The Medicalization of Birth

Posted by Katie Moriarty on May 11, 2020
Spoiler Alert: This post discusses events in Season 9 Episode 7.
Ctm s9 07 012 - katie blog
Editor’s Note: The opinions expressed in this blog post are solely those of the author.
“There are times when all we can do is our best. We’re tested. We’re challenged. We must have faith. We must give our utmost. We must trust in those around us. We must trust ourselves. We have to say: I CAN DO THIS. We have to believe it too! Belief is the beginning of all things.”

Watching this episode there were several topics that I thought about for writing my blog - substance use/abuse, disabilities, or advocacy; however, I decided to write about something that was to me - the elephant in the Room: the medicalization of birth. With the opening scene I could feel a visceral difference in the room and the approach to assisting the woman in childbirth. The woman that was “delivered” said she would give the doctor a smacker if she was not “trussed” up like a chicken (her legs were restrained in stirrups). This scene was a big variation from most of the Call the Midwives episodes as I hear the music and get tearful with an empowering, woman centered birth with the lights dimmed, and a family member along with a midwife present. They soothingly nudge and champion the woman in a positive tone. I note the increasing of physician participation within the realm of childbirth in Poplar. In a previous episode we had the residents arrive, live, and learn at the Nonnatus House. And now in this episode, Dr. McNulty is present to assist Dr. Turner with his caseload. The stark difference in approaches was evident in both episodes. The woman was not the center; but, instead the physician along with the procedure was the center of focus. The doctors often had to be reminded that the woman was there. They had to be reminded to look at the woman. They had to be reminded to talk and address the woman.

As a Modern Day Midwife living in the time of COVID-19, I reflected on how birth is occurring in the United States through this pandemic. I have seen statements put out by varying organizations. Some have felt truly counter intuitive to me as a midwife: a person that embraces evidence (and the emerging evidence); a believer in the process of physiologic birth; and the rights of women. I felt reaffirmed in some of my ruminations this past week as I participated in the Virtual International Day of the Midwife (VIDM). Virtual International Day of the Midwife (VIDM) is a 24-hour free online conference centered on May 5, 2020, for midwives and anyone interested in childbirth. VIDM 2020 celebrated the International Year of the Midwife. I eagerly listened and participated in varied sessions and many of them confirmed my paradigm or the world view that I live in: listening to women, support the physiologic processes, and advocate for the protection of these rights while paying attention to evolving knowledge and the evidence unfolding with COVID-19. It was good to see how different countries are dealing with the pandemic. As well it stood in juxtaposition to the vast variations that are occurring in much of the USA – the most medicalized epicenter for childbirth.

I reflected that women giving birth may be the only people at the hospital that are not “sick”—which is a truth even without the pandemic. I have been concerned as I have heard colleagues that are RNs that work in the Labor & Delivery (L&D) area reporting that they often are moved around in the hospital if census is low. They are working in areas they are not accustomed to working in and being exposed to sick patients and then being pulled back to L&D as needed.

It made me reflect on history and the Hungarian physician Ignaz Phillipp Semmelweiss. He is known as the pioneer of antiseptic procedures. He is often described as the “savior of mothers”. He discovered that the incidence of “childbirth fever” or puerperal fever could be reduced by the use of disinfecting your hands. At the time physicians were going from operating theaters to the delivery suite. Semmelweis proposed the practice of washing hands in the Vienna General Hospital’s First Obstetrical Clinic. The doctors’ wards had three times the mortality as compared to the midwives’ ward. Semmelweis’s observations conflicted with the established scientific and medical opinions and his ideas were rejected by the medical community. This was even in the midst of publications of results where hand washing reduced mortality and death to below 1 percent. The practice of handwashing did not become accepted until years later when Louis Pasteur confirmed the germ theory and Joseph Lister practiced and operated using these hygienic methods with great success.

Fast forward to the pandemic—and yes there is much we do not know; however, practitioners must pay attention to how we handle staffing/ we need to ramp up telemedicine/ examine visit schedules and how and where we conduct those visits/ and examine the decision making regarding varied things surrounding birth. There have been major changes without knowledge of the short and the long term implications. Examples are women laboring on their own without their partner, disallowing water birth, stopping the use of Entonox (laughing gas) for pain relief, often separating mother and baby. I heard from one of my graduate students that at their hospital they are to discourage breastfeeding, skin to skin contact, and rooming in.

One of the presenters at the VIDM showed this slide: “We should be wary of any use of the pandemic to institutionalize harmful practices in maternal healthcare. Rather than an effective response to COVID-19 they are a breach of women’s human rights and a cloaked manifestation of structural gender discrimination.” HRIC 2020

I loved and have always remembered a quote from the President of the International Confederation of Midwives, Franka Cadee: She said: “I urge midwives to stop being well behaved and to take on their duty to advocate for women’s right to a good birth.” I believe this is that time—we need to use your voice in opposition to some of what is occurring. This is not the time to meow like a kitten but to roar like a lion. I advocate for persistent activism and creative disruption by the use of evidence based practice within a shared decision making model of care to protect women.

Characteristics of a more medicalized birth are:

  • depersonalized and fragmented care
  • mother and baby are seen as separate
  • mistrust in normal physiology and the focus is on pathology
  • cultural belief in the ‘safety’ of technology and medical intervention
  • environment tends to be designed for the clinicians/ interventions/ and risk assessment
  • focus is on technology and the institutions
  • and often an environment where we see a limitation and mistrust of midwifery

Giving birth to a baby is birthing our humanity. Women deserve respectful, relationship-base care. The mother and baby are a dyad and should be considered inseparable unless there is truly a need. We need to trust the physiology of birth, rather than pathology being the focus. People should know the word salutogenesis as well as they know the word pathology!! Salutogenesis is an approach focusing on factors that support human health and well-being. The "salutogenic model" is concerned with the relationship between health, stress, and coping. We need to practice based on evidence and incorporate interventions when they are indicated. We need to think how we can support women and birth. If we can build field hospitals for the sick—why can’t we build pop up birthing centers beside the hospital for our healthy low risk women? For low risk women we have to have women at the center of care along with support for their choices (place of birth along with choices within their birth). We need to ramp up and accommodate these things. We need to scale up midwifery.

All women have the right to a safe and positive childbirth experience, whether or not they have confirmed COVID -19. They need respect and dignity/ clear communication by maternity staff/ a companion of choice/ pain relief strategies/ mobility in labor when possible and the birth position of choice (WHO).

ICM has stated that “in countries where the health systems can support homebirth, healthy women experiencing a normal pregnancy and with support from qualified midwives, with appropriate emergency equipment, may be safer birthing at home or in a primary maternity unity/birth center than in a hospital….”

There is a Norwegian Proverb “The greatest joy is to become a mother; the second greatest is to be a midwife.” With that joy comes great responsibility—humanity depends on it.

“There are always challenges in life. There are pieces to put together. Plans to lay and progress to be made. Sometimes there are no prizes, no medal to polish, or trophies for the shelf. The reward comes as a smile, a touch, a dawning sense that all will be well. But the future is smiling and opening its arms. And so we take courage for it is given to us in a squeeze of the hand, a pat on the back, and the magical words: I believe in you.”

RESOURCES

Virtual International Day of the Midwife 2020 (On YouTube)

Get Another Take: Recommended Call the Midwife Recaps 
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From WGBH Boston | Watch Drama After Darkor Read the weekly recap

About the Author

Katie Moriarty, PhD, CNM, CAFCI, FACNM, RN is a professor on faculty at Frontier Nursing University and a Certified Nurse-Midwife with WSUPG CNM Service at Hutzel Women’s Hospital in Detroit, Michigan. Katie serves on the Board of Directors for the American College of Nurse-Midwives as the Region IV Representative. Previously she was the Associate Director of the Nurse-Midwifery Education Program at the University of Michigan.