Attitudes toward medicalization in childbirth and their relationship with locus of control and coping in a Spanish population

The dominant model of childbirth in most Western countries is medicalized childbirth [1]. In 2007, the Spanish Ministry of Health and Consumer Affairs drew up the “Strategy for care of normal childbirth in the National Health System”. With broad institutional participation, scientific societies, experts, citizens’ associations and representatives of the Autonomous Communities, the aim was offering multidisciplinary care to women, newborns and families during labour and birth, guaranteeing adequate conditions of safety, quality and efficiency in the management of hospital maternity. For more than a decade, the National Sexual and Reproductive Health Strategy of the Spanish NHS (ENSSR) has been promoting a model of care for childbirth, based on scientific evidence and, therefore, attentive to the needs of the labouring woman and the newborn human being (NB), respectful of the physiology of labour and birth, advocating the least possible interventionism, the personalisation of care, as well as the principle of women's autonomy. In 2018, of the total number of births attended, 81.1% took place in the NHS. With regard to the type of delivery, while in 2018 NHS network hospitals had 21.8% of deliveries by caesarean section, in private hospitals this rate was 36.5%. Caesarean section rates persist above the World Health Organisation (WHO) reference standards (less than 15%). The percentage of amniotomy was 13% and the percentage of induced deliveries was 34.2%, compared to the WHO recommendation of 10%. Epidural anaesthesia was used in 62.9% of deliveries, an episiotomy was performed in 27.5%, and 17.5% of deliveries were instrumental. These data are some of the conclusions of the descriptive analysis of the data related to perinatal care in the period 2010–2018, focusing on hospital health services. The sources of information are the databases of the Specialised Care Information Systems (SIAE), Minimum Basic Data Set (CMBD) (2010–2015) and Specialised Healthcare Activity Register (RAE-CMBD) (2016–2018) [2].

Medicalization begins at pregnancy, with prenatal care that transforms pregnancy into a condition of permanent risk, which requires medical monitoring [3]. Although medical and technological advances in maternity care have drastically reduced maternal and infant mortality, the danger of introducing the routine use of technology in birth is that it can cause what has been called in the literature ‘a cascade of intervention’, where one intervention leads to another [4].

The concept of medicalization emerged in the 1970s, and most of the literature on this topic still comes from the social sciences [5‐7], although there are some authors in medical academia who address this topic [8, 9]. Kishore’s Dictionary of Public Health [10] defines medicalization as “the way in which the field of modern medicine encompasses many problems that were not previously considered medical entities”, and adds that it includes a wide variety of manifestations, such as the normal phases of the reproductive and vital cycle of women (menstruation, pregnancy, childbirth and menopause), among others.

The medicalization of pregnancy and childbirth benefited, in its genesis, from the emergence of biomedicine and evidence-based medicine, the development of obstetrics and the generalization of surgery, and the development of the preventive approach and the explosion of new technologies applied to biomedicine. The generalization of the phenomenon was favoured by economic, political, social and cultural factors [11‐13].

Health professionals necessarily function as agents of this medicalization, but we should consider their situation with respect to social expectations and demands [11] and review in what way a greater participation by patients in decision-making would influence the delivery process. It could be the case that patients contribute to medicalization through their “desire and demand”- in relation to both contextual factors (advertising, media, social networks and the Internet), and psychological variables [13‐17]- or on the contrary, that they are influenced by the numerous initiatives that advocate a more natural birth or greater control of the process [18, 19]. This last choice would mean distancing themselves from the dominant medical model [20, 21] and assuming responsibility for the outcome of the delivery [22].

The fact that a woman has a more favourable or less favourable attitude towards medicalization will influence the choices she will make in relation to labour, the degree of planning for it, and finally the outcome and experience of childbirth [22‐24]; hence it is important to know what factors, in addition to contextual ones, influence or are related to attitudes towards medicalization. Benyamini et al. [1] found that, in Israel, the attitude was more favourable among young women, with less education, who were immigrants or had a complicated obstetric history. These attitudes, measured during pregnancy, were related to a greater fear of childbirth and a greater probability of having a more medicalized delivery. Continuing with the factors related to or underlying these attitudes or beliefs and the choices they make, a cohort of Swedish and Australian women were categorized into three attitudinal profiles:’Self determiners’, ‘Take it as it comes’ and ‘Fearful’ [24]. Comparison between these groups revealed that the “fearful” group was more likely to have poorer self-assessed emotional health than the “self determiners” group, to prefer a caesarean section, to show less positive feelings towards the pregnancy, and to choose an epidural delivery etc.; the “take it as it comes” group was more likely to accept obstetric interventions when expressed as being for the well-being of the child, and the “self determiners” group was more inclined towards a more natural birth and assuming greater control over it. These three attitudinal profiles described by Haines could be related to different types of locus.

The locus of control (LOC), which was first used by Rotter in social learning theory (SLT) and served as the basis for the Wallston scale [25, 26], is one of the concepts used in understanding health behaviours and beliefs. This concept is defined as the degree to which people believe their health is controlled by internal or external factors [26]. According to this idea, individuals can be classified as internal or external. People with internal LOC are convinced that they can control their own destiny, they feel responsible for their lives and their behaviour, and they are capable of internal growth and improvement through effort and the development of their abilities. These people assume that their health results are a function of the behaviours they have, and they use the information provided to improve and take control of their own health [27‐31]. On the contrary, the external LOC is typical of those individuals with a tendency to consider that their health outcomes, or what happens to them, is under the control of other people, or is predetermined, or uncontrollable, since it depends on external factors outside their control, such as luck, destiny, chance or the supernatural [32]. The locus of control has been seen to influence the choices women make at the time of childbirth; for example, a woman with internal locus of control, or external luck, is more likely to attempt a vaginal birth after a caesarean section than a woman with an external locus of control—powerful others [33]. The identification of the type of locus of control has proven to be useful, therefore, for predicting trends in health behaviours and could predict what type of attitude towards childbirth –medicalized to a greater or lesser degree– the woman will have.

Another important factor to consider is the evaluation that the woman makes of the future childbirth as a potentially stressful event, and the coping strategies that she is going to use in that situation. Stress can be defined as a demand appraised as taxing or exceeding the resources of the individual [34]. Coping styles are the stable tendencies to respond to the stressing event with a certain type of strategy, and strategies are specific ways to cope with stress. Some authors describe 3 types of coping strategies: 1) coping considered positive, based on preparation, planning strategies and focuses on the problem to be solved; 2) a style, in this case negative or of avoidance, focused on the emotion generated and used to escape from the distressing situation; and 3) a “spiritual” style that faces the situation by trusting in a higher power [35‐37]. Knowing if the type of coping strategies used by women during pregnancy are related to having a more favourable or less favourable attitude towards medicalization is of interest, so that this variable can be taken into account in the development of interventions. For example, if it is seen that the use of preparatory strategies can influence having an unfavourable attitude towards a medicalized delivery, use of such strategies could be encouraged during pregnancy. Moreover, if we see that adopting an avoidance strategy during pregnancy is related to medicalization, we will have to be alert and work on the use of other more adaptive strategies.

The objective of this paper is therefore to evaluate whether women’s locus of control and stress coping strategies are related to having a more favourable or less favourable attitude towards medicalization in childbirth, and if so, what type of locus of control and what type of coping strategy would be more related.

Participation in the study was offered to 301 women in 28 primary care centres, under the management of 6 IHO, by 25 midwives; in addition, the women were allowed to facilitate the link to other pregnant women. The number of women contacted by other women is not quantifiable, but we did know how many of them accessed the link and signed the consent form. Of the 341 women in total who accessed the mobile app and gave their consent to participate, 279 completed at least one questionnaire, and 248 of them completed all the questionnaires between weeks 8 and 41 of gestation (Fig. 1). Participants’ sociodemographic characteristics are presented in Table 1. Their mean age was 33.4 (± 4.74). They were recruited on average at 29.6 (± 8.0) weeks of gestation and 71.3% were primiparous.

The average ATMC score, as can be seen in Table 1, is 3.42; that is, favourable to medicalization in childbirth. In the present sample the mean scores ranged from 1.66 to 5 points. As in the original version of the questionnaire, no cut-off points were established for its use in our study. A summary score, after reversing negative items, was calculated as the mean of all responses. A high score indicates a positive attitude towards medicalization, with 1 being the lowest possible score and 5 the highest. Figure 2 shows the frequency of the items related to having a favourable attitude towards medicalization in childbirth vs. the frequency of items favourable to a less medicalized delivery. The issues that present a higher frequency of agreement (> 80%) are those about continuous foetal monitoring, medical supervision and the availability of emergency services; 64.8% consider the epidural a safe method and agree with its use. Other questions present a lower frequency of agreement (Fig. 2).

The mean score for the Internal locus of control was 23.1 (SD: 3.69); 15.72 (SD: 4.12) for Chance external locus; and 19.57 (SD: 3.27) for Powerful other externality. The mean score for the preparatory-scale questions of the Revised Prenatal Coping Inventory was 2.02 (SD: 0.58); 1.1 (SD: 0.53) for the avoidant scale; and 1.02 (SD: 0.74) for the spiritual scale. The mean score for W-DEC was 54.7 (SD: 20.17) (Table 1).

The univariate and multivariate analysis of the variables under study are shown in Table 2. Initially Locus of control (Internality and Chance externality), preparatory and spiritual coping, educational level and having a paid job (work for which economic remuneration is received, as opposed to work performed in the domestic sphere) appear to be significantly related to the ATMC score, but when we adjust for all the variables and select the best model (Table 3), only Internal locus (Fig. 3), preparatory coping (Fig. 4) and going out to work (Fig. 5) show an effect on ATMC. Table 3 presents the Final multivariate model of the ATMC and its relationship with other variables after eliminating the sociodemographic variables with lesser contribution to the model. For each point in “Internal locus” and “Preparatory Coping”, the ATMC score was reduced by 0.02 and 0.23 points, respectively, while it increased by 0.18 with not having a paid job.

In light of the results of this study, it seems that women in our region prefer a medical delivery. The fact of giving birth in a hospital environment, with the availability of a professional at their disposal, emergency services in case something happens and continuous monitoring of the baby's health seems to provide them with security. Only a minority consider that medical interventions in childbirth could be dangerous or affect the childbirth experience.

Women’s attitudes toward childbirth may be shaped by their backgrounds, experiences, beliefs, values, and needs, which in turn may reflect the social and political environment (in terms of resources) of childbirth and the dominant discourse of childbirth in a culture, or particular country [41]. Nevertheless, every intervention presents the possibility of untoward effects and additional risks that engender the need for more interventions with their own inherent risks. Unintended consequences to intrapartum interventions make it necessary to promote natural childbirth processes and advocate for policies that focus on education, ensuring informed consent and shared decision-making [4]. It is also essential to know what psychological factors influence or are related to having a more favourable or less favourable attitude towards the medicalization of childbirth, not only because of its influence on childbirth choices and satisfaction with the experience [22‐24], but also because they give us the possibility of proposing education that is better adapted to the woman’s needs.

The results of the present study show that both the locus of control and the coping strategies normally used to deal with stress, in general, could be related to their attitude towards medicalization in childbirth; specifically, presenting an internal locus of control can be linked to a more unfavourable ATMC, as is adopting preparatory stress coping strategies. Moreover, these relationships are seen independently of all the sociodemographic variables studied, with the exception of work. In this case, not having a paid job is associated with a more favourable attitude toward medicalization, and conversely, working outside is associated with a less favourable attitude toward medicalization. We have not found anything in the literature on this issue, but, perhaps the fact of working outside the home and having to solve the usual problems that arise in any job could somehow “empower” these women and make them feel more prepared to face new challenges, such as a natural childbirth.

Not surprisingly, women with an internal locus of control are less amenable to medicalization. Studies already published have related having an internal locus of control with the desire to actively participate in the childbirth process [33, 42], with the desire for information [31, 42] and with presenting more behaviour of preparation and self-care of health during pregnancy [28, 30]. According to some authors, the health locus of control may be an important pathway through which education, or health literacy, influences health behaviour [43, 44]. The internal locus of control has also been associated with the use of coping strategies focused on the problem, and are more adaptive than those strategies usually used by people with an external locus of control, which are more focused on emotions [45].

Moreover, a recent study concludes that pregnant women who use more adaptive coping strategies, especially planning-preparing coping, reported lower levels of anxiety/depression and engaged more in healthy behaviour. The study also suggests that obstetricians and health care providers should pay more attention to the roles of coping strategies, especially planning-preparation and avoidance coping, in improving health-promotion/health-harming behaviour patterns of pregnant women [46]. In the present study, it is seen that the majority of adopting preparatory coping strategies against stress are related to having a less favourable attitude towards medicalization, which could indicate that preparatory strategies could potentially be good for reducing the stress of future childbirth, making the woman feel more prepared to face it without the need for high technology or medical aid. Given that childbirth is an isolated event, adaptation strategies for dealing with the future situation are therefore be of a variable nature [34, 37] and, therefore, could be susceptible to modification if they turned out not to be useful for dealing with the delivery process.

In view of these results, the interaction between locus of control, coping strategies and attitude towards the medicalization of childbirth could be considered when proposing educational interventions, for example to promote a more natural delivery, ensure informed consent and shared decision making. Identifying the type of locus that the woman presents can be useful for offering the most appropriate strategy. The professional can represent a source of authority and be motivational [47] in the case of women who present an external “powerful others” locus, and therefore work could be done to encourage them to use preparatory coping strategies, if one wants to encourage a less favourable attitude towards medicalization in childbirth. If the woman presents an internal locus of control, the influence of the professional would be less, and the intervention perhaps less necessary. In this case, it might be more appropriate for them to self-manage their own resources. Both the consultation with the midwife and the group sessions of Maternal Education could be an appropriate space to start working on this type of intervention, but more research is needed on the most appropriate type of intervention and its implementation in clinical practice.

As this is an observational study, causality cannot be established with any of the associations. On the other hand, a longitudinal study would have allowed us to observe the changes that occur throughout pregnancy in each of the study variables.

Another limitation could derive from the self-selection of the sample, although measures have been taken to avoid introducing bias: the women were selected by 25 midwives belonging to 28 primary health care centres located in various population centres, both rural and urban, and of different socioeconomic and social characteristics. These 28 centres are part of 6 different Integrated Health Organizations. In light of the sociodemographic data, it can be said that the women in our study are representative of the study population.

The results of this study suggest that women have a favourable attitude towards medicalization of childbirth. Both the Locus of Control (LC) and the Coping Strategies (CS) of women during pregnancy are related to this attitude. Specifically, having an internal LC and using preparative CS both lower the probability of presenting a favourable attitude towards medicalization, while the lack of a paid job raises the probability. The influence of these psychological factors must be taken into account in the development of content and interventions that promote a more natural birth.