Medicalisation in Pregnancy and Childbirth: unintended consequences of interventions

Background:
Current evidence indicates that pregnancy and childbirth are increasingly managed, interfered with, monitored, and terminated by interventions. Current evidence indicates that interventions play an increasing role in the management of pregnancy and childbirth. Such medicalisation is intended to improve maternal and fetal outcomes. Nevertheless, most interventions have not only beneficial effects but also adverse effects. Globally, concerns have been expressed that interventions may be overused especially in middle- and highincome countries. This increases the risk of causing unnecessary treatments that may subsequently lead to adverse effects.
The current thesis aims to explore the possible impact of medicalisation in Danish maternity care. Medicalisation is described as a process in which human conditions become defined as medical problems and treated as such. Human conditions like advanced maternal age, late-term gestational age, and nulliparity were the point of departure for the analysis of this process.
Objectives:
To examine the association between advanced maternal age and the risk of having a caesarean section in a Danish population.
To evaluate fetal and maternal outcomes 5 years after the introduction of a new protocol recommending routine induction of labour 10–12 days after estimated due date. To analyse changes in intervention rates over an 18-year period among nulliparous women in Danish maternity care.
Methods and results:
Paper I: This national population-based cohort study included 1,122,964 Danish births in the period 1998–2015. The association between advanced maternal age and caesarean section was examined. A strong association between increasing age and caesarean section was found after adjustment for relevant confounders.
Paper II: A national Danish register-based cohort study was conducted, including 152,887 women (2000–2016). A new national protocol introduced in 2011 aiming to reduce stillbirth 39 and perinatal death was evaluated. Early routine induction in 41+3 gestational weeks replaced a previous recommendation of 42+0 gestational weeks. No change in perinatal outcome was observed after implementation. Induction of labour increased significantly as well as the number of uterine ruptures.
Paper III: This national population-based cohort study included 380,326 births of singleton nulliparous women. Induction of labour, synthetic oxytocin, and epidural analgesia were monitored over an 18-year period (2000–2017). Interventions increased substantially over time, as did the risk of receiving more than one intervention.
Conclusion and perspectives:
Using various epidemiological methods, attention was directed towards a possible medicalisation of normal conditions in pregnancy and childbirth in contemporary maternity care. Our studies pointed towards a medicalisation of advanced maternal age, late-term gestational age, and nulliparity. We found indicators that suggested a risk approach in which treatment was initiated based on risks rather than on pathological conditions. As no overall improvement in fetal and maternal health was found, unnecessary medicalisation is likely to have occurred, causing a risk that the general gains and improvements in maternal and perinatal health may be forfeited as a consequence. This substantiates a
need for a careful evaluation of contemporary maternity care. Globally, the
recommendation is to restrict unnecessary interventions as they may cause adverse effects and tend to undermine women’s own ability to give birth and negatively affect women’s experience of labour.