Sociology of pregnancy, birth and mothering

• Medicalisation

  • used to refer to the processes by which social phenomena come to be perceived and treated as illnesses
  • defining a problem in medical terms, usually as an illness or disorder, or using a medical intervention to treat it
• Medicalisation examples

  • deviant behaviours
  • recurrent excessive alcohol consumption
  • hyperactivity in children
  • natural body processes
  • ageing
  • pregnancy
  • menopause
  • death
• Clinical iatrogenesis - injury done to patients by ineffective, unsafe treatments
• Social iatrogenesis - resulting from medicalisation of life - more and more problems seen as amenable to medical intervention
• Cultural iatrogenesis - the destruction of ways of dealing with and making sense of death, pain and sicknes
• • Illich saw medicalisation about medical imperialism and expansion of medicine (including pharmaceutical companies)
  • saw increasing medicalisation as inevitable - linked to the progression of modernity
• Examples of where medical profession or interest groups may have been drivers in medicalisation

  • hyperactivity, menopause, childbirth (expansion of medical jurisdiction
  • alcoholism, post-traumatic stress disorder, alzheimer's disease (social movement)
• • wider social change means now more critical relationship between medicine and lay population, questioning of experts and knowledge
  • sociologists now see more as a continuum, degrees of medicalisation and that it is not necessarily inevitable
• medicalisation in context today

  • growing emphasis on self-care - places moral obligation on individuals
  • increasing emphasis on the value of healthcare, shared decision making
  • growing movements around over-diagnosis
  • international campaigns to reduce medicalisation
• overdiagnosis

  • separate but related concept to medicalisation
  • making people patient patients unnecessarily, by identifying problems that were never going to cause them harm or by medicalising ordinary life experiences through expanded definitions of disease
  • 2 main causes
  • overdetection
  • overdefinition
• medicalisation can be positive or negative. overdiagnosis has a consequence that causes more harm than benefit
• models of health and illness

  • one analytic approach used to help understand society in social sciences
  • medical vs social model
• pregnancy/birth are physiological events embedded in a social and cultural setting and therefore a good example of the application of a medical or social model

  • the average woman in childbirth is not ill; pregnancy is not an illness
  • pregnant women are deemed to need a lot of healthcare throughout pregnancy and childbirth
• medical model - pregnancy is only safe in retrospect
• social model - childbirth is in principle a normal physiological event, which only needs medical intervention in a few cases
• Medical and social models are not just used in childbirth - they are applicable in other areas including disability, addiction, dying, sexuality, infertility. Used in analysis by researchers but also by policymakers, interest groups, health and care practitioners
• • birth was uncommon in hospitals before the 20th century
  • increasing medical influence in 20th century - development of new analgesia, caesarean section, safe blood transfusion
  • maternal mortality reduced substantially
  • obstetric care has important role where there are complications in pregnancy or childbirth
  • WHO estimated that up to 15% of women develop complications requiring rapid interventions
  • many more women in developed countries have c-sections. Practices have become routinised without evidence of benefit
  • driven by complex social, cultural, legal and professional factors
• medical model

  • doctor-centred
  • objective
  • male
  • body-mind dualism
  • pregnancy only normal in retrospect
  • risk selection is not possible
  • statistical/biological approach
  • biomedical focus
  • outcome: aims at live, healthy mother and baby
• social/midwifery model

  • woman/patient-centred
  • subjective
  • female
  • holistic
  • birth is normal physiological process
  • risk selection is possible
  • individual/psychosocial approach
  • psycho-social focus
  • outcome: aims at live, healthy mother, baby and satisfaction of individual needs
• Levels of application

  • practical level
  • ideological level
  • analytical level
• Practical level

  • focuses on what people do - midwifery practice and obstetric practice
  • easy to spill over to ideology
  • obstetric practice
  • risk defined as statistical
  • high risk pregnancy based on statistical rather than individual considerations
  • midwifery practice
  • normal event
  • requires some special attention (antenatal, perinatal, postnatal care)
  • often minimal monitoring, advice and support
• In practice:

  • people/units fit somewhere in between two extreme ends of a continuum
  • individual staff or whole maternity units can change their working practice over time (i.e. not static model)
• important to consider working practices are:

  • neither rigid: all working practice is somewhere in between two extreme ends of a continuum
  • nor static: individual practitioners or organisations/maternity units can change their working practice over time
• ideology level

  • ideology always colours what one sees, in other words, how one experiences, approaches and describes a particular birth, antenatal visit etc.
  • freedom fighter vs terrorist
  • it is the exclusive correctness of a certain approach that the person who makes the claim tries to establish, in order to win others over to this practice
  • assertions are being made which cannot be proven, and which derive their appeal from ideological commitments
  • ideological claims are by definition absolute. In reality people borrow aspects of both
• analytical level

  • at this analytical level medical/social model of childbirth we make it a black and white contrast to help the situation
  • analytical levels less value laden than ideology but based more on underlying assumptions in e.g. defining nature of pregnancy
• medical

  • tends to focus on directly intended functions of technology used rather than other impacts for women
  • e.g. monitoring fetal growth, focus on potential of technology rather than on the fact that this technology can in certain circumstances be used to bring pressure to bear on pregnant women
• social

  • childbirth is in principle, and often in practice, a normal physiological process
  • a woman having a baby often changes not just medical status, but also social roles e.g. becoming a mother, and social status e.g. lower income, losing a job, increased financial dependency on partner, parents, social security
• where analysis contained in medical model stresses the risk element in itself, biomedical ideology adds the claim that obstetrical practice can best improve the chances of a positive outcome
• where social model accentuates in its analysis the active role of women in childbirth, the women-centred ideology adds the claim that midwifery practice is what can best stimulate the active involvement of the woman
• • understanding which model someone adheres to helps to understand their perspective/their likely view on the issue
  • whatever way one regards birth will determine the kind of intervention (action) one thinks is going to be effective
  • it may help if you can place yourself and others
• • medical model promotes risk
  • medical model stresses risk element and claims that medicine (obstetrics-led care based in large hospital) can best improve chances of a positive outcome
  • medical definitions of risk require that childbirth be accompanied by medical technology, monitoring and often intervention
• High-risk pregnancy defined on basis of statistical, rather than individual considerations. Risk is defined as statistical in nature, hence solutions based on measurements (statistics). Risks are identified and controlled through medical surveillance and treatment.
• Professional groups gain control by creating risk - that is by emphasising risk, by redefining life events as risky.
• RIsk-society is characterised by over-monitoring of populations and individuals caused by availability of information systems. The more information we have, the more we worry, and the more we create further risks.

  Our world is risk averse.
• • Risk is a value judgement. Hence going against dominant perception of risk is also morally wrong, non-compliant, or showing socially unacceptable behaviour. When a mother shows a reluctance to accept official protocols, she is often reminded about the risk to her baby.
• The way we define risk in relation to childbirth determines how society organises maternity care:

  • i.e. what is generally seen as the safest/best place of birth, and who the most appropriate maternity care provider is
• Has been argued that:

  • portrayal of birth may perpetuate the medicalisation of childbirth
  • portrayals of normal birth missing in popular media