Social Iatrogenesis with reference to midwifery

In his book Promoting Equality Neil Thompson refers to the book Limits to Medicine by Ivan Illich. This book was originally published in the seventies. In it Ivan Illich introduces the concept of social iatrogenesis. Thompson defines this as 'the ways in which the social organisation of healthcare becomes a causal factor in the experience of ill health'(P102). And he quotes Illich:

'It (social iatrogenesis) obtains when medical bureaucracy creates ill health by increasing stress, by multiplying disabling dependence, by generating new painful needs, by lowering the levels of tolerance of discomfort or pain, by reducing the leeway that people are wont to concede to an individual when he suffers, and by abolishing even the right to self-care.

Social iatrogenesis is at work when healthcare is turned into a standardised item, a staple; when all suffering is hospitalised and homes become inhospitable to birth, sickness and death; when the language in which people could experience their bodies is turned into bureaucratic gobbledygook; or when suffering, mourning, and healing outside the patient role are labelled a form of deviance.' (P 49.)

Thompson distinguishes iatrogenic illness which is experienced by an individual from social iatrogenesis which affects what he describes as the 'macro level'. In terms of the maternity services this relates to such phenomena as the concentration of childbearing women into large centralised maternity units; the blanket imposition of policies such as routine induction at a certain gestation; the general culture in which women defer to those they consider more expert rather than trust the validity of their own experience. Obstetric social iatrogenesis has helped to create a society where many women are terrified of giving birth vaginally, where caesarean section is considered a reasonable alternative. In other words women have so little faith in the ability of their bodies to function in the way for which they evolved that they prefer to consider their abdomens and wombs cut open; they consider the consequent comparatively high risks of infection and wound morbidity negligible in comparison to their fantasies of what might happen if they give birth normally. (They do not consider at all the increased risk of their own deaths and the increased possibility that their baby might be lacerated by the scalpel and the inevitability that their baby's initiation of respiration must take place without the helpful stimulus of vaginal compression followed by the sudden release of emergence.)

I think it is noteworthy that this change in attitude is coincidental with the increased exposure of the female genitalia in widely available pornography. I see it as analogous to the relationship between rates of breast-feeding and attitudes to the breast as a purely sexual part of the body. I am suggesting that social iatrogenesis does not occur in a vacuum but that the social and the iatrogenic relate synergistically. I am further suggesting that this concept is one which might usefully be employed by midwives in an attempt to grasp back some professional terrain.

I think it is ironic that Thompson in his comprehensive and thorough book falls into the trap into which medicine has already fallen of regarding death as pathological. For example, when considering inequalities in health across social class he writes: 'social inequalities in health continued to exist and, in some cases, there had actually been a widening of the gap (death rates, for example)'(P123). This phrase hit me. The death rate for all social classes is 100%. It might be better expressed in terms of different social class patterns of death. By choosing a set of words such as this there is a tacit acceptance of the inevitability of death. Such acceptance I think is necessary if midwives are to be able to tolerate uncertainty better. Childbirth, if it is not interfered with, contains many uncertainties, including notably the timing and pattern of labour.