Moms, Midwives, and MDs: A Mixed‐Methods Study of the Medicalization and Demedicalization of Childbirth by Alexandra Fowler Dalton Department of Sociology Duke University Date:_______________________ Approved: ___________________________ Linda K. George, Supervisor ___________________________ Rebecca L. Bach ___________________________ Deborah T. Gold ___________________________ S. Philip Morgan ___________________________ Suzanne Shanahan Dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Sociology in the Graduate School of Duke University 2009 ABSTRACT Moms, Midwives, and MDs: A Mixed‐Methods Study of the Medicalization and Demedicalization of Childbirth by Alexandra Fowler Dalton Department of Sociology Duke University Date:_______________________ Approved: ___________________________ Linda K. George, Supervisor ___________________________ Rebecca L. Bach ___________________________ Deborah T. Gold ___________________________ S. Philip Morgan ___________________________ Suzanne Shanahan An abstract of a dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the Department of Sociology in the Graduate School of Duke University 2009 Copyright by Alexandra Fowler Dalton 2009 Abstract This dissertation explores the simultaneous trends towards increasing and decreasing medical intervention in childbirth. Using the medicalization literature as a theoretical framework, I use a mixed‐methods approach to explore how both the medical community and laypeople think about and plan for childbirth. First, the midwifery and obstetrics literatures from the past 35 years are reviewed to provide a medical and scientific context for the trends seen in childbirth over this time period. Second, descriptive and logistic regression analyses of the Center for Disease Control’s Natality dataset, a census of U.S. birth certificate data, provide a picture childbirth trends and an understanding of the relationship between maternal characteristics and medicalized and natural births. Third, 35 qualitative interviews were conducted with pregnant women, focusing on their plans for their children’s birth. The interviews also address the factors that influence women’s plans and choices for childbirth, thus providing a better understanding of the social factors that affect birth plans. The key finding of this research is that most women would prefer to be able to have the “best of both worlds” – the ability to experience childbirth as a natural process for as long as is safe and comfortable, combined with immediate access to the medical skills and technology that can assist them and their babies in an emergency. iv The quantitative analyses demonstrate that alternatives to a mainstream model of childbirth are on the rise, even while these alternatives continue to represent only a small fraction of births. The increase in midwifery use while rates of hospital births remain relatively consistent suggests that many midwife‐attended births are taking place in hospitals. These data support the finding that women like the idea of a natural birth, but also want to have ready access to trained doctors, surgeons, and the best medical care available in case something goes wrong. There can be no doubt that childbirth, on the whole, had become a highly medicalized process. However, despite the fact that women want childbirth to be recognized as a natural process, there is no true movement for the demedicalization of childbirth. That is, women are not suggesting that medical intervention be removed entirely from childbirth. Instead, there need to be more options available to women, thus enabling them to give birth in a way that is comfortable and respectful of their preferences and goals, while simultaneously maintaining ready access to additional intervention, should it be necessary. Implications for future research in childbirth and other fields of study are discussed. v Contents Abstract .........................................................................................................................................iv List of Tables..................................................................................................................................x List of Figures ...............................................................................................................................xi Acknowledgements ....................................................................................................................xii 1. Introduction ...............................................................................................................................1 2. Theory and Literature Review ................................................................................................7 2.1 Theoretical Framework....................................................................................................7 2.2 Theoretical Definitions...................................................................................................14 2.3 Review of the Literature ................................................................................................16 2.3.1 Historical Origins of the Medicalization of Pregnancy and Childbirth.............16 2.3.2 Medicalized Childbirth: The Contemporary Scene..............................................19 2.3.3 Demedicalization and Critiques of the Medicalization of Childbirth................27 2.3.4 Who’s Buying in and Who’s Opting Out? .............................................................33 3. Perspectives From the Midwifery and Obstetrics Literatures, 1975‐2005.......................37 3.1 Data and Methods ..........................................................................................................37 3.2 Professional Reflections.................................................................................................41 3.2.1 The Practice of Midwifery and Obstetrics .............................................................41 3.2.2 Midwifery and Obstetrics – Past, Present, and Future ........................................49 3.2.3 Education and Training............................................................................................51 3.2.4 Other Topics in Midwifery.......................................................................................52 vi 3.2.5 Other Topics in Obstetrics........................................................................................54 3.3 Legal and Regulatory Issues .........................................................................................56 3.3.1 Practice Regulations..................................................................................................56 3.3.2 Insurance Issues and Regulations ...........................................................................57 3.4 Clinical Topics.................................................................................................................60 3.5 Conclusion.......................................................................................................................72 4. Descriptive and Logistic Regression Analysis of Childbirth Data, 1975‐2005 ...............74 4.1 Data and Methods ..........................................................................................................75 4.1.1 Data Overview...........................................................................................................75 4.1.2 Descriptive Analysis .................................................................................................77 4.1.3 Logistic Regression....................................................................................................78 4.2 Hypotheses......................................................................................................................85 4.3 Results ..............................................................................................................................87 4.3.1 Descriptive Analysis .................................................................................................87 4.3.2 Logistic Regression..................................................................................................101 4.3.2.1 Composite Medicalization Variable Analysis..............................................101 4.3.2.2 Place of Delivery ..............................................................................................105 4.3.2.3 Method of Birth ................................................................................................110 4.3.2.4 Attendant at Birth ............................................................................................112 4.4 Discussion......................................................................................................................115 4.5 Conclusion.....................................................................................................................120 vii 5. The ‘Best of Both Worlds’: Women’s Perspectives on Medicalized and Natural childbirth....................................................................................................................................122 5.1 Data and Methods ........................................................................................................122 5.2 Sample Description ......................................................................................................126