Education And Debate

Has the medicalisation of childbirth gone too far?

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7342.892 (Published 13 April 2002) Cite this as: BMJ 2002;324:892

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

Competing interests: No competing interests

28 May 2002
Felicity Plaat
Consultant anaesthetist
Amer Qureshi
Queen Charlotte's hospital, London w12 0HS