Exploring the Socio-cultural Aspects of Obstetric Interventions Through a Feminist Lens

by | 9 Dec, 2023 | Blog | 0 comments

Exploring the Socio-cultural Aspects of Obstetric Interventions Through a Feminist Lens

First published in Midwifery Matters 179

Childbirth in the UK is defined by societal and cultural beliefs, expectations and customs which influence women’s decisions (Luce et al, 2016). These beliefs become accepted as the ‘norm’ and are based on ideas which emerged during the 1700s, a time of significant advances in technology and science, when the wise midwifery ways were scorned as superstitious, archaic and risky (Davison, 2020). Respect was forming around the medical profession with the development of new birthing ideas based on science and knowledge of anatomy, leading to a belief that the body operated like a machine and childbirth was purely a mechanical process (Oakley, 2016; Davison, 2020). There is also a strong media influence within the UK around perceptions and expectations of birth, with reality television programmes often portraying birth as dramatic, painful and risky, (Luce et al, 2016) and, according to Wickham (2018), suggestive of a cultural ideology that birth requires medical assistance, and it is therefore safer to birth in a hospital (Newnham, 2021).

In 2010, following confrontation of an unsatisfactorily high rate of maternal and child mortality (Temmerman et al, 2015), a strategy was developed to improve maternal and child health, leading to a global movement and worldwide progress (Temmerman et al, 2015). Between 1990 and 2013 child mortality fell by 49%, maternal mortality by 45%, (Temmerman et al, 2015) highlighting that critical interventions such as family planning, management of labour and birth, and breastfeeding, are necessary for ensuring women, children and adolescents can survive, thrive and transform (Temmerman et al, 2015). However, in some societies women and children are still being failed despite some progress, with Temmerman (2015) proposing a holistic health policy and education programme approach is adopted.
Nevertheless, in most Western countries, medical technology continues to influence maternity care leading to medical intervention as the norm (Newnham, 2021). To date, despite a wealth of recommendations, (Department of Health, 1993, 2021; World Health Organisation, 2015; National Maternity Review, 2016; NHS England, 2019, 2021), little progress has been made to the delivery of maternity care services for women giving birth, traumatic or not (Newnham, 2021). The norm within a maternity system not set up to support spontaneous physiological birth, has become the medicalised hospital birth (Reed, 2021) with an emphasis on controlling the process through interventions to avoid complications. Yet this approach fails to acknowledge the complications and harm caused by the cascade of interventions which culminate in a high chance of a caesarean delivery (Levine et al, 2021), with evidence (Reitsma et al, 2020) suggesting that hospital births, subjected to high rates of interventions, do not improve outcomes for women and babies with many women perceiving birth as traumatic as a direct association of medical interventions (Reed, 2021). However, birth trauma may not be defined by a single event but a mixture of things throughout the pregnancy continuum (Moore, 2019). Moore (2019) further argues that how a woman is made to feel during birth is particularly important, with around 30% of women experiencing birth trauma (Moore, 2019). Svanberg (2019) suggests that because we expect birth to be the happiest day of our lives women’s needs are secondary to those of their baby, and additional barriers can be created between the person experiencing the traumatic birth and those offering support (Svanberg, 2019).

Whilst medical birth is viewed as the norm for some, most women would prefer giving birth without medical interventions (Downe et al, 2018). However, women are socialised to be “good girls,” further emphasised by a maternity system that sustains a medical approach to childbirth (Reed, 2021). Purdy (2021) further argues that the idea of women as “the vessel” has very deep roots in the patriarchy of obstetrics, with a paternalistic approach that implies women must do what they are told during labour and birth. Women were believed to be subordinate to the superior knowledge of men, who were considered to be more appropriate to preside over childbirth due to their practical and mechanically minded way of thinking (Oakley, 2016; Kitzinger, 2006; Newnham et al, 2017; Davison, 2020). Regrettably this led to the idea that in the process of birth, women’s bodies became a site for power and control (Newnham, 2017), women were seen as naturally passive and the infantilisation of women was adopted, and remains in some maternity systems today (Oakley, 2016; Davison, 2020). Relationships of power between men and women originate from patriarchy with cultural origins (Oakley, 2016). Within the UK maternity system more men occupy the powerful roles of Chief Executive and Consultant Obstetrician, but this is changing as more women enter higher education, although in the current system more male doctors hold the power (Dalvie, 2019) with Dalvie suggesting that the system has been anti-women from its inception.

Lesley Page (2011) argues that obstetricians have “persuaded the population that childbirth is dangerous and risky and that only obstetric care will guarantee a healthy baby.” This has led to a belief by some that women’s bodies do not work well and undermines women’s confidence (Page, 2011; Wickham, 2021). However, Changing Childbirth (Department of Health, 1993) and Better Births (National Maternity Review, 2016) strongly recommend making the woman the centre of her care, keeping birth ‘normal’, providing choice, continuity and control, whereas the medical model of care views women as patients, dependant on medical interventions. Consequently, springing from an obsession with risk, labour and birth care are in danger of being overcome with defensive practices (Symon, 2006). Walsh (2013) believes the fear of litigation is a driver, leading to obstetric decision-making attempting to contain the risk by taking the ‘safest’ option, for example, early intervention such as induction, before something can go wrong (Walsh, 2013).

The notion of risk is difficult to define as any suggestion of risk to the baby is a serious consideration to women, however, at the heart of risk management is the idea that birth is dangerous (Walsh, 2013). It may appear that the balance between a drive for normal physiological birth and the need to manage risk is a difficult one to achieve. Jansen et al (2013) argue that adverse effects can be caused when interfering in the normal physiological process of labour which necessitate further interventions (Jansen et al, 2013) with adverse consequences for mother and baby (Jansen et al, 2013; Oakley, 2016). Consequently, finding support for the National Patient Safety Agency’s (NPSA, 2006) suggestion that risk management is supportive to the provision of care for women is difficult, with Hallgrimsdottir et al (2017) arguing that “risk as a social narrative places trust in authoritative medical discourses”, (Hallgrimsdottir et al, 2017). Consequently, as Denis Walsh (2013) states, risk management is, to a certain extent, socially constructed and politically motivated to reinforce the power in health care (Walsh, 2013). The power within maternity care may remain within the hospital setting with intervention commonplace because of medical risk management that “deliberations need to be based on a salutogenic perspective of pregnancy and childbirth”, (Downe, 2010), focusing instead on aspects promoting health and wellbeing instead of aspects preventing adverse health outcomes which may contribute to increased interventions. Salutogenesis follows the thinking of Antonovsky (1979) as a theory to “explore health systematically in terms of movement along the health continuum, thereby eliminating a dichotomy of being in a state of health or in a state of disease”, (Smith et al, 2014, p.e152).

Historically, in the UK, women gave birth at home supported by female family and friends (Einion, 2017; Wickham, 2021). Birth was seen as “women’s business” and children grew up surrounded by stories of birth, viewed as a normal occurrence (Einion, 2017). The move to hospital began in the UK between the 1950s and 1970s as a response to beliefs and ideas that birth, and women’s bodies, needed to be managed (Wickham, 2021). Many post-war women were the first to give birth in a hospital away from their female friends and family (Davis, 2014), exposing them to a care model more medicalised than previously as attention focused on maternal and infant mortality (McIntosh, 2021). Influenced by obstetric specialists, several government reports appeared which stated that hospital was safer than home for birth, and understandably, people trusted that this was true (Ministry of Health, 1970; Wickham, 2018). In 1970 The Peel Committee report was published, recommending all births should be in hospital as this was safer for mothers and babies (Ministry of Health, 1970). However, this recommendation was based on little evidence that hospital birth was indeed safer; evidence suggested the opposite, according to Marjorie Tew (1985). Tew’s work remained unpublished until 1985 when hospital birth was firmly established as the norm (Wickham, 2021). Although maternal deaths reduced, there is little evidence that hospital birth was as influential in transforming health outcomes, as was the development of antibiotics, the availability of blood transfusions and improvements in general health, (McIntosh, 2021).

Midwifery services in the UK are under pressure to change from various inquiries (The Francis Report, 2010; The Kirkup Report, 2015; The Cwm Taf Report, Evans et al, 2019 and The Ockenden Report, 2020) looking into a failing system not meeting expectations, indicating a strong need for change. For the first time NHS forward plans prioritised maternity services and the first of these was Better Births (National Maternity Review, 2016). However, with a focus on continuity of care as the main health policy recommendation, no specific recommendations in relation to maternal mortality rates for mothers from different ethnic groups was made (National Maternity Review, 2016). In 2019 the NHS long term plan introduced a target to “achieve 50% reductions in stillbirth, maternal mortality, neonatal mortality and serious brain injury at birth by 2025”, conversely within the plan was a lack of commitment to reduce ethnic variation in maternal mortality with a focus instead on maternal mortality as a whole (Ali et al, 2021). A review of Better Births (NHS, 2020) showed that maternal mortality rates remained higher for ethnic minority groups. Furthermore, clear targets were set to roll out continuity of carer to Black and minority ethnic groups but failed to identify specific targets to reduce the maternal mortality rates within this group of women (National Maternity Review, 2021). It has been suggested that a community place-based approach is applied to reduce maternal health inequalities by the policymakers, the NHS and local government working in partnership with community leaders (Fernandez Turienzo et al, 2021). However, although this may make a difference, without broader measures to address inequalities and engagement, this will not be enough as the key to implementing measures to address inequalities are the perceptions and insights of lived experiences (Fernandez Turienzo et al, 2021).

In the UK the caesarean section rate is rising alongside other obstetric interventions including induction of labour, with no medical need (Dahlen et al, 2020; Wickham, 2021) suggesting interventions are often overused. Although underuse of obstetric interventions has been profusely researched, overuse is now emerging as a global concern (Fox et al, 2019) with the caesarean birth rate doubling in the past 15 years, as reported in the recent Lancet series (Boerma et al, 2018) alongside an increase in maternal and neonatal morbidity and mortality associated with a caesarean birth (Sandall et al, 2019). A recent large population study (Dahlen et al, 2020) found higher rates of post-partum haemorrhage in women who had their labour induced. The study concluded that the children of women who had their labour induced with no medical indication, had “higher odds of birth asphyxia, birth trauma and hospitalisation for infection between birth and 16 years of age”, (Dahlen, et al, 2020, p.9). Consequently Reed (2021, p.32) argues that “Women are not the cause of unnecessary and unwanted medical intervention in birth. Interventions are rising BECAUSE the maternity system was never set up to promote or support physiological, evidence-based, woman-centred practice”. Wagner (2001) further argues that when birth attendants have only experienced hospital, medicalised, high interventionist births they are blinded to the overwhelming effect these interventions are having and unable to see what normal physiological birth looks like without interventions. Arguably this is a barrier to change as they are “unable to see any other way of being with birth”, (Reed, 2021, pg.32). Page (2011) suggests that we have not only become blind to the risks of interventions but also to the importance of normal births for a good start in life. Page (2011) continues with the idea that society is reliant on technology and medical treatment to justify the rise in obstetric interventions. However, although UK maternity policy is progressive there is a dichotomy between policy and practice, particularly when maternity services may drive women towards the medical approach (Page, 2011) with women possibly coerced into interventions they do not want. Wickham (2021, p.63) further stresses that the medical way has become widely accepted and embedded into our culture despite little evidence base as some people “have a vested interest in maintaining the status quo!”
Wickham (2021) further states that many women are not being given accurate information about the evidence of medical interventions (Wickham, 2021). James and Reed (2021) discuss ‘groomed coercion’ where women are not given the full truth or information to make truly informed decisions based on best evidence. The Supreme Court Montgomery versus NHS Lanarkshire case (2015) was a landmark for informed consent in the UK and led to a ruling that a patient should be told whatever they want to know and not what the doctor thinks they should be told, however, they argue that the political and economic structures of the UK are designed to benefit few people (James and Reed, 2021).

Furthermore, the system cannot cope due to the pressures of medical interventions and the archaic ‘conveyor-belt’ approach to birth as a process (Kitzinger,2006; Strusberg, 2018). The new NICE guidelines (2021) on inducing labour recommend that induction is offered earlier to certain groups of women due to the risks of stillbirth, however, the data on this is sketchy and lacking trial evidence to show whether earlier induction would in fact make a difference (Wickham, 2021). Pressure on women to accept earlier induction may lead to pressures on the system, already understaffed in many units, making care less safe. Unfortunately, Wickham (2021) states that western medicine takes the approach that “this works so we’ll give it / do it to everybody.” However, the evidence is lacking and there is a discrepancy between the evidence and current guidelines, summarised by Coates et al that “clinicians should use the best available evidence to inform decision making and acknowledge when insufficient evidence is available” (Coates et al, 2020, p.31).

A 2021 retrospective observational cohort study (Levine et al, 2021) focusing on healthy pregnant women with no risk factors at term, showed that having labour induced increased the chances of a caesarean birth by almost 50%. Additionally, the authors noted that women who laboured spontaneously did not have poorer outcomes. These results contrast with the ARRIVE Trial (Grobman et al, 2018) undertaken in the US, where obstetric practices have resulted in some of the worst maternal and neonatal outcomes in the developed world (Harrigan, 2018). Consequently, the ARRIVE Trial (Grobman et al, 2018) is often quoted as evidence that the caesarean birth rate does not increase due to induction interventions (Grobman et al, 2018; Wickham, 2021). However, Wickham (2021) argues that the enrolment was designed to be too small to detect certain outcomes and women in the Trial had very medicalised care and as Wickham (2021) points out, there is a difference between what happens in a real-world study and what happens in a trial when participants may be following a protocol that does not exist in real world practice.

As discussed in this paper, historically obstetrics is deemed a male gendered profession; seen as active, technical, scientific and patriarchal in its belief system, with the midwife useful but inferior and passive in the hierarchy along with the woman, there to be kind and caring to the woman but to support the obstetrician (Kitzinger, 2006; Oakley, 2016; Newnham, 2017; Reed, 2021), whilst Nilsson (2014) implies that the power lies within the environment dominated by technology, viewing birth as risky from the outset, thus creating a fear around birth. Davison (2020) further suggests that obstetrics is “described as an assembly line of goods with the function of delivering the final product, the baby.” Healy et al (2017) argue that although policy supports midwives to be the experts in low-risk care, when obstetrics becomes increasingly prominent in the delivery room, the medical model is seen as reducing risks of litigation leading to some defensive practices reliant upon technology. By attempting to avoid complications through interventions the cascade of interventions ultimately reinforces the belief that birth is dangerous (Healy et al, 2017) and the ‘machine’ needs controlling (Davison, 2020).

In the UK and the Western world, we are fortunate to have advanced medical care, and lives are saved because of modern medicine (Hickey, 2019), however, our induced birth rates continue to increase. Of the 613,936 babies born in the UK in 2020 2,371 babies were stillborn, a reduction of 6% compared to 2019 and the lowest statistic since records began (ONS, 2020). Nevertheless, over a 30-year period the stillbirth rate has reduced from 4.3 per thousand to 3.8 per thousand, despite the increase in obstetric interventions (ONS, 2020) and the policies and campaigns announced by the government (RCOG, Each Baby Counts, (2015); NHS England Saving Babies Lives Care Bundle (SBLCB), 2019) to halve the rates of stillbirth from 4.7 per thousand to 2.3 per thousand by 2030, suggesting there is a long way to go to reach that target. Conversely care bundles are not always based on quality evidence and the effect on patients is uncertain (Lavallee et al, 2017). Where evidence is lacking, medical professionals look for what they consider ‘best practice’ based on their best guess, attempting to bridge the gap (Hickey, 2019). It is my understanding that we have increased screening, including fetal growth measurements and various other interventions, in the name of risk management and saving babies lives,, but the data suggests that over a 30-year period we have actually saved 0.5 of a baby per thousand! Therefore, this statistic identifies that our increase in interventions is not working. Unfortunately, what evidence does show is that more babies are induced early, and more mothers traumatised from birth with little evident change to the bottom line (Moore, 2019; Dahlen, 2021).

Version 2 of SBLCB (NHS England, 2019) urges care providers to consider avoiding intervention unless there is clear evidence of compromise to the baby (Hickey, 2019). Furthermore, Hickey (2019) states that there is rarely one single cause of stillbirth but several contributory factors which highlights the complexity and need for continued investment into maternity services to improve care for women and babies. This version of SBLCB also highlights the evidence for continuity models within midwifery showing how such models lead to improved outcomes (Homer et al, 2008; National Maternity Review 2016; Sandall et al, 2016). The government has now determined that this should become the default model of care for all women by March 2022 with a focus on women from BME groups and those living in the 10% most deprived areas,

for whom this model of care is linked to significantly improved clinical outcomes (Homer et al, 2017). Adamson (2015) believes that women must be at the centre of relationship-based models of care with midwives recreating a culture of trust and normality as this consistently provides the best outcomes for women and their babies. Renfrew et al, (2014) examined the contribution of midwives to the quality of care of women and babies globally. They identified more than 50 outcomes that could be improved by midwifery care including reduced stillbirth, preterm birth, decreased number of unnecessary interventions and improved psychosocial and public health outcomes, suggesting that midwifery is pivotal to this approach (Renfrew et al, 2014).

Birth interventions are increasing, and the medicalisation of childbirth continues in the Western world with research showing that high levels of interventions are not justified (Davison, 2021). Conversely, increased interventions are justified as improving outcomes and yet with a barely decreasing stillbirth rate (ONS, 2020) and increasing rates of birth trauma, (Moore, 2019; Dahlen, 2021) this increase in interventions is not reasonable for all. Ultimately, yes, we should focus on reducing maternal and neonatal deaths, but the answer is not with a ‘blanket’ policy of interventions. However, The King’s Fund (2008) argues that it is not possible to eliminate all obstetric interventions and that “reducing interventions to the detriment of safety” is a practice that should not be pursued. They further suggest that maternity care can be based on managing the risk within a normal physiological process (The King’s Fund, 2008).
As a Better Births Midwife, it is working with women which fuels the passion to ensure that a continuity model is seen as imperative for all women and not a few. I have been working to implement the changes for continuity of carer to become the default model of care for all women in the UK (NHS, 2021) as we know the effects of relationship-based midwifery care models improve outcomes, as already discussed. The research (National Maternity Review, 2016; Sandall et al, 2016) offers midwives the courage to lead change and work together (Homer et al, 2008). Competent, confident midwives with a clear vision and passion to embrace continuity of carer are what is needed (Homer et al, 2008). As a practising midwife I continue to counsel women about their birth choices and options to ensure they play a fully participatory role and remain at the centre of their care, providing midwifery care that remains woman centred. It is also essential midwives work autonomously with an understanding of the physiology of pregnancy and birth and are able to explain the evidence in a non-coercive way to ensure understanding and respect individuals personal circumstances ensuring care is personalised (Wickham, 2021). A collaborative approach is required which values the skills of all health care professionals with clear processes in place to facilitate women’s choices (Lindsay and Peate, 2016).

Throughout this article the limited evidence surrounding obstetric interventions has not shown improved outcomes in many cases. What is needed are competent and confident midwives (Homer et al, 2008) who will offer balanced evidence-based information to women that they can understand and make a decision that is right for them with the data and statistics presented to them in real-terms values (Cheyney, 2021). The realisation that the maternity system is broken is not necessarily a bad thing; it offers us a chance to fix and rebuild it using the evidence to incentivise healthy outcomes, low intervention rates and physiological birth using water and calming environments including the home.
There is an understanding and appreciation of the need for obstetric interventions for some women with medical care needs but there also needs to be a requirement for systemic change to provide genuinely safe and good quality care offering women real autonomy in childbirth (Reiger, 2010). Caution should be used for placing the responsibility on women to educate themselves around birth to ensure a positive experience when sending them into a broken, traumatised system that we are not setting them up to fail. A collaborative approach is needed to bring about real cultural change (Lindsay and Peate, 2016).

“Birth is far more than just a clinical event. How we treat women in birth matters deeply and we must recognise this and act now” (Cheyney, M, p.399).

About the author

Clair is a mother of 3 and a passionate advocate for women’s choices and continuity of carer. She has recently left the confines of the NHS to offer this way of midwifery across the South West. She passionately believes in the power of physiological birth, and that women should know their midwife, to enable a positive and trusting relationship to develop for improved outcomes.

References


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