In my visits around the UK and to different parts of the world over recent years, I have been struck by how intractable and pervasive the medicalisation of childbirth has become.
By medicalisation I do not mean medical care, which is a crucial part of maternity services. Medicalisation or medical control of birth may be characterised by excessive intervention, including caesarean sections (CS), instrumental deliveries and high rates of epidural anaesthesia, routine electronic fetal monitoring, as well as induction and augmentation—and still, in many parts of the world, elective episiotomy, routine shaves and enemas. Indeed, this is not reserved for high-income countries. Medical interventions, many without any scientific basis, pervade every corner of the world.
One aspect of this medicalised approach is that the power of respectful human support and importance of human relationships is often overlooked. Care is often fragmented and standardised.
Medicalisation is a process by which non-medical problems become defined as medical (Prosen and Tavčar Krajnc, 2013). This expansion of the medical jurisdiction over childbirth becomes a mechanism of social control through medical gaze and surveillance; normal processes become problematic, and a new consumer market is created (Prosen and Tavčar Krajnc, 2013). Medicalisation as social control in childbirth holds great power. Childbirth is a sensitive and critical point in human life, with the potential for enhanced health over the life span, or to do harm that may persist over a lifetime and even generations.
Opening the markets for commercialisation of birth
Medicalisation opens markets for the commercialisation of birth. Take, for example, the high rates of CS in private obstetric practice in many parts of the world. The effect of this shifts us further into territories where CS is the norm, and the acceptance of CS as a ‘safe’ choice spills over into public services and to groups of women who have little choice, and little support for recovery. Whether or not the women who ‘elect’ for CS in private practice actually have a choice is a moot point. Through much of the world, the CS rate has risen steadily, and the normal birth rate has fallen.
Medicalisation means normal processes become problematic
What is clear is that the medicalisation of birth is deep-rooted and cultural, exerting further power in various ways. Gradually, seeking to support normal or physiological processes has been questioned and even seen as deviant, and has sometimes been subject to extreme control or even criminalisation in some countries. Even in the UK—where there is universal provision of health care, a highly educated and skilled midwifery workforce, and national policy supports out-of-hospital birth—when staffing of hospital birth centres and labour wards is stretched, the homebirth service may be suspended (as though such a service is expendable) while little attention is paid to reducing CS rates.
Over time, the knowledge, skills and experience required to support normal birth have been lost in many countries and in many services. Moreover, interventions such as immobilisation during labour and breath-holding to bear down might be used. In such circumstances, outcomes will be jeopardised. The next step is apparent in the assertion that normal birth should no longer be seen as the default, but that women should be warned of its risks (Black, 2016). Without an understanding of how to support normal birth, and using intervention when required, normal birth is not given a fair test (Downe, 2016).
Shifting from medicalisation to humanisation
To move to maternity services that not only prevent death and promote health, but also set the woman, baby and family on the optimum path in life, it will be critical to move from medicalisation to humanisation of maternity care. One aspect of this is recognising the complex and delicate balance of psychology and physiology and the importance of human support—both from the woman's family, community and friendship groups and from skilled, compassionate professionals, particularly midwives, in services where women have open access to care that enables physiological processes along with access to appropriate evidence-based and individualised medical care. In addition, it is critical to understand the effects of inequalities and ensure every woman, baby and family has equal chances of health, social and psychological interventions, as well as medical care when needed.
Medical care is a crucial part of maternity, but we should recognise that the broad reach of medicalisation in the world today may limit safety and exert social control that damages health and inter feres with individual autonomy of women, the formation of family relationships and the transition to parenthood.
Skilled, educated, compassionate midwives, working in effective services with universal access, are essential for humanisation of birth. Evidence indicates that expanding midwife-led care and relationship-based continuity of care allows midwives to contribute to high-quality, safe maternity care. At the heart of this is an appreciation of the power of human relationships and support, aided by medical and technical intervention when needed.