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5 Case Study – Maternity Health Care Work

5 Case Study – Maternity Health Care Work

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7.5



Case Study – Maternity Health Care Work



89



The place of midwifery in the health care system has varied over time and

between countries. Across North America midwifery has had a marginal role in

maternity care where physicians have been favored. In Canada, until the 1990s, the

performance of maternity services was almost exclusively restricted to licensed

physicians and surgeons (Benoit et al. 2005). Financial support for midwifery services started to develop as a result of a decline in the number of physicians available

to undertake maternity care due to its impact on the personal lives of physicians and

an increase in malpractice claims. Midwives were seen as a cost-effective solution

by provincial governments to fill this gap, and a consumer social movement demanding greater choice for women provided further support (Benoit et al. 2005).

In Finland too midwives have a minor role in the provision of maternity care. The

provision of free maternity and infant health care during the Second World War had

a long run impact of increasing the hospitalization of birth under the jurisdiction of

obstetricians. In Finland there has not been a strong consumer-driven push to provide women-centred maternity care. The feminist agenda in Finland has emphasized ‘sameness’ between men and women, and so the idea of choice has been

deemed elitist. Paternity leave to involve fathers more intensively in the childbearing process and childcare has been the social policy solution (Benoit et al. 2005).

The place of midwives in The Netherlands provides an insightful contrast. More

than 30 % of births occur in the home in The Netherlands, and most of these are

attended by midwives. The Dutch state has a history of providing strong legislative

support for midwives going back to the nineteenth century when legislation provided a specific sphere of practice for midwifery. Throughout the twentieth century

the profession of midwifery gained more strength and enhanced standards of training and recruitment. In contrast to Finland, the Dutch state has not introduced policies to involve fathers in child rearing, but a conservative family-centred approach

positions men and women as having complementary roles. Due to this more emphasis has been placed on financially supporting midwife assistants who, during and

after childbirth, provide social support for the woman allowing fathers to have less

of a role (Benoit et al. 2005).

The case of obstetricians in Chile provides other insights into the way in which

maternity care is shaped by political and institutional settings. According to the

World Health Organization a justifiable rate of caesarian sections is around 10 % of

births. Chile has one of the highest caesarian section rates in the world with a rate

of over 30 % of births in 2008 (Gibbons et al. 2010). Murray and Elston (2005)

highlight the particular working conditions of obstetricians that provide some explanation for this outcome. They argue that a high level of competition amongst obstetricians for clients in urban centres, like Santiago, and an expectation that private

clients will receive individualized care, places pressure on obstetricians to control

their work time. With maternity care that means having to control the ‘natural’ process of birth.

Prior to the CIA-backed military coup of 1973, Chile had a National Health

System and a government administered health insurance plan that covered 85 % of

the population. After the coup government spending on health care fell by 40 % and

the state-controlled system was increasingly replaced with a market model. By the



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1990s one-third of obstetric deliveries were covered by private insurance. For most

obstetricians this resulted in a fragmented working life, with some clients attended

to in private maternity facilities where personal care from the obstetrician and their

team is expected, and other clients attended to in the public hospitals where continuity of care is not guaranteed. Obstetricians claimed that the low salaries offered in

the hospitals forced them into private work. But public hospital positions provided

some security in a situation where “a plentiful supply of obstetricians” made private

practice insecure for many practitioners (Murray and Elston 2005: 712). To be competitive many obstetricians in private practice would make themselves available at

any time of the day. This combination of working in different locations and requirements to be constantly available encouraged obstetricians to take control over time

schedules where they could, and one way to do this was by the use of elective caesarean sections. Obstetricians in private practice could plan these on days when they

did not have clinics and for the women it meant they could be sure of avoiding

surcharges for services that were provided outside of normal working hours.

Alternatively, women in the public hospital system, where obstetricians are not

placed under the same time constraints as they are working in rostered systems,

were more likely to start labour spontaneously.

What the case of the Chilean obstetricians alerts us to is the way in which political influences can have a major impact on the working circumstances of clinicians,

which in turn impacts on how and what health care is delivered. In this case the

medical profession was not able to successfully resist the political drive to diversify

the health care market (Murray and Elston 2005). The examples discussed so far,

including the case study of Chile, show us how the work of maternity care can vary

immensely in relation to the level of dominance of the medical profession in any

particular jurisdiction, particular ideologies about the role of mothers and fathers,

state concerns for efficiency, and health social movement concerns around women’s

rights and choice.



7.6



Everyday Health Work



A focus on the work of health professions can take attention away from the tremendous amount of health work that occurs outside of the organized health care system.

Although some argue that lay beliefs provide little in the way of a challenge to

medical dominance (Williams and Popay 1994) this perspective elides the extensive

amount of health work that occurs every day outside of the overview of health professionals. The health work undertaken in households is not usually overseen by

health professionals (there are of course exceptions, like health visitors and home

care workers in particular situations). In domestic spaces health care advice can be

worked and reworked as householders combine advice from different sources and

modify advice in response to their own observations and understandings. Lay people “adopt, mimic, critique, or rewrite expert positions” (McClean and Shaw 2005,



7.7



Conclusion



91



746). Householders instigate their own treatment interventions and procedures and

so homes are centres of health work in their own right (Dew et al. 2014).

An unremitting activity in households, and more so in those with children, is

diagnosis. Before a health professional is consulted about signs or symptoms the

householder has to determine that the signs and symptoms are appropriate for a

health care consultation. Is the headache just a result of tiredness, a late night, or has

it been going on a bit too long and should someone else try to make sense of it? The

parents and guardians of children get to know the ebb and flow of symptoms of illness and gauge how ordinary or extraordinary they are. Claire Williams (2000)

describes mothers of children with chronic illness as alert assistants as they identify

and anticipate the needs of their children. But the same can be said of partners

observing each other, or siblings or others who share the same domestic space.

Household observers make a determination of whether a child’s sickness, or their

own sickness, is one that requires the attention of a health professional or not. If it

is determined that a health professional should be consulted, then a decision is made

about which health professional to consult, maybe a pharmacist, a naturopath or a

general practitioner.

If a practitioner is not consulted some therapy may be prescribed in the household. The therapy may be based on what has worked in the past for this sort of thing,

or what is believed could work, including over the counter purchases from pharmacists or modifications in diet. Advice may be taken from other householders or family members. Mothers and grandmothers may be more likely to pass on ideas for

therapeutic interventions where children are concerned. Research work may be

undertaken in the domestic sphere with libraries used, Internet searches undertaken

or work colleagues consulted. Patients may develop expertise in particular

approaches, maybe aromatherapy or homeopathy, and prescribe their own solutions

for themselves and those around them (Dew et al. 2014).

If a health professional is consulted, householders may engage in careful observation of the treatment and its effects. They may vary the advice given and experiment with medications, or stop taking them altogether if the advised medication

does not align with their own views of illness or if it is seen as causing more problems than it solves. In short, there is a great deal of health work and therapeutic

decision-making that occurs in domestic spaces, away from the oversight of anyone

else and we could usefully think of the home as a hybrid clinical practice (Dew et al.

2014).



7.7



Conclusion



Health work occurs in many spaces, such as the home and workplace, and not just

in health care centres and hospitals. But certain professional groups gain status

through their capacity to claim control over particular health work activities. For the

medical profession the claim to the right to diagnose is a particularly powerful form

of health work, but as noted in this chapter that claim is contested and blurred in



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many different ways. Other professions, like nursing, have made inroads into claiming some rights to diagnose. In other situations diagnosis occurs even though it

cannot be given that name. In many situations diagnosis is a collective enterprise

and in everyday life diagnosis is a regular activity undertaken by lay people with

little or no health professional surveillance.

The case of maternity care demonstrates the variety of positions of maternity

care workers in different countries at different times, with midwives, physicians and

obstetricians having their working lives shaped by broader social and political

forces. The variety of ways in which maternity care is undertaken alerts us to the

fact that there is nothing inevitable about who undertakes health work and how it is

done.



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Chapter 8



Medicalization and Contested Illnesses



Abstract Medicalization is the process by which conditions, experiences, and situations, which were at one time not seen as medical in nature, come under medical

jurisdiction for treatment. This chapter explores the concept of medicalization historically, the different levels of medicalization, and the contemporary forces driving

medicalization. It draws on a range of examples of contested illnesses including

attention deficit hyperactivity syndrome, fibromyalgia, and pre-menstrual dysphoric

disorder, with a detailed case study of Gulf War related illnesses. Finally the chapter

addresses the recent phenomenon of biomedicalization, which is reorganizing

health care in a number of ways including a widening of the ambit of medicine to

incorporate enhancement processes applied to seemingly healthy bodies.

Keywords Biomedicalization • Gulf War related illnesses • Disease mongering •

Enhancement • Direct to consumer advertising • ADHD



8.1



Introduction



Medicalization is the process by which conditions, experiences, and situations,

which were at one time not seen as medical in nature, come to be seen as medical.

They thus come under a medical jurisdiction for treatment (Ballard and Elston

2005; Conrad 2005). Some conditions which have been medicalized include alcoholism, menopause, baldness, and obesity. Conversely, conditions can be demedicalized, coming to be seen as not relevant to medicine, although this process is far

less common. These simple definitions conceal trends which are often emotionally

intense, and can occasion social movements aiming at deep social change. For

example, the movement to demedicalize homosexuality was central to the politics

of gay liberation in the 1970s in several Western countries (Conrad 2007). Marches,

demonstrations, disruptions of professional conferences, challenges to the proponents of the medical view, and negotiations in the revision committees of the

Diagnostic and Statistical Manual: Mental Disorders (DSM) eventually brought

about a shift from an understanding of homosexuality as sexual dysfunction and a

mental disorder, to an understanding of it as an embodied identity (Conrad 2007:

100). Similarly, the medicalization of conditions such as flatulence, anxiety,

© Springer International Publishing Switzerland 2016

K. Dew et al., Social, Political and Cultural Dimensions of Health,

DOI 10.1007/978-3-319-31508-9_8



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alcoholism and impotence bring about major changes in the stigmatization, the

treatment and the experience of these conditions. Medicalization and demedicalization are processes which entail major changes in our way of discursively organizing

our world, and thus have profound impacts on our experience of this world.

Although the concept ‘medicalization’ dates only to the early 1970s (Illich 1975;

Zola 1972), the process of medicalization extends back to the late seventeenth and

early eighteenth centuries in Western countries (Bell and Figert 2012). The

Enlightenment entailed a shift from understanding many processes in the human

and natural world through a religious lens to seeing them scientifically, and acting

on them through health systems (Bell and Figert 2012; Porter 1990). Utilitarian

philosophy encouraged medical reformers to advocate for social change which

would bring about happiness for the greatest number of people. This philosophy led

to the development of sewerage systems, water treatment, epidemiological surveys,

food regulation, working conditions legislation and social security. These changes

were largely motivated by medical advocacy and seen through a public health lens

(Bell and Figert 2012; Rose 2007a; and see chapter 15).

Foucault’s socio-historical studies (1967, 1973) detail the processes by which

medical expertise came to define appropriate ways of behaving in relation to life,

death, sickness and madness. In The Birth of the Clinic, Foucault argued that the

modern state was constructed alongside medicalization; he later termed this process

of using state power and surveillance to enhance the health and well-being of the

population, “biopower” (Foucault 1973, 1979, 1980; Bell and Figert 2012). These

changes had a massive impact on the ways we organize society, live in the world,

govern ourselves, and experience our embodied lives. More recently, Allan Brandt,

a medical historian, has argued that medicalization was a critical part of the transformation of society in the late twentieth century; medicine absorbs ever greater

amounts of economic resource, and frames increasingly large swathes of human

experience (Bell and Figert 2012). Differences in medicalization – whether a society is over or under medicalized – are thus critical to addressing global disparities

in human security and the human condition (Bell and Figert 2012).

In this chapter, we will explore processes of medicalization as they have taken

place since the 1970s. We will explore the medicalization of attention deficit hyperactivity syndrome (ADHD), and then will look at some other contemporary processes of medicalization, in relation to such conditions and processes as menstrual

suppression, cognitive enhancement, preventative medicine, and Gulf War related

illnesses. By focusing on contested conditions, we can see the many drivers of medicalization and also the barriers to a comprehensive shift in this direction. We can

also become aware of the multiple meanings, both positive and negative, that this

concept can have. Towards the end of the chapter, we will introduce the new concept

of biomedicalization, which looks at the forms medicalization is taking in the

twenty-first century. The concept of biomedicalization sensitises us to the profound

shifts currently taking place in the organization and experience of health care.



8.2



8.2



The Concept of Medicalization



97



The Concept of Medicalization



The concept of medicalization was developed at what was, arguably, the high point

of prestige and status for the profession of medicine; it thus may be unsurprising

that this concept arose as a critique of medical imperialism (Ehrenreich and English

1974; Illich 1975; Zola 1972). As Irving Zola put it in 1983, more and more of

everyday life was coming under medical supervision, influence and dominion

(Ballard and Elston 2005: 230). Thus, medicine was becoming a more important

locus for social control than the Church, or the criminal justice system (Zola 1972).

The medicalization thesis was put particularly strongly in relation to women and

childbirth, where it was seen as an instantiation of patriarchal dominance (Oakley

1984; Rothman 1989). It was also stated strongly in relation to mental illness (Bell

and Figert 2012; and see chapter 12). In the mid-to-late 1970s, Ivan Illich was arguing that this medical imperialism was leading to the degradation of people’s independence and self determination, and thus changing the very meaning of being

human (de Maio 2010; Illich 1975).

However, beliefs that medicine was inexorably increasing in cultural and social

authority, that the populace was simply passive in relation to it, and that medicine

played a negative role in relation to social control and health, were soon to be questioned by a number of sociologists (Ballard and Elston 2005; Riessman 1983). In a

key paper of the early 1980s, Catherine Kohler Riessman (1983) argued that women

have as much to gain as to lose from medicalization, and that female patients play

an active role in relation to it. This position has been borne out by subsequent studies which show that women often welcome medicalized childbirth and new reproductive technologies (Brubaker and Dillaway 2009; Fox and Worts 1999; Gunson

2010). Studies of a number of contested conditions have shown that patients often

advocate for greater medicalization. As Jessica Gunson (2010: 1326) notes, framing

medicalization as medical imperialism presumes that there is some true, original

way of being in the body, which is somehow altered for the worse through medicalization. However, a constructionist account of the body would say that there is no

authentic and essential way of being embodied (Grosz 1994).

According to Peter Conrad and Joseph Schneider (1980a) medicalization can

occur on at least three different levels: the conceptual level, the institutional level

and at the level of doctor-patient interaction. The conceptual level encompasses

medical discourse, medical research and medical definitions. The institutional level

can range from sick notes for employers, to sickness and disability benefits, to the

educational systems’ understandings of ‘special needs’. The level of doctor-patient,

or clinician-patient, interaction can encompass everyday clinical encounters with a

variety of practitioners from surgeons and general practitioners to physiotherapists

and complementary health therapists. These three levels of medicalization can

develop at different speeds and even in different directions. For example, while the

common cold is heavily medicalized conceptually, it is less medicalized institutionally – where people might be expected to come to work with a cold, for example –



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and it is not medicalized at the level of doctor patient interaction; people often treat

themselves rather than visit a doctor when they have one of these viruses.

Medicalization is now driven by a number of forces, including pharmaceutical

company marketing, patient advocacy and social insurance systems; as we shall see,

physicians are not generally the most important agents of greater medicalization

(Barker 2011; Conrad 2005 and 2007). Conrad and Schneider (1980b) described a

five stage process involved in medicalization. The first stage involves a behavior or

condition being defined as deviant and undesirable. The second stage involves a

discussion, in medical terms, of this condition in a medical journal or conference.

The third stage involves claims-making from a variety of agents; these can include

pharmaceutical companies, self-help groups, professional associations, medical

researchers, entrepreneurial clinicians, family support groups, and so forth. The

fourth stage involves the legitimation of the claim and the fifth stage its institutionalisation in social organization. They tested this process against historical case studies – including attention deficit hyperactivity syndrome (ADHD), alcoholism, and

opiate addiction – and found it provided a helpful framework for understanding the

process of medicalization (Conrad and Schneider 1980b; Conrad 1992).



8.3



Contested Illnesses and the Changing Face

of Medicalization



The original thesis of medical imperialism, with its implicit assumption that medicalization was driven by doctors attempting to extend their professional standing,

has been superseded, as it becomes clear that the agents of medicalization can be

quite varied. For example, much of the pressure for the greater medicalization of

ADHD in children, at the institutional level and the level of doctor-patient interaction, has come from parents and teachers. Children who daydream in class, are

disruptive at school, are defiant towards teachers or violent towards other children

are, in some cultural contexts – particularly in North America – labelled as potentially having ADHD by teachers (Malacrida 2004; Rafalovich 2005). In Italy, where

the diagnosis of ADHD has been acceptable only since 2007, teachers may position

the hyperactive child as a threat to the successful management of the class, and a

risk to other children (Frigerio et al. 2013a). They often see medication as the only

way to accommodate such children within the school context (Frigerio et al. 2013a).

In North America, the Connors Rating Scale – which uses a Likert scale questionnaire to make an assessment of ADHD – is often used by school based teams;

schools may then pressure parents to take the child to a paediatrician for confirmation of the diagnosis (Rafalovich 2005). Parents can also be agents of medicalization. Mothers of hyperactive children may find that they face blame for their

children’s disruptive behavior, lessening their ability to take on a good mother identity (Brunton et al. 2014; Francis 2012; Frigerio et al. 2013b; Singh 2004). The

biological narrative of genetic causality partially removes this stigma in relation to



8.3 Contested Illnesses and the Changing Face of Medicalization



99



the quality of their parenting, repositioning them as the real experts in relation to

their child’s illness (Frigerio et al. 2013b). Such parents may thus take their children

to a number of paediatricians in search of a diagnosis of ADHD.

Another major agent of medicalization is the pharmaceutical industry (see Chap.

9). A particularly effective route by which the pharmaceutical industry sells medicalization at the conceptual level is direct to consumer advertising (DTCA) (Barker

2011; Ebeling 2011). This form of advertising is legal only in the United States and

New Zealand, although the internet provides a platform by which it can be diffused

more widely from these countries. As Kirsten Barker notes in relation to the contested illness of fibromyalgia, when DTCA encourages consumers to self diagnose,

and then to request a diagnosis from a physician, doctors may comply with such

requests, even if they are sceptical about the diagnosis (Barker 2011: 835). When

Pfizer received Food and Drug Administration (FDA) approval for its existing pain

medication, Lyrica, to treat fibromyalgia, it began to create a public awareness campaign around this disputed illness category. Central to its campaign was its intention

to legitimate fibromyalgia as a real disease, which is not psychosomatic in origin,

and for which a medical treatment exists. A biomedical explanation for the illness,

centering on ‘overactive nerves’ was provided in advertisements (Barker 2011).

This was welcomed by the largely female group of people living with the illness,

who struggle with delegitimation of their experience of chronic disablement.

However, the advertisements also trivialised fibromyalgia, presenting it as a minor

ailment that could be cured with a pill, something that is generally impossible to

accomplish (Barker 2011).

This process of selling a disease category, in order to generate a market for a new

treatment for it, has been termed “disease mongering” (Moynihan et al. 2002: 886).

As Ray Moynihan and his colleagues (2002) point out, disease mongering can

involve turning ordinary life conditions or minor ailments into medical problems,

seeing personal problems as being of a medical nature, treating risks as if they are

existing diseases, and framing prevalence estimates to maximise the potential market for a disorder’s treatment. An example can be seen in the way the pharmaceutical industry used symptom checklists within DTCA to sell pre-menstrual dysphoric

disorder, or what used to be known as premenstrual tension, as a major and treatable

disorder (Ebeling 2011). All of these strategies are designed to generate alarm

around a sometimes quite minor condition, in order to create the anxiety needed to

sell a potential treatment for it. In this respect, the disease mongering discussion

harks back to the critique, of medical over extension undermining self determination, made by Ivan Illich in 1975; thus, it may be seen as bringing the medicalization

debate full circle.

In addition to parents, teachers and pharmaceutical companies, patient advocacy

groups can be major agents of medicalization. When a condition is fully or partially

medicalized by patient action, in the face of medical or other institutional resistance,

it is called a contested illness. These illnesses are dismissed as illegitimate by

researchers, clinicians and policy makers operating within dominant paradigms

(Moss and Teghtsoonian 2008: 7), which means that patients carry the double burden of living with a disease, but without a legitimised sick role (Bϋlow 2008; Dumit



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8 Medicalization and Contested Illnesses



2006; Oldfield 2013). Gulf War related illnesses (GWRI) are examples of conditions that have been deeply politicised by the contestation between a health social

movement and a very powerful government.



8.4



Case Study – Gulf War Related Illnesses



Gulf War related illnesses are an outcome of The Persian Gulf War of 1991, which

was triggered by Iraq’s invasion of Kuwait in 1990. In response, a coalition of 37

countries, led by the United States, initiated a massive air assault on Iraq in January

1991. This was followed by a land offensive in February, which involved approximately 697,000 troops from the United States, as well as some troops from coalition

countries (Cable and Shriver 2010; Shriver et al. 2002). A ceasefire was declared at

the end of February 1991. Many veterans of the war soon found themselves experiencing debilitating symptoms which included abdominal pain, chronic diarrhoea,

severe fatigue, loss of concentration, insomnia, short-term memory loss, mood

swings, rashes, migraine headaches, shortness of breath, blurred vision, aching

muscles and joints, bronchitis, sexual dysfunction, multiple chemical sensitivities,

and asthma (Cable and Shriver 2010; Shriver and Waskul 2006). Approximately

200,000 soldiers and former soldiers – or 30 % of the American veterans of the

war – signed a register set up to collect asserted cases of Gulf War syndrome (Cable

and Shriver 2010; Shriver and Waskul 2006; Shriver et al. 2002).

The veterans experiencing these symptoms had a number of explanations for

them. These included exposure to chemical and biological weapons used by the

Iraqis; although the US government argued that most soldiers weren’t exposed to

such weaponry, returning soldiers noted that chemical weapon alarms sounded on

various occasions, and that unusual animal deaths were common. Depleted uranium

weapons were used by some coalition governments with health effects that are contested intensely by the United States and other governments, but are argued to be

extensive (Green 2006). Powerful vaccines and preventative medicines – such as

Anthrax vaccine and Pyridostigmine Bromide (PB) pills were given to soldiers

leaving for the war; the PB pills were given repeatedly to almost all of the soldiers

to protect against nerve gasses such as sarin (Brown 2007; Shriver and Waskul

2006; Shriver et al. 2002). Organophosphate pesticides were extensively applied on

the body to deal with biting desert insects. The retreating Iraqi army set fire to

Kuwaiti oil wells, creating enormous clouds of thick black oily smoke. The assumption amongst returning veterans was that the synergistic effect of all of these toxins

led to the Gulf War related illnesses.

These suspected causes all fell under the general and highly contested category

of environmental illness (Brown 2007). By asserting an illness etiology which is

sociopolitical, economic and environmental rather than based in individual genetics, lifestyle and chance, environmental health activists challenge what Phil Brown

(2007: 1) calls “the dominant epidemiological paradigm”. This paradigm locates ill

health causation in individual behavioral factors rather than in social structure and



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5 Case Study – Maternity Health Care Work

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