The need for appropriate language in the debate on medicalisation of pregnancy

Although the majority of pregnancies progress smoothly and result in the birth of a healthy baby, this is not always the case. Pregnancy can have severe complications, including stillbirth, affecting eight in 1000 pregnancies in France;1Cinelli H Lelong N Le Ray C Enquête nationale périnatale. Rapport 2021.https://enp.inserm.fr/wp-content/uploads/2022/10/rapport-2022-v5.pdfDate: 2022Date accessed: March 3, 2023Google Scholar maternal hypertension, affecting 74 in 1000,2Olié V Moutengou E Grave C et al.Prevalence of hypertensive disorders during pregnancy in France (2010–2018): the Nationwide CONCEPTION Study.J Clin Hypertens. 2021; 23: 1344-1353Crossref Scopus (17) Google Scholar or neonatal death, affecting three in 1000. Obstetrics and midwifery are the fields of study focused on pregnancy, childbirth, and the post-partum period. They aim to identify, by screening or diagnosis, pregnant women at risk of complications and offer ways to prevent or treat complications to improve outcomes. Recently, Richard Horton commented3Horton R Offline: FRENCH-ARRIVE—elles accusent.Lancet. 2022; 4001911Summary Full Text Full Text PDF Scopus (4) Google Scholar on the FRENCH-ARRIVE trial (NCT04799912). This large, nationwide, randomised trial in France aims to replicate or refute the findings of the US ARRIVE trial.4Grobman WA Rice MM Reddy UM et al.Labor induction versus expectant management in low-risk nulliparous women.N Engl J Med. 2018; 379: 513-523Crossref PubMed Scopus (666) Google Scholar The US trial showed that induction of labour in nulliparous women with uncomplicated pregnancies between 39 weeks (+0 days) and 39 weeks (+4 days) resulted in improved outcomes for the newborn baby than expectant management. Women induced also had lower rates of caesarean birth and hypertensive disorders of pregnancy. Horton responds to a book by Claudine Schalck and Raymonde Gagnon5Schalck C Gagnon R When inducing labor compromises a woman's motherhood: a psycho-sociological analysis of maternity as labor. Editions L'Harmattan, France2022Google Scholar that posits "induction of labour without any medically justified reason can be considered nothing less than 'obstetric violence'". Of note, Horton highlights emotive quotes from the French authors 13 times (eg, "control" and "abuse" are a "form of domination over women"; the woman "has neither body, nor power, nor place, nor role in childbirth"). By contrast, he quotes the FRENCH-ARRIVE investigators twice. This, we think, reflects his bias in the debate for which he calls. Horton's Comment deserves a rebuttal. The French research network Groupe de Recherche en Obstétrique et Gynécologie (GROG) is an excellent network that has done landmark trials that have improved care for mothers and babies. The FRENCH-ARRIVE study adds valuable obstetric knowledge to support decision making by women and their families. The best way to provide high-quality information for consumers and clinicians is with randomised controlled trials, such as ARRIVE and FRENCH-ARRIVE, and other studies, such as SWEPIS and INDEX, both of which assess induction at 41 weeks.6Alkmark M Keulen JKJ Kortekaas JC et al.Induction of labour at 41 weeks or expectant management until 42 weeks: a systematic meta-analysis of randomised trials.PLoS Med. 2020; 17e1003436Crossref Scopus (20) Google Scholar We are particularly concerned that Horton implies pregnant women lack capacity to consent. This contention echoes historical, paternalistic, patriarchal, and prejudicial attitudes about women and begs the question why he believes their consent capacity is any different than any other individual in the context of a research trial? We contend this attitude additionally promotes the exclusion of pregnant women from research, with the resultant impairment of maternal and child health. Suggesting that pregnant women should not be presented with information (eg, about the risks and benefits of an intervention, such as induction) and allowed to make decisions based on their own preferences and values is disrespectful. Instead, it is proposed that a higher authority should decide the philosophy to which they should adhere or the information with which they are permitted to engage. We would posit that just as it is problematic when women have interventions that they do not want, withholding information from women so they cannot make decisions for themselves as to what intervention (or non-intervention) is best for them is also problematic. In fact, in a recent UK law case, the judge upheld the right for women to have information about any material risk to make autonomous decisions about how to give birth.7Chan SW Tulloch Cooper ES Smith A Wojcik W Norman JE Montgomery and informed consent: where are we now?.BMJ. 2017; 12: 357Google Scholar The debate about the medicalisation of pregnancy (and medicalisation of life in general) is important, but that debate should never be conflated with good research or used to impugn researchers and clinicians who address important questions in an appropriate and ethical manner. In fact, GROG and other research networks have identified many interventions that are ineffective; these studies have protected women from the possible harm of such interventions.8Schmitz T Fuchs F Closset E et al.Outpatient cervical ripening by nitric oxide donors for prolonged pregnancy: a randomized controlled trial.Obstet Gynecol. 2014; 124: 1089-1097Crossref PubMed Scopus (22) Google Scholar, 9Senat MV Affres H Letourneau A et al.Effect of glyburide vs subcutaneous insulin on perinatal complications among women with gestational diabetes: a randomized clinical trial.JAMA. 2018; 319: 1773-1780Crossref PubMed Scopus (67) Google Scholar Additionally, the use of terms such as "obstetric violence" from The Lancet's Editor-in-Chief is unfortunate. Such inflammatory language shreds the ability for the nuanced, scientific debate that Horton is calling for. Similarly, we are surprised by the title of Horton's Offline, including the words "elles accusent", making a parallel between the FRENCH-ARRIVE study and the 1890's Dreyfus affair, a notable example of antisemitism in France. All in all, we welcome the debate that Horton wants to initiate, but, for reasons mentioned, we feel that this biased, provocative Offline comment is a false start. CdG is President of the Dutch Society of Obstetrics & Gynecology. BWM reports an investigator grant from the National Health and Medical Research Council (NHMRC; GN1176437); consultancy fees at an hourly rate for ObsEva, Merck KGaA, Guerbet, iGenomix, and Merck; and travel support from Merck KGaA. JEN is Deputy Vice-Chancellor and Provost at the University of Nottingham and a non-executive Director of a UK National Health Service Trust, and reports funding from UK charities and the UK Government to conduct clinical trials into improving outcomes for pregnant women and their babies. KP reports an investigator grant from the NHMRC (GNT2009765). SJS declares grants from the National Institute of Healthcare Research Health Technology and Assessment, Wellcome Trust, Medical Research Council, The Chief Scientist Office of Scotland, and Tommy's Charity, all paid to her institution; consulting fees on pre-term birth treatments to Natera; honoraria for educational speaking from Hologic, all paid to her institution; participation in the National Institute of Healthcare Research Health Technology and Assessment data monitoring committee and trial steering committee in the past 36 months; and a leadership role in the Trustee of Sands charity. All other authors declare no competing interests. Offline: FRENCH-ARRIVE—elles accusentThe accusation is direct and unflinching. The FRENCH-ARRIVE trial "obeys a pseudo-scientific rational logic" that is "a denial of what childbirth and motherhood mean to women". Claudine Schalck and Raymonde Gagnon are both registered midwives. Their book, When Inducing Labor Compromises a Woman's Motherhood (L'Harmattan, 2022), is one of the most remarkable denunciations of an ongoing research study ever published. It is also a sustained critique of the contemporary approach to obstetric care in many western nations today. Full-Text PDF

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