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
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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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests