: MYTHS AND MEDICALIZATION

yths are a construct which Alternatives to this provision of ma- The myth that childbirth can only be serve to denote the ‘cultural ternity services is homebirth but in many considered safe if it occurs in has Mfabric’ of a group; a shared European countries, with the exception of been challenged by the National Insti- culture creates myths which support the and the United Kingdom tute of Clinical Excellence (6) which has the beliefs and biases of the group (1). (UK), homebirths are difficult to obtain. published guidelines for the intrapartum Undoubtedly medical involvement in Obtaining a homebirth depends on local care for low risk women. This requires childbirth has done much to improve regulations and the availability of mid- that maternity care providers offer low outcomes for many women and their wives. experience difficulties in risk pregnant women options for the newborns who experience medical or obtaining insurance to provide home- place of . Options must include the related complications, but birth service and payment for midwives provision of , the availability in recent years there has been increas- may also be an issue. Relevant authori- of birth in a freestanding unit, ing evidence that widespread medical ties do not always provide information alongside midwifery unit or obstetric involvement in childbirth is not always to women about homebirth. Couples unit. Throughout Europe most pregnant in the best interests of women experienc- frequently experience considerable resist- women have no choice other than to ing straightforward low risk . ance to homebirth and the majority of attend their local to Myths about place of birth and safety, risk European countries report that less than give birth. assessment and technological advances 1% of take place at home (3). have led to the myth of high expectations Marjorie Tew (4) first demonstrated is now and positive outcomes for childbearing that better outcomes for and a safe procedure women. These myths are shaped by gov- newborns was not caused by increased The next myth we wish to explore is the ernment policies and have had an impact hospitalization and medical care but was safety of C/S. Throughout Europe and on both the resources for maternity care brought about by the improved health of even within individual countries there and also practices within maternity set- mothers. More recently, the Birthplace is substantial variation in C/S rates. tings. What we wish to explore here are study has provided data that identifies Cyprus had the highest overall rate, at the myths about contemporary childbirth the risks and benefits of giving birth in 52.2%, with the Netherlands, Slovenia, that include: the place of birth, caesarean a variety of settings (5). This identi- Finland, Sweden, Iceland and Norway sections (C/S) and midwifery led care. fied that for women having a second or the lowest with rates below 20% (3). The subsequent baby, a planned homebirth risk factors for C/S, such as maternal age Hospital is the safest place reduces the risk of interventions for the or parity,­ are not sufficiently marked to for birth and does not increase risk for the explain the wide disparities. Countries Perhaps the greatest myth about - baby. For women having a first baby, a with high proportions of older mothers birth is that it is in the best interest of planned home birth slightly increases the have both higher and lower rates. mother and baby that birth takes place risk for the baby and there is an increased There are global concerns about in hospital. The past several decades probability of transfer to hospital. increasing C/S rates and the impact this have witnessed a largely consistent and Birth centres are another alterna- has on both morbidity and mortality for persuasive argument that the hospital tive to birthing in large maternity units. women (7, 8) and while considerable im- is the best and safest place for babies to These have been successfully introduced provements have been made in the safety be born. Subscription to this overriding in ­several European countries and in of performing C/S, there is emerging 18 single policy has led to little choice for Germany, the Netherlands and the UK, evidence about the potential long term ef- women in terms of place of birth and has women increasingly have the option of fects on the from unnecessary C/S. resulted in almost complete elimination attending a midwifery led birth centre. Early adverse effects includes the poten- of homebirth services in many countries. Birth centres may be free standing or tial for impaired function, reduced The drive to concentrate maternity may be adjacent to, or within maternity temperature control and pressure, services into larger units with the provi- . The Birthplace data identi- alterations to metabolism including feed- sion of multidisciplinary care undoubt- fied that when birth took place in either ing and more worryingly immune pheno- edly improves outcomes for women with a freestanding or alongside birth centre, type (9). Recent evidence has identified complex pregnancies. However, the there were no significant differences in alterations in the infant’s microbiome trend across Europe for birth to occur adverse perinatal outcomes compared associated with abdominal rather than in large units is problematic for women with planned birth in an obstetric unit. vaginal birth. This may be linked to the who are at low risk of complications as These women had significantly fewer emerging evidence that children delivered larger units have a greater propensity for interventions, including substantially by C/S have an increased rate of immune intervention in labour and lower rates of fewer intrapartum C/S, and more ‘normal related disorders such as asthma, diabetes spontaneous births (2). births’ (5). and obesity which may be related to their Agnes Rhona Phelan O’Connell

altered microbiome (10). Increases in tion that pregnant women with low risk 4. Tew M. Safer Childbirth: A Critical systemic connective tissue disorders, juve- of complications should attend hospital History of Maternity care. : nile arthritis, inflammatory bowel , under obstetric led care to give birth is Chapman Hall, 1995. immune deficiencies and leukaemia have outdated. The awareness that rising C/S 5. Brocklehurst P et al. Perinatal and also been reported. Another new area may have long term health problems for maternal outcomes by planned place of research is in relation to the potential is a concern and the evidence of birth for healthy women with low for the mode of birth to have an impact indicates that the way to reduce unneces- risk pregnancies: the Birthplace in on the epigenetic profile of the newborn sary interventions in childbirth, without England national prospective cohort infant (11). If this is so, then the mode of placing the mother or baby at increased study. BMJ 2011 23;343:d7400. birth may have a generational impact on risk, is to provide women with one to one 6. NICE Intrapartum Care. Intrapar- future populations. midwifery care. This is best provided tum care: care of healthy women and away from obstetric services in alongside their babies during childbirth. 2014 Obstetric led care is best or free standing midwifery units and National Collaborating Centre for for all women should include the option for home birth. Women’s and Children’s Health. The third myth we wish to explore is that Important to the expansion of 7. Villar J et al. Caesarean delivery rates obstetricians should be involved in the midwifery led care is that collaborative and pregnancy outcomes: the 2005 care of women experiencing straightfor- relationships between professional groups WHO global survey on maternal and ward low risk pregnancies. While team must be maintained to ensure best care perinatal health in Latin America. work between midwives and obstetricians for women and their newborns. Trust Lancet 2006;367(9525):1819-29. is key to the provision of maternity care, and respect for each member of the 8. MacDorman M et al. Neonatal the evidence is widespread that obste­ multidisciplinary team is required and is Mortality for Primary Cesarean and tric involvement in low risk women is particularly important to ensure seamless Vaginal Births to Low-Risk Women: un­neces­sary and leads to an increase in transfer of services between midwifery Application of an “Intention-to- intervention in comparison to midwifery and obstetric care when this is required. Treat” Model. Birth 2008;35(1):3-8. models of care. Midwifery led care for 9. Hyde M et al. The health implications normal pregnancy and childbirth is an Agnes Phelan, BSc Nursing, RM, of birth by caesarean section. Biol. efficient and effective model of care and Lecturer, Rev 2012 ;87(1):229-43. has been promoted as part of the Birth- School of Nursing & Midwifery, 10. Sevelsted A et al. Cesarean Section place studies (12). Providing - University College Cork, and Chronic Immune Disorders. Cork, Ireland, led care for low risk women may offer 2015;135(1):e92-8. [email protected] a means of reducing costs compared to 11. Dahlen H et al. Is society being obstetric led services (13) and the recent reshaped on a microbiological and Lancet Series on Midwifery states that Rhona O’Connell, Med, PhD, RM, epigenetic level by the way women midwifery is the solution to the provision Lecturer, give birth? Midwifery 2014 30(12): of high-quality maternal and newborn School of Nursing & Midwifery, 1149-1151. care. University College Cork, 12. Schroeder L et al. Birthplace cost-ef- Cork, Ireland, fectiveness analysis of planned place of [email protected] The way ahead birth: individual level analysis. Oxford: A medicalized birth is not the best NPEU, 2011. 19 outcome for every and traumatic 13. Ryan P et al. An assessment of the birth experiences are well documented. References cost-effectiveness of midwife-led care Statistics and research findings challenges 1. Wood P. Guest editorial. NZ College of in the United Kingdom’. Midwifery the widespread belief that out of hospital Midwives J 2004, 31, 4-6. 2013;29(4):368-76. births are not safe for women with 2. O’Connell M et al. The philosophy of straightforward pregnancies. practice governs the rate of obstetric In changing the debate around child- intervention: analysis of 212 units in birth and to ensure that maternity ser- the United Kingdom. J Matern Fetal vices meet the needs of women, decision Neonatal Med 2003;13(4):267-70. makers and providers of maternity care 3. European Perinatal Health Report. The should ensure that women have informa- health and care of pregnant women tion about the safety of birth in various and babies in Europe in 2010. EURO- settings and ensure that they have options PERISTAT, 2013. Available at: www. in relation for their care. The presump- europeristat.com.

No.81 - 2015