ļ»æEpisode 125 - The Medicalisation Spectrum
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD. In each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:21] Hello, everyone, and welcome to the Great Birth Rebellion podcast. Today we're talking about what I call the medicalization spectrum and this is understanding pregnancy and birth 101. If you don't understand the medicalization spectrum, everything else will feel a little bit cloudy for you and you won't quite have the words that you need to explain a lot of what you'll come up against as a woman and also if you're a maternity care provider, this will help you understand what you're up against when you go about your work, wherever you work. And the things I'm going to tell you today will ultimately help you plan a pregnancy, birth and postpartum journey that you are most satisfied with. And for care providers, it will help you understand where you personally sit on the medicalization spectrum, including anyone who's listening. Understanding where you sit on the medicalization spectrum will help you place yourself accurately. Now, on my social media channels, at Melanie the Midwife and at The Great Birth Rebellion on Instagram, there's also a visual tile that I use to explain this concept. You don't have to be looking at it when you are listening to this episode. But if this doesn't hit with just my words, go to the social media pages at Melanie the Midwife or at The Great Birth Rebellion and check.
[1:47] You'll see this, there's a pink tile called the medicalization spectrum, and that's what I'm working off today. So have a look at the graph that I created to explain this in a more visual way, if that's how your brain works. If you're on the mailing list for this podcast, though, you'll also see this tile in the resource folder. And before we kick off with any of that, some super exciting news is that we have finally finalized and landed on the most beautiful podcast merch that I have ever seen. It's been a journey for about the last eight months. I've been testing products and all kinds of manner of parts that move in this merchandise creating world. And I've landed on some Great Birth Rebellion merch that is ready for sale in the next week or two. The first people who will hear about the merch are the ones who are on the mailing list for this podcast and in the show notes below you can get on the mailing list and they're all going to receive a discount code for early purchase so please do get on the mailing list to be the first to hear about it.
[2:55] Okay let's get started on the medicalization spectrum. So the medicalization spectrum describes the spectrum So there's two extreme ends, and then there's lots that sits in the middle. First, the medicalization spectrum is a way to understand your personal birthing philosophy. So at the very left-hand side of the spectrum, you've got what we call a physiological philosophy of understanding birth. And this sits in the least medical mindset about birth so if you have a physiological philosophy about birth then you'll be believing that for most of the time birth is safe that our bodies are made to give birth that if we have the right environment and the right care provider we're well and healthy that our bodies should function normally through labor and birth and most of the time.
[3:58] The woman and baby will be safe and well and healthy afterwards. So that's a physiological philosophy, a belief that your body is physiologically made for labor and birth and feeding your baby, and that labor and birth is just a normal part of our functioning in a female body. Similar to how our body knows how to wee and poo and digest and pump blood around our bodies, it knows the hormonal process and the physical process that needs to occur for your baby to be born and so a physiological philosophy has this kind of understanding and because that's the understanding because birth is seen as just a normal everyday event that women are designed to do.
[4:47] There's not a lot of fear around that process. There could be apprehension in a sense of it's a new thing. We don't do it very frequently, but not fear that things are going to go wrong. So we're not existing in a state of fear when we're thinking about labor and birth in a physiological mindset. So that's the very left-hand side of the spectrum. You know, the most extreme end of that is people who believe that birth never goes wrong. The other end of the spectrum is a belief that birth always will go will go wrong in some way and this is what we call a biomedical philosophy and the biomedical philosophy believes that pregnancy birth labor is a state of pathology so you're in a so that it would be a medical mindset, in a sense that you're going through this process of having a baby and at some point in that process, something is going to go wrong where you need help from a health professional and therefore you need to be somewhere where those health professionals have the tools and equipment that they need to help you. So that's a biomedical philosophy that pregnancy and birth is a high-risk situation.
[6:06] That most of the time something goes wrong and that most of the time you will need the help of some kind of expert like a midwife, obstetrician.
[6:17] Pediatrician, anaesthetist, that somewhere along the line this is not going to work, that your body's going to malfunction and that there's going to be danger. And so in order to build safety into the childbirth process you need to have medical attention and surveillance and supervision. So that's a biomedical philosophy and there's a real focus on risk and the belief is that you're not safe in childbirth if you don't have supervision and if it's not in a medical facility. Because in a biomedical philosophy, birth is seen as a medical event, not a normal physiological event. That's the very right hand side of the spectrum is the biomedical philosophy. Birth is a medical event, it's most of the time going to go wrong and most of the time we'll need the supervision and intervention of an expert or a health professional. Whereas on the very, very other side, on the very left, the physiological philosophy says, look, birth is mostly going to go well. It's a physiological function. Sometimes we need to intervene, but most of the time not.
[7:28] So those are the two extreme ends. And then there's this spectrum in the middle. So there's this big area in the middle of perspectives and philosophies about birth. That's the medicalization spectrum. And so the very first thing for you to do is to understand where you personally sit along that spectrum. And there's no right or wrong answers here. It's not like there's one philosophy is better than the other or more correct than the other. I mean, we all have our own opinion about that, but you'll be having your own personal experience with this spectrum.
[8:06] Honestly, see if you can plot yourself on this spectrum. Are you more favoured towards a physiological philosophy or do you more favour a biomedical philosophy? Are you in between? Are you not sure? The very first step in planning your own pregnancy birth journey and in your work as a care provider is to understand
[8:26] where you sit on the medicalisation spectrum and be honest with yourself about that. On the little graph that you'll see on my social media or in the resource folder, if that's what you're looking at, you'll see then the next level of this medicalisation spectrum is that I've plotted where various care providers within the maternity care system sit along this medicalisation spectrum.
[8:51] And so typically at the physiological philosophy end, you're going to have your less medically minded care providers. So that could include doulas and midwives who sit at the more physiological end on the left side of the spectrum, who are more in favor of the philosophy that birth is a physiological process. Most of the time it goes just fine, but that occasionally we need to intervene. And these clinicians are also in the work of facilitating physiology. Because of this belief that it's a physiological process, that it's something our body knows how to do, many midwives and doulas are in the business of trying to protect your birth space so that your body can fully express its physiological function without interruption. And then as you move along the spectrum, the clinicians can get more and more medically minded. So there'll be midwives scattered all the way from the physiological philosophy, all the way up to the biomedical philosophy. And part of your work as a pregnant woman is.
[10:02] Is to work out where your care provider sits on this spectrum. So while as midwives, we're trained to facilitate physiological birth and our intention is to protect physiological birth, the system that we work in is very much sitting at the biomedical philosophy side of things that fundamentally believes that childbirth is a medical event and that it will most of the time need intervention, management, supervision, and surveillance. And so you'll find that a lot of midwives will have their philosophy hijacked
[10:38] by the culture of their workplace. And they do genuinely start to believe that birth is a pathological event, partly because they see a lot of pathology, because when you medicalize birth and you only see medicalized birth, you start to lose the idea that birth could be anything else other than complicated and so what you'll find is although midwives are supposed to be the protectors of physiology is that their minds and behaviors are hijacked by a medicalized system and so they start to act in a biomedical way they start to act and practice as if birth will always go wrong and so your care provider will sit anywhere along this spectrum and part of the challenge of hiring a care provider or sort of sizing up a care provider is trying to work out where they sit on this spectrum.
[11:32] So firstly my suggestion was to work out where you sit on the birth philosophy spectrum and your next job is to work out where your care provider sits on the birth philosophy spectrum because when you find somebody who meets your philosophy you have this feeling of a big breath out of a knowledge that you're not going to need to fight hopefully you're not going to need to fight for the type of birth that you want because you and your care provider are philosophically matched.
[12:04] Now if we go back to where care providers sit on the medicalization spectrum at the very very right end at the most biomedical end you'll usually have the more medical practitioners, and these are the obstetricians, pediatricians, anesthetists. And a collection of midwives will sit in this biomedical philosophy where the assumption is, is that birth is always pathological. There is always risk. We must always supervise and manage labor and birth. And then they also have the belief that they are the best care provider to be caring for you in that circumstance because they're trained to do that. This comes from a medical philosophy. They are medically trained.
[12:48] Obstetricians are not trained to facilitate physiological birth. There are some incredible obstetricians who have taken on the intention of attending and facilitating physiological birth. So certainly not all obstetricians are on the biomedical end of things, but that's certainly how they're trained. And so in the same way as we as midwives are theoretically trained to have a physiological philosophy and then we end up through the course of our career potentially becoming more biomedically minded there are obstetricians who are trained with the biomedical mindset who do work at understanding birth in a physiological way and so again when you're choosing your care provider if you are choosing an obstetrician you still need to be assessing where do they sit on the on the medicalization spectrum and does it match your personal philosophy?
[13:47] And so that's where your care providers interact with the medicalization spectrum. Now we know that if you sit on the physiological end of the spectrum along with doulas and some midwives hopefully, then you're going to be exposed to the least medically managed care that's available. Whereas if you are engaging with clinicians that sit on the biomedical side of things, they're going to be naturally inclined to heavily manage and intervene in your birth simply based on their philosophy. So you're going to get more medicalized care when you go to the very right far side of the medicalization spectrum.
[14:31] So physiological birth philosophy with midwives and doulas, you're likely to experience the least medicalised birth, the least interventions, a method of caring for you that seeks to only intervene when it's absolutely medically necessary, when things are actually not going right, not as a routine way of managing your pregnancy and birth. However, on the more medical side of the spectrum, in the biomedical philosophy.
[15:00] Interventions are the routine, regular strategy that they'll use to manage your birth. They believe that if they don't routinely intervene, then there's no way that your body and birth can proceed healthily and normally, what they believe to be normally. And so they will believe that most interventions are necessary. They will routinely intervene. whereas at the least medical side of things, interventions are only offered when you're confronted with actual complications, not theoretical complications. It's not this defensive practice where you intervene in case something goes wrong. You seek to only intervene if something is going wrong. Okay, so that's our medicalization spectrum. The two philosophies, the physiological philosophy that believes birth is mostly safe on the very left-hand side and the biomedical philosophy where birth is considered mostly dangerous and risky on the right-hand side. Your care provider will be scattered somewhere along that spectrum as will you and your birth partner or birth support team or the father of your child or the parent of your child will be scattered somewhere along that medicalization spectrum.
[16:15] Everybody sits along that spectrum in their philosophical beliefs about pregnancy, birth and postpartum. And so identifying where you sit, where your care provider sits, where your support people sit, where your doula sits, your partner, your mum, anyone who's interacting with you. If you can understand where they sit along that medicalization spectrum, you'll understand what they are going to offer you through your pregnancy, birth and postpartum because all of our actions come out of our philosophy and belief about pregnancy and childbirth. All right, now let's plot on top of that, as we layer this medicalization spectrum, let's plot the options of where you're going to give birth. And how they match with this medicalization spectrum. So if you are seeking a less medicalized birth, the least medical, that favors a physiological philosophy that honors the physical process and the physiological process of giving birth as mostly safe.
[17:16] Then the options that sit closest to that end of the spectrum are the option of free birth, which is where a woman chooses to give birth at home without any attendance of or somebody with medical skill to assist them. So that's a free birth. Then you've got the option of home birth and you can have a home birth, at least here in Australia, with various care providers. So you could hire a private midwife and private midwives are not connected in with the maternity care system in the same way as a publicly employed midwife. And so they usually have a lot more autonomy and less restriction on their practice. And home birth private midwives are considered to be one of the more physiologically minded practitioners that don't have an allegiance to hospital policy or hospital governance or oversight. And so if you want to have a physiological birth with a care provider who also has a physiological mindset, the most likelihood of you matching with your care provider is.
[18:27] Is at a home birth with a private midwife. Not everybody has access to that and also there are private midwives who some women feel sit further along that medicalization spectrum than they would like. So some women who are having a home birth have a mindset that sees birth as physiological whereas there have been times and there are circumstances where women hire a private midwife assuming that their philosophy matches their own and then discover later that the midwife is has a more medicalized
[18:58] philosophy than the woman was anticipating. So at any stage in this medicalization spectrum, as you're choosing your birth location and choosing your care provider, there could be a mismatch in philosophy. So if you're physiologically minded and you choose home birth with a private midwife and all those philosophies match up, you're in the most ideal circumstance.
[19:24] However, if you have a medicalized mindset and you want a heavily managed labor and birth and then you choose to give birth at home with a private midwife, you're going to be very disappointed and potentially feel unsafe and unsatisfied with your care because the birth location and the birth philosophy of your care provider don't match your own. And this is the importance of discovering your own and then discovering that of your care provider and then choosing a location that also matches your philosophy. So then as we go along the spectrum towards the more medical end, we start to move into the next option and that is a home birth with a publicly funded midwife.
[20:07] And these are your publicly funded home birth programs where you would go to the hospital to access these because the hospital is running a publicly funded home birth program. So usually the midwives who choose to work in these programs, however, their practice is restricted by the policy and governance of the hospital. And often these programs will only take women who have very, very few risk factors in their opinion. And the midwife's practice is also governed by a medicalised framework. So in a publicly funded home birth program, they'll often have time restrictions on how long they're allowed, in adverted commas, allowed to labour at home. And they'll have quite strict criteria for what the midwife must do in various scenarios.
[20:57] And so while it's closer to the physiological philosophy for the clinician and the woman, we're starting to see the impact of the medicalised system impacting upon the clinical practice that can occur in this setting. Something for us also to remember is that the system, the maternity care system here in Australia sits in a biomedical philosophy. There are some heroes within the system who have physiological mindsets but overall we are all battling against a system that fundamentally believes that birth is a medical event and that's how policy and insurance and guidelines and everything is written around the assumption that something is going to go wrong. And so anybody who doesn't have a medicalized biomedical philosophy is in direct conflict with the system and this is where this challenge comes for care providers is that their philosophy is physiological but they have to work in a system that has a medicalized philosophy and then we have this moral conflict and moral distress is what they call it where we want to work in one way because that's philosophically where we sit but we're required to work a different way and this causes moral distress for people working in this scenario.
[22:22] It also causes distress for the women who have a physiological mindset who are giving birth in a medicalised system. This is where the distress and trauma can come from and vicarious trauma can come from this mismatch in philosophies. So just know that along the spectrum, the medicalisation spectrum.
[22:42] Hospitals and the maternity care system sits in the more medical, biomedical framework. All right, so if we move now from home birth with a public midwife and where we sit along the spectrum, as we move further and further along towards a more medical part of the spectrum, there is an option to give birth at a detached birth center that's not part of a hospital. Again, these are really rare services. They're usually staffed by midwives. Again, usually staffed by midwives who have a physiological philosophy, who believe that birth only goes wrong a small percentage of the time, which is why they feel confident to be attending birth outside of a hospital. They know that only occasionally that medical care is required. And then the same as home birth, there's a process and a plan for how to transfer care from a low medical setting into a high medical setting if that's what's required. But also midwives who work in these settings are highly skilled. And so we have the capacity and skill to manage a certain number of medical complications without needing to go to the hospital. And then there's a point where we work out at what point are we no longer within our scope and we can then transfer to a more medicalized setting where the scope for treatment is much broader. So that's a detached birth center. Then we move to the option of an integrated birth center that is actually.
[24:10] I guess, a birth center by label and location, but it's located within a hospital. But it's a birth center that's integrated into a hospital, and these start to become a lot more medical because you're no longer outside of the hospital. You are now inside of the hospital and the governance and surveillance of the staff working inside of the hospital is more intense and more targeted than when clinicians are working outside of the hospital. They can, you know, outside of the hospital, clinicians can exercise their autonomy and work more in line with their own philosophy than when they start to move inside of a hospital setting because there's a lot more surveillance and there's a lot more expectation that staff is going to toe the line and uphold the biomedical philosophy that the system has. Again, there's this internal battle for midwives who work in an integrated birth center because usually their mindset will be physiological. That's why they want to work in a birth center, that they believe in low intervention, low medical birth. However.
[25:21] They're working within a system that doesn't value that. So here's where the pull of the system starts to get more dramatic. Then we move into more streamlined, centralized care options.
[25:33] And these sit somewhere in the middle of the spectrum, but probably more so to the right in a more biomedical philosophy. And you've got a public hospital with midwifery continuity of care. So this is where you're going into the big hospital systems and institutions, but they've got a midwifery group practice model which means they usually have some allocated teams of midwives who will take on what we call a caseload of women. So you might be allocated a team of three midwives. You would ideally have one that you know very very well and who's on call for you and they'll care for you through your pregnancy, birth and postpartum. So you have what's called midwifery continuity of care but it's within a hospital setting. Some of these programs the midwives will see you at your home for home visits. Some of them will have internal clinics at the hospital and then when it's time for you to give birth you would go into the hospital and your midwife would come and join you or a member of that midwifery team and ideally the idea is that you would meet your team of midwives and you know that your care is going to be delivered by one of these three or two midwives, depending on how the MGP is set up. And this is the same if you're having birth center care or if you've got a public midwife.
[26:55] Having a home birth, and definitely if you've got a private midwife having a home birth. The benefit of these midwifery care models is that you would know your midwife, that they would be your carer for your pregnancy, birth, and postpartum. And so this is what we call continuity of midwifery care. And these are usually the least medically inspired birth models. And certainly the research sits in favor of midwifery continuity and care in terms of outcomes and satisfaction. Now, these are definitely more boutique birth services.
[27:30] Approximately 30% of women in Australia will have access to either a home birth with a private midwife, a home birth with a public midwife, a detached or integrated birth center with a midwife, or a publicly funded hospital continuity of care model. All of those physiologically minded and less medical birth options are the minority
[27:53] services available to women here in Australia. The majority of women, around 70% of women, will either only have access to or choose the biomedically minded and medically minded birth options that sit on the more right hand side of the spectrum. Again, although you can have physiological midwives working in these biomedical models, you have to understand that fundamentally when you're entering to these services on this more medicalized end of the spectrum you're going to be fighting for a physiological birth and clinicians are fighting to give you physiological care within a biomedical system and so the next step after public hospital midwifery continuity of care programs is a public hospital with just standard care.
[28:42] So let me tell you about standard care. Standard care is what we call fragmented which means that when you go for your antenatal appointments into the clinic at the hospital you will see a different person every time. There's no continuity of care. It's fragmented in a sense that you'll see a different person every time usually and you'll never know who that is.
[29:07] You You don't know what their skill level is. You don't know them and they don't know you. That's what we call standard care. That's what the majority of women in this country have access to. It's publicly funded, so you won't pay for it, but it's definitely substandard when you compare it to the options with cognitive care with a midwife. It's substandard not only from the women's experience, but also for the outcomes, because Their outcomes are not as good in a fragmented model. The research is on the side of continuity of care. However, most women will experience and have access to fragmented care. And this can also include, so if you're in a more rural setting, you might have care by a GP.
[29:56] Sometimes the GPs are giving what we call potentially continuity of care. But women often access GP shared care models like this because that's the only option available to them. And now remembering GPs are medically trained. So they are sitting in the biomedical philosophy most of the time. I'm sure there are some anomalies. But if you've got only access to GP shared care and publicly funded fragmented care, then know that again, you're being exposed to biomedical medicalized care. And it's what we call fragmented. but it's considered standard. Now the next step and we're getting more and more medical here because we start to include doctors into care. So public hospital with a public doctor. So this is often where women who have risk factors end up getting positioned within the system.
[30:48] It's the least ideal because it's fragmented and it's with a medical clinician who doesn't have midwifery skills and the management is very very medical it's not socially minded it's not usually conscious of the woman's emotional needs and her autonomy and unfortunately often women with risk factors are not allowed in inverted commas to have access to midwives in a publicly funded model even through the standard care so what you end up having is the women who need the most midwifery care who have the most risk factors and who are most vulnerable are left in the care of medical clinicians who have a biomedical philosophy. So that's the next option.
[31:35] Now if you want to start paying for care what you'll see on the on the right side of the spectrum on the most medical side of the spectrum is that this is where women start paying for their selected doctor. So it's continuity of care with an obstetrician, you can either choose to have your own obstetrician in a public hospital or go completely, completely on the biomedical side and have a private obstetrician in a private hospital. And that's certainly where we see the most intervention levels, the highest interventions for inductions, for early labor, cesarean sections, for episiotomies. You'll see that with private doctors in private hospitals. So.
[32:22] If you really want every single medical intervention, all of the medical options, high interventive birth, you're happy for a cesarean section, you're happy for episiotomies and inductions and vacuumed forceps and that's where you feel most safe, the most likely chance you're going to be exposed to that is with a private obstetrician in a private hospital or with a private obstetrician in a public hospital or in a public hospital with a public doctor. However, if you're of a mindset where you want a low intervention birth and you don't want a cesarean section or an induction, then you're creating a battle for yourself if you choose to give birth with a doctor. Having said that, women who have continuity of care with an obstetrician do express higher satisfaction levels than the people who have fragmented care without their known care provider. And so a really important part of your care plan is to at least, at the very least, plan to have a known care provider.
[33:26] What you'll notice, though, is the models where you have a planned care provider that you know that takes you through your pregnancy, birth and postpartum, these ones are the most resource heavy on the woman. The woman usually has to pay for those out of pocket or through their private health fund. So this requires some financial resources to make these decisions. What you'll see is that the government will publicly fund the options that are actually least in line with the research in terms of satisfaction and outcomes. So for women who don't have the resources to hire somebody that they know, or they can't access a publicly funded continuity model, end up getting lumped with substandard care. You also have less choices.
[34:14] Because if you are a physiologically mindset woman, but then you're only able to access models of care that have a biomedical framework, then you're in for an uphill battle to fight against clinicians who don't match your own personal philosophy and also a location that doesn't match your own personal philosophy. So know that along the medicalization spectrum, if you want to get the type
[34:41] of care that matches your philosophy. It has to also match your resources. So can you financially afford the care and the location that matches your philosophy?
[34:53] Also, in your area where you live, do you even have access to these types of care options? There's some real issues, particularly in Australia, we're so large and so vast that not every woman has access to the option that she would prefer. And so sometimes we have to tolerate a mismatch. And this is what leads to a battle and possibly trauma, as you have to fight to keep your own philosophical preferences at the forefront. And unfortunately, sometimes you have to fight with your care provider, and sometimes you have to fight with the fundamental background, culture, and philosophy of the place that you've chosen to give birth at. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, at Melody the Midwife on socials and the show at The Great Birth Rebellion. All the details are in the show notes.
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