Medicalization of pregnancy care and childbirth in Poland
Relatively little is known about pregnancy care in Poland from a qualitative perspective of experts, thus it is valid to first highlight the broader context of medicalization from the perspective of healthcare professionals:
At a big conference in Poland, there was a comparison of pregnancy care in Poland versus (...) some rich countries in Western Europe (...) We do so many tests! A lot of ultrasound exams, while there are some countries where there are only two throughout the entire pregnancy. Midwives manage pregnancies. I think our model is highly and strictly medicalized. (3_KE, OB-GYN in a hospital & at a private clinic[3])
Our study shows that Polish experts vary in their awareness and evaluation of medicalization of pregnancy and birth. On the one hand, OB-GYN respondents were expectedly keen on leading pregnancy as sole decision-makers. They saw privatization and medicalization as underpinnings of optimal care and outcomes, especially during birth:
I think giving birth in a hospital is an absolute must, securing surgery suites, medication, adequate tools. Birthing homes are perhaps a cool idea, the conditions are homier, but they need to have hospital backup (...) And there’s the Health Ministry’s standard, it has systematized (...) and legally confirmed the schedule of visits and care. (10_KE, OB-GYN in a hospital)
On the other hand, midwives, doulas and specialist consultants like psychologists saw the risks of such a model, especially in the absence of a holistic approach, limited input from other professionals and disenfranchisement of patients. They typically contested the power of doctors being as far-reaching as it is at present:
In Poland we continue to have this inflated medical aspect (...) I think there is this massive need to medicalize, the inducements of births, redressing normal labour into frames where two hours pass and then there goes a caesarean and the thing is over. I think we should draw more from the evidence-based Western medicine, knowledge based on scientific facts about perinatal care. In Poland we are really so behind. This is evident also with the pandemic situation. In the interest of women, we need to look more to the West. (14_KE, midwife at a hospital & at a private practice)
As above quotes show, perceived high medicalization of pregnancy and birthing in Poland is not unequivocally regarded as a negative phenomenon. Expectedly, those working in the strictly medical field argued that the medicalized health system makes the process safe for a mother and a foetus/ new-born, with safety guaranteed by doctors and midwives. However, especially in the opinions of those who often see negative implications of medical interventions, the current overmedicalization may be conducive to denying patients’ agency, causing wellbeing-related problems noticed by maternity experts.
Getting pregnant during a pandemic
The experts in the (blinded for review) project have been observing growing fears that impacted on the preconception processes and reproductive decisions of women (19). OB-GYNs, following the Ministry of Health recommendations, stopped provisioning fertility treatments and urged postponement of pregnancy plans during the pandemic. They drew on the fear stemming from the unknown consequences of this virus for mothers and unborn children:
Women who planned to have a child are scared. Doctors simply advise them not to get pregnant because not much is known about the virus. It is impossible to say how it could influence the foetus during the orthogenesis, when all organs are formed. One does not know if the baby would be healthy. Both pregnant women and those who planned on getting pregnant, and the birthing women, they are all negatively affected by this situation. (48_KW, physiotherapist at a private clinic & at a private practice)
Importantly, interviewees anticipate that the pandemic might get worse and last long. This especially holds as the impending recession factors begin to overlap with the weakening conviction about the economic viability of one’s reproductive plans (19), on which one interviewee claims that “many women will alter their plans due to economic reasons” (39_MW, physiotherapist with own private practice). At the same time, experts argued that not all women have a privilege of holding off, referring especially to those struggling with infertility and being in their late 30s or early 40s. While they might be in the risk group, the desire to have a baby appears stronger than COVID-19 fears:
There are these women who are older, born in the 70s and 80s. When it comes to pregnancy, especially the first one, they feel a breath of time on their necks and don’t believe they can wait. They have been trying for a while and they simply think that - virus or no virus - they will get pregnant. This is their decision and even though our recommendations are clear on discouraging getting pregnant, it is also true that our experiences with corona-virus in early pregnancy are non-existent. (10_KE, OB-GYN at a hospital)
The uncertainty connected with COVID-19 – according to maternity experts – brings on stress and anxiety among women who are considering conception.
Pregnancy care during COVID-19
According to experts who interact with pregnant women on a daily basis, uncertainty and information chaos are pervasive, especially as recommendations and practices vary between WHO, national experts and local practitioners. Inconsistencies are the source of nervousness:
There is so much news in the media, it’s a giant mess. In Poland we do not cope with information well and we have recommendations differing from what is happening abroad, not in line with WHO. If someone reads English and has friends abroad, they might get completely lost, ask themselves what does it mean that someone else could do something but they can’t, each doctor says something different. We’re feeling lost, it’s a giant mess. (5_KE, midwife/ breastfeeding advisor at a private clinic)
The confusion about decisions and their ownership does not change the experts’ perception of women as facing an injustice. Recommendations aside, expecting women are portrayed as made highly vulnerable by the pandemic, also because their carefully planned antenatal activities have been upended from one day to the next:
This is very stressful. I see young women being completely cut off from doctors, from consultations, from ultrasounds, various control visits. They are really affected by this and the fact they cannot see anyone, can’t access (services), everything was cancelled. (34_KW, sling advisor at a private practice)
The access to various medical procedures, which warranted feeling safe, has been cut off. According to experts, women were expected to trust the professionals fully before the pandemic, so erasure of support required sudden switch to alternative advice or practices: be it online or though self-assessment. The medicalization before the pandemic was an everyday experience in Poland, so it can be argued that women were not accustomed to self-reliance. As representatives of supporting professions indicate, without any preparation, pregnant women were left alone with neither professional support nor knowledge about norms:
Doctors simply closed their clinics from one day to the next, which for me was really unacceptable. I simply cannot imagine leaving a pregnant patient, just saying that well, it’s closed now, go find yourself someone else. (41_KW, doula with a private practice)
There was an observable pattern that the closer the expert was to clinical care (e.g. working in a hospital ward), the more concerns about adverse medical outcomes they voiced. Particular attention was drawn to those who require specialist care but were left alone without any options, abandoned in the middle of the process:
Women have restricted access to doctors and examinations. There are those who have high-risk pregnancies, need to be overseen by a diabetologist, endocrinologist - these visits were made much more difficult (...) Some things cannot be done well in an online visit. For instance, the half-point ultrasound, it would be unthinkable to have it not happen at the right time. Cancelling those visits, I don’t know but I think that we will see women suing because their right to healthcare is being restricted. I do not believe these key appointments should be cancelled. (7_KE, midwife with a private practice)
Consequently, the interviewees predict that the upcoming waves of births and new-born cohorts will be negatively affected by the pandemic:
I see my patients and in August and September we will have a brood of crying children, children hard to regulate because women are loaded with cortisol. I understand that birthing classes happen (virtually) but we are social beings and this online relationship is simply not sufficient for critical situations. (44_KW, physiotherapist with a private practice)
As Polish medical professionals work with very tight and extensive schedules as regards pregnancy care, they underline possibly serious health implications. Moreover, the professionals indicate that both sudden decisions and a prolonged social lockdown might affect parturition:
If a woman is pregnant and already has small children that she needs to isolate and they cannot go out, then I’d imagine that the perinatal risks are going to be higher for the new-born. This pregnancy is then exhausted. It is not a physiological pregnancy, even if it has a physiological presentation. The environmental factors have an incredible bearing on how the pregnancy unfolds, the well-being of a foetus and the birth itself. (44_KW, physiotherapist with a private practice)
However, decisions connected with cancelling visits at doctor’s offices are perceived through a dual lens: the well-being and medical consequences for a woman and her unborn child, and possible implications of a lockdown on the maternity support sector and professionals more broadly, i.e. when specific practice or specialist might not be able to run their business for a longer time during the lockdown. The tensions between doctors, midwives, doulas and other experts are more vivid during the pandemic, yet also, collaterally to the market lockdown and closing of outpatient clinics and on-site services, telemedicine and online provision of classes has blossomed quickly:
Pandemic resulted in a speedy development of telemedicine, which is how I work now. It turns out that even pregnancies can be managed through telemedicine (...) Even though we were critical of those methods, the pandemic shows the usefulness of digitalization, introducing e-prescriptions and medical leave confirmations online. We might not yet realize the benefits it gives us, the fact that it is (now) permitted. Even my private practice can be run this way because I have all documentation online. (3_KE, OB-GYN at a hospital & at a private clinic)
In a peculiar manner, the lockdown challenges the typical medicalization of pregnancies in Poland, wherein women usually visit their managing doctors every 2-3 weeks. For some of the experts, pandemic served as a means to reflect on what is truly needed, limiting personal visits only to absolute emergencies:
It is indeed easier not to drag the patient for a face-to-face examination, it is enough to give some advice or consult about the results of a test online (…)The patients are no longer trying to push for a hospital stay, we don’t see one million consultations in the ER. From this perspective, it became much calmer. A woman would think ‘OK, I am not dying, nothing serious is happening. So maybe there is no reason to run to the hospital or the doctor’s office’. (10_KE, OB-GYN at a hospital)
From this dual perspective, it can be observed that experts other than OB-GYNs have their doubts towards inaccessibility of health care services. They might judge women as not accustomed to being experts in their own pregnant bodies. The expert, therefore, link uncertainty and lack of preparations through medical consultations with anxiety and stress for expecting mothers and their babies. At the same time. some experts became protagonists of limiting face-to-face meetings with pregnant women.
Birthing during pandemic
For those women who are planning to give birth in hospital and more or less follow the medicalized way of childbirth, the pandemic has several implications. Midwives and other experts who participated in the research pointed out that a clinical model not only does not improve outcomes but actually implies that non-evidenced-based actions are allowed during a national lockdown perceived as an emergency.
The (birthing companion ban) will have a tremendous impact. I have a patient who cannot imagine giving birth in a different setting, without her husband present for this crucial moment. (Women) are at the hospital wards alone, nobody is allowed to visit them. If a woman experiences something bad, encounters a difficult event at the hospital in connection to birth, then she will be facing a much more difficult situation due to being alone with it. I think this is the main negative impact, (pregnancies and births) became psychologically harder. (6_KE, midwife at a a hospital)
The Polish experts seem to have limited access to knowledge, so the distributed information and soundness of recommendations varies on a case-by-case manner:
The national consultants for midwifery and neonatology issued a peculiar update last week, saying that there was never a ban on accompanied births at all. It seems that the restrictions were introduced by the hospitals, which is not true because these came from the consultants’ recommendations. Factually, we followed ‘recommendations’ though no legal, banning act was introduced. At the same time, the advice from regional and national consultants was to stop allowing birth companions (13_KE, midwife at a public clinic)
While midwives, doulas and psychologists/therapists tended to worry about women’s fears, they also proclaimed interesting benefits of the pandemic re-empowering Polish women and posited, that expecting mothers gained stronger convictions about their own capabilities:
Women gained more self-confidence and trust towards their own judgement, observing their bodies, their pregnancies and their babies, it’s all very common-sensical now. (10_KE, OB-GYN at a hospital)
However, such an optimistic perspective is rather an exception among the experts and seen as a potential that would need to be realized in a longer-term, the more immediate concerns and predictions relate to a new wave of medical interventions resulting from the increased anxiety and stress. The most common predictions are connected with expecting
It is very difficult now. More so because pregnancy and the perinatal period should not be marked by anxiety. The births will not start, they will not begin and they will need to be induced. We will have thousands of C-sections. From C-sections, we will have children separated from mothers. This will be terrible. As usual, women will be the victims. (45_KW, doula with a private practice)
Decisions about caesareans were, subsequently, connected with predicted or real problems with physiological childbirth and tied back to the explicit fallback to a clinical model. Experts - medical and support professionals alike - asserted that hospital doctors regained absolute power, undoing the work towards safeguarding women’s dignity during birth:
Situation of pregnant women changed dramatically because we have horrendous consultants, useless, 60-year-old geezers who decide how women are supposed to birth children (...) And they completely ignore WHO recommendations. (Pandemic) changed women’s situation because their visits are cancelled and this causes anxiety. Everyone was already taking away their competence, now they suddenly have none left. (45_KW, doula with a private practice)
In connection to what Rocca-Ihenacho and Alonso (23) argued in the face of the pandemic more broadly, Polish experts also wondered about the potential to challenge medicalization:
Women who wanted to give birth at home, those who are very aware and have their own midwives, well, they are still well taken care of, nothing has changed. This really shows the dissonance as to how a hospital was supposed to be this safest place, but now we see it is absolutely not. Women who rely on midwives, they have continuous care and will give birth at home, naturally. (5_KE, midwife/ breastfeeding advisor at a private clinic)
In this context, the epidemiological situation may once again reframe the debate on what the best place and model for giving birth might be
[3] Every quote is described with an interview number, as well as profession and further information on the place of work.