REPRODUCTIVE JUSTICE
MEDICALIZATION IN MATERNAL HEALTHCARE
**NOTE**
Medical
advancements have saved the lives of women and babies at risk for injury or
death during pregnancy and birth.
This site is not about the doctors who properly use interventions to save lives;
it is about those who use them unethically for profit or convenience.
Improperly used interventions have led
to harm and death of women and babies and obstetrics
is the only field in which mortality
rates are rising and non-medically needed interventions such as c-sections are
related to 66% of maternal deaths.
**NOTE**
This site is designed to share valid evidence for those working to change
the maternal healthcare system who do not have access to databases of peered
research.
Chronological order allows users to find new data.
It also begs the question of why, when we have known for decades that
such practices are harmful, do they not only continue to be used but are
increasingly used.
BIRTH SITES: HOSPITAL, BIRTH CENTER OR HOME
It has been found that the very culture of hospitals can affect rate of non-medical use of interventions such as c-sections. Hospitals are where people who are sick or injured go to be healed/treated. Doctors in hospitals feel the need to heal or treat and often believe that they have to “do something” thus leading to the use of interventions designed to save lives for nonmedical reasons, causing harm to mothers and babies. For women who are low risk, "doing something" often leads to harm. In addition, hospitals often pressure doctors to perform interventions for financial reasons such as higher pay from insurance companies, less night and weekend staffing of hospital personnel, etc.
Example/comparison of two in Massachusetts - both are part of the same medical system, but taking birth out of the hospital to the midwife led birth center reduced c-sections greatly.
Cambridge Hospital (C-section rate = 15%) See https://www.challiance.org/locations/cambridge/birth-center
Tufts Hospital (C-section rate = 30%) part of the same Alliance
Why is it so important that the current models in hospitals, especially in the U.S., be changed? The U.S. has the worst record of all developed nations for maternal healthcare with the highest maternal mortality rate. The maternal healthcare segment is the ONLY segment of healthcare that has an increasing mortality rate (Gingrey, 2020).
FACILITIES WITH A MODEL OF COLLABORATIVE/COOPERATIVE CARE
UNITED STATES
Massachusetts: Camabridge Birth Center: Collaboration of midwives and obstetricians. Cambridge Birth Center) is in Victorian House across from hospital. It mimics home birth. and is part of the Harvard Medical School Teaching Hospital Cambridge Health Alliance. The center has emergency equipment but it is hidden out of sight and an obstetrician is assigned 24 hours for emergencies, but midwives and doulas are primary. Midwives perform over half of all deliveries at center and at main hospital and the natural birth focus has also brought about change in the main hospital. The c-section rate has dropped to below 15% and it was named the best maternity hospital of 2021 by Newsweek. https://www.challiance.org/locations/cambridge/birth-center
Why Choose the Cambridge Birth Center
NEW YORK: Mt. Sinai West Midwifery Collaboration:: Partners with birth centers such as Oula which states "our collaborative team of midwives and obstetricians work together to navigate, educate and help you make choices that are best for you so you feel empowered and safe from start to finish. We believe it’s best when doctors, midwives, and patients work together" https://www.mountsinai.org/locations/west/care/obgyn/pregnancy-birth/midwifery .
NEW YORK: Homebirth Midwives of New York provides information about finding a midwife in New York for those wishing a home birth as well as resources for those wishing to explore this option. https://www.nyhomebirth.com/ .
WHAT DOES THE LITERATURE SAY?
2023
GRANT:
AABC Foundation Access
https://www.ruralhealthinfo.org/funding/4835
2023
2022
American Association Birth Centers. (2022. What is a birth center? Accessed https://www.birthcenters.org/page/bce_what_is_a_bc
CONCLUDED (from site) "The birth center is a health care facility for childbirth where care is provided in the midwifery and wellness model. The birth center is freestanding and not a hospital. Birth centers are an integrated part of the health care system and are guided by principles of prevention, sensitivity, safety, appropriate medical intervention and cost-effectiveness. While the practice of midwifery and the support of physiologic birth and newborn transition may occur in other settings, this is the exclusive model of care in a birth center. The birth center respects and facilitates a woman’s right to make informed choices about her health care and her baby’s health care based on her values and beliefs. The woman’s family, as she defines it, is welcome to participate in the pregnancy, birth, and the postpartum period."
Columbia University School of Nursing (2022). New law will ease licensure for New York's midwife-led birth centers. Accessed https://www.nursing.columbia.edu/news/new-law-will-ease-licensure-new-yorks-midwife-led-birth-centers
“Perinatal and birth outcome measures are improved when midwives are integrated into regional healthcare systems. Successful integration of midwifery-led birth centers—importantly, as Article 28 facilities—will allow pregnant and birthing people to seek care in an environment that aligns with their values and health needs and ensure seamless transition of care if those health needs change.”
George, E., Mitchell, S. and Stacy, D. (2022) Choosing a Birth Setting: A Shared Decision-Making Approach. Journal of Midwifery & Women’s Health. https://doi.org/10.1111/jmwh.13377 Accessed https://onlinelibrary-wiley-com.webdb.plattsburgh.edu:2443/doi/full/10.1111/jmwh.13377
CONCLUDED: "Engaging in a shared decision-making approach regarding birth setting options would support people to have the information and ability to judge for themselves how benefits and risks across birth center, home, and hospital settings would best fit with their values and personal health. A patient decision aid about birth setting options could facilitate increased equity regarding access to birth settings that offer improved perinatal health outcomes, helping to reduce perinatal health disparities in the United States."
2021
Almanza, Karbeah, J. ’Ma., Tessier, K. M., Neerland, C., Stoll, K., Hardeman, R. R., & Vedam, S. (2021). The Impact of Culturally-Centered Care on Peripartum Experiences of Autonomy and Respect in Community Birth Centers: A Comparative Study. Maternal and Child Health Journal, 26(4), 895–904. https://doi.org/10.1007/s10995-021-03245-w
CONCLUDED: "Conclusions for Practice Our study confrms previous fndings suggesting that giving birth at a community birth center is protective against experiences of discrimination when compared to care in the dominant, hospital-based system. Culturallycentered care might enhance the experience of perinatal care even further, by decreasing variance in BIPOC experience of autonomy and respect. Policies on maternal health care reimbursement should add focus on making community birth sustainable, especially for BIPOC provider-owners ofering culturally-centered care."
Daviss, B.-A., Anderson, D. A., & Johnson, K. C. (2021). Pivoting to Childbirth at Home or in Freestanding Birth Centers1 in the US During COVID-19: Safety, Economics and Logistics. Frontiers in Sociology, 6. https://doi.org/10.3389/fsoc.2021.618210 Accessed https://www.frontiersin.org/articles/10.3389/fsoc.2021.618210/full
This article examines the intersections of safety, economic efficiency, insurance, liability and birthing persons’ needs that have become critical as the COVID pandemic has ravaged bodies and economies around the world. Those interests, and the challenges and solutions discussed in this article, remain important even in less troubled times. Our economic analysis suggests that having an additional 10% of deliveries take place in private homes or freestanding birth centers could save almost $11 billion per year in the United States without compromising safety.
2020
COURTOT, HILL, I., CROSS‐BARNET, C., & MARKELL, J. (2020). Midwifery and Birth Centers Under State Medicaid Programs: Current Limits to Beneficiary Access to a High-Value Model of Care. The Milbank Quarterly, 98(4), 1091–1113. https://doi.org/10.1111/1468-0009.12473
CONCLUDED: "Many of the barriers to midwifery and birth center care identified by the Strong Start evaluation are not new; regulatory and reimbursementrelated obstacles for these providers have been documented since interest in midwifery care increased in the 1980s and 1990s.31 However, the evaluation also found that midwifery care provided through birth centers resulted in better outcomes and lower costs. This presents an especially compelling case for scaling up this model of care, particularly in light of the fact that the typical (hospital- and physician-based) maternity care system has struggled to improve outcomes for mothers and newborns despite significant spending. Investments that increase access to midwifery and birth center care are critical given the current performance of the US maternity care system. If progress is made in addressing the barriers to the model of care identified in this study, both women and their infants enrolled in Medicaid would experience better birth outcomes, and the Medicaid program could reap significant savings."
Gingrey, J. (2020). Maternal Mortality: a U.S. Public Health Crisis. American Journal of Public Health. Accessed https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7067092/
CONCLUDED: (from article) "Think about all the medical advances that have occurred in recent times, and yet the risks associated with pregnancy have not declined. These figures say to me we are failing women during what should be a most wondrous time of their lives. No developed nation has a more shameful record."
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Division of Behavioral and Social Sciences and Education; Board on Children, Youth, and Families; Committee on Assessing Health Outcomes by Birth Settings; Backes EP, Scrimshaw SC, editors. Birth Settings in America: Outcomes, Quality, Access, and Choice. Washington (DC): National Academies Press (US); 2020 Feb 6. The National Academies of SCIENCES • ENGINEERING • MEDICINE. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK555495/
From conclusion: The challenges facing the current U.S. maternity care system, while urgent, are The challenges facing the current U.S. maternity care system, while urgent, are not insurmountable, and opportunities for improving the systems that support childbirth exist. To improve maternal and infant outcomes in the United States, it is necessary to provide economic and geographic access to maternity care in all settings, from conception through the first year postpartum; to provide high-quality and respectful treatment; to ensure informed choices about medical interventions when appropriate for risk status in all birth settings; and to facilitate integrated and coordinated care across all maternity care providers and all birth settings. not insurmountable, and opportunities for improving the systems that support childbirth exist. To improve maternal and infant outcomes in the United States, it is necessary to provide economic and geographic access to maternity care in all settings, from conception through the first year postpartum; to provide high-quality and respectful treatment; to ensure informed choices about medical interventions when appropriate for risk status in all birth settings; and to facilitate integrated and coordinated care across all maternity care providers and all birth settings.
Rodríguez‐Garrido, P., Pino‐Morán, J. A., & Goberna‐Tricas, J. (2020). Exploring
social and health care representations about home birth: An Integrative
Literature Review. Public Health Nursing (Boston, Mass.), 37(3),
422–438.
https://doi.org/10.1111/phn.12724
2019
Diamond-Brown. (2019). Women’s Motivations for “Choosing” Unassisted Childbirth: A Compromise of Ideals and Structural Barriers. In Reproduction, Health, and Medicine (Vol. 20, pp. 85–106). Emerald Publishing Limited. https://doi.org/10.1108/S1057-629020190000020010 Accessed https://www.emerald.com/insight/publication/doi/10.1108/S1057-6290202020
CONCLUDED: "Unassisted childbirth, also known as “freebirth,” is when a person intentionally gives birth at home with no professional birth attendant. The limited research on unassisted birth in the United States focuses on women’s reasons for making this choice. Studies suggest women are committed to birthing without a professional and that this choice is rooted in religious or naturalfamily belief systems. These studies do not adequately account for the ways a framework of “choice” obscures the role structural barriers play in decisionmaking processes. International research on unassisted childbirth finds that it is not always a first choice and may be a last resort for women who have had negative experiences with maternity care. More research on unassisted birth in the United States is needed to better understand if people face similar structural barriers. In this paper I examine how structural limitations of the US healthcare system intersect with values in decision-making processes about childbirth. Drawing on in-depth interviews with nine women who gave birth unassisted in the United States, I examine the women’s shared ideological commitments, negative experiences with health care, and barriers faced seeking care. I discovered that unassisted birth may not be a first, or even positive choice, but rather a compromise informed by ideological commitments and constrained choices. Structural barriers in the US healthcare system prevented women from having a professional birth attendant who they felt was acceptable, available, and accessible. I conclude by discussing the implications of these findings for debates about birth justice and health policy"
Kozhimannil, K. (2019). Impossible math; Financing a free-standing birth center and supporting health equity. accessed https://www.ajmc.com/view/impossible-math-financing-a-freestanding-birth-center-and-supporting-health-equity
Births in freestanding birth centers are increasing, and the number of birth centers is increasing, as well, but capacity is not keeping up with demand. Freestanding birth centers provide many of the same services that are provided for low-risk pregnancies in hospitals, and there is evidence of equivalent or better outcomes of care both here in the United States and in abroad. Yet, freestanding birth centers are paid less than hospitals for doing the same work.
2016
Alliman, & Phillippi, J. C. (2016). Maternal Outcomes in Birth Centers: An Integrative Review of the Literature. Journal of Midwifery & Women’s Health, 61(1), 21–51. https://doi.org/10.1111/jmwh.12356 Accessed https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.12356
CONCLUDED: "Birth centers are a maternity care model for low-risk women leading to positive outcomes. Women who receive birth center care have higher rates of spontaneous vaginal birth and postpartum perineal integrity when compared with matched hospital cohorts. Using intent-to-treat analysis, intrapartum birth center care was also associated with lower rates of medical interventions and procedures including oxytocin augmentation, episiotomy, assisted vaginal birth, and use of pain medication. Quantitative and qualitative studies found that women were very satisfied with birth center care. Overall transfer rates from the birth center ranged up to 54.7% of women beginning prenatal care, but the majority of transfers were for nonemergency conditions. This data clearly supports that birth centers are a safe model of care for low-risk women when associated with a health system able to provide higher-level care. Although more research is needed, birth centers should be supported by clinicians, policy makers, and health insurance carriers to enable low-risk women to access this evidence-based model of care."
Arbour, K. (2016). Home Birth vs. Hospital Birth. Voices in Bioethics, 2. https://doi.org/10.7916/vib.v2i.6331 Accessed https://journals.library.columbia.edu/index.php/bioethics/article/view/6331
CONCLUDED: "The medicalization of childbirth has generated a dichotomy between “natural” and “medical” births.[1] Great strides in medicine over the past several decades have resulted in the ability to address complications that may arise during delivery, and as such have promoted childbirth in a hospital setting. However, the baggage of the technological imperative and the alienating atmosphere of a hospital demonstrate the flip side to the capabilities of modern medicine. The Mayo Clinic cited several reasons a woman may choose home births, including: “a desire to give birth in a familiar, relaxing environment surrounded by people of your choice; a desire to wear your own clothes, take a shower or bath, eat, drink and move around freely during labor; a desire to control your labor position or other aspects of the birthing process; and cultural or religious norms or concerns."
Larsen, Nicolette (2016) "Birthing Center versus Hospitalized Birth," CrissCross: Vol. 4 : Iss. 1 , Article 4. Available at: https://digitalcommons.iwu.edu/crisscross/vol4/iss1/4
From abstract: While hospital nurses and physicians provide advanced medical care, birthing centers focus on holistic care of the family unit emphasizing mental, spiritual, and physical health. Doctors often perform cesarean sections (C-sections) for nonmedical reasons, causing an increase in preterm births and health complications in both mother and baby. The rate of C-sections in the United States has increased astronomically since 1996 from a rate of 21% to 32.7% of births. Birthing centers have a decreased rate of C-sections in relation to hospital births and therefore have fewer health complications. This differences between hospitalized deliveries and birthing center deliveries are evident in relation to maternal and fetal health, and global, economical, and political implications. Overall, birthing centers provide healthcare to low risk pregnant women achieving better health outcomes than a hospital.
Pecci, C., Culpepper, L. and McMahan, T. (2016). The birth of a collaborative model: obstetricians, midwives and family physicians. Accessed https://www.bumc.bu.edu/obgyn/files/2016/12/1-s2.0-S0889854512000460-main.pdf
CONCLUDED (from article). "However, mistrust and lack of respect between midwives and obstetricians created a culture that discouraged communication. Midwives worried that their patients would receive unnecessary interventional or operative care from the obstetricians whereas obstetricians worried that midwives would not consult in a timely manner. Evidence-based discussions about labor management between midwives and obstetricians often were not resolved to the satisfaction of either party. Residents and 324 Pecci et al students gained minimal appreciation for midwifery care because interactions were limited to situations that required the assistance of a physician."
2015
Burns, E. (2015). More Than Four Walls: The Meaning of Home in Home Birth Experiences. Social Inclusion, 3(2), 6–16. https://doi.org/10.17645/si.v3i2.203
CONCLUDED; (material omitted) "The
“return” to home for childbearing should be seen as existing within a
broader social and cultural movement in Australia toward sustainability and
environmental awareness, an idea that the more “natural” something is, the
less mass produced, the more local, the better it is. Viewing home birth in
a broader social and cultural sense opens the possibilities of “knowing” the
home and birth beyond the confines of medicalisation. The impact of a focus
on space and place in home birth experiences directly responds to the
growing literature on therapeutic landscapes, with places and spaces moving
beyond geographical location/social contexts of places, and into a more
holistic understanding of the meaning of place for people, and the impact
these meanings have on health and wellbeing (Gesler & Kearns, 2002; Kearns &
Gesler, 1998)"
CONCLUDED (from abstract) "This
essay analyzes the production of three influential home birth texts of the
1970s written by self-proclaimed lay midwives that helped to fuel and
sustain a movement in alternative birth practices. As part of a
countercultural lifestyle print culture, early “how-to” books (Raven Lang’s
The Birth Book, Ina May Gaskin’s Spiritual Midwifery) provided readers with
vivid images and accounts in stark contrast to those of the sterile hospital
delivery room. By the end of the decade, Rahima Baldwin’s more mainstream
guidebook, Special Delivery, indicated an interest in translating home birth
to a wider audience who did not necessarily identify as “countercultural.”
Lay midwives who were authors of radical print texts in the 1970s played an
important role in reshaping expectations about the birth experience,
suggesting a need to rethink how we define the counterculture and its
legacies.
2014
Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health, 59(1), 17–27. https://doi.org/10.1111/jmwh.12172 Access https://onlinelibrary.wiley.com/doi/full/10.1111/jmwh.12172
Of particular note is a cesarean rate of 5.2%, a remarkably low rate when compared to the U.S. national average of 31% for full-term pregnancies. When we consider the well-known health consequences of a cesarean -- not to mention the exponentially higher costs -- this study brings a fresh reminder of the benefits of midwife-led care outside of our overburdened hospital system. Home birth mothers had much lower rates of interventions in labor. While some interventions are necessary for the safety and health of the mother or baby, many are overused, are lacking scientific evidence of benefit, and even carry their own risks. Cautious and judicious use of intervention results in healthier outcomes and easier recovery, and this is an area in which midwives excel. Women who planned a home birth had fewer episiotomies, pitocin for labor augmentation, and epidurals.
2013
Stapleton, S. R., Osborne, C., & Illuzzi, J. (2013). Outcomes of Care in Birth Centers: Demonstration of a Durable Model. Journal of Midwifery & Women’s Health, 58(1), 3–14. https://doi.org/10.1111/jmwh.12003 Access https://www.researchgate.net/publication/235384271_Outcomes_of_Care_in_Birth_Centers_Demonstration_of_a_Durable_Model
Discussion: This study demonstrates the safety of the midwifery-led birth center model of collaborative care as well as continued low obstetric intervention rates, similar to previous studies of birth center care. These findings are particularly remarkable in an era characterized by increases in obstetric intervention and cesarean birth nationwide
2012
Overgaard, Fenger-Grøn, M., & Sandall, J. (2012). The impact of birthplace on women’s birth experiences and perceptions of care. Social Science & Medicine (1982), 74(7), 973–981. https://doi.org/10.1016/j.socscimed.2011.12.023
CONCLUDED (from abstract): " Overall birth experience is an important outcome of birth, and studies of psycho-social birth outcomes and women’s perspectives on care are increasingly used to evaluate and develop maternity care services. We examined the influence of birthplace on women’s birth experiences and perceptions of care in two freestanding midwifery units (FMU) and two obstetric units (OU) in north Denmark, all pursuing an ideal of high-quality, humanistic and patient-centred care. As part of a matched cohort study, a postal questionnaire survey was undertaken. Two hundred and eighteen low-risk women in FMU care, admitted between January–October 2006, and an obstetrically/socio-demographically matched control group of 218 low-risk women admitted to an OU were invited to participate. Three hundred and seventy-five women (86%) responded. Birth experience and satisfaction with care were rated significantly more positively by FMU than by OU women. Significantly better results for FMU care were also found for specific patient-centred care elements (support, participation in decision-making, attentiveness to psychological needs and to wishes for birth, information, and for women’s feeling of being listened to). Adjustment for medical birth factors slightly increased the positive effect of FMU care. Subgroup analysis showed that a significant, negative effect of low education and employment level on birth experience was found only for the OU group. Our results provide strong support of FMU care and underline the big challenges in providing individual and supportive care for all women, especially in OUs. Policy-makers and professionals need to consider how the advantages provided by FMU care can support the effort to improve women’s birth experience and possibly also the combat of the negative effect of social disadvantage on health."
2011
Cheyney. (2011). Reinscribing the Birthing Body: Homebirth as Ritual Performance: Reinscribing the Birthing Body. Medical Anthropology Quarterly, 25(4), 519–542. https://doi.org/10.1111/j.1548-1387.2011.01183.x
CONCLUDED (from intro): "We want mothers to reflect on their births, to be amazed at what they have accomplished, and to fall madly in love with their babies. As women in this society, we are told that something is wrong with us at every turn. We have PMS that requires medications so we’re not too bitchy. We need thousands of dollars worth of technology to get our babies out alive. Our breast milk is a burden, so we’re offered a substitute ... The myth of the totally dysfunctional female body is big business! That’s a lot to ask women to take in—to be made to feel totally incompetent. But then we’re expected ... to raise up new members of our society. Midwifery is about listening to all of that and saying “I don’t buy it!” ... We’re overturning unfounded notions about our bodies one birth at a time. —Lucinda, a 62-year-old “illegal” homebirth midwife, who has been catching babies for almost 40 years "
2008
Cheyney. (2008). Homebirth as Systems-Challenging Praxis: Knowledge, Power, and Intimacy in the Birthplace. Qualitative Health Research, 18(2), 254–267. https://doi.org/10.1177/1049732307312393
CONCLUDED (from abstract): "Findings interpreted from the perspective of critical medical anthropology suggest that women who choose to birth at home negotiate fears associated with the “just in case something bad happens” argument that forms the foundation for hospital birth rationales through complex individual and social processes. These involve challenging established forms of authoritative knowledge, valuing alternative and more embodied or intuitive ways of knowing, and knowledge sharing through the informed consent process. Adherence to subjugated discourses combined with lived experiences of personal power and the cultivation of intimacy in the birthplace fuel homebirth not only as a minority social movement, but also as a form of systems-challenging praxis."
Last updated June 2024