Disciplinary discourses: rates of cesarean section explained by medicine, midwifery, and feminism

State-level structural sexism and cesarean sections in the United States

The United States (U.S.) has one of the highest cesarean rates in the world yet little research considers structural factors, like racism and sexism, associated with the higher than recommended cesarean rate. New research operationalizes and quantifies structural sexism across U.S. states, which allows for consideration of how social norms and values around women and their bodies relate to the overmedicalization of birth through cesarean sections. We obtained restricted natality data for 2018 from the U.S. National Center for Health Statistics. In 2018, among people 15-49 years, 987,187 births fit the criteria for low-risk of cesarean section. Structural sexism scores were derived from 6 elements covering economic, political, cultural, and physical arenas that were totaled and standardized to create an aggregate index for each state and DC (scores range from -1.06 to 1.4). Using multivariable logistic and multilevel mixed effects logistic regression models, we examined the associations between structural sexism and low-risk cesarean section for all fifty states and the District of Columbia, controlling for relevant confounders. We found that structural sexism in 2018 was highest in historically religious mountain states and the South. Nationally, the low-risk cesarean rate was 25.1%. Multilevel models show that people living in states with higher structural sexism scores were more likely to have a cesarean section (OR = 1.22, 95% CI: 1.07-1.39). Structural sexism is related to low-risk cesarean rates in U.S., providing evidence that social ideas and norms about women and their bodies are related to overmedicalization of birth. Health policymakers, providers and scholars should pay attention to structural drivers, including structural sexism, as a factor that affects overmedicalization of birth and subsequent health outcomes for pregnant people and their infants.

Tipo de parto y sensibilidad materna: Efectos en el desarrollo socioemocional de niños y niñas al año de edad

La infancia temprana es un periodo de gran relevancia en el desarrollo socioemocional infantil; de hecho, es donde se sientan las bases del desarrollo futuro. En este sentido, las adquisiciones durante el primer año de vida son predictores importantes de las habilidades sociales y emocionales futuras, de modo que la sensibilidad materna, según evidencia respecto a sus efectos en el desarrollo socioemocional del niño, ha demostrado ser un aspecto fundamental durante este periodo. Teniendo esto en cuenta, y considerando la relevancia de dicha competencia, así como el alza mundial y nacional en las tasas de cesárea y los posibles riesgos asociados al tipo de parto vivenciado, el presente estudio tuvo como objetivo analizar la influencia dela sensibilidad materna y del tipo de parto en el desarrollo socioemocional infantil al año de edad. Para ello, se estudió una muestra no probabilística intencionada de 91 madres con sus respectivos hijos o hijas de distinto nivel socioeconómico que asistían a salas cuna públicas o privadas en la ciudad de Santiago, Chile, por medio de dos instrumentos: la escala de sensibilidad del adulto (ESA) y la functional emotional assessment scale (FEAS). En general, los resultados no mostraron diferencias en el desarrollo socioemocional de los niños según el tipo de parto, aunque sí se pudo apreciar una relación entre una mayor sensibilidad materna y un mayor desarrollo socioemocional de los niños al año de edad. Al final se discuten las implicaciones de promover la sensibilidad materna con el fin de apoyar un óptimo desarrollo socioemocional en los infantes.

Pathologising diversity: medical websites offering female genital cosmetic surgery in Australia

Female genital cosmetic surgery (FGCS) is increasingly popular. Medical organisations report concern about adverse outcomes and inadequate clinical indications. Given the Internet's role in health decisions, we aimed to discover what was being communicated about FGCS on Australian provider websites. Thematic analysis of 31 prominent websites identified six themes: seeking aesthetic perfection; resisting natural diversity; gaining from FGCS; indications for surgery; a simple procedure; and ethical practice. Desirable vulvas were represented as 'neat' and 'youthful'. Sites promoted a discourse in which to be 'feminine' means having no visible sex organs, consistent with the historical repression of women's sexuality. FGCS was constructed as a simple and empowering solution, improving women's comfort, hygiene, self-esteem and sexual relationships. The apparent primary concern was commercial. Attention was rarely paid to ethics. Sites reinforced women's responsibility to strive for aesthetic perfection, implied that vulvar diversity is pathological, made unfounded claims for the benefits of FGCS and downplayed adverse consequences. Findings have implications for public health and medical authorities in countries where FGCS is practised and advertised. Enforcing the first do no harm principle would reduce websites' capacity to promote discourses and practices that damage women's bodies and wellbeing.

A narrative analysis of women's experiences of planning a vaginal birth after caesarean (VBAC) in Australia using critical feminist theory

BACKGROUND

Most women who have a caesarean can safely have a vaginal birth after caesarean (VBAC) for their next birth, but more women have an elective repeat caesarean than a VBAC.

METHODS

The aim of this qualitative study was to explore the experiences of women planning a vaginal birth after caesarean (VBAC) in Australia, the interactions with their health care providers and their thoughts, feelings and experiences after an antenatal appointment and following the birth. The study explored the effect of different models of care on women's relationships with their health care provider using a feminist theoretical lens. Eleven women who had previously experienced a caesarean section and were planning a VBAC in their current pregnancy used the 'myVBACapp' to record their thoughts after their antenatal appointments and were followed up with in-depth interviews in the postnatal period.

RESULTS

Fifty-three antenatal logs and eleven postnatal interviews were obtained over a period of eight months in 2017. Women accessed a variety of models of care. The four contextual factors found to influence whether a woman felt resolved after having a VBAC or repeat caesarean were: 'having confidence in themselves and in their health care providers', 'having control', 'having a supportive relationship with a health care provider' and 'staying active in labour'.

CONCLUSIONS

The findings highlight that when women have high feelings of control and confidence; have a supportive continual relationship with a health care provider; and are able to have an active labour; it can result in feelings of resolution, regardless of mode of birth. Women's sense of control and confidence can be undermined through the impact of paternalistic and patriarchal maternity systems by maintaining women's subordination and lack of control within the system. Women planning a VBAC want confident, skilled, care providers who can support them to feel in control and confident throughout the birthing process. Continuity of care (CoC) provides a supportive relationship which some women in this study found beneficial when planning a VBAC.

B Butterfly Campaign: A social marketing campaign to promote normal childbirth among first-time pregnant women

PROBLEM

The steep increase and inappropriateness of caesarean birth represent a healthcare problem in Iran.

AIM

The purpose of study was to evaluate the effect of a campaign based on social marketing to promote normal childbirth.

METHOD

The study was designed as a prospective case control study. The social marketing campaign was implemented from March 2016 to January 2017. A demographic data questionnaire, obstetrical history questionnaire, maternal knowledge assessment questionnaire, and maternal health belief questionnaire comprised the instruments for this study. Only women planning a caesarean birth without any medical indications for the caesarean were enrolled in the study as a case. Those who met the same inclusion criteria and did not want to participate in the campaign were assigned to the control group.

FINDINGS

In total, 350 first-time pregnant women who composed the campaign group (n=194) and control group (n=156) completed the study. The mean baseline level of knowledge and Health Belief Model component score did not differ between the two groups at baseline. However, after the campaign, knowledge scores, perceived severity, perceived susceptibility, self-efficacy, and cues to action scores differed significantly between the campaign and control groups. The follow-up of all participants in both groups showed that 35.6% (n=69) of participants in the campaign group chose natural birth as their birth method, whereas only 13.5% (n=21) in the control group delivered their newborn vaginally.

CONCLUSION

The B Butterfly social marketing campaign successfully targeted first-time pregnant women who chose to have unnecessary elective cesarean births.

Discursive constructions of professional identity in policy and regulatory discourse

AIM

To examine and describe disciplinary discourses conducted through professional policy and regulatory documents in nursing and midwifery in Ireland.

BACKGROUND

A key tenet of discourse theory is that group identities are constructed in public discourses and these discursively constructed identities become social realities. Professional identities can be extracted from both the explicit and latent content of discourse. Studies of nursing's disciplinary discourse have drawn attention to a dominant discourse that confers nursing with particular identities, which privilege the relational and affective aspects of nursing and, in the process, marginalize scientific knowledge and the technical and body work of nursing.

DESIGN

We used critical discourse analysis to analyse a purposive sample of nursing and midwifery regulatory and policy documents.

METHOD

We applied a four-part, sequential approach to analyse the selected texts. This involved identifying key words, phrases and statements that indicated dominant discourses that, in turn, revealed latent beliefs and assumptions. The focus of our analysis was on how the discourses construct professional identities.

FINDINGS

Our analysis indicated recurring narratives that appeared to confer nurses and midwives with three dominant identities: "the knowledgeable practitioner," the "interpersonal practitioner" and the "accountable practitioner." The discourse also carried assumptions about the form and content of disciplinary knowledge.

CONCLUSIONS

Academic study of identity construction in discourse is important to disciplinary development by raising nurses' and midwives' consciousness, alerting them to the ways that their own discourse can shape their identities, influence public and political opinion and, in the process, shape public policy on their professions.

From expectation to experience: humanizing childbirth in the Brazilian National Health System

During the past 15 years Brazil has increased efforts to humanize maternal care within the Brazilian National Health System (SUS). Humanization efforts come along with de-medicalization of birth even if quality care and reduction of inequalities are still pressing matters in the country. For this qualitative study we interviewed ten women regarding their experiences of pregnancy and childbirth. The study took place in Brasília (DF) and women narrated their birth experiences at local hospitals or a birth center. Women were mostly satisfied with their attention during childbirth, specifically those giving birth at the birth center, in contrast to women giving birth at local hospitals. However, the humanization movement, essentializing women's bodies can also reproduce normative discourses that shape a sense of self-blame and disappointment if the ‘ideal birth is not achieved.

Assessment of the efficacy of group counselling using cognitive approach on knowledge, attitude, and decision making of pregnant women about modes of delivery

The choice of casarean deliveries by mothers is highly influenced by inadequate knowldge and negative attitudes towards vaginal birth. In this semi-experimental study, we compared knowledge, attitude, and decision making about modes of delivery between nulliparous pregnant women who received eight sessions of group consultation and those who took routine prenatal education. Contrary to the control group, the improvement of knowledge and attitudes were significant in the consultation group (p < 0.001), as well as mothers' decisions for vaginal birth (p = 0.03). Group consultation is an appropriate approach to improving knowledge, attitudes, and tendencies of mothers toward natural birth.

Fear, Risk, and the Responsible Choice: Risk Narratives and Lowering the Rate of Caesarean Sections in High-income Countries

In Canada, as elsewhere in the world, caesarean sections are the most common surgical procedure performed in hospitals annually. Recent national statistics indicate 28% of infants in Canada are born by c-section while in the United States that number rises to 33%. This is despite World Health Organization recommendations that at a population level only 10-15% of births warrant this form of medical intervention. This trend has become cause for concern in recent decades due to the short and long-term health risks to pregnant women and infants, as well as the financial burden it places on public health care systems. Others warn this trend may result in a collective loss of cultural knowledge of a normal physiological process and, in the process, establish a new "normal" childbirth. Despite a range of interventions to curb c-section rates-enhanced prenatal care and innovation in pregnancy monitoring, change in hospital level policies, procedures and protocols, as well as public education campaigns-they remain stubbornly resistant to stabilization, let alone, reduction in high-income countries. We explore-through a review of the academic and grey literature-the role of cultural and social narratives around risk, and the responsibilization of the pregnant woman and the medical practitioner in creating this kind of resistance to intervention today.

Reducing the rate of cesarean delivery on maternal request through institutional and policy interventions in Wenzhou, China

The objective of this study was to evaluate the effect of institutional and policy interventions on reducing the rate of cesarean delivery on maternal request (CDMR) in Wenzhou, China. Institutional interventions included health education, painless delivery introduction, and doula care. Additionally, a series of health policies were developed by the Chinese central and local governments to control cesarean section rates, mostly through controlling CDMR rates. We conducted a pre-/post-intervention study using 131,312 deliveries between 2006 and 2014 in three tertiary-level public hospitals in Wenzhou, China. Chi-square tests and predictive models were used to examine changes in the CDMR rate before and after institutional and policy interventions. After institutional interventions were introduced, the overall CDMR rate increased from 15.76% to 16.34% (p = 0.053), but the average annual growth rate (AAGR) of the overall CDMR rate quickly declined from 20.11% to -4.30%. After policy interventions were introduced, the overall CDMR rate, the AAGR of the overall CDMR rate, and the probability of performing CDMR declined. Further, the overall probability of a woman undergoing CDMR decreased in all three age groups (group one: <24; group two: 24–34; group three: >34) after institutional and policy interventions. These results show that institutional and policy interventions can reduce the CDMR rate. Additionally, the CDMR rate should be included in hospitals’ performance assessment matrix to reduce the CDMR rate further.

Women's reasons for, and experiences of, choosing a homebirth following a caesarean section

Background

Caesarean section is rising in the developed world and vaginal birth after caesarean (VBAC) is declining. There are increased reports of women seeking a homebirth following a caesarean section (HBAC) in Australia but little is known about the reasons for this study aimed to explore women's reasons for and experiences of choosing a HBAC.

Methods

Twelve women participated in a semi-structured one-to-one interview. The interviews were digitally recorded, then transcribed verbatim. These data were analysed using thematic analysis.

Results

The overarching theme that emerged was ‘It’s never happening again’. Women clearly articulated why it [caesarean section] was never happening again under the following sub themes: ‘treated like a piece of meat’, ‘I was traumatised by it for years’, ‘you can smell the fear in the room’, ‘re-traumatised by the system’. They also described how it [caesarean section] was never happening again under the sub themes: ‘getting informed and gaining confidence’, ‘avoiding judgment through selective telling’, ‘preparing for birth’, ‘gathering support’ and ‘all about safety but I came first’. The women then identified the impact of their HBAC under the subthemes ‘I felt like superwoman’ and ‘there is just no comparison’.

Conclusions

Birth intervention may cause physical and emotional trauma that can have a significant impact on some women. Inflexible hospital systems and inflexible attitudes around policy and care led some women to seek other options. Women report that achieving a HBAC has benefits for the relationship with their baby. VBAC policies and practices in hospitals need to be flexible to enable women to negotiate the care that they wish to have.

Conflicting contexts: midwives' interpretation of childbirth through photo elicitation

INTRODUCTION

This study seeks to explore midwives' perceptions about childbirth and in particular their beliefs about normality and risk. In the current climate of increasing interventions during labour, it is important to understand the thought processes that impact on midwifery care in order to examine whether these beliefs influence midwifery clinical decision-making.

METHOD

12 Midwives who worked in a variety of metropolitan hospitals in Sydney, Australia were interviewed about how they care for women during labour. The study utilised an inductive qualitative design using photo elicitation during the interview process.

RESULTS

Six themes emerged from the data that clearly indicated midwives felt challenged by working in a system dominated by an obstetric model of care that undermined midwifery autonomy in maintaining normal birth. These themes were: desiring normal, scanning the environment, constructing the context, navigating the way, relinquishing desire and reflecting on reality. Most midwives felt they were unable to practice in the manner they were philosophically aligned to, that is, promoting normal birth, as the medical model restricted their practice.

DISCUSSION

The polarised views of childbirth held by midwives and obstetricians do little to enhance normal birth outcomes. Midwives in this study expressed frustration that they were unable to practice midwifery in a way that reflected their belief in normal birth. This, they cite is a result of the oppressive obstetric model prevalent in maternity care facilities in Sydney and the over use of technological interventions during childbirth.

Splitting bodies/selves: women's concepts of embodiment at the moment of birth

Little sociological research has focused specifically on the moment of birth. In this article we draw upon interview data with women who had very recently given birth for the first time to explore the ways in which they described both their own embodiment and that of their infants at this time. We use the term 'the body-being-born' to describe the liminality and fragmentation of the foetal/infant body as women experience it when giving birth. The study found that mode of birth was integral to the process of coming to terms with this body during and following birth. The women who gave birth vaginally without anaesthesia experienced an intense physicality as they felt their bodies painfully opening as the 'body-being-born' forced its way out. In contrast the women who had had a Caesarean section tended to experience both their own bodies and those of their infants as absent and alienated. Most of the women took some time to come to terms with the infant once it was born, conceptualising it as strange and unknown, but those who delivered by Caesarean section had to work even harder in coming to terms with the experience.

The best laid plans? Women's choices, expectations and experiences in childbirth

The past decades have seen a drastic increase in the medicalization of childbirth, evidenced by increasing Caesarean section rates in many Western countries. In a rare moment of congruence, alternative health-care providers, feminist advocates for women's health and, most recently, mainstream medical service providers have all expressed serious concerns about the rise in Caesarean section rates and women's roles in medicalization. These concerns stem from divergent philosophical positions as well as differing assumptions about the causes for increasing medicalization. Drawing on this debate, and using a feminist and governmentality framing of the problem, we interviewed 22 women who have recently had children about their birthing choices, their expectations and their birth experiences. The women's narratives revealed a disjuncture between their expectations of choosing, planning and achieving as natural a birth as possible, and their lived experiences of births that did not typically go to plan. They also reveal the disciplining qualities of both natural and medical discourses about birth and choice. Furthermore, their narratives counter assumptions that women, as ideal patient consumers, are driving medicalization.

Critical discourse analysis: understanding change in maternity services

This paper provides an example of the use of critical discourse analysis (CDA) in the area of maternity care policy and describes the process of CDA as an effective research method for understanding the influences of change in the context of Australian maternity services. CDA is a methodological approach that examines how discourse is formed and given power, as a result of how power is used, who uses it and the context within which this usage takes place. The application of CDA is described in this study for the purpose of examining key-stakeholder use of knowledge and power for the purpose of influencing the direction of the maternity services reform. The CDA theoretical framework guided discourse identification and analysis of the purpose behind the discourse through examination of power relationships between key stakeholders. The use of a theoretical lens in the form of neoliberalism to supplement the theoretical framework facilitated the exposure of forces intrinsic to the maternity care context driving change.

Recognizing cesarean delivery on maternal request as a social problem: utilizing the public arenas model

Nearly one in three babies in the United States are now born surgically. While many causes for this surge in cesareans have been suggested, the phenomenon of cesarean delivery on maternal request (CDMR) has been the subject of the most controversy. Utilizing Hilgartner and Bosk's public arenas model, this article examines the ways in which CDMR has been framed and a collective definition of the problem established. Recognizing CDMR as a social problem is the first step to creating policies to ensure that the health and safety of mothers and babies are protected.

The struggle for contested boundaries in the move to collaborative care teams in Australian maternity care

BACKGROUND

the maternity services reforms announced by the Australian government herald a process of major change. The primary maternity care reforms requires maternity care professionals to work collaboratively as equals in contrast to the current system which is characterised by unequal relationships.

AIM

critical discourse analysis (CDA) using neoliberalism as an interpretive lens was employed to determine the positions of the respective maternity care professionals on the proposed reform and what purpose was served by their representations to the national review of maternity services.

METHOD

a CDA framework informed by Fairclough, linking textual and sociological analysis in a way that foregrounds issues of power and resistance, was undertaken. Data were collected from selected written submissions to the 2008 national review of maternity services representing the position of midwifery, obstetrics, general practitioners including rural doctors and maternity service managers.

FINDINGS

maternity care professionals yielded several discourses that were specific to the discipline with a number that were shared across disciplines. The rise in consumerism has changed historical positions of influence in maternity services policy. The once powerful obstetric position in determining the direction of policy has come under siege, isolated in the presence of a powerful alliance involving consumers, midwives, sympathetic maternity service managers and some medical professions. The midwifery voice has been heard, a historical first, supported by its presence as a member of the alliance.

CONCLUSION

the struggle for contested boundaries is entering a new phase as maternity care professionals struggle with different perceptions of what multidisciplinary collaboration means in the delivery of primary maternity care.

Hidden costs associated with the universal application of risk management in maternity care

This paper presents a critical analysis of risk management in maternity care and the hidden costs associated with the practice in healthy women. Issues of quality and safety are driving an increased emphasis by health services on risk management in maternity care. Medical risk in pregnancy is known to benefit 15% or less of all pregnancies. Risk management applied to the remaining 85% of healthy women results in the management of risk in the absence of risk. The health cost to mothers and babies and the economic burden on the overall health system of serious morbidity has been omitted from calculations comparing costs of uncomplicated caesarean birth and uncomplicated vaginal birth. The understanding that elective caesarean birth is cost-neutral when compared to a normal vaginal birth has misled practitioners and contributed to over use of the practice. For the purpose of informing the direction of maternity service policy it is necessary to expose the effect the overuse of medical intervention has on the overall capacity of the healthcare system to absorb the increasing demand for operating theatre resources in the absence of clinical need.

National review of maternity services 2008: women influencing change

BACKGROUND

In 2009 the Australian government announced a major program of reform with the move to primary maternity care. The reform agenda represents a dramatic change to maternity care provision in a society that has embraced technology across all aspects of life including childbirth.

METHODS

A critical discourse analysis of selected submissions in the consultation process to the national review of maternity services 2008 was undertaken to identify the contributions of individual women, consumer groups and organisations representing the interests of women.

RESULTS

Findings from this critical discourse analysis revealed extensive similarities between the discourses identified in the submissions with the direction of the 2009 proposed primary maternity care reform agenda. The rise of consumer influence in maternity care policy reflects a changing of the guard as doctors' traditional authority is questioned by strong consumer organisations and informed consumers.

CONCLUSIONS

Unified consumer influence advocating a move away from obstetric -led maternity care for all pregnant women appears to be synergistic with the ethos of corporate governance and a neoliberal approach to maternity service policy. The silent voice of one consumer group (women happy with their obstetric-led care) in the consultation process has inadvertently contributed to a consensus of opinion in support of the reforms in the absence of the counter viewpoint.

Elective caesarean section: a case study

Caesarean section as a means of delivering babies has been around for centuries with numerous references to the procedure appearing in ancient writings (Simm & Matthew 2008). It is now the most common major surgical intervention carried out on women in the world, with between 23% and 30% of deliveries in the UK performed by caesarean section (Beech 2004). This rate is all the more surprising when one considers that caesarean section accounted for just 5.3% of UK births in 1973 (Kitzinger 1998). This rising rate has many implications for both clinical practice and the NHS. An Audit Commission report (1997) suggested that each 1% rise in the caesarean section rate would cost the NHS five million pounds per year. However, the increased rate also has clinical implications, with some studies suggesting that maternal mortality is three to seven times greater following abdominal rather than vaginal birth and maternal morbidity is proportionately even greater, even with elective procedures (McCourt et al 2004).

Why do women request caesarean section in a normal, healthy first pregnancy?

BACKGROUND AND CONTEXT

a growing number of childbearing women are reported to prefer a caesarean section in the absence of a medical reason. Qualitative research describing factors influencing this preference in pregnant women is lacking.

OBJECTIVE

to describe Australian women's request for caesarean section in the absence of medical indicators in their first pregnancy.

DESIGN

advertisements were placed in local newspapers inviting women to participate in a telephone interview exploring women's experience of caesarean section. Thematic analysis was used to analyse data.

SETTING

two states of Australia: Queensland and Western Australia.

PARTICIPANTS

a community sample of women (n=210) responded to the advertisements. This paper presents the findings elicited from interviews conducted with 14 women who requested a caesarean section during their first pregnancy in the absence of a known medical indication.

FINDINGS

childbirth fear, issues of control and safety, and a devaluing of the female body and birth process were the main themes underpinning women's requests for a non-medically-indicated caesarean section. Women perceived that medical discourses supported and reinforced their decision as a 'safe' and 'responsible' choice. KEY CONCLUSIONS AND RECOMMENDATIONS FOR PRACTICE: these findings assist women and health professionals to better understand how childbirth can be constructed as a fearful event. In light of the evidence about the risks associated with surgical birth, health-care professionals need to explore these perceptions with women and develop strategies to promote women's confidence and competence in their ability to give birth naturally.