ļ»æEpisode 200 - How to choose great maternity care for you
[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, and 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.
[0:28] Welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and today I'm talking about the medicalization spectrum, which is a little diagram actually that I created myself with information that I've pieced together over time about the context of the maternity care system. I'm holding up. It's on my little piece of paper here for me for notes. But if you're watching this on Spotify or on YouTube, you'll see the diagram next to me as I'm talking. And also I'm going to post this on my social media page on Instagram at Melanie the Midwife or at The Great Birth Rebellion where you can keep up with everything about the podcast anyway. But it's called the medicalization spectrum and it's something that you as a woman need to understand as a care provider and as a support person if you're in the birth space. All birth workers need to understand the medicalization spectrum if we're fully
[1:26] to understand how to engage with the maternity care system. Before we get started, I would love to thank the sponsor of today's podcast, Poppy Child. Poppy is a doula and hypnobirth practitioner and she is the creator of the Birth Box. And the Birth Box is a collection of tools that are designed around the hypnobirthing technique to help you work through labor.
[1:51] Birth, and your life postpartum as a parent in a calm-centered way with strategies to help you work through those hard times. Poppy is offering great Birth Rebellion listeners 25% off the birth box. And in there, it includes the oxytocin bubble, which is a collection of these great tracks that you can use to listen to during labour and birth, during pregnancy to practice these techniques and afterwards to help calm yourself. Go to the show notes below, click the link if you want to get access to the birth box at 25% off. Okay, let's jump into this episode about the medicalization spectrum. And when I'm talking about the medicalization spectrum, what I need you to understand is that in Western societies, in modern birth contexts.
[2:41] Labor, birth, pregnancy, and to a point postpartum has been lumped into a medical frame of mind. We call it the medicalization of childbirth. The reason we call it that is that historically, before the rise of the physician, GPs, doctors, birth was in the realm of the community. Women were the wise women who understood and knew birth. And there has historically been midwives who've attended births way, way, way before doctors ever even existed. It wasn't until around the 1900s and more so by the 1940s that doctors even became involved in birth in a hospital setting. There was a time in early history where doctors would come to the home because that's where the majority of women were giving birth was in the home. There wasn't a place for women to go. Other than having your babies at home, that was the only option. It was highly unusual for a woman to give birth in hospital before the 1920s. So hospital birth is relatively new. Only within the last 100 years have women been giving birth in hospital.
[4:00] Prior to that, birth was just considered a regular event in your life, albeit a big one and a momentous one. But it was something that women's bodies did. And you called in the women around you, your support people, the midwives. The husbands were rarely part of this. Men were rarely part of birth. There are cultures that are different. Obviously, I'm talking in a very Western white context. But then over time and this is there's a huge history to how birth got medicalized over time birth became medicalized so now we believe that birth on the whole is dangerous should happen in a hospital and should be under the supervision of medical people but that is a new concept that is a new modern concept that is not a traditional concept of birth. So when I'm talking about the medicalization spectrum, this is the basis, this is the background of what I want to talk about. So if you're seeing the graph, and I will try and explain it to you, if you're just listening to this and you haven't got the graph in front of you, I'm going to visually also explain this to you. So there's four layers to the medicalization spectrum, and I'll explain one at a time. The first layer of the medicalisation spectrum is birth philosophy.
[5:24] And you as a person, whoever you are listening, if you're a woman, a birth worker, a midwife, a doctor, a healthcare provider, whoever you are, a partner, anybody, you'll have your own philosophy about birth, what you believe about birth. So I believe, for example, my birth philosophy is that birth is generally a physiological process. So something a woman's body can do that sometimes does go wrong. And that's why a midwife and a care provider is a good idea. But most of the time, if the woman has what she needs, pregnancy, birth and postpartum will be smooth. There are things that can go wrong, but that's why healthcare providers are around. That is my philosophy.
[6:11] Some other people will have a philosophy that says every time, 100% of the time, birth is an emergency, every time it will need a care provider and need assistance and every time something could go wrong, that you are at high risk of death or damage during birth and that's why you should have a doctor and that's why you should be in a hospital. That's another philosophy. And so the medicalization spectrum explains, if you think, if you're thinking in your mind's eye of this graph, on the very left of the spectrum is physiological birth. This is where maybe my philosophy sits in a physiological birth philosophy. And as you go all the way along the spectrum to the very right, the very end of the spectrum, we call this a medical philosophy or a biomedical philosophy.
[7:04] If you have a physiological philosophy of birth, you think birth is less of a medical event or should be less of a medical event. You think it's more of a social event, a physiological event, not completely a medical event. If you go all the way back along, all the way to the right of the spectrum, you think it's always, always a medical event. And if that's where you sit, you will feel safest in hospital. But if you believe, if you have a physiological mindset about birth, then you're probably more likely to choose things like a home birth or a birth center because that's where physiology is allowed to reign. Whereas in hospitals, you've got high acuity care for something that you believe needs high acuity care because you're in a medical situation or a medical emergency.
[7:55] So that's the first layer. It's about philosophy. Where do you sit? and you can sit at any point along there. You can be right smack bang in the middle and it depends. You might sit in a different place to your partner, for example, or you might sit along the medicalisation spectrum differently to your care providers. And the big point I want to make today is that depending on where you sit on the medicalisation spectrum, depending on what your philosophy is, that will depend on the other choices that you make that sit along the medicalization spectrum as we go up these next four layers.
[8:36] And there was a research project that I was a part of. It was my very first research project. I was a research assistant to Hannah Darlan at Western Sydney University. And the very first project we worked on was the birth position study. And what we discovered is that the women who were most satisfied with their care and the outcome of their birth care were the ones whose birth philosophy aligned with their care providers and with the location that they chose to give birth. And this is why I want to have this conversation today. Because if you sit along the medicalization spectrum and you identify where you sit along on the medicalization spectrum, the rest of your choices are going to flow out of your philosophy. And it's the same for your partner and it's the same for your care provider. And so if you can align your philosophy with all the other people in the room, you're most likely to feel satisfied with how you were treated and the outcome of your birth.
[9:37] So typically on the medicalization spectrum if we're thinking about birth workers and where they sit now already you can start to think about where do you sit on the medicalization spectrum where does your partner sit on the medicalization spectrum now where does your care provider sit on the medicalization spectrum and I'm making generalizations here of course there is variety But as a general rule, midwives and birth workers, doulas and lay midwives and unregulated birth workers will sit in a physiological philosophy. Believing birth to be less medical than what society is promoting it to be. And typically, medical care providers and nurses, doctors, obstetricians, pediatricians, anesthetists, sonographers, these people sit in a medical philosophy of birth. Believing birth to be mostly medical and in need of medical supervision and management.
[10:42] So you can already start to piece together if you are in a physiological mindset and you're thinking great uh yet birth is not a medical event but you go ahead and choose a care provider whose philosophy tells them that birth is always a medical event and you're more likely to disagree at forks in the road at decision making points because your philosophies are fundamentally different. Whereas if you hired a midwife for example who you knew had a physiological mindset you're more likely to align when it comes to decision making points and therefore you're more likely to get the thing that you want out of your birth simply because you've chosen a care provider who aligns with your philosophy. So the take-home points for that first layer of the medicalization spectrum is that it flows from physiological birth on the left goes all the way along to medicalized philosophy at the other end. If you have a physiological philosophy you believe birth should be managed in a less medicalized way and pregnancy and postpartum. If you have a medicalized philosophy you believe that pregnancy birth and postpartum should be managed in the most medical away and then it's all grey in between and there's a mixture of things in there.
[12:04] Birth workers and midwives are the most likely people to hold a physiological mindset. In fact, that's the training that midwives get is in physiological birth. Predominantly, that's the midwifery role.
[12:17] And as you go along the spectrum, you're more likely to have a care provider who has a medicalised mindset if they're a doctor and a medically trained professional, like doctors and obstetricians, pediatricians, GPs. And I will say here, part of the discussion that's going on in the birth world is this situation where midwives are becoming medicalized and being indoctrinated into a medicalized system. Because the maternity care system itself, on the whole, is organized around providing medical care. It's not organized around providing physiologically based care that supports your physiology. It's built around providing medical care. And the backshot of that is that care providers who work within these medicalized systems become indoctrinated into medical ways of working. And so they become less and less capable of providing care that is based on the woman's own physiology as much as they would love to. There are so many midwives and care providers who work in hospitals who respect, honour and understand physiology, but they're prevented from fully practising like that because the maternity care system is rooted in medical ways of managing birth.
[13:43] And this always upsets people when I say this, but I'm not just making up stories. This is not just my opinion.
[13:51] The fact is, is that maternity care systems that center around an institution like a hospital are medical in their organization. I'm not saying that all the care providers in that facility are medically minded. Maybe there's a proportion that have a physiological mindset, but they're working in a medicalized system and a medicalized institution. So as much as it's an uphill battle for you to have a physiological birth in a medical facility, it's an uphill battle for those practitioners to provide physiological care in a medicalized setting.
[14:29] Okay, so that's layer one of the medicalization spectrum. Now we're going to go up next level. These layer upon each other so you can see how they align with each other.
[14:39] The next level is models of care. So once you've determined your philosophy, are you sitting more physiological or medical, then you start to move up and you think, okay, if I have a physiological mindset, what models of care also center around a physiological mindset? So if we go on the left, the physiological left of this spectrum, if you want to have care that prioritizes physiological birth, you will choose preferably a midwife continuity of care model where your midwife is caring for you in pregnancy, birth and postpartum.
[15:22] That's the most likely scenario that you're going to have physiological care that sits in a physiological philosophy. So continuity of care and continuity of carer with a midwife are your best bet. As we move along the spectrum, maternity care services have started to introduce these kind of hybrid continuity of care options where you might have the same midwife through your pregnancy and postpartum, but a different midwife for your birth. And these hybrid care models, sometimes they call them MAPS, so it's like maternity care for antenatal postpartum services.
[16:06] These hybrid models, again, are a bit of a blend of physiological and medicalised approach to birth because it's not the full continuity of care. Then on the very end of the medicalised spectrum is you have what we call fragmented care, where the most likely chance that you have a highly medicalised birth care is if you're in a model where you don't know who your care provider is from appointment to appointment, you don't know who you're going to see for the birth, and you have a variety of different care providers all through your pregnancy, birth, and postpartum. There's just no continuity. your care is completely fragmented across a number of care providers who you may or may not know. The only caveat here with continuity of care on this medicalisation spectrum is.
[16:56] Is that you could have continuity of care with an obstetrician, for example, or a GP, and you'll be seeing them all through your pregnancy, through your birth, and maybe they'll provide some postpartum care as well. However, because they fit into a medicalised philosophy, and I know there are a lot of obstetricians who have a physiological mindset, but they've worked at that because they are trained medical professionals. They are not trained in physiology. Midwives are obstetricians are trained in medicine and intervention and emergency management and surgery, which is fantastic. We need that. This is not a bad thing. All I'm saying is that if your continuity of care provider is a medically trained health professional like a GP or obstetrician, you need to be aware that you are more likely going to be cared for from a medicalized philosophy. There are unicorn obstetricians who are woman-centered and who are supportive of physiological birth. I'm not saying they don't exist, but as a general rule, they're trained medical professionals in a medical philosophy. And so if they're doing something opposite to that, it's because they've done their own work in trying to provide that.
[18:13] So while you would have continuity of care if you hire an obstetrician or if you have a GP, you'd be able to do that. You aren't necessarily getting one that's going to support physiological birth. You'll need to ask really specific questions around that, around their philosophy. You can ask them what their statistics are for cesarean sections and inductions and episiotomies and delayed cord clamping, all these things. What are their statistics? You'll start to understand how do they work. Do they have highly interventionist type care, which is a hallmark of a medicalized care model?
[18:50] Or is the care they provide really low intervention, in which case you could be more encouraged that they're possibly of a physiological mindset even though they're trained in a medical profession. So that covers our models of care. Continuity of care with either a midwife or an obstetrician, again, they might sit on two separate ends of the spectrum, but generally if you're in a fragmented model of care where you don't have any choice over who your care provider is and you just have to accept whoever you receive on the day, assume that you are in a medical model of care that is going to favour a medical type, an interventionist type approach to labour, birth and postpartum. And that means you know what to be ready for. And a lot of women don't have a choice as to what type of care they have. I acknowledge that continuity of care in this current maternity care system is unique and a privileged position to be in. And of course, if you can get continuity of care with a private midwife, for example, then you're again going to sit further along on the physiological philosophy side of this spectrum.
[20:04] So now we've been through the first layer, our birth philosophy,
[20:07] our second layer, how the models of care align with each of those birth philosophies. And the next layer up, the third layer on the medicalization spectrum is about place of birth. So it's one thing, for example, imagine you've got continuity of care with a midwife, but your midwife works in hospital. So that model of care will sit differently along the medicalization spectrum than if you have continuity of care with a private midwife who provides home birth services. So that's more further along on the left of the physiological birth spectrum than a continuity of care midwife who provides hospital birth services, for example. And that's just owing to the fact that the birth is happening in a medicalized context in an institution. These things make a difference. So let's have a look place of birth this is our third choice to make when you're thinking along the medicalization spectrum where are you going to give birth and how does that align with your own birth philosophy let's start on the physiological philosophy side so on the very left of our medicalization spectrum.
[21:20] You've identified in this scenario, you've identified that you have a physiological birth mindset. Potentially, you've pursued continuity of care with a midwife. And then next, we go up to the next level. And now it's time to work out, okay, I've chosen my care model. What's my care location that aligns with a physiological mindset? And the first option is free birth. And I won't go into too much detail but a free birth is where you so heavily believe in the capacity of your body and your ability to give birth that you don't even feel like you need to have a medical care provider or any registered qualified care provider present at your birth because you so far believe in the physiology of birth as working almost all the time. A lot of people do not have that mindset. The majority of people acknowledge that something can go wrong in pregnancy, birth and postpartum. However, there's a unique group of women who have a belief system that believes that birth almost never goes wrong. So long as the right ingredients are there, so long as their mindset is set, so long as they've done all these little rituals and health practices. I'm not saying that's where I sit. I'm saying there is a collection of women who have that belief. And if that's you, you might be inclined to choose free birth.
[22:50] That's the very, very left of the spectrum. The next option, if you're of a physiological mindset, is planning a home birth with a private midwife. Then there's the option of a home birth with a publicly funded midwife. So if you've got access to a publicly funded home birth program. Then as we keep going along the spectrum and we creep slightly closer and closer and closer to the medicalized end of our spectrum, then we have the option of a detached birth center. So you're attending a birth center, most likely under the care of a midwife, a continuity of care midwife. We're still in our physiological philosophy side of the spectrum. You're not in a hospital yet. You're still detached from a hospital. The next option after that, as we keep moving along the spectrum, is an integrated birth center. So some hospitals will have a birth center type setting within their institution. But we're, again, getting more and more medical as we go. Now, the big leap here is that once you get into a publicly funded hospital, now we're fully in a medical institution for labour and birth. And this kind of represents the middle of the spectrum where we've swapped over from a community setting of birth, home or community, into a medical institution. There's a clear line.
[24:17] Public hospital with a midwifery, continuity of midwifery care program is your most diluted option in terms of the grey area of the medicalisation spectrum. You could have a blend of type of care providers. Often the midwives who care for women in continuity of care programs, particularly the midwifery continuity of care programs where you'll have the same midwife for your pregnancy, birth and postpartum. These midwives do typically have a physiological mindset. you're more likely to get one in this scenario.
[24:51] Then as we move on from those along the spectrum it's a public hospital with medical care with a public doctor. So if you are a woman with risk factors and potentially you've not gotten access to the midwifery care program or you've just had fragmented care through your whole pregnancy, then the other option now is that you will have midwifery care in hospital, but you won't know who that woman is. But there will usually be a public doctor also involved in your care more intimately than if you have midwifery care in a hospital setting, continuity of midwifery care in a hospital setting. Those midwives tend to be able to only involve medical healthcare providers on an as-needed basis, whereas if you don't know your midwife and you're not part of a continuity program and you're getting more fragmented type care, the hospital system has policies that kind of builds in the involvement of medical professionals the whole way along your pregnancy, birth and postpartum care. And so you might be more exposed to that if you haven't got continuity of care, if you've got fragmented care in a public hospital.
[26:10] The next option down the spectrum is that you give birth in a public hospital with a private doctor, and then it goes on further from there is a private hospital with a private doctor, or the most medical way of giving birth, if you're on the very, very right of the medicalisation spectrum, you might choose to have your baby in an operating theatre. For example, you might choose to skip over the whole labour and birth part and opt for a caesarean section. And that can be for a variety of reasons, and this will be triggering for some people who have chosen elective cesarean section, but perhaps you have not been of a medical mindset. So sometimes a cesarean section is medically necessary, but you've got a physiological mindset.
[27:03] And this is where this malalignment in your philosophy and the actual place and outcome of your birth, the further apart they are, the more likely it is that you're going to be dissatisfied or disappointed with what happened at your birth. So a woman who's hired a private obstetrician because she's of a medicalised mindset and who wants to have an elective caesarean section in a private hospital with her private obstetrician in an operating theatre, she'll be far more satisfied with her care because it's all in alignment than a woman who had potentially chosen to have a home birth with a midwife and then circumstances required that she have her birth in an office. Operating theatre or in a more medicalised setting. There's more room in that for disappointment and dissatisfaction than in a scenario where the woman's philosophy, choice of practitioner and birth location aligned.
[28:07] And that's our fourth layer of the medicalization spectrum, is you have to layer
[28:13] upon all these three things, your philosophy, your model of care, the birth location. The final layer is your actual health needs. And you layer that upon all of the other decisions. So it's one thing if you say to yourself, I really want to have a home birth with a midwife because I believe that birth is not always a medical event. I have a physiological philosophy. However, as you assess your pregnancy, birth and postpartum needs, we may potentially start to discover that there are some complexities that require a different model of care, a different location. And you need to start adjusting your place of birth and your model of care based on your health needs. And this doesn't necessarily mean you will have a disappointing experience, but it helps you to understand that there are times where your philosophy won't align with your care provider choices or the place of birth because you need to think about your health needs as a priority and as a way of deciding the other things that layer upon each other in the medicalisation spectrum.
[29:34] So in that fourth layer, if your care needs are simple and basic and you have an uncomplicated pregnancy, then you can have very simple risk mitigation strategies that don't require too much additional care. However, if your healthcare needs or mental health needs or social needs are more complex, then this requires more complex risk mitigation. And that means involving higher care providers who can provide higher acuity care, more medical care, like doctors and obstetricians and GPs, pediatricians, than if you had less complex health needs. And then also you need to be in a location that suits your health needs.
[30:23] And just understanding the very context of where your philosophy is against all of the things that unfold in your labor and birth, this can help you understand why maybe you'll have feelings of disappointment or why you're having trouble making decisions that require more medical care. Because you've already identified, I really wanted a low intervention birth because I'm of a physiological mindset that my individual needs require me to choose things that are more medically minded. And immediately you can identify where the disappointment is, is there's a misalignment from your philosophy to the reality of things. And that can help you rationalize your feelings around this scenario. Are you?
[31:13] But if you've got the opportunity, if your health needs are not high acuity, you don't need high acuity care and you know that you're of a physiological mindset, you can use the medicalization spectrum to align your place of birth, your care provider with your health needs and your own philosophy. And that is going to set you up for the most satisfying birth scenario and pregnancy birth postpartum scenario that you can possibly set yourself up for. My advice would be, first, is to identify where you personally sit on the medicalization spectrum. Are you of a physiological mindset or are you of a medical mindset or are you sitting somewhere in the middle?
[31:58] And also identify where your partner is because imagine this. Let's go the other way. imagine you are of a medicalized mindset and you think right I absolutely want an epidural an induction on my due date I'm happy for an episiotomy I you know would absolutely happy to consent for a vacuum forcep cesarean section I have no worries about any of that if it needs to happen absolutely go for it in fact maybe you'll choose an elective cesarean section that would indicate, that kind of thinking would indicate that you have a medicalized idea of birth and potentially you have some fears around the process of labor and birth. But imagine your husband or your partner is of a physiological mindset that says, hey babe, what do you reckon if we have a home birth?
[32:54] And you cannot think of a worse thing. You can't understand why he would suggest something like that because you're thinking, oh my gosh, birth is a medical emergency. I need constant medical care. There's no way I'm having a home birth without an epidural and without all these other things available to me. You can see immediately...
[33:16] That there is a long way for each of you to help each other understand each other's perspective because your philosophy is completely different. And this happens with women who say to me, how do I convince my partner to have a home birth? Well, mate, possibly your partner is sitting all the way at the other end of the medicalization spectrum and can't even imagine why you would want to have a home birth because their philosophy is so far from yours. And this takes time and education and conversations to bring people around. But if you can immediately say, ah, I know why we're not agreeing. Our philosophies are completely different. So you could ask your partner, what do you believe about birth? What are you scared of? And they might say, well, I think that birth could go wrong at any time, that you could bleed, that the baby could get stuck, that this might happen and this might happen, and immediately you're going, okay, my partner has all these fears around birth, probably means they're in a medicalized mindset. And that explains why they're not on board with the idea of a home birth, for example. And obviously it can work the other way around.
[34:31] That is today's episode on the medicalization spectrum. And if you want this graph, this picture that I've been talking through, through this episode, and that if you've watched on the video that you've seen, you can go to Melanie, the midwife on Instagram or the great birth rebellion on Instagram. It'll be on the grid there. Or if you want really easy access to it, join the podcast mailing list because we have a resource folder that's full of all the research, all the documents, everything that I use to make every single podcast episode. This is episode 200. So once you get access to the resource folder, you just go to, resource folder for episode 200. And this graph will be there for you to use and for you to work through. And the other thing that we've created for this episode, for episode 200, is a podcast catalog of the first one to 200 episodes of the Great Birth Rebellion podcast. They're all listed in the catalog. You can tick off the ones that you want to listen to, that you've already listened to. We've also grouped them in topic areas. So if you have a particular topic of interest, maybe it's induction.
[35:45] VBAC, physiological birth, hospital birth, home birth, whatever it is, we've grouped those into categories so you can sift through the podcast episodes that are of most interest to you. And I also have a collection of fact sheets and checklists that I've built up over the time of the 200 episodes of the Great Birth Rebellion podcast, and they are all in the podcast catalogue. You can click the link down below in the show notes to get access to the podcast catalogue or the resource folder so you'll have everything you need to plan a great pregnancy, birth, and postpartum. I'm Dr. Melanie Jackson, and I will see you in the next episode of the Great Birth Rebellion podcast. 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 @melaniethemidwife on socials and the show @thegreatbirthrebellion all the details are in the show notes.
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Ā©2026 Melanie The Midwife
