ToTell
a
Vision....
....2020
Green Maternity Care ~
a natural partner with StepItUp2007 in an effort to reduce global warming
Part TwoHow did we stray so far from our planet-friendly, common sense traditions?
Our current medicalized maternity care system was put in place in 1910, when the newly emerging obstetrical model first began to heavily influence birth-related care of healthy women. Prior to that, obstetricians were only called by the family, the midwife or a general practice physician when there was an evident obstetrical complication. The only women to routinely used the maternity services of hospitals were ‘charity cases’ -- the poor or homeless -- and those who were seriously ill or had obviously complicated pregnancies. During the first two decades of the 20th century the obstetrical profession came to believe that healthy women were the rightful patient-base for their surgical specialty.
How and why this happened is the topic of this section. It is also the most important untold story of the 20th century. But to understand these events, they must be seen in their proper historical context. The purpose is not to blame but to understand, so that the problems can be corrected and the system rehabilitated. This is the first and most crucial step in the process of developing "green maternity care" in the US.
In the late 1800s and first decades of the 20th century, life in the US was hard and dangerous for everyone. While most Americans no longer feared wild animals or starvation, things were grim and life expectancy was less than half what it is today. A large percentage of the population suffered from poor nutrition and the wide spectrum of health problems associated with poverty – no clean water, no public sanitation, life in crowded urban tenements or desperately poor rural farms. Tuberculosis was a particular problem when many people were packed together with neither sanitary facilities nor any understanding of hygienic principles. There were no social programs to teach nutrition, no government food programs to provide nutritional supplements pregnant women or infants. Modern medicine as we think of it did not yet exist. There was no way to prevent or effectively treat life-threatening epidemics of tuberculosis, diphtheria and typhoid fever.
It’s hard for contemporary Americans to imagine what life was like without the contribution of science to good health and our contemporary form of 'modern' medicine, but here is a chilling example. In Chicago in 1890 a terrible storm caused raw sewage to be washed into the inlet pipe for the city’s drinking water and within a few weeks 90,000 people -- a one quarter of the city’s entire population – died. There was nothing the 19th century medical profession could do.
For childbearing women in 1910, the picture was even worse. There was little or no preventative, diagnostic or emergency medical care as we know it today, no safe or effective contraception and for most women, no access to obstetrical services when pregnancy complications occurred. The average birth rate per was six children, so problems relating to pregnancy and childbirth were reoccurring ones. Modern diagnostic devices did not yet exist and prenatal care had not yet been invented. There were no lab tests, ultrasounds, or blood pressure cuffs. No one listed to the fetal heart beat and there was no way to distinguish the healthy mother from the ill, injured, those with congenital or acquired anomalies, such as rickets or a fractured pelvis. The first time a midwife or doctor met their maternity patient was after they were already in labor.
The new profession of obstetrics stepped into a world populated by women with untreatable and potentially fatal diseases. A significant proportion of the childbearing population suffered from heart disease, kidney infections, TB, syphilis, high blood pressure, diabetes, etc, in addition to the usual pregnancy complications, such as premature labor or placenta previa. Most of these serious and even fatal dangers were associated with poverty, malnutrition, overcrowding, overwork, forced childbearing and a constant stream of closely spaced pregnancies. Its no surprise that a large number of pregnant women suffered complications in childbirth at the beginning of the 20th century.
When a complication occurred during childbirth, antibiotics, safe blood products or safe anesthesia were not available at any price, as they hadn’t been invented yet! Modern developments in medical science did not make a widespread impact on obstetrical care in the US until the end of WWII. But for the obstetricians and patients of 1910, the wonderous ways of modern medicine were decades away.
Strange Bedfellow—
Territorial Imperatives, Industrialization and the New Obstetrical ProfessionThe last half 19th and first half of the 20th century in the United States were also an expansive time of territorial imperatives that coincided with the intense levels of industrialization in both Europe and the US. The kick-start effect of this era was like rolling the Wild West and the Robber Barons together into one gigantic firecracker. Many Americans, including doctors, were heavily influenced by the manly arts of industrial strength problem-solving -- the ‘dream big, take-the-bull-by-the-horns’ approach.
In the general area of medicine, there was an enormous, sustained and ultimately successful push by the American Medical Association to promote the German or ‘allopathic’ form of medicine. The goal of the AMA was to identify the scientific use of drugs and surgery as the basic standard and foundation for all healthcare. Doctors trained in the allopathy method described themselves as “regular” doctors. The campaign to eliminate ‘irregular’ doctors and non-allopathic forms of health care was well-organized, aggressive and ultimately successful.
Drugless practitioners of naturopathy, homeopathy, chiropractic, acupuncture, Chinese medicines and the use of herbs and non-prescription preparations (described then as “snake oil”) all came under the the AMA's gun. With the help of the Flexner Report in 1910, the method of choice by organized medicine was to close down or financially freeze out all medical schools that taught unapproved “healing arts” or who accepted minorities or women as students. In short, anything that was an ‘art’ was bad, anything that had the word ‘science’ in it was good, so long as it was associated with allopathic school of thought.
In obstetrics, doctors dreamed of a brand new, “modern” form of obstetrical care based on allopathic principles. They genuinely believed that drugs and surgery would be able to eliminate childbirth-related death and disability once and for all. It was a wonderfully bold and noble idea. First on this ambitious list was the elimination of potentially fatal infection known as “childbed fever”.
Claiming the right of ‘imminent domain’ and taking elements of industrialization as their role model, they simply declared the broad category of maternity care to be the rightful occupation of the medical profession. This was before women had the right to vote. Obstetricians didn’t ask women for their opinion about these changes and there was no politically effective way for women to object. In that sense, obstetric care was like pediatric care and veterinarian services – it was just done to you, without asking for your consent.
True to the industrial model of the day, the obstetrical idea of childbirth was founded on a 19th century reductionist view. Birth was seen as a mechanical problem – just like getting a toy ship out of a bottle, whatever it takes, including breaking the glass when lesser methods failed. As a result, the obstetrical profession veered very far from the common-sense principles of normal biology.
Childbirth Under Medical Management
Labor and birth were immediately identified as a medical condition under their professional purview. The first causality was continuity of care. Using reductionist methods popular in manufacturing, the biology of birth was reduced to its most basic elements. Then standardized procedures were developed for each stage and phase. Labor was separated from birth and divided in unequal proportions along gender lines between the medical and nursing professions. Textbooks of that era referred to labor as “the waiting period before the doctor arrives”.
The slow, tedious, poorly-compensated woman’s work “half” went to ancillary personnel; the exciting photo-finish, high status, highly compensated second “half” went to physicians. Then a host of discrete caregiver tasks were parceled out to an assembly line of nurses and low-paid helpers, with obstetricians in charge and ruling over this vast assemblage. And presto, obstetrics had invented the industrialized way of childbirth and set the standard for maternity care for the entire 20th century.
While most people still thought of the birth of a baby as something the birthing mother did, doctors had a different take. First they renamed the childbearing woman – she was now a ‘labor patient’, her own clothing exchanged for the low-status ubiquitous patient gown and assigned to a passive state that diminished her role and separated her from the support of her family. Then obstetricians renamed normal birth of the baby, calling it ‘the delivery’, and identifying it as a medical procedure and something that only doctors did.
In this new obstetrical model, socially-isolated mothers labored in bed on their back, a painful state that eliminated the right use of gravity. The issue of pain was medically managed by ordering nurses to administer repeated doses of “twilight sleep”, a mixture of narcotics and hallucinogenic drugs, which effectively obliterated normal consciousness. In contrast to the inert state of the labor “patient”, doctors stood on their own two feet, striding around the room at will. When the time arrived for the baby to be born, the doctor assumed the active role, and performed the ‘delivery’.
In the vocabulary of this new world order, mothers no longer “gave birth”-- instead, doctors delivered babies, a system disturbingly similar to the childhood myth of the Stork. The same way the Royal Canadian Mounted police always ‘got their man’, doctors, with easy access to anesthesia, forceps, episiotomy and even Cesarean, could be depended on to always ‘deliver the goods’. For the father in the waiting room, it was comforting to rely on the doctor. In that sense, the natural biological abilities of childbearing women were rightly characterized as undependable, the bad old days before we were liberated by the wonderous new ways of 20th century science.
When obstetricians were finished inventing obstetrically-defined childbirth, labor was a medical condition that required the supervision of a physician; ‘delivery’ was a medical procedure to be ‘performed’ by physicians and only physicians. Once the obstetrical profession had taken control of all maternity care, there was no one to left provide oversight or accountability. And there was certainly no place in the medicalized model for the messy, time-consuming, unpredictable aspects of normal biology. You couldn’t running a factory like that; it was believed you shouldn’t run a maternity ward that way either. In a very short time, the traditional forms of non-medical maternity care came under fire as inadequate, unscientific and, doctors believed, dangerous. Equally important, non-obstetrical forms of care competed with obstetrics and were thought to diminish the ideological purity of the profession and its status in the eyes of the public.
While these motives were ever so well-meaning, the plans to totally reconfigure childbirth services were based on bad data, untested theories and a strong dose of irrational enthusiasm. Were obstetrics to be reconfigured today, the result would be strikingly different. But in the early 1900s, the all-male obstetrical profession generally believed that childbirth was an inherently dangerous and dysfunctional aspect of female biology. Based on this outlandish idea, even healthy women with normal pregnancies were assumed to be in desperate need of rescue from the gender-related mistakes imposed on women by a cruel Fate. As Freud was to observe, if you were female, your biology determined your destiny. It wasn’t a pretty picture.
The Pre-Emptive Strike as Policy
In this war against female biology obstetricians were identified as the first line of defense. The weapon of choice was the obstetrical version of the pre-emptive strike. Medical and surgical interventions were routinely used in normal birth as a ‘precaution’. Obstetricians were genuinely convinced that this ‘pre-emptive’ posture was the safest and most responsible plan of action, that it would be downright negligent and unethical not to use them during each and every labor and birth.
These ideas generated antiseptic protocols that required laboring women to be isolated from their families behind doors marked “No Admittance – Authorized Personal Only”. On admission to the labor ward each labor patient was scrubbed down with soap, then doused with antiseptic solution and put in a sterile hospital gown. Then she was obstetrically prepped, that is her pubic hair was shaved off and an enema administered, to be repeated at twelve hour intervals until she delivered. These rituals were all based on the erroneous idea of ‘auto-infection’, which wrongly assumed the pathogens which caused childbirth septicemia were being introduced into the ‘clean’ hospital environment by the ‘dirty’ patient, the result either of her own poor personal hygiene, aberrant sexual practices or her husband’s sexual indiscretions with prostitutes.
After the admission rituals were finished, patients were given a double dose of sleeping pills and put to bed. From that point forward they were kept NPO (non per os or no food or drink). Then they were injected every 2-3 hours with a narcotic mixture known as “twilight sleep” – large and frequently repeated doses of narcotics and scopolamine. Scopolamine is a potent hallucinogenic drug that causes short-term memory loss and permanent amnesia of events occurring under its influence.
Under the effects of twilight sleep, women sometimes became temporarily psychotic and physically fought with the staff and even bit the nurses. If left unattended for even a minute, they often fell out of bed and chipped teeth or broke an arm. When the nurses were too busy to say at the bedside, they had to put labor patients in four-point leather restraints, the kind used in the psychiatric ward. This forced women to labor flat on their back, a position that interferes reduces blood flow to the uterus and placenta, making labor extremely painful and often causing fetal distress.
Unfortunately, the vast majority of these practices – the ritual decontamination of maternity patients, immobilizaton in bed, being kept NPO, large and frequently repeated does of narcotics, laboring on their back – these protocols, despite the high hopes of the obstetrical profession, failed to eliminate complications as expected. In spite of their intensive efforts, nosocomial infection was still the major cause of maternal mortality, as well as the source new problems caused by the interventions.
The more problematic that medicalized childbirth became, the more obstetricians believed that the earlier and more aggressive use of interventions were medically indicated, a Catch-22 that unintentionally exacerbated the problem of nosocomial and iatrogenic mortality. And in that same Catch-22 sense, this high mortality and morbidity then validated the obstetrical profession’s believe that childbirth was fundamentally dangerous. Logically-speaking, if a woman was in a world class hospital, cared for by a famous doctor and a skilled professional staff, her labor medically managed under the many antiseptic rituals of the day and her birth medically managed by an obstetrician under antiseptic conditions, and she still died, then childbirth must really be extraordinarily dangerous.
Birth as a Dangerous Medical Condition -- another rational for expansionism
Having defined normal birth as a dangerous medical condition that always required the services of a physician, the next logical step was to eliminate those who provided physiologically-based maternity care. By this time non-allopathic maternity care had come to the attention of the Flexner Report and been placed on the list of verboten ‘healing art’. Their first target was midwives and the plan was remarkable successful. The winning strategy was two fold. First was an aggressive PR campaign in conjunction with the Hearst newspaper empire. Human interest stories that praised the miracles of obstetrical medicine were frequent. They informed the public that obstetrical care was the hot new way to have a baby – scientific, safe and superior in every way to that of a midwife. The second part of the plan was getting new legislation passed that made midwifery practice illegal in a majority of states.
The problem from the standpoint of healthy women was that physicians took over their care without being familiar with the philosophy or principles for managing normal birth traditionally used by midwives. They didn’t have any experience or skills in the physiological model care or appreciate the greater safety and other benefits afforded by adhering to physiological management.. By virtue of their allopathic training, they also did not acknowledge any of the psychological and social needs of laboring women. It goes without saying that they had little understanding of the dangers introduced by medical interference and surgical interventions.
From their standpoint, the care of healthy childbearing women was seen as an important source of clinical material, an opportunity to develop better skills in interventionist obstetrics. Chloroform, episiotomy, forceps and manual removal of the placenta was routinely used at every normal birth. This kind of clinical training was greatly appreciated, as it provided medical students a chance to learn surgical techniques and allowed graduate physicians to keep proficient in the use of obstetrical forceps. As the traditionally non-medical care of midwives was replaced by the medicalized care of physicians, the maternal mortality rate increased by 15% each year and the birth injury rate for newborns increased by 44% over the brief span of one decade (1910-1920). [yes/no citations here?]
However, the appalling rise in maternal-infant mortality did not deter organized medicine from its policy of eliminating midwives as birth attendants. The number of midwife-attend births fell from 50% to 13% between1910 and 1920. By 1930, the only ones left were black granny midwives in the Deep South. By the 1950s, the obstetrical profession had totally eradicated the midwifery as a respectable profession or legal form of care.
After midwives were out of the picture, non-obstetricians physicians were next on the1950’s version of the Flexner Report hit list. The same political and economical motives were applied to general practitioners and family practice physicians. But since these doctors were themselves allopathically trained, the issue was the usual doctrinal reasons. Instead, maternity care as provided by GPs and FP docs seemed to mock the longer, more rigorous education and surgical status of obstetricians. The party line was that obstetrics was a surgical specialty, and that every birth had to be attended by an obstetrically trained surgeon. That eliminated everyone from the ‘birth business’ but obstetricians. By 1980s, all forms of non-obstetrical maternity care – both FP physicians and midwives –had been eliminated in all but the poorest or most rural areas of the country.
Delivering on the Obstetrical Promise of Perfection – Bad Timing
For all the success that obstetricians had in eliminating midwives in the early decades of the 20th century, the original 1910 plan to medicalized maternity care suffered from a serious streak of bad luck. Actually, it was bad timing, or more specifically, being 50 years ahead of the curve. The “miracles” of modern medicine linked to 20th science had not yet been invented when obstetrics first began claiming the ability to prevent all childbirth ‘disasters’. In the early 1900s, at the same time that obstetrics was emerging as an independent profession, endemic poverty was the norm and a lot of over-worked and underfed women were both very sick and very pregnant.
Many strategies to prevent these tragedies were tried, but few were effective. The average doctor had plenty of reason to believe that childbirth was a near fatal condition. One issue was the danger inherent in the efforts to help, i.e. medical and surgical procedures, that often introduced iatrogenic (doctor or treatment-related) and nosocomial (hospital-acquired) complications. Historically, hospitals have always been a bio-hazardous environment. Before the discovery of antibiotics, hospitals were repeatedly plagued by epidemics.
The earliest decade of the 20th century was an era in which women with untreatable and potentially fatal diseases -- typhoid fever, diphtheria, TB, syphilis, high blood pressure, diabetes, heart disease, kidney infections, etc – were a huge proportion of the childbearing population. Complications in childbirth were common.
The very first ‘wonder drug’ (the sulfonamide family of antibiotics) did not become available until 1935. Before that, giving birth in a hospital greatly increased the danger that both mother and baby would die from a birth-related septicemia commonly called “childbed fever”. The culprit was hemolytic streptococcus – a virulent hospital-acquired infection. During the centuries before the invention of latex exam gloves, it was spread from patient to patient on the unwashed hands of doctors and medical students. The typical vector of infection was the common practice of having medical students and their obstetrical professors performed autopsies on all the newly delivered women who recently died and then doing pelvic exams on every woman in the labor ward that day. Childbirth septicemia was also spread by contaminated linens, dirty delivery instruments, unhygienic practices and the unsanitary conditions associated with institutional care.
Before the germ theory of disease was widely understood, doctors couldn’t figure out what was causing maternity patients to become septic and die, but they did realize it was provoked by aggregating childbearing women together in an institution. It was common knowledge among the medical community and the lay public that maternal and newborn deaths were several times higher for the poor and homeless women who delivered in charity hospitals than the general population of women who gave birth at home. This was even true for women who delivered precipitously on the hospital doorstep, before any medical care could be given (no vaginal exams or exposure to dirty linens, etc).
The Germ Theory of Contagion
The disease-causing role of bacteria and other microorganisms was not ‘discovered’ until 1880. Before that, seasonal epidemics of maternal and infant mortality sometimes reached as high as two out of every three women who delivered in the charity hospitals of Europe. The origin of this deadly infection was first established by an obstetrical professor in 1847. At the Vienna Lying-in Hospital, where by Dr Ignatius Semmelweis trained and taught, an average of two new mothers (and their babies) died every day, a staggering 700 a year. Between 1841 and 1846, 2,000 women died in the medical division.
In an effort to stop this carnage, Dr. Semmelweis searched for the reason why women who gave birth in his hospital died in great number, while women who gave birth at home did not. After months of meticulous study, he identified childbed fever as an iatrogenic and nosocomial disease by proving that the fatal septicemia was a direct result of purulent organic material (bacteria and human cells) carried under the fingernails of the obstetrical professors and medical students in his institution.
Before people knew about micro-organisms and prior the invention of sterile exam gloves, the specific practice in question was medical students doing sequential vaginal exams on healthy laboring women without having washed and disinfected their hands between each labor patient or between the dissection room and the maternity ward. As a result of this dangerous practice, undelivered mothers became contaminated with the hemolytic streptococcal bacteria and developed a virulent septicemia that caused an agonizing death within 72 hours.
At great risk to his own career, Dr Semmelweis brought these facts to the attention of the medical profession. As is so often the case, his good deed did not go unpunished [read Dr Semmelweis’ story in “The Cry & Covenant”]. Much to the consternation of his students and the medical staff, he instituted mandatory hand-washing in a weak chlorine bleach solutions, as well as instituting other aseptic techniques. He also forbid student who had attended an autopsy from entering the labor ward for 24 hours afterwards. In April of 1847, the frequent epidemics of childbed fever in the maternity wards of his hospitals immediately stopped.
His theories were diametrically opposed to the scientific opinion of the time, which blamed disease on bad air and many other fanciful explanations. They also insisted that washing their hands each time before treating a maternity patient, as Semmelweis advised, would be too much work. Last but certainly not least, doctors did not want to admit that they something they did was causing so many or their patients to die.
As a result, his professional colleagues never forgave him for exposing them to public ridicule and their revenge was sweet. While history knows him the “father of infection control”, his contemporaries were ruthlessly contemptuous of his ideas. He lost his reputation, then his position at the hospital and finally his ability to practice. In 1865, after a nervous breakdown, he died tragically in an insane asylum. He was only 47.
Medical Education & Medical Ethics Crash into One Other
Hospital-acquired infection has been acknowledged by medical professionals for centuries. Institutional setting of any kind have always been (and still are) dangerous places for babies, childbearing women, the elderly and those with suppressed or impaired immune systems, which unfortunately are the categories of people most likely to need and benefit from medical services. However, hospitals were also recognized by the profession to be a model of efficiency for teaching medical students. The key ingredient to effective medical education was clinical training. The word ‘clinical’ refers to ‘bedside’, but it is usually interpreted as “hands on”. Clinical training requires ‘clinical material’ and hospitals were an irreplaceable source for these all important teaching cases.
Clinical training was vital to acquiring the manual dexterity required to perform medical procedures, surgical operations and the deft use of obstetrical instruments such as forceps. These important skills would eventually permit doctors to rescue mothers and babies from serious or fatal complications of childbirth. Historically, clinical education was crucial to the development of “modern” medicine. But institutional care was a mixed blessing at best to those early maternity patients, and for too many, it cost them their life.
A frequent topic of discussion among obstetricians was whether they should move all their healthy maternity patients back out of the institutional environment in order to eliminate the frequent epidemics of nosocomial deaths. As long ago as 1880s, a professor of obstetrics at the Edinburgh Maternity Hospital in Scotland lamented the infectious dangers of aggregating pregnant women and babies in institutional settings and the virulent nature of the nosocomial disease among this cohort of hospitalized women.
In a paper presented to the Edinburgh Obstetrical Society Session in 1881, this professor detailed his disappointment about the obstetrical profession’s inability to eliminate nosocomial death in their own maternity wards. To the question of whether normal childbirth services should be moved back to the family’s home, he regrettably concluded that the proper training of medical students absolutely required the medical profession to perpetuate hospital-based maternity care for its access to the needed volume of ‘clinical material’. His observations ended with a Victorian rational by associating poverty with moral turpitude to explain the high maternal mortality rate among hospitalized maternity patients, thus relieving doctors of any responsibility:
“These maternal deaths … have been shown … to be striking in their frequency. In our own hospital I find that out of 10,043 women who have delivered in it, almost 2 percent or nearly 1 in 50 have died.
What then is the nature of this disease, which has proved fatal in our new hospital to one out of every 32 women who have been delivered here? And is it feasible to suppose that it can be prevented? I do not believe that we can hope to prevent puerperal fever entirely…. but I feel certain that by strict attention to antiseptics we shall be able to reduce its occurrence to a minimum and render its presence in hospital practice, where I have just said it is most common, a rarity.
….. To me it seems sufficiently established that maternity hospitals must exist, as much for the benefit of women at a time when they most need shelter and assistance, as for the clinical instruction which the medical student can receive there and there only.
It must be borne in mind that the majority of the intern cases [hospitalized maternity patients] are single women who have been seduced, and who, apart from their mental condition, ...have previous to admission, been in straitened circumstances and badly nourished, and are consequently specially liable to be quickly and gravely affected by any septic influence under which they may be brought. [Edinburgh Obstetrical Society Session 1880-1881 “On the systematic use of antiseptics in midwifery practice”; emphasis added]
The Medical Education Dilemma for American Obstetrics
At the end of the 19th century, the situation in the US was little better than described by the Edinburgh Obstetrical Society paper in 1881. The obstetrical education of doctors and the art and science of the profession depended entirely on hospital-based clinical training. But the end product of childbearing in institutions was an unnaturally large number of birth-related difficulties for the poor mothers who either had no choice or who graciously permitted themselves to be used as clinical material.
Approximately one out of 50 women still routinely died of hospital-acquired hemolytic streptococcus or iatrogenic complications surgical delivery, such as anesthetic accidents and hemorrhage. What proportion of these problems was the result of Mother Nature run amok and which were the detrimental effects of civilization is hard to say.
Whatever the origin of these problems, physicians were desperate to stop the disheartening carnage, which was both a humanitarian catastrophe and a profession frustration. People didn’t expect midwives to be able to treat these serious complications, but once a university-trained medical man (the preferred title for doctor) was called, it was embarrassing for him to stand by helplessly while a mother died. When you put all these things together, it is not surprising that obstetricians of that era believed pregnancy was “a nine-month disease that required a surgical cure”.
But improvements were in on the way. By the end of first decade of the 20th century, obstetrical medicine had advanced the care of pregnancy and childbirth with an improved knowledge of anatomy, the use of specially designed stethoscope the first time to monitor fetal heart rate during labor and the implementation of the germ theory, routine use of asepsis techniques in patient care.
It would take another 30 years before the most important life saving drugs used in obstetrical practice – antibiotics, anti-hemorrhage drugs, safer anesthetics and safer blood transfusions -- were developed. Without antibiotics, infection in hospital-based maternity care continued to be the leading cause of maternal death. This era was also before a safe version of an artificial hormone was available to safely contract a tired uterus after the birth to prevent excessive bleeding. Especially for women who had instrumental deliveries under general anesthesia, the rate of postpartum hemorrhage was very high. Without anti-hemorrhagic drugs and safe blood transfusions, this was still an untreatable, often fatal complication.
Down through the centuries, important obstetrical advances usually owed their development to ideas stimulated by clinical training. These ideas were developed through the trial and error experimentation made possible by access to a steady stream of charity patients who could be used as teaching cases in return for free care. Preserving hospital-based childbirth was seen as the bedrock of obstetrical professionism, the twin towers of scientific education and scientific advancement.
As observed by the Edinburgh professor, this all depended on adequate numbers of hospitalized maternity patients. As in the Edinburgh Maternity Hospital, the biggest threat to the orderly flow of clinical material was the many deaths from childbirth septicemia associated with hospital birth. The association between birth and death made people with other resources avoid hospital care if at all possible. To protect obstetrical education it was necessary to preserve hospital birth. To preserve hospital birth, it was necessary to protect its reputation. To protect its reputation, it was vital that that the obstetrical profession eliminate the fatal epidemics of hospital-acquired septicemia. In that regards, the interests of the obstetrical profession and the well-being of maternity patients were the same – ending this tragic and unnecessary loss of life.
This generated a conundrum between medical education, medical ethics, the welfare of the public and the perverse nature of the problem. You can’t have medical practitioners who are trained and effective and able to save lives in an emergency, without first having medical education. However, medical educations requires clinical training, which means both teaching cases and the plain fact that students must “practices” on patients, the way a student of music must practice the piano. Someone who is a just learning a skill will obviously make mistakes from time to time, perhaps even fatal one. For sure, the intern or resident will not have the same qualities of expertise that he or she will have many years done the road as a graduate physician.
Unless medical students are afforded an opportunity to learn on actual patients who have real medical problems, we can’t have the very thing we value most, which is access to skilled medical practitioners. This makes clinical training something of a perverse round robin. But the risks associated with being a teaching case is seen differently when the patient is already sick or seriously injured. These patients might have died anyway, from whatever was making them sick. It’s difficult to tell if their death was caused by the original illness or the medical student’s treatment.
These ethical issues are even a bigger problem as in obstetrics, because it provides care to a healthy population. In order for obstetrical interns and residents to develop diagnostics skills and clinical judgment, the obstetrical education process must expose a certain percentage of perfectly healthy women with normal pregnancies to the happenstance of the clinical training process. That’s good for society. But the price of that social benefit for any individual woman may be enormously high – death or life-long disability of mother, baby or both. It’s a conundrum without any easy answers.
How Normal Birth Became a Surgical Procedure in 1910 & Why It Matters Now
What follows might best be thought of as a forensic examination of how and why childbirth morphed into the category of a surgical procedure during the first decades of the 20th century. It continues to track the historical conundrum of clinical training versus patient safety but the real issue for us in the 21st centry is its impact on contemporary maternity care practices. For contemporary readers, many aspects of this story may seem to be a ‘distinction without a difference’, but in the world of medicine, these distinctions make a world of difference. Let’s start by identifying the major players -- the individuals who made most of the critical decisions -- and by defining the concept of ‘medical’ versus ‘surgical’.
In 1910 the most famous and influential American obstetricians were Doctors Joseph DeLee and J. Whitridge Williams. Today these two obstetricians are considered to be the fathers of modern American obstetric and are credited with developing the ideas that have become our current method of providing obstetrical care. Both fervently believed that only the pre-emptive use of the most aggressive means could reduce the large number of maternal and infant deaths occurring in their patient population. Today we would recognize iatrogenic or nosocomial causes to be the deciding factor in a majority those deaths. Drs DeLee and Williams would not have agreed, believing as they did that the real problem was the pathological nature of childbirth itself.
Up to this point in the history of obstetrics, the ‘delivery’ was already identified as a medical procedure, which was a knowledge-based situation, not too different than contemporary midwifery. As a medical procedure in1910, the purpose of the professional’s presence was for what they knew, that is, recognizing the signs of an impending problem, or God forbids, if a problem should in fact occur, the idea that they would “know what to do”. Today we might describe this as medical supervision of the birth.
For women with complications of delivery, for example, cephlo-pelvic disproportion (baby tight fit for pelvis) that required forceps or a retained placenta that had to be manually removed, medical knowledge and medical skills were an important contribution. But when it came to preventing the nosocomial infections that frequently followed a normal childbirth, birth as a medical procedure seemed to make no difference. In fact, physicians of the day described puerperal sepsis as a maddeningly persistent disease that defied their very best efforts. The more they did, the more the answer seemed to elude them and the problem would just pop up somewhere else with twice as many mortalities.
The next iteration in the war against childbirth ‘disasters’ was a bold move by DeLee and Williams. They were so determined to eliminate nosocomial epidemics of puerperal sepsis in hospital maternity patients that they took the extreme position that hospitalized birth – that is, the ‘delivery’ – had to be conducted under conditions of surgical sterility – no different than having brain surgery or an abdominal operation.
The idea of surgical ‘sterility’ as we know it today is little more than a 100 years old. It was not until the discovery of anesthesia in the 1840s to control the inevitable pain of surgery and 40 years later, the germ theory of disease and the use of sterile technique to prevent the infection that surgery became a reasonably effective form of medical treatment. Before this time, the public was rightly frightened of invasive techniques and the use of surgical instruments. Due to infection, they were extremely dangerous and correctly seen by the public as a method of “last resort”. In 1910, the idea of germ-free techniques was in its infancy, as it took several decades to figure out how to best use aseptic, antiseptic and sterile techniques to prevent the inevitable contagion associated with hospital-based care.
When the ‘delivery’ first morphed from merely a medical procedure conducted by a physician, to a ‘surgical procedure’ performed by a physician, the original purpose of this designation had nothing to do with performing an operation such as a Cesarean. The original purpose of birth as a surgical procedure was focused simply on eliminating the nosocomial complication of puerperal sepsis. The proposed solution was to tighten the screws and carry aseptic technique to its ultimate conclusion. Birth as a surgical procedure actually describes an organizing principle related to the guarantee of an absolutely germ-free or ‘sterile’ state.
Since sterility was a recognized precursor for surgery, the medical profession typically refers to this degree of asepsis (which extends to control of the total environment), as ‘surgical sterility’ and any ‘procedure’ that requires sterility as a ‘surgical procedure’. However, birth under conditions of surgical sterility does not necessarily mean that surgery, such as episiotomy, forceps or a Cesarean section, is being performed. Technically-speaking, one can conduct normal birth under totally sterile conditions without cutting or penetrating human tissue or inserting the surgeon’s hands into a sterile body cavity, such as the uterus.
Whether or not any real ‘surgery’ is to be done, birth as a surgical procedure still calls for an elaborate and expensive (capital-intensive) institutional system. It is necessary to provide the proper environment and a supportive professional staff. Not only must the mother be in a hospital, but in a special, restricted part of the building with a germ-free environment and special facilities with special equipment – scrub sinks, changing rooms, lockers, stretchers, OR tables and lights, instrument trays, anesthesia machines, oxygen, suction, etc --, giving rise to a whole genre of the medical-industrial complex. Of course, the hospital staff needs special training and special clothing -- scrub suits, caps, masks, shoe covers, etc. The birth attendant must do a proper surgical scrub of hands, don scrub hat, shoe covers and surgical mask, then be helped into a sterile gown by the nurse and finally put on sterile gloves. All instruments and other materials will have been sterilized and laid out on a sterile instrument table.
These special circumstances logically extend to the mother herself. When the time came to give birth, the physician was notified and the labor patient moved by stretcher to an OR-style delivery room. She also had to be “scrubbed” with antiseptic solution, draped with sterilized sheets and above all, must lie perfectly still and touch nothing. It is very difficult (read this as nearly impossible!) to assure that a childbearing woman in the throes of a natural labor, pushing hard with every contraction, lying on her back while working to get her baby uphill and around that infamous corner (the Curve of Carus), will be able to stay still and not accidentally touch any of the surgically sterile drapes. Dr Delee’s description of this problem is particularly colorful. The word he uses for obstetrician is “accoucheur”:
“Antiseptic surgery has very properly given way to aseptic surgery. An example will illustrate the need for this: A parturient is ideally prepared for delivery, with sterile night-gown, sterile leggings, sterile sheets and towels, all safely pinned together , with a sterile towel under the buttocks, leaving only the vulvae orifice exposed; the accoucheur is dressed as for a major laporotomy.
What happens? The woman, in her throes of pain, tosses about, disarranging all the sterile covers; she grasps the hand of the attendant, or puts her hand over the sterile towels to the vulva; she coughs or expires forcibly and the droplets of saliva are blown on to the sterile cloths; the second stage drags on, one, two, or three hours, dust settles on the extensive area of sheets, leggings, towels, gloves, gowns, basins, etc., which are supposed to be sterile.
How many of these things are really sterile when the actual time of delivery arrives and may safely be touched?” [ DeLee 1924 obstetrical textbook, p. 338, emphasis added]
Nurses routinely restrained the mother’s hands with heavy leather wrist restraints to keep her from touching anything sterile. Then the mother was put to sleep with general anesthesia, all as a part of the process of protecting the sterile field. In light of Dr DeLee’s bitter complaint about how “the second stage drags on, one, two, or three hours, dust settles on the extensive area of sheets, leggings, towels, gloves, gowns, basins, etc.,” this no doubt influenced his enthusiasm for the routine use of episiotomy and forceps. Dr DeLee genuinely believed that instrumental delivery was a beneficial procedure that “saved” both mother and baby from the ravages of childbirth disabilities, but contemporary science does not agree with this opinion.
However, the use of chloroform anesthesia made episiotomy and forceps necessary for all but the most expedient of deliveries, in order to reduce the harm from the anesthesia. Any laboring woman who was kept under general anesthesia for “one, two, or three hours”, might herself die from the effects of the anesthesia and certainly her baby would not be able to breath spontaneously after its birth. It is a truism that allopathic practices often gives rise to ‘side-effects’, which can at times be worse than the condition they were to prevent or the disease they were to treat.
In the minds and hearts of obstetrical profession, birth as a surgical procedure was both final frontier and final solution. If a maternity patient were to become septic after all these elaborate rituals of surgical sterility and surgical delivery, doctors could at least say they had “done everything possible”, since they provided aseptic care equal to major surgery. This, it turns out, is a precursor the use of the same expression by obstetricians today regarding Cesarean section. When a Cesarean is performed, one benefit to the practitioner is that he or she can assure the family that ‘everything possible’ had been done, again shielding the medical profession from the shadow of culpability for any kind of bad outcome.
But in 1910 protecting the physician from liability was not as high on the list as the most important benefit. That honor went to the preservation of obstetrical education via the continued presence of a large pool of hospitalized maternity patients available for clinical instructions. For a host of reason having little to do with the conduct of a surgical ‘delivery’, hospitals were eventually able to stop the epidemics of puerperal sepsis. A generally improved understanding of aseptic technique, steam sterilization (autoclaves) and better training for nurses all contributed. While individual mothers still got infections, it was no longer at the level of public scandal. The discovery of sulfa in 1935 vastly improved the ability of obstetricians to counter the problem of nosocomial infections.
Other serendipitous advantages of surgical delivery included its ability to relieve doctors from having to hang around during the long, slow tedious hours of labor. Timing of the birth could be controlled thru the use of forceps deliveries. Also by renaming birth as a surgical procedure, nurses and midwives were both disallowed from attending births, since ‘performing’ any surgical procedure by a nurse or midwife would be an illegal practice of medicine. This restricted childbirth services to ‘doctors only’, and put doctors into the center of the childbirth equation, making the doctor’s role more central than the mother’s. As a surgical procedure, the doctor was the most important person in the room. As expected, this monopoly drove up the professional fees the public was expected to pay.
Within the first decades after DeLee and Williams invented the surgical delivery as a sterile procedure, the original reason – elimination of nosocomial epidemic of childbirth septicemia – began to get lost. Gradually the idea of ‘surgical’ sterility morphed in the notion that normal birth actually was surgery – like a hysterectomy. Instead of just a sterile technique and sterile environment, it required an obstetrically-trained surgeon. The point no longer just sterility, but the technical skill of performing an operative delivery. This contributed greatly to the idea that it was inappropriate for GPs and family practice physicians to provide maternity care, as they weren’t trained as obstetrical surgeons.
It is just a fluke of history that the epidemic nature of puerperal sepsis in hospital settings of the end of the 19th centuries so influenced and defined the development of maternity care for healthy women in the US for the entire 20th century. This accident of history turned labor into a medical condition and normal birth into a surgical procedure and eliminated the traditional, non-medical care of family practice physicians and midwives.
The Continuing Legacy of DeLee and Williams’ Brand of Obstetrics
Fear and distrust of normal biology were a primary attribute of Dr. DeLee and Dr. William’s relationship to childbirth, as was an enormously ambitious plan to make obstetrics in a powerful new surgical specialty. Their brand of obstetrics was franchised all across American between 1910 and 1930, defining the standard of care and generating the policies and practices that underlie our industrialized form of childbirth. However, the health of childbearing women and the abilities of modern medical science were vastly different by end of 20th century than they were at the end of the 19th century. But despite this enormous improvement, the idea of an obstetrical model as the standard for all maternity care has never been reexamined.
For the entire 20th century, obstetrics in the US has been defined by the belief that medical and surgical interventions were necessary in each and every normal childbirth. Medicalized practice differed very little between the routine care of healthy women with normal pregnancies and those with pre-existing diseases or complications. Both groups of childbearing women were treated in essentially the same, interventionist manner.
As a result, industrialized childbirth, with its emphasis on standardization, doesn’t make a distinction between those interventions necessary to treat or prevent a serious complication and what is better described as interference. Interference is what happens when these same ‘interventions’ are applied to women who don’t need, want or benefit from them. Today, we recognize the iatrogenic or nosocomial harm associated in unnecessary interference with the biology of normal birth. But for most of the 20th century, it was assumed that the benefits of obstetrical intervention to far outweighed any detriment. In fact, the obstetrical profession generally credits its interventive form of care – the pre-emptive strike --for the improved maternal-infant outcomes that occurred during the 20th century.
However, advances in maternal-child health in the United States during the 20th century are primarily the result of a dramatically standard of living. The most important contributions were brought about by public sanitation projects, better access to education, a better diet, adequate housing, improved working conditions, appropriate access to medical care when needed, the safety net of social programs and access to effective contraception.
Twentieth century obstetrics played an important role for those with complications of pregnancy and childbirth, but has been unable to make normal childbirth safer for those who were already healthy. This system has been very good for the very sick mother-to-be or the very complicated childbirth (30%), but not so good overall for healthy women (70%). No medical devise, drug, surgical instrument or operative procedure developed over the millennia of western culture has been able to make birth safer in healthy women with normal pregnancies than spontaneous labor and normal birth.
Now, in the 21st century, the health of the childbearing population is generally excellent. Childbearing in healthy women with normal pregnancies is not fundamentally dangerous and does not routinely benefit from surgical skills. The fact that human species has survived and thrived for untold millennia before the adoption of the obstetrical methods in early 20th century attests to the biological success of normal birth.
Even for older mothers, the problems associated with delayed childbearing are primarily infertility and prematurity, neither of which is relevant to giving birth normally at term. Contemporary obstetricians attributes the increased Cesarean rate to an older childbearing population and bigger babies – both of which are a small but legitimate source of difficulties, but statistically unable to account for these wildly inflated numbers. In our time, more than 90% of today’s women are healthy when they conceive and 70% are still healthy and have a normal pregnancy at term. With science-based maternity care and appropriate physiological management of labor, they would have every good reason to expect to have a normal and spontaneous vaginal birth.
However the relationship of the obstetrical model to normal childbirth has changed very little since being standardized in 1910. It still applies a fixed set of obstetrical interventions to both low and high risk women. The combined rate of labor induction and operative delivery in 1910 was only about 10%. But as women got healthy and medicine got better every decade, the rate of obstetrical intervention inexplicably and illogically increased each and every decade. Obstetrics is an “expert” system that has failed most in the very area it was supposed to have the most mastery and expertise -- preserving the health of already healthy mothers and babies.
While the ratio of pregnancy complications in 2007 is many times less than it was in the early 1900s, obstetrical interventions have sky-rocketed all out of proportion to the number of complicated pregnancies. In a remarkably healthy population of women a quarter of all labors were induced in 2005. The number of episiotomies, forceps, vacuum extraction and Cesarean sections performed on healthy mothers is over 70 % of otherwise healthy vaginal births.
For our 21st century purposes, the idea of normal birth as a surgical procedure has long outlived its usefulness, if, indeed, it ever was an effective intervention.
Go on to Part Three
The final section examines “The Perfect Storm”, the intersection of unmet expectations, litigation and the obstetrical escape clause – “when it doubt, cut it out”
NIH wades in the elective Cesarean debate and muddies the waters
The Obstetrical Escape Clause – an explanation of ‘when in doubt, cut it out’
The Politics of Reconciliation -- a green rainbow coalition – a planet friendly happy ending, in which everybody wins
