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;324:892All rapid responses
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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
Competing interests: No competing interests
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
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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!
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests