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(Over)medicalization of Childbirth as a Public Problem: Material Trajectories, Public Controversies and Institutional Changes – HYPMEDPRO

Overmedicalization of Childbirth as a Public Problem : Material Trajectories, Public Controversies, Institutional Changes

During the last decades, public criticism of « overmedicalized » childbirth has gained weight in many geographies. Sometimes publicised within denounciations of « obstetrical violence », such criticism has catalyzed the emergence of alternative knowledge and practices as well as regulatory and even institutional changes. This research program tackles these new dynamics in an international perspective, by focusing on five countries with different medical cultures and histories.

Research Problem & Goals

HYPMEDPRO investigates the multiple –and sometimes paradoxical— paths followed by the most widespread obstetrical techniques and practices. Five countries are considered for a comparative analysis : France, Turkey, Italy, Canada, Brasil. In each of these countries, the resort to childbirth techniques and technologies has speeded up from 1980s sofar, but according to different modalities. Brasil and Turkey count among countries with very high C-section rates in the world (respectively 52 and 48%), just like Italy in Europe (37% against the European average of 22%), whilst Quebec is the Canadian province with the highest rate of resort to epidural (70%), like France in Europe (80%). Shifting the survey between different geographies (european, middle-eastern, and accross the Atlantic), but also between industrialized vs. « emerging » countries, our ambition is precisely to reveal the singularity of each case : singularity according to health systems, legal and regulatory frames, but also according to medical, political, religious cultures, as well as dynamics of activism and collective action. We aim, for instance, to explain why in Turkey and in Brasil, two so-called « emerging » countries, paradoxically, a more high-tech model of birth (C-section) gradually became the norm. We investigate the reason epidural had the same kind of success in Quebec and in France, despite the fact that it was contested for very long time in Quebec (which is different from the French case). More generally, we aim to highlight the different ways in which a problem is framed (noting that a « problem » like epidural in France, can be formulated as a « solution » elsewhere) ; we aim to decipher the various conceptions of what is called a « humanized » or, on the contrary, an « overmedicalized » or « fordist » birth ; we analyze the dynamic boundry work aiming to oppose categories of the natural to the artifical, the medical to the biological, the modern to archaic.

This research program relies on three transversal paths : (1) scientific evaluation and regulation of risk ; (2) collective action and public controversies ; (3) institutional responses/changes. In order to allow a rigourous international comparison, two research objects are tackled as a priority : epidural anesthesia and caesarean delivery. In research path#1, we analyze the evolution of scientific debates and controversies on the benefits and risks associated to C-section and to epidural over four decades. For each of the five countries surveyed, we plot the manner in which these debates influenced the existing regulations. We pay a particular attention to the « mal practice », and to juridical affairs. Research path #2 proposes a sociohistorical analysis of activist networks and groups claiming « alternative » or « humanized » birth. We focus on some of them, with the hypothesis that a three level periodisation can be envisaged in this frame (1970s, 1990s-2000s, 2010s). In research path#3, we deal with the various impacts that the above-mentioned debates, mobilizations and controversies have had on the institutions. We focus on two key moments. The first one concerns the redefinition of C-sections as a problem by governments. The second one concerns key decisions on epidural, which roughly went through two phases that contrast with each-other : the process that led to the reimbursement of epidural vs. the developments that opened the way to the legalisation of « birth centers ». This research program is fed by a stream of analytical tools that belong to comparative sociology of public problems, cultural history of medical knowledge and techniques, sociology of collective action, as well as ethnographic research. We mobilize three types of emprirical survey methods that will allow us to conduct our analyses at different levels : (1) archival research, (2) interviews, (3) participatory observation in maternity hospitals.

The results achieved during the first operational phase of HYPMEDPRO feed the existing research and knowledge in three main directions. (1) Regarding the social history of scientific and medical regulations and debates, they hightlight the importance and the convergence of dynamics of ignorance production (Gross & McGoey, 2015) concerning the risks and the undesirable effects of routinized techniques and practices (such as epidural anesthesia or caesarean delivery). (2) Regarding hospital ethnograpies, the research that we conducted in Italy, Turkey and France reveal the omnipresence of the calls or the injunctions to « natural birth » even in contexts of high medicalisation r technicisation of birth. (3) Finally, concerning the study of public/collective mobilizations and of institutional responses, the bibliographical and archival research that we conducted in France suggest a gradual technicisation in the ways of framing the problem of medicalized childbirth from 1970s on. In this frame, the recent controversy on ‘obstetrical violence’ represents a moment of rupture – a moment of deep reconfiguration of statements, arguments and action forms.

The HYPMEDPRO program aims to produce new empirical and theoretical knowledge and to strengthen interdisciplinary dialogue in the study of human reproduction and childbirth. The issue addressed in this research is still relatively unexplored not only in France but also internationally. HYPMEDPRO provides an opportunity to increase scientific knowledge particularly on the health, economic, political, cultural and gender consequences of over-medicalized childbirth. More globally, HYPMEDPRO provides analyses and results that are likely to support the strengthening of the dialogue between health professionnals and women/patients, and thus the improvement of medical care in childbirth. Last but not least, the results of the HYPMEDPRO program are expected to contribute to a comparative understanding of potential adverse consequences linked to the excessive medicalization of care during childbirth, thereby opening the path to a better regulation of clinical interventions in low-risk women, and even the construction of new health care systems in which both the singularity of each patient’s trajectories and the cumulative character of iatrogenic harm engendered by unnecessary interventions are betten taken in charge.

During the first 18 months of the HYPMEDPRO program, we organised 3 conferences (2 international, 1 national) and we launched a monthly research seminar at Ehess (24 ECTS, 3rd edition in progress). A special journal issue (on technological childbirth in a transnational perspective) is forthcoming within the British sociological journal Health, Risk & Society (publication programmed for spring 2019). A second special journal issue (on the production of ignorance in fields of childbirth and human reproduction) as well as an edited book volume (on the governance of the reproductive and the maternal body in Turkey) are in progress, as well.

During the last decades, criticism on the « overmedicalization » of childbirth has gained in importance in many geographies, thereby transforming the historical imbrication between childbirth and medicine into a public problem. Such criticism in some cases facilitated the emergence of new forms of expertise and regulation, the legitimation of alternative practices, as well as the implementation of key organisational reforms. Focusing on the debates relating to medicalized birth and the joint institutional changes, this research programme aims to tackle these new dynamics in an international perspective. It looks toward both publicized and discreet arenas of debates and controversies, from 1970s to today.

Our starting hypothesis is the following : criticism and protestation that emerged in various geographies most commonly denounce an excess of medical interventionism, but very different meanings and problematizations exist on what is considered as « medical », or too medical, or, on the contrary, « natural ». Indeed, since the almost entire displacement of the place of childbirth from house to hospital (starting from the middle of the 20th century), medical interventionism took very diverse forms from one national context to another. For instance, C-sections have almost been normalized in some countries (Brasil, China, Turkey) as a no-risk and no-pain option to natural birth. In some other countries, like France, rather the normalization of epidural anesthesia or of oxytocin is contested as a sign of overmedicalization.

Conducted by a team of historians, sociologists and anthropologists specialized on the study of science, medecine and collective action, this research programme will rely on a multi-sited fieldwork so as to investigate the diverse, and sometimes rivalling paths followed by the most widespread medical techniques and practices in obstetrics. We aim to analyze how, to what extent, and on the initiative of which players medical techniques – promoted, for long time, as a means to master the « nature » (i.e. woman’s body and its hazards)— have themselves gradually become a problem to master. Five countries will be considered for a comparative analysis : France, Canada, Italy, Turkey, Brasil. This research programme relies on three transversal analytical axes : (1) medical instruments & scientific evaluation and regulation of risk ; (2) collective action and public controversies ; (3) institutional responses/changes. It will first and foremost tackle two research objects : epidural anesthesia and cesarian. It will be fed by a stream of analytical tools that belong to comparative sociology of public problems, cultural history of medical knowledge and techniques, sociology of collective action, as well as ethnographic research. We will be mobilizing three types of emprirical survey methods that will allow us to conduct our analyses at different levels : (1) archival research, (2) interviews, (3) participatory observation in maternity hospitals.

Project coordinator

Madame Sezin TOPCU (Institut Marcel Mauss (UMR 8178 CNRS-EHESS))

The author of this summary is the project coordinator, who is responsible for the content of this summary. The ANR declines any responsibility as for its contents.

Partner

IMM Institut Marcel Mauss (UMR 8178 CNRS-EHESS)

Help of the ANR 195,031 euros
Beginning and duration of the scientific project: September 2016 - 36 Months

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