the accepted rule. I would have loved to spend that night providing life-changing care to all those women and babies. Instead, I was gasping for air just trying to keep everyone safe. Too many women, too many babies, not enough staff.

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The professional cost of giving the ‘bare bones’ of care was a constant source of frustration and anger to me. Job dissatisfaction corrodes morale. I have a friend who is a decorator. He painted my living room last year. He is a perfectionist, prides himself on his smooth finishes and straight lines. He offers sage advice when I get carried away with clashing colours and he leaves every house he paints a better place to live. Each job he completes fires him up for the next. He is proud to show his customers his work.

Imagine if he was a midwife. ‘I’ve slapped some colour on the walls – if you squint a bit, you can’t see the dodgy lines; sorry I didn’t get a chance to do the skirting boards, you can hide them with the furniture; didn’t do the ceiling but it’s not so bad, just try not to look up. Anyway, got to go, didn’t want to say but I’ve been decorating two other houses at the same time, and I’ve not finished them either.’

It would be demoralising, embarrassing, sad. Not what he trained for.

During my last shift, I attended to a distraught mum as she delivered a 20-week-old, much-wanted baby in the maternity reception bathroom. The desperate mum was waiting for a bed. There were no beds. And not enough midwives to staff one even if one was available. It was 3 a.m. in the morning. Ten years from that inspiring interview and seven years on since qualification, I was done.

Sadly, I was not alone. Approximately one-third of my cohort of 30 had left the profession by the time I hung up my stethoscope. Some stayed within the NHS (I did). Some could not get far enough away and went into other roles, as diverse as overseas property management and cake making.

The solution appears simple – hire more midwives. But like me, so many just would not go back, and so many newly qualified just will not stay. Changing the landscape of midwifery goes far deeper than throwing more hands into the fields. The fields need to be radically dug up and a new fresh and women-centred field sown.

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Answer me this… would midwifery be in this dire a state if men gave birth? I can’t see that men would be expected to tolerate a maternity system that struggles to provide safe, never mind (don’t make me laugh), holistic care if they were the pregnant ones.

The way we treat our pregnant, labouring and postpartum women is a tragic indictment of the way society too often treats women, and mothers in particular. Second-class, disposable, put up and shut up, vessels for male folly, unworthy of care. That women and their bodies don’t matter is no more evident than in maternity wards worldwide.

My love affair with midwifery will never end. I can’t go back to the trauma of the wards, but I can’t completely walk away either. My passion for the care of women is still as unshakable and necessary as it ever was, if not more so. Grassroots change is needed, and my pen is mightier than my stethoscope at this point.

So, I sit here, shoeless, swinging on my chair, animatedly chatting to Substack, writing about midwifery, misogyny, mental health, and more. Advocating for women, for mothers, for families. I never wanted to leave midwifery; midwifery is my home. I cannot deliver babies anymore, but I am working on delivering the truth about the treatment of women and mothers. I would love for you to join me.

Miscarriage is a relatively common occurrence – roughly one in five women go through it at some point in their lives. For some, it’s a dreaded, recurring experience. For many, it’s an incredibly taxing one, physically and emotionally.

It wasn’t always recognised as such. Advocacy campaigns, academic research and women openly sharing their stories have done a great deal to raise awareness of the reality of pregnancy loss. Those changes have been gradually matched by evolutions in its clinical management — notably, the recognition of ‘pregnancy remains’ as deserving of respect and sensitivity, to be handled separately from clinical waste.

In the UK, ‘pregnancy remains’ refers to any tissue expelled or removed from a woman’s body following the end of her pregnancy prior to 24 weeks’ gestation1. It is legally the woman’s tissue, and those who miscarry at home are free to handle the material in any way they wish, with most flushing it down the toilet. But the clinical setting is an institutional context, imbued with meaning-producing power not held by the home. Clinical practices are an extension of social beliefs: as such, they are subject to much higher-stakes scrutiny.

British public opinion was especially roused to the issue of proper disposal following a series of scandals. The unauthorised storage of 1,500 miscarried, stillborn or aborted fetuses at Alder Hey Children’s Hospital caused widespread outrage, leading to the passing of the 2004 Human Tissue Act and the creation of the Human Tissue Authority (HTA) to establish a framework for sensitive disposal. Later scandals saw the establishment of specific HTA guidance and a National Bereavement Care Pathway (NBCP) to help professionals provide more humane and understanding care.

With these developments, practices evolved to distinguish the treatment of fetal tissue from that of clinical waste, “on the basis of its potential to develop into a human being”2. Official guidance also evolved to present women with choices commensurate with the pain of their loss: ceremonial cremation or burial, release for private arrangements or to a funeral director, and separate incineration. To ensure a paper trail, this choice is typically recorded using a consent form — a seemingly bureaucratic detail that actually proves central to women’s experiences.

A world of lived experiences

Susie Kilshaw, a professor of medical anthropology at University College London, has been studying ‘pregnancy ends’ for a decade. She uses the term in order to better “encapsulate the complexity and nuance of women’s experiences”, from miscarriage to stillbirths, ectopic pregnancies, molar pregnancies and terminations.

This semantic choice also aims to “remove intentionality as the defining element”. Women’s complex and nuanced reproductive experiences are often restrictively categorised using only the metric of choice — not just pregnancy outcomes, but infertility and childlessness, as ’s work sensitively highlights. Talking about ‘pregnancy ends’ lessens the potent moral assumptions that come with categories of loss, and makes room for women moving between categories, as when a miscarriage happens just before a planned abortion.

Similarly, Kilshaw’s work “engages with understandings of the foetus” but speaks of ‘pregnancy remains’ to acknowledge the fact that not all situations include a foetal body (in the case of partial miscarriage, for example) and honour the extreme emotional ambiguity that surrounds the material reality of pregnancy. “The foetus”, she writes, “is a shifting and flexible entity, which can be several things simultaneously, from a part of the woman’s body to separate tissue, a bundle of cells, a site of diagnosis, a baby, or a child”.

This ambiguity is precisely what Kilshaw explores in two 2024 papers based on ethnographic research conducted between 2012 and 2023 with women in England3. Most of her participants had experienced first-trimester miscarriages requiring surgical management, “either to remove the entire pregnancy or ‘retained products of conception’ when a miscarriage was incomplete”. Interviews focused on their experience of the consenting process for sensitive disposal, including both the discussions with the medical staff and the aforementioned physical consent form.

‘I’m a mum too’

For some interviewees, institutional assumptions surrounding miscarriage supported their own framing. Malaika4, who miscarried at 14 weeks, was grateful for the ability to spend a few final moments with her baby, and the sensitivity with which its body was treated:

“I was in hospital for four or five days, and the sisters on the ward said, ‘Do you want to see your baby?’... They brought him with so much respect… in a little basket. He was on a beautiful, embroidered sheet with a little blanket on top. […] I was able to sit with him. I took a little picture. His body had changed a lot… so I just took a picture of his little foot near my fingernail.”

Jennifer and her partner similarly welcomed the ceremonial service offered to them by the clinic after their 10-week miscarriage, and the opportunity to write their child’s name in a book of remembrance.

“You didn’t just lose a pregnancy, you lost the one-year-old you imagined and the five-year-old on the first day of school and the grown-up that you pictured in your mind, even in just those few short weeks… Even though they might not have been public and it might not have been a child you met and held… It was your child… I’m a mum too. Just because I’m not pushing a buggy or going to the school gate, it doesn’t mean that I wasn’t a mum.”

For these women, the understanding of miscarriage as “the loss of a baby, who leaves behind a mother whose appropriate reaction is one of bereavement” was crucial to their grieving and healing process. It was a much-needed recognition of the magnitude of their loss — especially vital when the outside world might not always validate their pain, particularly for shorter pregnancies like Jennifer’s. The institutional framework comforted them in their experience.

‘It wasn’t a baby’

But all of Kilshaw’s participants did not feel the same. In an otherwise extremely understanding and gentle process, with most women voicing their gratitude at the incredible care provided to them by the medical staff, the disposal pathway stood out to many as “inappropriate” if not “distressing”.

For Scarlett, language like ‘funeral director’ and ‘ceremonial cremation’ felt alien to how she had been conceptualising of her pregnancy end:

“For me... with my personal belief system... it’s not a baby. It’s a clump of cells that has a lot of hopes and dreams attached to it and it could be a baby, but it’s not a baby... So then being confronted with ... that consent form and the treating of it as more than a small clump of cells, [...] it made it a lot more upsetting because it makes it a baby, which isn’t how I had been thinking of it.... So being asked to treat it like it was a baby suddenly became very upsetting.”

The women’s testimonies repeatedly highlighted a disconnect between the object of their loss and the biological material. For many, their grief was directed towards an abstract idea of what could have been rather than towards the remains themselves — especially at an early gestational stage, before the 12-week scan that typically marks a crucial step in the “production of fetal personhood”5.

“[T]here wasn’t a real emotional attachment. That’s not to say I wasn’t upset, there was a lot of crying and upset about what could have been, but not really upset about what it was at that point.... For me, it wasn’t a baby loss. That’s very different. I think if it had been something like 22 weeks or something much later, I would have had a completely different response to it”.

Thinking of the pregnancy remains as medical waste or tissue, an extension of their own bodies similar to material removed during other kinds of surgeries, often helped the women cope with their loss. Being confronted with ‘person-making’ language suddenly made it “babylike” and therefore “much more traumatic”.

In most clinics, no differentiation was made between different types of pregnancy remains, which also led to even starker disconnects: one participant who had an anembryonic pregnancy (no fetus or embryo present) was still presented with the option of a funeral service.

The timing of the process sometimes worsened the disconnect. The topic of disposal was only broached at the time of surgery, which could come weeks after women were told they had miscarried6. The disposal discussion therefore often re-opened a healing wound, stirring up emotions many had already processed and begun to recover from:

“Then to have the consent... to talk about the remains... it really threw me... because I think for a while now it hasn’t been a pregnancy for me, it’s been an illness, a chronic illness that I’ve been dealing with and trying to get better from.”

Several women also felt that the consenting process robbed them of agency in their own miscarriage, merely informing them rather than “including them as active participants” — despite the fact that had they been home, they would’ve been free to handle their pregnancy end as they wished. Others, by contrast, were overwhelmed by the introduction of a choice they were not warned about at any point in the care pathway:

“I did not realise there was going to be a discussion, I thought … they take it out and it goes down a tube into medical waste… it almost bothered me that I had to make that decision. [...] I would have preferred not to have the choice”.

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It might seem odd that tick-boxes on an administrative form should hold so much emotional weight for these women, especially as the more ‘personhood-dependent’ choices were typically offered alongside neutral ones.

But as Kilshaw’s work shows, in times of uncertainty and ambivalence, official meanings hold a special kind of normative authority. The form does not draw an explicit moral hierarchy between the choices, of course — but motherhood is already so laden with moral categories, with pronouncements of good and bad mothers, helicopter mothers and refrigerator mothers, that value judgments have a tendency to creep into every stage of the journey.

Maggie’s fetus’ heartbeat stopped at 18 weeks, and she underwent medical management of miscarriage to remove it from her body. She told Kilshaw:

“The specialist midwife said: . . . ‘what we do is if you don’t want to have a service or funeral. . . all of the babies are cremated’ . . . And that just made me burst into tears because I felt like somebody else is arranging a service for my. . fetus that I am not going to. So now I am like a weird mother that doesn’t care: ‘there was a service for your baby, and you didn’t go?’”

Even a hint of, “just so you know, others are choosing to do X, to enact this special kind of reverence” is enough to make women feel like their choice is the wrong one. And in a time as sensitive as pregnancy loss, that feeling is a failure of care7.

The overcorrection trap

Paradoxically, in trying to be more sensitive, the evolution of disposal guidance inadvertently introduced new potential for pain. The pendulum swung too far in one direction, leaving little space for experiences that didn’t match the upgraded understanding.

This pattern has been highlighted in other healthcare settings. In a conversation with On Being host , surgeon, writer, and public health expert explains that in gradually moving away from ‘doctor knows best’ paternalism towards patient autonomy, modern medicine sometimes leaves too much room for agency, creating unduly anxiety in patients who seek a reassuring expert opinion.

“‘Here is your condition. Here are the options: option A, option B, option C. Here are the pros, the cons, the risks, the benefits. Now what do you want to do?’ [...] That was the way I was taught to exercise my authority, give people knowledge and then ask what they want to do with it. But what I found in the real world was that patients would ask back, ‘Well, what would you do?’

And so what we’re taught to say, and so that you don’t take away their agency, was, “No, no, no. This is not for me to decide, this is for you to decide. […] You have to make the call here, around what’s more important to you.” And people felt completely abandoned. […] But the palliative care clinicians or geriatricians, they would go one step further. They would listen, and ask, “What are your goals? What are your priorities? What really matters to you?

You have to be a genuine counselor, and the only way you can offer wisdom is by connecting what you know and have observed […] to the goals that this individual person has. […] And that is hard, I had to learn from the palliative care folks.”

It isn’t a coincidence that palliative care professionals bring the most sensitive approaches. They also happen to be the ones whose work is closest to the ongoing, intimate dependency care that one might give to a child or an elderly parent. They understand most viscerally that care has to be tailored; that flexibility is key to adapt to an individual’s ever-changing needs and circumstances.

In the same way, Kilshaw’s research shows that even the best-intentioned approaches fail if they remain ‘one-size-fits-all’. Some women were comforted by the assumption of bereavement, some distressed. Some found it validating to be asked if they wanted to give their baby a name, while some felt that once offered, declining to choose would mean denying their fetus an identity. In caregiving contexts, which deal with incredibly complex emotional worlds, being prescriptive rarely works. The strength of the anthropologist, like that of the caregiver, lies in shedding in-built assumptions in order to get as close as possible to the reality of individual experience.

Changing the rules

This adaptability is precisely what Kilshaw managed to bake into the 2024 updated HTA guidance. Indeed, this wouldn’t be The Fifth Wave if we didn’t talk about innovation: and in a move many academics spend entire careers dreaming about, Kilshaw actually got the official policies changed based on her findings.

She worked for months with the HTA and the NBCP, tailoring their guidance to better “accommodate a diverse range of approaches” and avoid “challenging a woman’s experience of and agency about her body, pregnancy and pregnancy remains”. The previous version already specified that women should be afforded the possibility not to have to make a decision, but many trusts didn’t allow for this. Even when they did, women were still confronted with the sometimes distressing list of options in order to decline choosing.

So Kilshaw pushed for a clear and mandatory opt-out from the consenting process itself, with better, discussion-based information sharing earlier in the care pathway so as to gradually appraise what information the patient wants, instead of immediately presenting them with potentially upsetting language.

Moreover, if the choices do get presented, offering all disposal options is now mandatory, including regular incineration previously listed as an option only ‘in certain circumstances’. This means all women now have the choice not to pick a ‘personhood-centred’ option at odds with their understanding of their pregnancy remains.

I was able to track down the archived 2015 version of the guidance8. On top of the changes to the actual rules, there are subtle but crucial changes in language that further emphasise the breadth of possible lived experiences. For example, the 2024 update adds a mention that “some women might not experience pregnancy loss as a bereavement”; as well as, “in some cases, a woman may welcome receiving the information”, to honour the fact that it isn’t the automatic or even the majority view.

No longer in charge

Beyond the UK context, Kilshaw’s research in Qatar shows that experiences of pregnancy loss are not only dependent on the individual, but culturally and socially contingent. Qatari women are more likely than British women to know of others who have miscarried, and typically perceive the event as “relatively normal and common”, a natural, inevitable process that simply means the baby was not meant to be born. Strong faith helps in retaining joy and hope: lost babies are ‘birds in heaven’ who will welcome their mothers into paradise.

Building on both her research and her own experience of miscarriage, Kilshaw offers a fascinating reflection on control:

“The British women we spoke to waited until later in life to get pregnant and were used to managing their careers and lives to a fine-tuned degree. Most of our interviewees were in their 30s and had decided to get married as a preface to family life, with the intention of having a baby as soon as possible after the wedding. Most planned their pregnancies and prepared their bodies by taking vitamins, exercising, limiting their alcohol intake, and using various tools to chart and map their fertility. They often had named their babies and thought of them as children by an early stage of pregnancy. The sense of loss in the wake of a miscarriage was as much about losing control and an envisioned future as about the death of the baby.

In Qatar, where faith is pervasive, the women we spoke with often felt that things were in God’s hands rather than their own. Control had already been ceded, and the grief was often less intense compared to what most of our U.K. interviewees experienced. Although birth control is available, women saw pregnancy as the expected outcome of sex with their husbands, and miscarriage as part of the normal experience of a woman’s reproductive journey.

After my first miscarriage 10 years ago, I felt isolated, devastated, and unable to access a framework that would help me make sense of the experience. But each time I had a miscarriage I responded differently. For me, the ultimate lesson I learned from my pregnancies and miscarriages was that I would have to relinquish a sense of control over my life—a message that became even more significant after I had two healthy daughters. If there’s one thing a baby teaches us—whether through a miscarriage or a full-term delivery—it is that we are no longer in charge.”

Kilshaw’s research drives home the fact that caregiving, too, be it in an intimate home setting or a clinical one, is about relinquishing a sense of control over those we care for. How they experience the world, how they react to their circumstances, even when it doesn’t fit what we expect or think is right. Rather than imposing pre-conceived frameworks, caregiving is about offering a presence that makes space for every shade of experience, every tear — or lack thereof.

This research also shows that building the futures of care takes many forms: from the most radical new models to painstaking word changes to obscure official documents. And each of those changes matters, visible or invisible. They are building, brick by brick, a more caring future.

References

• Kilshaw, S. (2024). ‘Now I’m a weird mother who doesn’t care’: Women’s experiences of pregnancy remains disposal following miscarriage in England. Mortality, 30(1), 215–232.

• Kilshaw, S. (2024) Women’s experiences of the consenting process for pregnancy remains disposal following early miscarriage. BMJ Sexual & Reproductive Health, 50, 99-106.

• Kilshaw, S. (2017) ‘How Culture Shapes Perceptions of Miscarriage‘. Sapiens.

There are many more fascinating insights and subtleties in Kilshaw’s work, I really recommend reading the papers themselves if you are interested. All open access.

For more resources, check out the Sands charity or Tommy’s, both doing crucial work in this space. The new Birth Companions Institute also has great material.

Further reading

The term ‘institutional care’ is an ambiguous one. On the one hand, it can simply refer to care in institutions, i.e., organisations and spaces that formally structure the provision of care to specific groups of people: nursing homes, daycares, hospitals, maternity wards, at-home healthcare services.

But another, pejorative association refers to orphanages — or, according to British charity Hopes and Homes for Children, “residential facilities for large groups of children” characterised by a one-size-fits all approach, depersonalisation, rampant sexual abuse, lack of privacy, disempowerment, and social isolation. This is not what this piece is about.

However, one sentence in Hopes and Homes for Children’s explanatory article struck me: “‘Institutional care’ is an oxymoron – institutions cannot by definition care”.

Putting aside the specific context of HHC’s mission, that sentence sums up much of the current sentiment around the organisation of caregiving in modern societies. Formal structures and institutions are often synonymous with chopping up family life, breaking up communities, and compartmentalising society into neat categories. Eldercare on one side, daycare on the other. Work is work, family is family, and the two can’t interact. Parenting is a private thing to be managed by the parents alone, and “kid-free” cafés ensure that people who dislike children can opt out of interacting with them (apparently even in places originally designed for kids).

The various industries in the care sector are plagued by headline after headline showing how privatisation, optimisation and compartmentalisation produce hyper-strained systems with dangerous if not outright life-threatening failures of care. See Australia’s scandals over private aged care, childcare and acute hospitals, or French journalist Victor Castanet’s two investigative books that respectively exposed the country’s private eldercare then private childcare corporate monoliths. It’s fairly evident by now that caregiving and private equity do not tend to make for great bedfellows. In many countries, childcare is even described as an outright market failure.

None of that girly stuff

This tension has deep roots. With a feminist lens, the history of economic, social and cultural change over the past five hundred years can be broadly understood as the manufactured separation of worlds and their reconstruction as opposites: public versus private; the medical versus the embodied; masculine versus feminine; adult from child; ‘rational’ from ‘emotional’; the industrial from the natural. And in those artificial separations are of course hierarchies: the public, the medical, the male, the adult, the ‘rational’, the industrial: we could call that the Tier 1 world, i.e. the serious world, the real world, the economically valuable world, the productive world. The rest – the private, the human, the female, the child, the emotional, nature, all of which caregiving is associated with – is Tier 2. Secondary, less worthy of attention, of policymaking, of academic study.

For something like caregiving, the process of bringing it from the private Tier 2 sphere to the public Tier 1 world by formalising it into institutions therefore often means stripping it of its pesky Tier 2 attributes: empathy, feelings, human connection. What matters is keeping its technical, ‘logical’, ‘rational’ (heavy on the quotes here) aspects, central to well-functioning economic systems. The rest is fluff.

In practice, this looks like care systems prioritising medical and sanitary outcomes over meaningful human connection and emotional well-being, which get relegated to mere add-ons instead of central KPIs. The history of the institutionalisation of care is rife with iterations of this, with the medicalisation of childbirth through the exclusion of (Tier 2) midwives by (Tier 1) male doctors being perhaps the most well-documented example with the most dire consequences for mothers. More recent ‘innovations’ like task-based pricing in hospitals incentivise the optimisation of each technical procedure at the expense of the equally vital moments of interaction between patients and staff. Compassionate explanation, connection and reassurance get squeezed in between bloodwork and surgery - leading to worse health outcomes, lower patient satisfaction and higher rates of medical staff burnout.

This status quo can be summarised by ’s formula of ‘minimum viable care’: “a system designed to sustain just enough care from just enough caregivers, [which] prioritises maximum efficiency and minimum surplus, [stripping] dignity and stability from both labor and consumers.”1

The tendency to formalise things by segmenting them is not unique to systems of care. It's also not necessarily harmful: it can make some things work much better. But unlike automobile assembly lines or management consulting, caregiving suffers especially from compartmentalisation. Because the connection, the empathy, the deeply intimate… are kind of the whole thing. That’s what care is. Care is what makes the self relational - it’s the antithesis of separation. It is interdependence. A hand held out. A stranger offering to hold your baby. An Auntie spending time with children who aren’t her own. Care is about the process of human connection much more than about measurable outcomes. So when you strip that, well, you basically strip care altogether.

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To the forest we go

In the face of all this, some are tempted to just do away with formal care institutions. It can seem that, since institutions are bound to be compartmentalised, and compartmentalisation acts on care like Roundup on a patch of green grass, institutions indeed “cannot by definition care”. Care can never be healthily coupled with any kind of profit-making, daycare is cruel, and putting one’s parents in a nursing home is inhumane. Away with all that, let’s have exclusively natural, home births, reject modern medical systems, and go raise our children on feminist communes in the woods.

I’m obviously being caricatural here. Efforts to strengthen community life, re-build ‘the village’ and recreate conditions akin to that of small-scale societies are extremely valuable. But even those typically require a lot of intentional thinking and concrete action, in order to build structural conditions that allow for spontaneous and collective care to take place. Complete withdrawal from organised care is almost never an option, and it also does not scale well into systemic solutions.

This becomes very obvious when comparing the state of public policy discourse around care in different countries: in places with existing universal support systems, public opinion is often focused on pointing out their inadequacies, but in countries like the US, many parents and caregivers are desperately begging for the implementation of formal structures to help relieve the pressure off of individuals.

This is the institutional paradox of care: the same structures that make care institutions deeply flawed also make them absolutely essential to well-functioning modern societies. Faced with this paradox, it often seems we have a binary choice: we can either completely disengage from formal structures to preserve the spontaneous and organic nature of care (but as I said, that’s only an option for a very select few), or ‘give in’ to institutions that inevitably strip it of its relational essence.

But reality isn’t binary, and when we step out of manichean frameworks, we see that formal care structures don’t have to be (and so many aren’t!) soulless vessels we’re just forced into by modernity for lack of viable, organic alternatives. When built correctly, they can also be places of beautiful connection and joy, allow caregivers to pursue meaning in other ways, and help shift some of the heavy responsibility that interdependence tends to place on women to keep communities thriving. Institutions can help ensure that a greater number of people get adequate levels of care without relying exclusively on the sometimes fluctuating goodwill of family members.

So how do we overcome the paradox? How do we formalise care in a way that provides much-needed structure to social life and relief for caregivers, without manufacturing disconnection? As often, the boring, nuanced answer is the most promising one: it’s all about compromise. Not opting out of institutions entirely, but building ones that leave enough space for the natural porousness of care to freely manifest. Ones that institutionalise fluidity.

This isn’t to say that everyone should have to opt in to institutions – there should also be substantial support, resources and recognition for those who want to give birth at home, stay home with their kids in the first few years and live with their ageing parents to support them in late life. But institutional alternatives that preserve the essence of care should be widely available for those who need them.

Building the futures of care institutions

One strategy involves making existing institutions and spaces more porous through external intervention – like with ’s “bring your baby to work” proposal. While of course impossible to generalise to every type of workplace and work schedule, this is a great way to normalise both the presence of babies and children in spaces not ‘meant for them’ (thereby also questioning the legitimacy of such segmentation) and the fact that alloparents can also play a role in caring for children (thereby reducing the expectation that parents have to do it all by themselves). It also helps to make visible the work associated with parenting, potentially raising its value in the eyes of those with no direct experience of it.

Another strategy consists in building porous care institutions from the start. Michel Odent’s concept of ‘home-like birth centres’, for example, is a now increasingly adopted compromise that brings both the benefits of a familial, organic-feeling environment and the safety of an institutional setting. In a similar spirit, there has been a recent re-emergence of intergenerational shared sites that merge childcare and eldercare facilities.

Pioneered in Japan in the 1970s, these facilities come in a variety of forms: a preschool or a daycare inside a nursing home, a residence for older adults next to an afterschool community centre for kids, etc. Kids might simply play in a delimitated area within the nursing home’s garden, or have dedicated shared activity times with elderly residents - reading, creative writing, theater, cooking. The sites have nothing but benefits for everyone involved: the young are more tolerant, more comfortable around disability and difference; they learn skills and hear life stories from their elders, and develop creative pursuits under their coaching. They learn to be around a variety of adults who aren’t family, with a diversity of lived experiences.

The elderly participants, meanwhile, are healthier, less isolated, live longer, and most importantly feel helpful, needed, and valued. The sites encourage prosocial behaviours, sensory stimulation and intellectual development in both age groups. One paper also highlights that “the nurturing presence of older adults helps bring a familial aspect to the preschool setting”, potentially offsetting some of the more anxiety-generating aspects for young kids.

Shared sites are also more attractive to staff, raising the value and meaning of their work while making it logistically easier for them to meet their own family caregiving needs. French startup Tom&Josette, a network of micro-creches implanted within eldercare facilities, built their entire organisational model around valuing the expertise and field experience of daycare workers. On each site, decisions are decentralised, teams are more engaged, and governance is shared and more flexible. On top of their day-to-day responsibilities with the children, the early childhood professionals design the modalities of their interactions with the elderly residents and have their say in the recruitment of incoming daycare staff.

Founders Astrid Parmentier and Pauline Faivre say they were inspired by Dutch at-home healthcare company Buurtzorg, founded in 2006 by Jos de Blok and a team of professional nurses. Frustrated with years of bureaucratic reforms that impoverished their profession and stripped their relationships with patients of their humanity and of opportunities for connection (that lovely institutional care-icide effect again), they set up Buurtzorg “to look after people at home, in a way their values and craft demanded.” [The name translates to ‘neighbourhood/community care’].

The Buurtzorg model has three core principles: a holistic, rather than purely medical, view of the human person and her needs beyond the physiological; an emphasis on the quality of the caregiver-patient relationship, notably by minimising the number of different individuals caring for a single person; and a priority put on the patient’s autonomy, through therapeutic education and the mobilisation of their social support network. Buurtzorg nurses also have a much greater latitude in making decisions around timetables and patients’ needs.

Over the course of a couple years, the company revolutionised in-home care in the Netherlands, rising to the top of patient satisfaction rankings and reducing spending by about 40% per accompanied person, which translated to an average of 3000€ in savings for the patients themselves. They showed that bureaucracy and aggressive management styles were not vital, but actually detrimental to good care organisations. In 2011 and 2012, they were voted the country’s ‘best employer of the year’.

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All hands on deck

Tom&Josette and Buurtzorg are both for-profit companies. They’re also remarkable examples of formalised caregiving that doesn’t completely drain care of its human and relational essence. They show that the spectrum of social change around caregiving is not zero-sum: while we should keep radically rethinking the way we structure care in our societies, there is also hope in building desirable innovations within existing constraints. As put it in her interview with Anu Sharma, founder of perinatal care startup Millie:

“It’s tempting to join the ‘blow up the model and build something better!’ rally cry [...], but the conversation with Anu added a critical angle: how do we ground the rally cry within the constraints of the healthcare system, target the right levers of change, and continue to effectively move the needle forward.”

We can still be critical of institutions, still strive to foster organic spaces and community outside of economic equations. We can also build resilient alternatives that future generations will have the luxury of taking for granted.

The fact that an organisational philosophy originally designed for at-home eldercare can inspire innovations in childcare is also a perfect example of the need for further integration across care systems, as well as between thinkers and practitioners. The Fifth Wave’s mission is to be a space for such integration to happen. A platform where a philosopher specialised in the ethics of care can learn from the hands-on experience of a nursing home worker; where a father eager to do more for parents can connect with a midwife to start a local perinatal support center. A hub for bold, radical and pragmatic thinking about the futures of care.

If that’s something you care about, you’re in the right place. Welcome to The Fifth Wave.

France is a relatively good country to be a father.

With four weeks of paternity leave (including four mandatory days) for no change in salary, it sits comfortably above its average European neighbour.

About 70% of eligible fathers actually take leave, and of those, about 65% use the full allocated time. We have a long way to go, and four weeks is still a far cry from what mothers need to truly flourish in their postpartum, but those are not terrible numbers.

Besides this common form of leave, France also has a more extensive version, confusingly called ‘educational parental leave’. This refers to the specific right of every worker to dedicate themselves to raising their first or second child up until its third birthday, without losing their job in the process (for the third child or more, the period can be extended up to five years). Though this is much less universally used, about 400.000 families benefit from it every year.

In theory, it is indiscriminately open to both parents. They can choose to completely stop working, and receive a monthly compensation of about 400€ - roughly 30% of French minimum wage - or work part-time, in which case the compensation drops to about 250€.

In practice, the policy is obviously designed for only one parent to take leave, given that it’s virtually impossible for a family to live off that kind of money. Unsurprisingly, in 2014, 95% of beneficiaries of the provision were women.

An attempt at change

That same year, French lawmakers decided to tackle this imbalance by reforming the compensation structure of parental leave. The objectives? Encourage a fairer split between parents, and boost mothers’ reentry into the workforce.

To achieve this, the duration of compensation payments was reduced from three to two years in case of non-shared leave, making it impossible for one parent only to be paid for three. This essentially earmarked one year specifically for dads, nontransferable. If a couple wanted to receive payments for the full three, they now had to take at least a year of leave each.

Last week, economists Mathilde Guergoat-Larivière and Mathieu Narcy published a paper evaluating the effects of this reform. Verdict: it didn’t do much.

To ensure that families observed would have comparable conditions in all respects bar that of the reform, they analysed couples’ rates of parental leave use the month just before it came into effect, versus the month just after. The effect was negligible. Rates of part-time leave use among fathers rose by a meagre 1.4 percentage points, and only by 0.2 for full-time leave.

Note: the second parent is most often a man and therefore referred to as a ‘father’, even though some couples in the sample are made up of two mothers.

Proponents of the reform were particularly banking on the fact that mothers, suddenly unable to be paid to stay with their child for a third year, would “pass the relay” onto their partners. But even in those scenarios, the objective of 25% shared-leave arrangements was far from met: for those fathers whose partner had to give up the extra year of compensation, the effect was a little stronger but still of only 4.4 points for part-time leave, and 0.6 for full-time.

Lawmakers were also hoping the policy would incentivise women to go back to work earlier. That, too, didn’t really happen. Two-thirds of those women who lost access to a 3rd year of compensation still stayed home, for no pay. Presumably because they either wanted to, or because even with a salary, it’s still often cheaper to stay home than to pay for childcare.

So, what does this tell us?

First, let it be said that the results themselves are not particularly surprising. It would be unrealistic, for one, to manage to drastically change something as ingrained as the socio-sexual division of care labour in the span of a month. What I am more surprised by is that those behind the policy were surprised. I think this example holds a precious lesson about how policymakers (and researchers!) categorise parenthood - and what they fail to understand about it.

The devil is in the sock drawer

As a potential cause for the weakness of the effects, the authors of the study first point to the weakness of the compensation: since men typically have higher salaries than women, the revenue loss associated with parental leave is greater for them. This higher opportunity cost probably explains why, when men do “take the relay” from their partners, they do so almost exclusively part-time.

But they nuance this by pointing out that fathers who make less than their partners (about 30% of the sample) also didn’t change their behaviour post-reform - even though it would’ve overall been financially advantageous for the household.

Even more telling is another study they cite, which shows that even fathers who were already working part-time did not decide to take part-time leave, even though that would have meant receiving extra money for no change in their work patterns and allowed them to avoid foregoing a full year of compensation.

So, financial incentives are not it. The authors then point to the obvious culprits: culture, gender roles, stigma and negative employer attitudes around paternity leave. They also acknowledge that women are typically the ones handling the paperwork associated with family benefits, which ties them to the caregiver role.

But wait: this last point, mentioned in passing, seems to me to be the absolute heart of the matter.

What the reform’s designers seem to have failed to consider is that taking care of a child does not just require continuity of presence - having someone there, whoever it may be. It requires continuity of knowledge.

Parenting is not a hobby you can take up, then transfer to someone else for a couple months, then pick back up again. Parenting is hard work. And like any form of work, it requires patience, time, mistakes, and a lot of learning to develop the set of skills needed to do it properly.

Handing over the full-time responsibility of children to your husband when you have spent the last two years taking care of them without him makes about as much sense as writing the first half of a novel, then handing the manuscript over to your toddler who can’t read.

I caricature, of course. Many men who work full-time are also very involved fathers. (Many are not.) But there is a crucial difference between ‘involved parent’ and ‘parent who knows’. Knows what foods the kids will and won’t eat, the name and address of their dentist, when the eldest has to go to football practice and which socks to pack for her; knows the kids’ vaccine history, the last time the fridge was fixed, what groceries are low in the pantry, how to pay the fee for the youngest’s school outing and how to sign him up for cello practice and when the annual talent show is and what costumes they need for that… and when the next child benefits payment is coming.

In a podcast conversation about parental leave with Elena Bridgers, marriage and motherhood expert Cindy DiTiberio explains:

“Incompetence can start very early on, because an infant requires very specific things. If you are not there to know all the things, you look to your wife, and she becomes the expert. [The only way to avoid this is] if both parents are tasked with fully being responsible for that infant early on - and by fully, I mean, let that mother leave for a day. She probably won’t like it either! I don’t know how young the infant needs to be, but let it happen early enough on so that the father is fully responsible.

[That is the only way] he can feel just as capable. He’ll learn his own methods. But the hierarchy starts there, in those early days. Again, it’s hard, especially when breastfeeding is involved. But I just think we have to be really careful. We’re all so tired during that stage, without some intentional practices, what ends up happening is we slip into, ‘mom knows all the things and dad bumbles along as a helper’. […]

That parent will also be responsible for that child for the rest of their life. He should be an equal parent, an equal partner.”

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Bibbidy, bobbidy, parent!

This ‘hierarchy of knowledge’ produced by mother-centric parental leave structures cannot be magically fixed over the course of a month just because the state said so.

Maybe part of the reason French men didn’t take parenting over from their wives for the last year of paid leave is because they would not even know where to begin. In a professional job replacement, they would go through a handover period, with some training. But here, they are to be suddenly entrusted with a set of responsibilities that they’ve had no part in shouldering since the birth of their children. And to make matters worse, be paid very little for it.

This study does not allow us a closer look at these in-couple dynamics. But it shows that cosmetic changes to the incentive structure of parental leave policies cannot disrupt the deeper roots of the gender parenting imbalance. Making parenting a truly shared enterprise starts in the very beginning. And the ‘one caregiver, one worker’ model (even in a world where they did alternate) still not only cements the idea that care is not work, but that a child’s early years are best spent in the care of one exclusive caregiver. A far cry from “it takes a village”.

As often with public policies around care, this reform was neither malicious nor completely unwelcome. But it failed to grapple with the gendered micro-dynamics that structure family relationships. It failed to recognise (and properly compensate) parenting for what it is: a lot of work, involving specific knowledge and specific skills. And therefore, it inevitably failed to deliver the kind of creative, radical overhaul of our current systems that is needed to truly make parenting - and all care work more broadly - fair, valued and collective.

If that’s something you care about making happen, you’re in the right place. Welcome to The Fifth Wave.

Guergoat-Larivière, Mathilde, and Mathieu Narcy. 2025. “What can we learn from the 2015 parental leave reform?”. Centre for the Study of Employment and Work.
[In French, untranslated]

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