Why is childbirth a medical procedure?

In the last thirty years, women's experiences of childbirth have changed dramatically in that, for many, the chances of having a normal birth, that is one without medical intervention, are slim.

Most of the women in the UK will have experienced at least one of the medical interventions described below. Indeed, of the 600,000 or so deliveries in the UK each year, it is estimated that less than half of these could be described as 'normal'. Routine interventions in childbirth include:

• artificial rupture of membranes
• caesarean section
• continuous electronic foetal monitoring
• epidural anaesthesia
• episiotomy
• recumbent birthing position

Childbirth has become an increasingly medicalised phenomenon whereby the majority of women no longer experience or have knowledge of what it is to give birth to their baby without interference. Almost all women give birth in hospital and the majority are subjected to a cascade of medical and technological interventions throughout pregnancy and birth.

In England, most recent figures (DoH, 2004) suggest that twenty per cent of deliveries are artificially induced or accelerated. Thirteen per cent of women have an episiotomy and one third have an epidural, general or spinal anaesthetic during labour. These same figures also suggest that 11 per cent of women have instrumental deliveries.

Why do so many first steps into the world take place through medical procedures? [Image: Daquella manera under CC-BY licence]

Perhaps, and most worryingly, the number of caesarean deliveries has also increased dramatically in the last fifteen years. Whilst the World Health Organisation recommends that the caesarean rate should be no more than 10 – 15 per cent, the average caesarean rate across the UK is 22 per cent. Indeed, many hospitals in the UK now have caesarean rates that exceed 25 per cent (BirthChoice UK, 2005).

Justification for the medicalisation of birth

Several explanations have been put forward to justify the medicalisation of childbirth. Concerns with safety, defensive medical practice and the concept of women's choice are particularly significant.

Safe motherhood?

The medical model of childbirth assumes that the female body is always ready to fail. Indeed, childbirth is seen as a highly risky business. The majority of women who give birth in hospital do so because they assume that a hospital birth is safest. However, all the research evidence that exists demonstrates that, for a healthy woman with a normal pregnancy, a planned home birth is as safe as a hospital birth (BirthChoiceUK, 2005). In spite of this research evidence, not everybody agrees, and many health care professionals insist on claiming that a medicalised hospital birth is still the safest option.

Defensive medicine

There has been an alarming increase in litigation against the NHS over the last few years. In fact, 70 per cent of all litigation involves obstetric cases (Johanson et al., 2002). Not surprisingly, defensive medical practice has been identified as another reason for the increasing medicalisation of childbirth.

We live in a society where relatively few babies die and, when they do, it is assumed that someone or something must be blamed. However, defensive practice serves to undermine clinical decision making for the benefit of women and their babies in favour of practices, such as caesarean delivery, which serve to protect the medical profession.

Choice in childbirth

The report, Changing Childbirth, enshrined the concept of 'choice' within the maternity services and it has been suggested that the increased medicalisation of childbirth can be attributed to the kinds of choices that women themselves make.

For example, it has been argued that an increasing number of women are choosing a caesarean birth. Whilst this is true, it is worth noting that only seven per cent of caesareans are performed at maternal request (RCOG, 2001).

Many have argued that choice in childbirth is merely an illusion and that we often talk about choice as though it were the single most important factor when thinking about women's experiences of birth. But when medical interventions are presented as routine and when women are encouraged to make 'choices' that will be better for their babies, then it is easy to see how women's choices are being managed within a medical model of childbirth.

Reactions to medicalised birth

Reactions to the medicalisation of birth have been various. For some women, the technology and surveillance that is brought to bear on the birthing body is welcomed as a comforting presence to help ensure that the baby remains safe and well. Whilst it is vital that we recognise this, it is worth remembering that it is the routine medicalisation of childbirth practised either as a form of defence or idiosyncrasy that is in question here.

Many women, and others, have been critical of the medicalisation of birth and have sought ways of subverting this.

Pressure groups, including the National Childbirth Trust (NCT), the Association of Radical Midwives and the Association for Improvements in Maternity Services, amongst others, have campaigned against many aspects of the medicalisation of childbirth. They have been particularly critical of the routine use of medical procedures, such as induction and episiotomy and continue to campaign for improvements in maternity care.

Many women, often supported by some of the groups described above, also seek to resist and subvert intervention in childbirth. For some women, this may mean booking a home delivery. For others it may mean writing a birth plan, attending alternative childbirth preparation classes, or booking a water birth.

The feminist movement has also been influential in the reaction against the medicalisation of childbirth. For many feminist writers, the obstetric medical domination of childbirth has denied women the right to control their own bodies and make their own decisions. They argue that women no longer have faith in their own bodies and are afraid of giving birth.

Many midwives, and some obstetricians, have been critical of the medical management of childbirth in our society.

The future of birth and the role of the midwife

We live in a world where we no longer really believe that women can give birth without pharmaceutical, technological or medical interventions. Shulamith Firestone (1979) once compared giving birth to 'shitting a pumpkin' and, yes, childbirth hurts - a lot - but it is nonetheless a normal, everyday event for many women all around the globe. The routine medicalisation of childbirth robs women, midwives, and society, of the knowledge and experience of what it is to have a normal birth.

Maternity Standard 11 of the National Service Framework for Children, Young People and Maternity Services states that women should:

'. . . have as normal a pregnancy and birth as possible, with medical interventions recommended to them only if they are of benefit to the woman or her baby.'
(DoH, 2004)

To this aim, 2005 sees the launch of a major new UK-wide initiative called the Campaign for Normal Birth. This campaign, launched by the Royal College of Midwives, aims to inspire and support normal birth practices and is underpinned by the philosophy of pregnancy and birth as normal physiological processes. The campaign is underpinned by a commitment to the reduction of unnecessary intervention and surveillance during childbirth.

If we are to turn back the tide on the medicalisation of birth it is important that we recognise the place of technology in today's world. We must, however, remember that giving birth is a normal physiological process and that the majority of women - given a chance - can achieve a normal birth without intervention.