1. BACKGROUND In the 1700s, Barber-surgeons, predecessors of the obstetricians belonged to a low social standing, similar to that of carpenters and shoemakers, members of the arts and trade guild. In an attempt to create social mobility and improve social status, barber-surgeons saw the opportunity to expand their expertise and redefined the perception of their skill as life saving, a higher moral order. Soon, barber-surgeons gained a competitive edge over midwives to practise at difficult home-deliveries, through manual non-medical-instrumental extraction of fetus from the birthing woman (Dundes, 1987).
Contrary to lay belief that fetal life began only at the point of “quickening” when expectant woman felt fetal movement (20 weeks), Obstetricians utilized their bio-scientific knowledge from the expertise of the microscope to claim that the start of perinatal life begins from the point of conception (Costello, 2006). This Interprofessional rivalry sparked resistance from the displaced midwives. However, English midwives succeeded in certifying midwifery practice through the 1902 Midwifery act (Costello, 2006).
This was an important step in establishing midwives not as physician-rivals, but as para-medical subordinates. In the same year, 1902, the Journal of Obstetrics and Gynecology of the British Empire was published (Drife, 2002). Early physician Mosher observed inverse relationship of declining birthrate and increasing abortion rate. He hypothesized that women opted for “criminal abortion” to avoid childbirth pain. This sparked widespread attention from society to reduce the disincentives of childbirth. Hence, obstetricians made claims to be able to alleviate childbirth pain, creating a market for obstetrics.
In 1900s, only 15% of deliveries were in hospitals (Jones, 1994), after the ministry of health expanded maternal hospital facilities, hospital deliveries sored from 60% in 1925, to 70% in 1935 and 98% in 1950 (Loudon, 1988). This sharp increase also correlates with the emergence of chloroform and ether as the first analgesics during the mid 1800s, followed by the Twilight Sleep consumer movement, of scopolamine and morphine, in the early 1900s, championed by middle and upper class women for fundamental rights to painless childbirth.
Under the guise of these feminist efforts, medicalization of pregnancy and childbirth changed the orientation of childbirth to something unnatural, and created consumer demand for medical intervention. Finally, the formation of universal healthcare systems, such as the NHS, in an attempt to provide welfare-state equality to healthcare access, gained power over women’s reproductive status and decisions. 2. INTRODUCTION Medicalization occurs when a social problem is “defined in medical terms, described using medical language, understood through the adoption of a medical framework, or ‘treated with medical interventions” (Conrad, 2007).
Pregnancy and childbirth has been subjected to the process of medicalization through increased medical jurisdiction and medical surveillance over these natural domains of life. There are three levels of medicalization: conceptual, institutional, and interactional (Conrad, 2007). This essay explores ways at which these three levels of medicalization have been applied to pregnancy and childbirth, and its consequences. 3. DISCUSSION 3. 1 Conceptual medicalization Pregnancy was an experience strictly confined to women, while childbirth was a domestic event attended by female relatives and midwives.
This exclusive and empowering experience opposed and threatened patriarchy, the dominant culture of modern society, creating a social problem of female superiority. Hence, professional obstetricians emerged, eliminated midwifery, and created a medical model of practice that cast a disabling view on pregnancy and childbirth, allowing male participation as women’s salvation or at least, her equal. Medical authority and medical technologies attempt to reduce the private and individual experience of the women, and allow participation of men in the shared pregnancy and childbirth experience.
One way of removing power from the female experience is to shift the focus away from adaptive bodily functions, to a desexualized and depersonalized birthing experience, with introduction of elements of patriarchy. The agency of the women was further removed through the application of the lithotomy (dorsal recumbent) position and epidural anesthesia. The lithotomy position has the woman lies on her back, facing the ceiling, with her legs separated and held by stirrups.
She is given no visual or physical access to the birthing process, and no free access to movement. She merely allows. Epidural anesthesia removes bodily sensations from the waist down. Hence, the birthing woman does not receive contraction signals from her body to bear-down and expel the child. She has to depend on obstetricians for objective data on her delivery progress. Risks and choices are also presented in medical terms, hence, women are unable to understand and make informed choices or negotiate participation in their pregnancy and childbirth process.
Then, the woman is stripped of her individual identity and given identities based on the age, maternal co-morbidities, number of pregnancy (Parity), and point of time in delivery (Gravid). These gives obstetricians biological information of the individual, allowing better assessment of the body and applying of the concept of risks to the management of care. Furthermore, the woman’s identity now revolves around the unborn child. Her choice of diet and lifestyle is now dictated by the risks she is willing to put on the unborn child.
The rights of child over mother are highly contested in the literature. After depersonalizing the woman, weakening the gender ideology at birth, an attempt to desexualize the birthing process is done by creating taboo and discomfort to the sexual nature of childbirth. In Midwifery techniques, hands-on perineal massage, which involves preparatory stretching of the vaginal passage; and stimulation of the nipples and clitoris to elicit biological hormones that relaxes and lubricates the vaginal walls, supports natural delivery.
However, obstetricians attempted to remove suggestions of female sexuality from the birthing process to allow involvement of a male-dominated profession. Substituting the natural, with artificial injectable hormones (Pitocin) to induce labor; cesarean sections to remove the child from an above-naval-abdominal surgery; and episiotomies (clean incision and straight reunion of the skin, as opposed to a irregular natural tear) as a mark of the obstetrician. This decreases the empowering experience of the body and increases the dependency on external medical interventions.
They also offer episiotomies and cesarean sections to “intercede” for the husband, who assumes legal access and possession of the body and sexuality of the birthing woman who has been “destroyed” by the birth of her child. Another example to illustrate presence of patriarchy is how technology “reveals” and shares the individual pregnancy experience of the pregnant woman with her husband, is through ultrasonography-enabled-visualization of the child in formation. As such, he pregnant women no longer has authoritative knowledge over her pregnancy, but now engages in an more egalitarian relationship with her husband, an equal partner in the pregnancy experience. 3. 2 Institutional Medicalization Obstetricians became self-governing-businessmen through private practice. Their capitalistic motivations were achieved solely through their medical authority, and not through training in business management. They could determine the type of obstetrical interventions women of each social class deserved.
A 75% cesarean section rate among private patients compares to 25% among general patients in New York (Hurst and Summey, 1984). This suggests a difference in professional accountability of physicians treating different paying classes. Private obstetricians receive out-of-pocket fees directly from their patients; maintain continuity of care, a personal doctor-patient relationship is expected. Obstetricians become “socially indebted” to direct-paying patients; hence they may exercise their skill of medical interventions in exchange for the fee, imposing medical procedures on women even in the absence of indication.
Furthermore, the closer doctor-patient relationship of private practitioners allows the professional to better evaluate the emotion-translated financial willingness or financial ability to pay for additional cost of medical interventions. High information access through prenatal education and consultations positively correlates with high prenatal care and high cesarean rates (Hurst and Summey, 1984). Theoretically, increased prenatal care should decrease the risks of pregnancy and childbirth; hence less medical intervention should be required.
Hence, it is suggested that with medicalized care expanding its surveillance to the prenatal period, there is increased awareness of the dangers of childbirth complication, and of alternate birthing methods, putting high SES New York women at risk for choosing medical intervention, which carries surgical risks on its own. Interestingly, women of lower SES in public hospitals in India were also subjected to more medical interventions and became targets of governmental missions of population control and subjected to pressure to undergo sterilization after delivery (Van Hollen, 2003).
Another notable finding was the extensive use of drugs to induce labor, where drug-induced labor was a means of crowd-control, to free up maternity beds for new patients (Van Hollen, 2003). This infrastructure constraint defers from the picture of many modern western countries. In which extensive infrastructure was built in more fertile days, and with declining birth rates, more invasive medical procedures such as cesarean section ensures longer hospital stays, utilization of resources and sustaining jobs of healthcare workers in the maternal hospital (Hurst and Summey, 1984).
By medicalizing pregnancy and childbirth, the state, through government hospitals and public policies can effectively control the rate of reproduction. Hence, it is seen in both social classes, obstetricians have different motivations for the medicalization of childbirth. Another factor fuelling the medicalization of childbirth is obstetrician’s fear of malpractice suits. Government employers indemnify obstetricians working in general hospitals, however private practicing obstetricians do not receive this privilege. Hence, private patients are able to bring malpractice suits directly to the practitioner, and his practice’s reputation.
Fear of malpractice suits are frequently cited for the increase in cesarean rates in New York (Hurst and Summer, 1984). Hence, private practitioners reduce the risk of being legally liable for unsuccessful or complicated childbirth by relying on their skills and exercising authority to decide on medical interventions. Private practitioners also pay a huge premium for malpractice insurance to cover for themselves. In New York, malpractice insurance premiums have risen from $3,437 to $50,000 over three decades (Hurst and Summey, 1984). Application of costly medical interventions helps private obstetricians to cover this cost. . 3 Interactional medicalization Through the cultural interaction between obstetrician and his patient, obstetricians attempt to control culturally deviant behavior medical and intervene with obstetric medicine. Obstetricians routinize medical interventions as professional rituals to establish a sense of security and control over the unpredictable natural process of pregnancy and childbirth (Davis-Floyd, 2002). As part of the obstetrician’s professional duty, they experience the agonizing prospect of the encountering a biological defect or a loss of human life or biologically defective.
Hence, when in the power to establish control mechanisms over nature, obstetricians instate medical interventions to protect themselves from emotional distress, from disability, death or blame from their patients. However, Floyd fails to acknowledge the functionalist and symbolic interactionist perspective, where obstetricians may employ medicalization, not solely from the power of professional authority but for social service to women, and a social duty maintain society’s order.
Simonds, 2002 points out that “as small durations of time become socially meaningful, the perceived scarcity of physical time increases, perceived control of events in one’s life decreases”. This rightly illustrates increased value and meaning of the period preceding childbirth, as social pressure to produce a new functional member of the social group, on both women and obstetricians increases. Ultimately, medical interventions not only serve the interest of obstetricians, but also to women and society as a whole.
For example, the change from trimester to weekly monitoring of pregnancy and the introduction of a scheduled hourly-charting at labor, does not merely enable increased medical surveillance and control, but also increases social contact which legitimizes woman’s gender role and addresses the valued significance of pregnancy and childbirth as social events. To the same effect, the medical category expansion to include prenatal screening at dated-pregnancy-checkpoints is also a social construction influenced by the 20th century eugenics project.
Prenatal screening allowed in-utero detection of “biological defects” such as Cleft lip; Spinal bifida; Down’s syndrome, and determination of sex, this screening creates points of knowing for crucial decision-making. Through selective abortion another obstetric procedure, obstetricians and women “play God”, make choices on rejecting or accepting the child into the family and society. This stems from the desire to have a perfect child in a eugenic society. Next, risks is defined by obstetricians, whether a women is or not allowed to have a normal birth.
Medical students are taught in terms of the very dichotomous high or low risk assessment of pregnancy. Obstetricians are able to develop diagnoses to categorize deliveries as high risk. Previously, due to poor nutrition, women suffered from a calcium deficiency known as rickets, hence malformed pelvis caused difficulty in vaginal delivery (Drife, 2002). Now, doctors socially construct small pelvis as a diagnosis of cephalo-pelvic disproportion (Beckett, 2005). Women then see themselves as defective, blame themselves, hile doctors use this emotional-blackmail, threatening women of her baby’s death, usually into submission, hence legitimizing his obstetric power. Hence, obstetricians attempt to use objective criteria to label the highly subjective definition of complicated or high-risk pregnancies. Another example is obesity. Women with obesity have higher rates of cesarean section (Beckett, 2005). Hence, these deviant behaviors are perceived as abnormal and have a higher rate of medical intervention.
Obstetricians also exaggerate the dangers of childbirth (Cahill, 2001), implicitly suggesting the potential for complications and risks. It is suggested that women internalize gender systems such as knowledge, discourses and practices of the female norm and “acts” it out during childbirth (Martin, 2003). Middle-class women view themselves as relational, caring, selfless, and discipline their bodies to adhere to the prescribed gender identity. At childbirth, women may actively request for medical intervention, such as analgesia, epidural anesthesia, cesarean sections under general anesthesia, to prevent deviant behavior.
This social driver for medicalization of childbirth is also reflected in the increased risk of childbirth portrayed by the media. Media constantly focuses on exaggeration, creation of a medical crisis. The birthing women agonizing in pain, the use of machines to denote life or death, and the swarming of medical personnel at the birth bed portrays an increase tension and risks at childbirth. Also, news reports home birthing, and finding of abandoned newborns as irresponsible, and linked to pathological child-abusers (Craven, 2005). . CONCLUSION Medicalization of childbirth and pregnancy is an attempt by society to maintain hegemony over the female body and the family, to perpetuate patriarchy, capitalism, vigilance and risk-caution as the dominant culture. However, there is a vast difference in the motivations of this social process. Society sees inequality of gender as a social problem, hence it attempts to control female subordination through the medicalization of pregnancy and childbirth, experiences paramount of the female gender identity.
Then, society attempts to control the reproduction of the population by structurally categorizing women according to their ability to access maternal facilities of care. The “ideal” childbirth experience was then linked to the idea of Socio-economic status. Women, who could afford medicalized care, received the most current and “advanced” technologies. While women who could not afford medicalized care often received less medical interventions, creating a subjective experience “lesser” than that of the already established norm of hospitalized painless childbirth.
Also, the state could more effectively control population growth through the authority of the attending obstetricians. Lastly, society attempts to control the ideal construction of a society, seeing the unpredictability of childbirth as a social problem, hence attempting to control it with an expansion of medical category to include risk assessments such as prenatal screening and intensive monitoring of delivery process at childbirth. Society also sees the unruly behavior of women at childbirth as deviant and attempts to control it with medicine and medical interventions.
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