Deficient bodies and divine interventions : women, midwives, and the medicalisation of childbirth - a gender perspective

Abstract: Background In Sweden, one of the safest countries to give birth and to be born in, there is a trend towards increasing interventions during childbirth, and fewer women than ever give birth without having their labours induced or augmented, epidural analgesia, or caesarean section. While interventions at times are vital for a safe birth, there is a growing body of evidence demonstrating that an overuse of medical and technological interventions may have adverse effects on woman and child. Furthermore, intervention rates vary widely between different hospitals, suggesting varying local practices and in some places, poor adherence to national recommendations. In addition, the ‘Swedish maternity care crisis’ continues to attract media attention, with recurrent reports of overcrowded labour wards, overworked midwives, and of women feeling mistreated during labour and birth.Aim The overall aim of this research project was to explore the implications of a medicalised birth culture for birthing women and midwives in a Swedish context. Through a mixed-methods approach, combining qualitative and quantitative methods, focus was placed on women’s expectations before birth; their preferences for and actual use of pain relief; rates of intrapartum interventions; women’s level of satisfaction with the birth experience; their written evaluations of the birth experience; and interactions between women and midwives in the birth room. The project was informed by a gender perspective, aiming to illuminate the impact of gender on childbirth experiences and practices.Methods The thesis is based on four papers. Data collection for Papers I, II, and III consisted of birth plans, data from medical records, and written birth evaluations. Four hundred women were invited to participate, of which 259 consented. Out of these, participants were selected according to the specific aims of each study. Thus, Study I included women with birth plans (n=132), and data was analysed through qualitative content analysis. Study II was a cross-sectional study analysed by means of descriptive statistics and logistic regression, and included women with a birth plan (n=129) and without a birth plan (n=110). Study III included women with written birth evaluations (n=190), and the analysis consisted of word frequency and thematic analysis. Finally, Study IV was a focused ethnography, gathering data through participant observation during eight births, as well as interviews with the women who gave birth and with the midwives who assisted them (n=16). Data was analysed by thematic analysis. Results Women and midwives alike had similar ideals of childbirth, many valorising natural childbirth and a woman-centred, relational care, based on trust and reciprocity. When comparing women’s expectations and wishes for pain relief as expressed in their birth plans, with actual pain relief used, first-time mothers with birth plans used more pharmacological pain relief than intended, and 93.6% of them had some form of intrapartum intervention, such as induction or augmentation of labour, internal foetal monitoring, or urinary catheterisation. Regardless of having a birth plan or not, primiparas used more pain relief, had more interventions, and were slightly less satisfied with their birth experiences than multiparas: VAS 7.4 vs 8.4 respectively. In their written birth evaluations, written within 48 h of birth, women were mostly satisfied with the support they had from the midwife. In a manner that is suggested to affect their birth experiences, women displayed examples of a gender-normative behaviour, being thankful, sympathetic, and belittling of their own feelings or requests, despite the fact that some women felt that they had not had the support or overall birth experience they had hoped for. In the interaction between women and midwives in the birth room, the midwives continuously bridged the gap between the medical and the social models of care, integrating medicalised practices into midwifery care. Although very passionate about their work, low staffing, hospital hierarchies, and working against their ideological convictions came with a price, at times leaving midwives with feelings of inadequacy and a bad conscience, when trying to meet the needs of the birthing women and colleagues, as well as the demands of the work place.Conclusion Women’s birth choices and experiences and midwives’ working conditions are closely intertwined, and mirror contemporary discourses not only on childbirth, but also on women’s rights and position in society. The present work illustrates that women’s and midwives’ birth ideals, i.e. relational, one-to-one care, incidentally supported by a growing body of evidence, is in conflict with a medicalised and efficiency-driven labour care organisation, leading to job strain for midwives, and a fragmented and interventionist birth care for women. More attention needs to be drawn to the impact of societal and cultural gender norms on contemporary birth practices. There is also the need to recognise birth as existential, emotional, and potentially empowering experiences for women. To achieve this, women need to be informed of, and offered, choices in the way they give birth. At the same time, midwives must be given the time and the support of the organisation to be able to practice ‘watchful attendance’, acknowledging the values of relational care and emotional support.