Rapid Responses to:

EDUCATION AND DEBATE: Richard Johanson, Mary Newburn, and Alison Macfarlane Has the medicalisation of childbirth gone too far? BMJ 2002; 324: 892-895 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Go bang someone else's drum

Paul Duff   (12 April 2002)

Regional analgesia in labour - a good thing!

William Camann, MD   (13 April 2002)

Supply and Demand in OB

Robert A Knuppel, 125 Paterson St., New Brunswick, N.J. 08901   (13 April 2002)

Medicalizing birth is like putting beauty itself in a cage

Leilah McCracken   (13 April 2002)

Caesarean sections and augmented labours in Greece

Heracles Dellagrammaticas   (14 April 2002)

Fear has no place in childbirth

Stephanie A. Coleman   (14 April 2002)

Timely intervention is the key.

Meh-Noi Lim, Stephen Ong   (15 April 2002)

Re: Go bang someone else's drum

Sue M. Maguire   (15 April 2002)

Risks of childbirth medicalisation

Peter W Achterberg   (15 April 2002)

Informed Consent

Kari E Benson   (16 April 2002)

Moving with the times

Isidor J Papapetros   (18 April 2002)

Re. Go bang and moving with the times

Elizabeth M. McAlpine   (21 April 2002)

Re: Go bang someone else's drum

Cory A. Mermer   (22 April 2002)

Re: Moving with the times

Marie L Tyndall   (23 April 2002)

Extinction of endangered normal childbirth in Taiwan - systematic childbirh medicalisation

Peter S Yeh, 424 Pa Te Road, Section 2, Taipei 105, Taiwan   (24 April 2002)

Re: Re. Go bang and moving with the times

Isidor J Papapetros   (24 April 2002)

Re: Re: Re. Go bang and moving with the times

Charlene Lewis   (30 April 2002)

Remind safety of childbirth

Josef Wisser   (30 April 2002)

Objectivity required in the childbirth debate

Felicity Plaat, Amer Qureshi   (28 May 2002)

Is home midwifery-attended home birth a good option?

Gail W. Johnson   (18 July 2002)

Re: Supply and Demand in OB

Jenny M Hatch   (2 February 2003)

Go bang someone else's drum 12 April 2002
Paul Duff, Rural GP Bright Australia 3741 Send response to journal: Re: Go bang someone else's drum	The UK perinatal mortality rate has fallen from 500 in the 1850's (in deprived areas) to 18 in 1979. Of course, you say, because we had no antibiotics in those days and sanitation was poor and the poor had no obstetric care etc. etc. The simple introduction of hot water and clean linen would have accounted for a substantial part of that reduction. But how then to explain the further decrease from 1979 to 1996 where the perinatal mortality has fallen again, from 18 to 7! How dare anyone say that in 1979 we had poor sanitation or an obstetric underclass or no antibiotics. I was there! Yes, there may be women who end up with a forceps delivery, rather than the satisfaction of struggling though another 10 hours of labour in the OP position but there is no getting away from the fact that today, 993 of 1000 woman who deliver, go home with a baby in their arms; 11 more than who did so in 1979. Since there has been no decrease in medicalisation in the past 20 years, then it must be that same medicalisation which accounts for the fall! So, while I regret the high intervention rate, the high Caesarian rate and all those processes which take away from a "natural birth" I ask for some credit for judicious medical intervention.
Regional analgesia in labour - a good thing! 13 April 2002
William Camann, MD, Director of Obstetric Anesthesia Brigham and Women's Hospital, Harvard Medical School. Boston, Massachusetts, 02115 Send response to journal: Re: Regional analgesia in labour - a good thing!	I read with great interest the article entitled "Has medicalisation of childbirth gone too far?" (Johanson et.al, BMJ April 13, 2002). Several points deserve comment: First, anaesthetic-related maternal mortality has dramatically declined over the last few decades. Recent surveys from both the UK and the USA find that the very few fatal complications of anaesthesia in obstetrics are usually related to complications of general anaesthesia, e.g., loss of airway and/or hypoxia.(1,2) The dramatic decline in the use of general anaesthesia for caesarean delivery must, in part, be attributed to the rise in use of regional analgesia during labour (3). In fact, the American College of Obstetricians and Gynecologists has issued a statement: "Failed intubation and pulmonary aspiration of gastric contents continue to be leading causes of maternal morbidity and mortality from anesthesia. The risk of these complications can be reduced by careful antepartum assessment to identify patients at risk, greater use of regional anesthesia when possible, and appropriate selection and preparation of patients who require general anesthesia for delivery" (4). Second, the article by Johanson states that women are "encouraged" to receive epidural analgesia in labour. This paternalistic attitude ignores the fact that most women in labour choose epidural analgesia, of their own volition, without influence. I am a firm believer that the choice for women to elect to undergo "natural", or unmedicated childbirth should always be available (within the limits of safety with regard to certain high-risk conditions), just as some of us choose to climb mountains or run marathons. This should also be accompanied by the attitude among all obstetric and anaesthetic care providers that there is nothing "wrong" with women who choose unmedicated, or uninterventioned, childbirth. But most people do not run marathons or climb mountains. Pari passu, most women do not want to have pain during childbirth. The widespread use of regional analgesia in labour should not be bemoaned, but rather celebrated as one of the blessings of having a baby in this millennium. Pain-free childbirth has become as much a part of modern culture as the cell phone or the microwave oven. Third, Johanson et.al. state "Childbirth without fear should become a reality for women, midwives and obstetricians". Inasmuch as one of the cardinal fears of labour is pain, the widespread availability and use of regional analgesia should go a long way towards decreasing the incidence of such tocophobia. 1. de Swiet, M Maternal mortality: Confidential enquiries into Maternal Deaths in the United Kingdom. Am J Obstet Gynecol 2000; 182: 760-6 2. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related Deaths during Obstetric Delivery in the United States, 1979-1990. Anesthesiology 1997; 86: 277-84 3. Tsen L, Pitner R, Camann W. General anesthesia for cesarean delivery at a tertiary care hospital. Int J Obstet Anesth 1998; 7: 147- 52 4. Anesthesia for Emergency Deliveries. ACOG Committee Opinion Number 104, March 1992.
Supply and Demand in OB 13 April 2002
Robert A Knuppel, Professor and Chair OB/GYN Robert Woood Johnson Medical School, 125 Paterson St., New Brunswick, N.J. 08901 Send response to journal: Re: Supply and Demand in OB	The article by the late Richard Johanson et al, regarding medicalization of childbirth speaks to the more global issue of physician capacity and malpractice. Clearly, we in the established medical society, have found it difficult to continue the cultural movement in the early 1970's to normal childbirth. It was a pleasure assisting women in the joy of a natural childbirth with little intervention. Alas, the electronic fetal monitor, amniocentesis, ultrasonography and the improved safety of caesarean sections converged to allow plaintiffs to allege causation by "failure to use or diagnose and surgically extirpate the fetus before neurologic damage." The evidence for fetal/newborn neurologic impairment caused by lack of proper utilization of the new technology in labor is lacking. IN fact,the rise in the rate of lawsuits, claims, and settlements along with enormous jury rewards are directly related to the statistical rise in the incidence of neurologic impairment in the newborn. The system is broken and patient empowerment with the democratization of reliable information is needed. How far have we come? The patients now request c/sections to avoid perineal insult. What happened to the natural childbirth movement...it recognized, albeit unassumedly, that there was little medicine could do to improve the outcome.
Medicalizing birth is like putting beauty itself in a cage 13 April 2002
Leilah McCracken, chilbirth writer/researcher Vancouver, Canada Send response to journal: Re: Medicalizing birth is like putting beauty itself in a cage	Yes, the medicalization of birth has gone too far. And this paper does not go far enough in addressing how hurtful the medicalization of birth truly is. As a woman who has given birth to eight children, five them them in hospitals, I can personally attest to the damage that comes from medicalized birth- physically, intellectually, emotionally and spiritually. Physically: In each of my hospital births I was harmed. Through the cesarean section operation, anesthetic drugs, and myriad labor inductions; as well as through many other "lesser" traumas- like needles, tubes, pelvic exams and lithotomy. Upon careful research after the births, I learned that the vast majority of my interventions were needless, and given without an iota of true informed consent. My children were harmed physically too: through many of the same "lesser" traumas, as well as through the immediate amputations of their umbilical cords, resulting in dramatic losses of blood volume and a forever-lost opportunity for the most optimal form of "cord blood banking" there is: inside their bodies. Intellectually: As a result of being regarded as a birth catastrophe waiting to happen (and being managed as though I were one happening already), I regarded myself as a broken woman. For many, intellect stems from one's feelings of competence and self-worth- and as long as I was stunted as a woman in my most elemental role, I was stunted in my capabilities as a person. Only when I realized my own competence as a birthing woman during my sixth's home birth did my intellectual and artistic capabilities reach their zenith. My brain power stems directly from my woman power... (Note that true emancipation for women may well be held back by the fact that they are controlled by men, or male models of birth, in what should be their most innately female time. Women cannot be free as long as their births are held captive- even if women are programmed to believe they are making intelligent childbearing choices by having medicalized births.) Emotionally: The following words describe what many women feel in their actively managed hospital births: humiliation, helplessness, hopelessness, despair, rage, bitterness, deep loss- grief; feelings that are not conducive to smooth, healthy birth experiences (despair actually leads to "failure to progress" and other iatrogenic labor complications). Doctors should put themselves in their "patients'" positions- naked, helpless, under enormous pressure to "perform"- imagine themselves becoming the omega females instead of the alpha males. Perhaps then they would learn some compassion. Many women describe their hospital births as "rape"- and rape it is indeed when a woman is helpless, prone and harmed in her most viscerally sexual time. Spiritually: I knew no God until I saw the face of God in gentle, holy home birth. My births were too traumatic and managed in the hospital to be anything but routine medical procedures. With my sixth, finally there was gentleness where there had been so much pain- sparking a rich healing that spread throughout my sprit. Now I know there is more than only the crudely physical to existence... This is the degree that gentle births matter- they can turn hard atheists into richly spiritual beings. Birth is more than a human infant being expelled through the female reproductive. It is a whole woman coming in hot contact with her own creation- with her past, present future- and if left alone, every part of her will play in orchestral magnificence in her own unique, intrinsic birth dance. And the more that crude medicalization "cuts into" this rich dancing, the less chance a woman has of understanding her own magnificence as a human being; and this iatrogenic stunting of self can metastasize into a lifetime of broken dreams and abilities. Medicalizing birth is like putting beauty itself in a cage, and expecting it to conform to the cold confines of its bars for the pleasure and efficiency of those who confine it. Birth cannot be understood medically... it took me five medicalized births, then one home birth, to understand this. Says Marsden Wagner, MD, MSPH about the difference between home birth and hospital birth: "After asking the pregnant woman for permission, [the midwife] took me along to a prenatal visit so I would not be a stranger at the time of birth. Already I was beginning to see that this was very different from the obstetrical approach, that the medical and social models of birth were completely distinct. It would be impossible for me to exaggerate the influence of my experience with homebirth on my opinion of obstetrical authoritative knowledge and practice. Home birth is as different from hospital birth as night is from day. Trying to describe home birth is like trying to describe sexual intercourse- you can give the outlines, but you can never adequately describe the personal dynamics, feelings, ambience." (Excerpted from "Confessions of a Dissident", Chapter 14 from Robbie Davis-Floyd's book "Childbirth and Authoritative Knowledge: Cross-Cultural Perspectives". Read the full text on www.birthlove.com) If medicalized birth actually saved lives, the great loss of potential for beauty and happiness might be acceptable. But active management does far more harm than good- and the loss to humanity because of it is unconscionable. If anyone who is reading this is interested in learning more about the potential of childbirth, please write me and I will PDF you a copy of my critically acclaimed book, Resexualizing Childbirth. I would especially love it if obstetricians read this book... if even one came to regard women more gently because of it, that would be more gratifying than I can say here. Leilah McCracken www.birthlove.com
Caesarean sections and augmented labours in Greece 14 April 2002
Heracles Dellagrammaticas, Associate Professor in Neonatal Paediatrics NICU,2nd Department of Paediatrics, University of Athens, 11527 Athens, Greece Send response to journal: Re: Caesarean sections and augmented labours in Greece	Sirs, I read with interest this paper and paediatricians in Greece wre also concerned with the issue of the vanishing 'normal delivery'. The example of Spain used in the paper although striking is not perhaps nearly as impressive as the one of Greece. In Greece tha vast majority of pregant women are managed privately and the contribution of midwives is extremely low. Caesarean section(C/S) rate is in the order of approximately 40% and nearly all labours are augmenented using oxytocin. All babies conceived by assisted reproduction methods are delivered by C/S, even singletons. To my knowledge there is no study showing for uncomplicated unifetal pregnancies delivery by C/S is safer compared to vaginal delivery. Even for twin pregancies there is controversy as to whether C/S should be routinely the preferred mode of delivery. A number of women prefer to deliver by C/S but I suspect that the contribution of Obstetricians in making this decision is substantial. It is true that both perinatal and neonatal mortality rates have both fallen but it would be a dangerous oversimplification to be attributed to medicalisation of childbirth
Fear has no place in childbirth 14 April 2002
Stephanie A. Coleman, Arlington, Texas 76006 Send response to journal: Re: Fear has no place in childbirth	While I am pleased to see an article such as yours discussing the medicalization of childbirth, I have knots in my stomach from the way in which medicalization is presented here. To this I say, ASK THE MOTHERS!!! Women will give birth with whom they choose and where they choose.But, that doesn't mean they are making the best decisions. Women in our society are brain-washed to believe that birth is safest in a hospital with an obstetrician {or male} attending or "managing" birth. Childbirth in this country is medicalized for one reason only- the doctors fear of litigation. Period. No matter what anyone says, the fear of litigation controls the way doctors practice in every aspect of medicine.But, is that right? No. Fear has no place in childbirth. Especially from the attendant at the birth. The person attending a woman in birth {midwife, ob, family doctor, husband} should have no fear regarding the woman's birth. This fear can cause a person to do things that can harm the mother or baby. Cesarean section, forceps delivery, episiotomy, premature cutting of the umbilical cord, forceps or vaccuum delivery, and managing a labor with dangerous and lethal drugs such as pitocin and cytotec {which it should be considered a criminal act to give these drugs to any woman giving birth, yet doctors don't pay attention to the manufacturer on this one either!} And let me make that clear- birth is not the practice of medicine. Birth is a normal, natural life event - if left alone, it will progress on its own. Birth does not need medalsome doctors who are afraid of being sued if they don't produce a perfect baby. It is a travisty in our country that we put so much responsibility and expectations on our doctors to carry such a heavy load. We expect them to produce our perfect child. They, of course, can not guarantee anything. But, they try their hardest to cover their butts in every aspect of the birthing process. Every intervention is their safe haven. The legal system in our country believes that if you "do" something that you are trying. I believe that by not "doing" something, you ARE doing something. Doctors need to learn a healthy respect and reverence for the sacred event that is called birth. Birth, as in death, is spiritual and sacred. It does not call for a large audience of strangers or poking machines or drugs to interfere. Doctors should be REQUIRED to work alongside midwives to learn and observe what normal birth is. That way, when they are faced with problems in birth, they will know what is truly normal, what is iatrogenic {doctor-caused}, and what is truly abnormal. Doctors have their place in childbirth. They belong in the surgery room for the very rare complications that arise in childbirth. Midwives should be attending the majority of women in childbirth who have normal births, just as the norm is in the UK and European countries. Those countries have far better marternal morbidity and mortality as well as perinatal outcomes than the United States and we are supposed to be the richest country in the world. Well, the country with the most money also has the most toys and we know that the boys {or those trying to be like one of the boys!} just love their toys! At the expense of the women and their babies. As a woman who has given birth twice, once by cesarean and once vaginally, and from the extensive research I have done, I have come to the conclusion that birth in this country is a sad reflection on what our society as a whole places value on. Our society does not really value the importance of the experience of childbirth as one of the most joyous and exciting times during family life. Instead, it is seen as a medical event or an emergency waiting to happen. While it is viewed in this light, it is treated and managed as a medical emergency waiting to happen and the interventions that doctors use to help "cover their butts in court" are also the very things that contribute to the unnecessary problems and death in childbirth that could have been avoided if birth had just been left alone. I am lucky to be alive today, DESPITE the interference of well meaning, though self-serving doctors. I know full well the problems that can arise from a doctor's cascade of interventions. They can be deadly and lethal and it is the mother and baby who suffer. The doctor can go home at the end of the day and wash his/her hands of it all. The mother and her baby must live with the repercussions for years later- the emotional, physical, mental, and spiritual problems that accompany such medicalization. So, what can we do to stop the medicalization of childbirth? We can revere and honor birth for the sacred event that it is and treat it as a holy and special time in life. We can take normal birth out of the hospital, where it does not belong. You are correct in assuming that doctors and midwives need to work together. Doctors need to do what they are best at and well trained for: surgery - in emergency situations. And midwives need to attend to the rest of the majority of normal birthing women- at home and away from the hospital where interventions will be used because they are available. Not because they are needed, but because they are there. Midwives will refer women who have complications to the doctor for surgery and doctors will refer women to midwives who do not have a complication that will result in surgery. Insurance companies should pay for midwife attended birth ONLY unless referred to a doctor by a midwife. Let us not forget the mother in all of this. The mother, who has been forgotten in all of the interventions that are present in modern day obstetrics. True, the safety and health of our baby is of upmost importance.But, it is only through respect and admiration for the mother's comfort and well being that we will be able to help improve the baby's chances for an optimum birth. Let us not let the fear of litigation cloud our judgement and thinking and let us think of the mother and the baby, first and foremost.
Timely intervention is the key. 15 April 2002
Meh-Noi Lim, Senior SHO in Obsteterics and Gynaecology Walsgrave Hospital, Coventry, CV2 2DX, Stephen Ong Send response to journal: Re: Timely intervention is the key.	Johanson and colleagues imply that medicalisation of childbirth has led to a high Caesarean section rate, and quote data from Catalonia to Ontario(1). They have forgotten their neighbours in Ireland where the Active Management of Labour(2) is practised in some units. The National Maternity Hospital in Dublin, for instance, boasts of a section rate that has been consistently amongst the lowest compared to other units in developed nations. The practice of a strict criteria for the diagnosis of labour, early amniotomy, timely use of oxytocin and the involvement of a senior obstetrician at an early stage are cornerstones to the Active Management of labour. In addition, units in Dublin believe strongly in patient choice, and epidural analgesia is widely used. Do Johanson and colleagues not consider these interventions as medicalisation? Active Management of labour was designed primarily to reduce morbidity (and mortality) associated with prolonged labour---something that most obstetricians of the present generation seem to have forgotten about. One of the side effects of the Active Management of labour is a reduction in the Caesarean section rate. Surely the authors must accept that some of the reasons why the U.K. has a high section rate has to do with the fact that a) we don't know how to diagnose labour (ask any midwife/ obstetrician and you will get a myriad of ludicrous responses), and b) we don't know when to perform an amniotomy, use oxytocin or involve a senior obstetrician. No, the problem isn't that the medicalisation of childbirth has gone too far. Rather, the problem is that we don't know when to intervene. We agree with the authors that " visits to other units and countries- ----- should be encouraged". More of us should travel across the Irish sea. 1) Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002;324:892-5. 2) O'Driscoll K, Meagher, Boylan P. In:Active Management of Labor. 1993, Mosby, London. Competing intersts: none
Re: Go bang someone else's drum 15 April 2002
Sue M. Maguire, Pharmaceutical Advisor and Co-chair of Research Networkers Panel of the National Childbirth Trust 107, Bilton Road, Rugby, CV22 7AS Send response to journal: Re: Re: Go bang someone else's drum	Whilst not disagreeing that the perinatal mortality rate has fallen over the last 20 years there are a number of other factors which may have contributed to the decline, other than the increased medicalisation of childbirth. Care of premature and very premature infants has improved a great deal, aided by the evidence-based administration of corticosteroids to women with threatened premature delivery. Survival rates have increased although some infants have life-long handicaps. We also have increased use of diagnostic tests, in many forms, to screen for fetuses with abnormalities, resulting in many fetuses with serious abnormalities being aborted. A proportion of these fetuses would have had life-threatening abnormalities.
Risks of childbirth medicalisation 15 April 2002
Peter W Achterberg, RIVM 3720 BA Bilthoven, the Netherlands Send response to journal: Re: Risks of childbirth medicalisation	The article by Johanson et al., presents a good review of the situation and is quite to the point. What I do miss, however, is the topic of risk, risk perception and risk communication. Although it is evident that over-use of operative interventions in childbirth occurs frequently, we also should keep in mind that the birth- giving population is changing, especially in Western countries. The average age of women giving birth and the fraction of women giving birth to a first child have increased sharply. This is associated with increased risks of complications during and after childbirth. In various European countries the rates of births to mothers from ethnic minorities, who also have increased risks, has increased sharply over the past few decades. In addition, women have started smoking some decades ago and are not giving up smoking during pregnancy in many Western countries. Medical interventions way before birth (DES-daughters) or somewhat closer to birth (hormone treatments and IVF for infertility treatment) have also increased and have led to increased risks around birth, a.o. by increased multiplet birth rates. Although these increased risks will certainly not explain the increased rates of medical interventions in most Western countries, they do play a role. More important is, however, that mothers-to-be have not been educated well about these risks, or about the situation in which their risks are negligible. This increased risk awareness of future mothers could possibly contribute most to a future decrease in childbirth medicalisation.
Informed Consent 16 April 2002
Kari E Benson, biologist/informed patient Lynchburg, VA Send response to journal: Re: Informed Consent	I am concerned about the several responses addressing interventions that women request during labor and delivery. Most patients are unable to read articles in medical journals, or are willing to submit to their doctor's advice. It is quite standard for patients to be ill-informed about the data suggesting that interventions may have negative impacts on labor and delivery. There are many examples of situations in which doctors often are not thorough in their discussions of the trade-offs involved in care. Most women are not informed that an epidural may slow labor, have a negative impact on breastfeeding, cause a fever, increase their chances of requiring a c-section, or decrease their mobility. Most women in the U.S. must allow hospitals to use fetal monitors (even when data suggest that the increase in c-section rate does not correspond to increased health of babies or mothers). Many women agree to AROM, although this often reduces the duration of any allowable trial of labor (due to infection concerns), and may result in cord prolapse if the baby is not engaged. Admittedly, time is sometimes of the essence, but there is simply insufficient discussion of the implications of interventions, particularly for those patients that trust their doctor to make decisions. Similarly, my physician did not, even while informing me that I must have an epidural, that it may slow labor (although I was aware myself). She did not mention the increased risk of discomfort due to intestinal gas, decreased success of breastfeeding, potential for problems with pain medication to breastfeeding child (which I experienced), bleeding, death, or potential rupture, placenta previa, or placenta accreta in future deliveries when she suggested that I have a surgical delivery. Were these on the form that I signed - I signed something while being given an IV, flat on my back, while two other people were talking to me. Is this informed consent? She did not mention the increased risk or 3rd or 4th degree tears when she informed me that if we delivered naturally she would have to have consent for an episiotomy. This is not really informed consent. In discussions with other mothers, particularly many American women that have had c-sections, it is quite common for physicians to minimize the risks in their discussions. I am not implying that physicians are intending any harm to their patients. Many physicians are not trained in alternative solutions to problems. My doctor was unaware that alternative positioning might enable me to encourage my asynclitic child to present LOA. I asked repeatedly to labor on my hands and knees and was not allowed, they requested that I deliver in lithotomy position or sitting up. My doctor was convinced of the safety of c-section over vaginal birth in case of any malpositioning. Physicians are regularly sued over not performing interventions (and ofter lose). Although my c-section was unecessary, and my recovery very difficult, it is unlikely that I could have successfully sought reparations for the delivery, bladder injury, or lengthy recovery. Thus, from an economic perspective, she could protect her livelihood by performing interventions (that she believed in). This is true, even when these interventions resulted in some very unpleasant consequences, including the probability that no hospital will allow me to VBAC given the current recommendations from ACOG. Many US hospitals are requiring ERCS to avoid potential litigation from the unlikely (0.5-1.0%) event of rupture in a low transverse incision. If you visit many women's birth stories, I believe that you will find that my experiences are not unusual.
Moving with the times 18 April 2002
Isidor J Papapetros, Sydney Australia Senior VMO Bankstown-Lidcombe Hospital 2200 Send response to journal: Re: Moving with the times	The paper by the late Richard Johanson et al, entitled, “Has the medicalisation of childbirth gone too far”? 1 is yet another example of research in which many papers in support of a theme can be selectively quoted to support that theme when the reality is quite different. Without going into too much detail, there are two obvious examples in this paper. The high Caesarean section rate in Brazil is consumer driven not Doctor driven 2 and as for medicolegal pressures and defensive practices being a cause of increased Caesarean deliveries, why is it that in Brazil, litigation is almost non-existant? Johanson’s paper casts an unnecessary slur on Brazilian doctors as it also does on Private practice when the reality is quite different. A higher Caesarean section rate in Private practice more often reflects the management of a greater number of older women who are more likely to have problems in labour. 3 Medicalisation of childbirth has not gone too far. Indeed, one can say that medicalisation has come to the rescue of nature’s imperfections by being Proactive rather than Reactive in management. If women want to return to nature, then let these same women be prepared to take what nature dishes out. As quoted in this paper, even in modern times with all the improvements in hygiene etc, the North American religious community that declined all forms of professional assistance sustained a similar maternal mortality to 100 years ago. One only has to read Dr Catherine Hamlin’s experience in Adis Ababa to appreciate the same appaling morbidity from natural childbirth. 4 Given the same resources women in third world countries would welcome the medicalization and interventions of modern childbirth with their proven safety record. The reality is that women having a baby in the 21st century in Western Society are a privileged group. Childbirth in the last 200 years or so is well documented , not only by medical historians 5, but in other historical texts. 6. Never in the history of man has there been a safer time in childbirth for both baby and mother and having a baby in a dignified manner. I have no doubt for example that Charles Darwin’s wife Emma, who in 1850 screamed for the Chloroform, would have welcomed an epidural had it been available to her. 6 As most sensible and educated women become more aware of adverse outcomes, no longer do they want the prolonged labours and difficult vaginal births with their associated morbidities. This means that they want the Doctors to intervene and Johanson et al themselves acknowledge that in relation to litigation “most obstetric cases relate to labour ward practice, and 99% of these relate to ‘failure to intervene’ or ‘delay in intervention’.” 1 This information alone actually makes a good case in support of medicalization. Similarly, their data also shows clearly that since 1955, the instrumental rate has risen in parallel with the Caesarean Section rate. However, from the mid 1970’s onwards, the time mostly in question, as the Caesarean Rate continued to rise the instrumental rate has fallen and this is consistent with an informed cultural response from modern women wanting to avoid prolonged labours and difficult vaginal births. It is time that a true and honest acknowledgement was made of the value of medicalization. A proactive approach recognises that the outcome of childbirth is unpredictable and that often one only has very litttle time to act in an emergency. This approach has achieved an unprecedented safety in childbirth and a dignified one at that. It is my contention that future generations of doctors will judge our current times favorably. In the same context, they will judge the thrust of various articulate feminist groups who intimidate their peers into rejecting medicalization (or moving with the times) as another example of Woman’s Inhumanity to Woman. 6 References: 1.Johanson R, Newburn M, Macfarlane A, Has the medicalisation of childbirth gone too far? BMJ 2002;324:892-895 2.The pressure on Brazilian obstetricians to perform caesarean sections, Quadro Luis GA, Caesarean Sections on Demand, Pablo Millares Martin, BMJ 319, 1999, Electronic responses to Belizan JM, Althabe F, Barros FC, Alexander S “Rates and implications of caesarean sections in Latin America: ecological study” BMJ (1999) 319:1397-40. 3. Is there an incremental rise in the risk of obstetric intervention with increasing maternal age? British Journal of Obsterics & Gynaecology, 105, 10 1998. 4. The Hospital by the River. Hamlin C, Macmillan 2001 5. The Greatest Benefit to Mankind, Porter R, Fontana Press 1997 6. Darwin, Jesmond A & Moore J, Penguin Books 1992 7. Woman’s Inhumanity to Woman. Chesler P, Thunder’s Mouth Press/Nation Books, 2001
Re. Go bang and moving with the times 21 April 2002
Elizabeth M. McAlpine, midwife Royal Women's Hospital, Melbourne Send response to journal: Re: Re. Go bang and moving with the times	I refer both of you to BMJ 321, 15th July, 2000, 'Rates for obstetric intervention among private and public patients in Australia', Roberts, et al. The WHO has stipulated that for 80% of women, the most appropriate carer is the midwife. Why then are obstetricians intervening in 'normal' births? Further, neonatal care has advanced greatly since the 70s so altering the NND rate.
Re: Go bang someone else's drum 22 April 2002
Cory A. Mermer, researcher independent Send response to journal: Re: Re: Go bang someone else's drum	Dr Paul Duff (duffer@bigpond.com) says "there is no getting away from the fact that today, 993 of 1000 woman who deliver, go home with a baby in their arms; 11 more than who did so in 1979. Since there has been no decrease in medicalisation in the past 20 years, then it must be that same medicalisation which accounts for the fall!" Hey "Duffer", that is certainly a significant statistic. Of course nobody wants dead babies! But the fact is that a MUCH higher percentage of babies delivered today will have permanent handicaps and disabilities. Some of these disabilities will be obvious and expected, such as with very low birthweight and very premature infants. Many others will later be diagnosed as having behavioral/developmental disorders like Autism, ADD/ADHD, and related disorders. How come Dr Duff gives "medicalisation" of birth complete credit for being responsible for the decrease in infant mortality, but does not hold it accountable for other statistics that are not as favorable? Simply saying that an extra 11 living babies is a great achievemnt of modern obstetrics is like looking at the data through a VERY narrow lens. But the bottom line is - let's use the common-sense "interventions" that save lives when they are needed and get rid of the interventions that are not evidence-based and may destroy the quality of those lives. For more information about one such practice please visit www.cordclamping.com
Re: Moving with the times 23 April 2002
Marie L Tyndall, midwife, anthropologist, birthing mother Asociación Primal, Costa Rica Send response to journal: Re: Re: Moving with the times	There is plenty of evidence that obstetric routine practices are detrimental to birth (for example, M. Tew: Safer Childbirth?, WHO guidelines for Normal Birth, M. Wagner: Birth Machine, H. Goer: Obstetric Myths, just to name a few of many sources) and Brazil is a good example. However, Mr. Papapetros is sadly misinformed and his attitude is detrimental to women. Women in Brazil may ask for a c-section because standard hospital care is generally appauling: humiliating, pain-causing and unscientific. Women in Brazil do not sue for damages because their social standing, economic resources and knowledge of their rights is so low compared to the revered high-class doctors. There are no known mechanisms for securing human rights in Childbirth. Brazil is a land of great inequalities and injustices due to its colonial history. This statement it particularly distressing: "If women want to return to nature, then let these same women be prepared to take what nature dishes out." As a birthing woman or a profesional birth attendant, I would hate to find myself in need of his services, this kind of arrogance and revengefullness is unprofesional, anti-ethical and anti-scientific.
Extinction of endangered normal childbirth in Taiwan - systematic childbirh medicalisation 24 April 2002
Peter S Yeh, Senior Resident in Obstetrics & Gynaecology Taiwan Adventist Hospital, 424 Pa Te Road, Section 2, Taipei 105, Taiwan Send response to journal: Re: Extinction of endangered normal childbirth in Taiwan - systematic childbirh medicalisation	Dear Editor, Taiwan had transformed itself from a developing to a developed country in recent decades (1). As it did so, medical resources had improved dramatically and now compare favourably with any Western industrialised nation. Alas, in childbirth, medicalisation had likewise took hold and permeate through the obstetric profession. Nearly every learned and acquired intervention in childbirth is perceived as necessary and good. For example, pregnant women on entering a delivery suite are subjected to routine enema, routine pubic shaving, routine nil-by-mouth, routine intravenous cannulation and routine intravenous hydration. Paternalist approach is the norm. Term-pregnant women with prelabour rupture of membranes are subjected to routine induction of labour. Again, the paternalist approach offers no choice. Expectant management for even the next 12-24 hours is perceived as too risky an alternative. Now, even pregnant women at 36 weeks gestation are subjected to the same routine protocol. Routine midline episiotomy for all labour women is practised. Every labouring women regardless of gestation - term or preterm - is subjected to this intervention. Episiotomy rate approaches 100%. The above practices are so entrenched that any change of practice would be difficult and meet much resistance. Increasing medicalisation has led not to diminishing but increasing medico-legal cases. A viscious cycle ensues. Obstetrician now act and intervene even more for fear of litigation. Govenment Health Statics show that there has been a decline in the number of registered midwives in the last decade, from 1,891 in year 1990 to a mere 558 in year 2000. During the same period, the number of registered doctors rose from 19,921 in 1990 to 29,585 in 2000. This is for a population of 20 million in 1990 and 22 million in 2000. (2) As Taiwan now seeks an Observer status in the World Health Organisation (WHO), it is fitting for professional bodies and governments in Taiwan to promote obstetric practice as contained in the WHO Report - "Care in Normal Birth: A Practical Guide" (3), which aims to improve obstetrics practice in normal childbirth. References: 1 Chiang T-L. Economic transition and changing relation between income inequality and mortality in Taiwan - regression analysis. BMJ 1999; 319:1162-5. 2 Department of Health, Taiwan. Republic of China. Health & Vital Statistics Republic of China 2000. 3 The World Health Organisation Report. Care in Normal Birth - A Practical Guide. 1996
Re: Re. Go bang and moving with the times 24 April 2002
Isidor J Papapetros, Consultant Obstetrician & Gynaecology Sydney Send response to journal: Re: Re: Re. Go bang and moving with the times	Might I suggest to Marie L Tyndall that such a forceful tirade of words as "arrogance and revengefullness is unprofesional (spelt wrongly), anti (should be un)- ethical and anti-(should be un)-scientific", that she chooses to use publically is a display of bitterness and aggression that is more befitting of text for a local woman's magazine from the last century rather than an eminent journal such as the BMJ which is moving into the 21st century. There is no need to get personal in a scientific forum. Clearly, her destructive attitude is aptly demonstated in Phyllis Chesler’s book Woman's Inhumanity to Woman and this destructive attitude as Chesler states in her book is independent of race, class and country. Nowhere is this inhumanity better demonstrated than women’s intimidating attitudes to other women in fertility, childbirth and lactation. Is it not a coincidence that the majority of negative electronic comments have come from women in their capacities as biologists, anthropologists and childbirth writers most of whom have no idea about the management of labour let alone about being proactive in the difficult ones before they end up as disastrous emergencies. As for the few midwives who write in, whilst their skills are invaluable, they do not have the scientific and surgical training to continue managing the difficult labours which often and inevitably end up in a disastrous emergency requiring urgent medical intervention (reactive management). The key to modern obstetrics is to be proactive and the reality is for those who care to face it, that medicalization has rescued the imperfections of nature. Furthermore, the reality is that there are very many happy women today living quality lives who in times gone by would have died or been severely damaged. WHO readily quote that 99% of maternal deaths and perinatal deaths occur in third world countries. Women in third world countries through no fault of their own are destined to what nature dishes out. How is this an offensive comment? However, for those not trained to accept the ultimate responsibility for the care of women in labour, it is offensive to intimidate and adversely influence women into avoiding medicalization which will help them. Lastly, I might also point out to Marie L Tyndall that there are some very wealthy women in Brazil as well as poor women. Why don't they sue? It is the wealthy women who are requesting Caesarean Sections and their reasons are not only related to their wealth and ability to afford them but also as to how they perceive their sexual welfare after childbirth. Indeed these women have been 20 years ahead of their western counterparts. As for the poor women, their Caesarean Section rate is 26% which is more than their western counterparts. Her statement that poor women “cannot sue for damages because their social standing, economic resources and knowledge of their rights is so low compared to the revered high-class doctors” only serves to cast another slur on Brazilian doctors and displays her own anti-doctor bitterness and envy. Who is “sadly misinformed” Ms Tyndall and whose “attitude is detrimental to women”? To Elizabeth M. McAlpine, who referred myself and Paul Duff to 'Rates for obstetric intervention among private and public patients in Australia', Roberts, et al. May I too refer her to a letter I wrote in response to this article and which the BMJ chose to publish in its letters BMJ 2001; 322: 430. Titles of articles can be misleading. Try looking at their data with some lateral thinking. Some of the greatest modern (medicalized) discoveries in Obstetrics and Gynaecology came from lateral thinkers seeking the betterment of women’s health. I think they were men!
Re: Re: Re. Go bang and moving with the times 30 April 2002
Charlene Lewis, student Palomar College,USA 92069 Send response to journal: Re: Re: Re: Re. Go bang and moving with the times	I'm currently a student at a community college in the US. I am on my journey in becoming a midwife. I just wanted to put my two cents worth on this subject. My philosophy about homebirth versus hospital is simple. It's a choice that pregnant women make and it should not be taken away. There are statistics to say in low risk women that a home birth is safe. But, only if the woman wants to do that. Yes, OB's are there for a reason and thank God they are, or my first son wouldn't be here. I guess what I'm trying to say is that there is reason for midwives and there is reason for OB's and instead of constantly bickering over who has more of a right to deliver babies we should start thinking about ways we can work together to bring in those precious miracles into loving families. I believe that if both ends of the spectrum are equally valuable then we would be able to work in harmony. Thank you.
Remind safety of childbirth 30 April 2002
Josef Wisser, Oberarzt, Dept. Obstetrics University of Zurich CH-8091 Zurich Send response to journal: Re: Remind safety of childbirth	There is no good that cannot be made better. Therefore, the proposals by Johanson et al. (1) in the 13rd April issue of the BMJ to improve obstetrical care are very much appreciated. However, all the considerations have to take into account, that the main aim of obstetrics is to keep maternal and perinatal mortality and morbidity to a minimum. The authors claim that modern obstetrics is characterised by increasing rates of unnecessary interventions such as intravenous infusion, augmentation of labour with oxytocin, electronic fetal monitoring, pain relief by epidural analgesia and an increasing caesarean section rate. The author’s proposals to demedicalise childbirth suggests that a low caesarean section rate is a good measure to assess the quality of the obstetrical service. Undoubtedly giving birth is a physiological process and normal childbirth is via the vaginal route. Nonetheless, we should not be proud soley of a low caesarean section rate but of the fact that obstetrics in developed countries is the safest ever practised for mother and the fetus/neonate. To keep this high standard of safety should be kept in mind, if we change our daily practise. Because of the extremely low prevalence of complications associated with childbirth in developed countries it is difficult to assess the effects of changes in clinical practise on the basis of statistical evidence (2). This plea for evidence based medicine has to be applied to demedicalisation of childbirth as well. If we assume that a change in obstetrical care in central Europe would double maternal mortality from 5/100000 to 10/100000, statistical evidence with a type I error of 5% and a power of 90% can be disclosed only by studying a minimum of 284 608 patients in each group (3). This is hard to achieve, but scientific obstetrics has to remember all proponents of the demedicalisation of obstetrical care, that they have to take this burden and prove, whether their proposed measures do not increase the risks for mother and child. Obstetricians need not only good arguments, but they need hard facts, even if these are extremely hard to get. Reference: 1. Johanson R., Newburn M., Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002;324:892-5 2. Mongelli M., Chung TKH., Chang AMZ. Obstetric intervention and benefit in conditions of very low prevalence. Br J Obstet Gynaecol 1997;104:771-4 3. Florey CV. Sample size for beginners. BMJ 1993;306:1181-4
Objectivity required in the childbirth debate 28 May 2002
Felicity Plaat, Consultant anaesthetist Queen Charlotte's hospital, London w12 0HS, Amer Qureshi Send response to journal: Re: Objectivity required in the childbirth debate	EDITOR – in their discussion about the medicalisation of childbirth Johanson et al associate the phenomenon of falling normal delivery rates with increasing rates of medical intervention(1). Whilst the authors acknowledge the dramatic fall in maternal mortality during the last 100 years, they suggest this might be despite rather than because of developments in obstetric practice. Indeed the demonisation of the medical profession, (in particular obstetricians and their anaesthetic colleagues), is the dominant theme of this paper. The authors describe how ‘ in many countries women who have straightforward pregnancies are "subjected" to infusions and are "encouraged" to have monitoring and epidurals, presumably by doctors who must also bear the blame for ‘perineal injury’ being ‘standard’. None of these assertions are referenced. In fact no evidence is offered to support the inference that this increased intervention is actually unnecessary. It is suggested that normal birth rates might be increased through community based care: merely ‘planning a home birth’ or booking at a midwife led centre decreases the risk of operative delivery. The cynical reader might just assume this reflects exclusion criteria for such centres. A second suggestion is the need for a ‘commitment to one to one supportive care during labour’. One of the studies cited as supporting this was carried out at Queen Charlotte’s hospital(2) and showed that women who received continuity of midwifery care did have a lower intervention rate, including regional analgesia. However the sad fact is not a lack of commitment to this type of care but that there is a lack of midwives to deliver it. The authors quote the phrase ‘childbirth without fear’: but fear of what? Data from the National Sentinel Caesarean section audit(3) revealed that the most important consideration for women in labour is the safe birth of the baby. Fear about the pain of childbirth is also a significant consideration. Will we really be ‘involving women fully in decision making’ if we try to minimise the use of regional analgesia which has been shown to be effective and safe? Regional analgesia does slow down labour but does not increase the risk of Caesarean section(4) Care during childbirth is critical to women’s heath and well being. It is crucial that it develops in the right direction. The emotive style and language, and the scanty and selective use of references in this article does not take the debate further. References 1. Johanson R, Newburn M, Macfarlane A. Has the medicalisation of childbirth gone too far? BMJ 2002; 324: 892-895 2. McCourt C, Page L. Report on the evaluation of one-to-one midwifery. London: Hammersmith Hospital NHS Trust. Thames Valley University, 1996 3. Paranjothy S, Thomas J. Royal College of Obstetricians & Gynaecologists Clinical Effectiveness Support Unit. The National Sentinel Caesarean Section Audit Report. London RCOG 2001. 4. Sharma SK, Alexander JM, Messick G, Bloom SL, McIntire DD, Wiley GRN, Leveno KJ. Cesarean delivery: A randomized trial of epidural analgesia versus intravenous meperidine analgesia during labour in nulliparous women. Anesthesiology 2002;96(3): 546-551. F Plaat Consultant anaesthetist A Qureshi Senior SpR in anaesthesia
Is home midwifery-attended home birth a good option? 18 July 2002
Gail W. Johnson, CPM Eden Song Maternity, Inc. 76054 Send response to journal: Re: Is home midwifery-attended home birth a good option?	This response comes rather late, but I thought it might be of interest to those who believe that home birth is unsafe and hospital birth is the "obvious choice." Infant Mortality Rate (IMR) data, from the Texas Department of Health, Bureau of Vital Statistics: Year M.D. IMR Midwife IMR M.D./Midwife IRM Ratio   1990 7.6 3.0 2.5 1991 7.3 3.0 2.4 1992 7.5 2.3 3.3 1993 7.3 1.8 4.0 1994 6.8 1.7 4.0 1995 6.5 2.1 4.0 1996 6.3 1.1 5.7 1997 6.1 2.8 2.2 1998 5.7 1.7 3.3 1999 6.0 1.2 5.0 2000 5.5 0.3 18.3 Average (1990 - 1999) excluding year 2000 data   6.5 2.1 3.5 What does this mean? It means that home birth, by Direct Entry Midwives, according to the midwifery model of care, is statistically safer (for those women who are candidates for home birth) than physician-attended birth in Texas. Look at it another way. Examine the infant mortality rate for MOST world countries. From “The CIA World Factbook – 2001” estimated infant mortality rates (1 year): United States - IMR 6.76. This IMR places the United States 40th on the World Facts Book’s list of 234 countries ranked by infant mortality. The IMR in Texas is better. Texas would rank about 26th, but if Texas Midwives were included on that list their IMR would place them FIRST. True, at times there are medical complications that require a physician's services. When they are really needed they provide a wonderful birthing option. Granted, physicians often get the "harder births," but not all of their births are the difficult ones. Since the C-Section rate in Texas is 25% on average for the year 2000, we might assume that 75% of women are likely candidates for "unremarkable" births. Many, if not most of those women have not been told that there is a statistically safer birthing option and that, by the way, it is cheaper as well. However, don't fault the women too much. Insurance companies often refuse to pay for home birth and justify their policies on home birth by stating that it "isn't safe" or it isn't recommended by physician guidelines Gail Johnson, CPM
Re: Supply and Demand in OB 2 February 2003
Jenny M Hatch, Mother Home Maker - 80027 Send response to journal: Re: Re: Supply and Demand in OB	The natural childbirth movement went home. We are now happily birthing in ecstatic, vibrant, holistic beauty at home. Some of us had to learn the hard way, my husband and I had three hospital births before coming home to have two additional Freeborn sons, but couples by the dozens are jumping on the unassisted childbirth freight train, some with a first birth. Now it is a trickle, and if medicine doesn't reform itself, soon it will be a flood of families running from the birth machine. Don't worry, you will always have a demand for what you have to offer with your drugs and surgery birthing, but for those of us who wish to retain our sovereignty, sacred couples birthing is our passion and our birthright. Jenny Hatch www.naturalfamilyco.com "Healthy Families Make A Healthy World!" Competing interests:   I am actively teaching couples about unasissted childbirth on the web through my web site, my books and a video of our second conference in the US. If that is a competing interest, then yes, I do have a financial stake, as I charge money for everything I offer.