Historic & contemporary problem for midwives, California families & taxpaying public ~ overview-part 1

link back to: “Dr. Bishop tells our story for us — why doctors need to have supervision removed from the LMPA”

Editor’s Note: Eventually I will add a bibliography with links from this post to the supporting documents, as well as stand-along excerpts from exceptionally informative resources, such as the results of the 3 different “Listening to Mothers” surveys by Childbirth Connection (formerly Maternity Center Association of NYC).

The problem of affordable maternity care for childbearing families and the taxpaying public starts with the lack of access to physiologically-based care during pregnancy and childbirth for healthy women. I know that ‘physiological’ is a long word, and unclear concept, but if you just think of this as ‘normal care for normal birth’ you can’t go wrong.

Unlike many other developed countries, healthy pregnant women in the US are primarily cared for by physicians trained in the surgical speciality of obstetrics, instead of family practice physicians and professional midwives. Countries with low rates of medical intervention for normal childbirth generally provide low-tech, high-touch maternity care. In this model the most frequent birth attendant  is a professionally-trained midwife who is providing care within the mainstream healthcare system.

Not only is this a far more cost-effective system, but these countries also have much better maternal-infant outcomes. The connection between cost-effective, hands-on care and better outcomes is not a new phenomenon. These same European countries had dramatically lower rates of maternal-infant mortality as far back as 1900*.

However, this model of affordable, maternity care was the road not taken in America. As a result, a cost-effective maternity services were not, and still are not, a normal part of the healthcare system in the United States. Instead Americans, including California residents, spend more on maternity services any other country (more than double), and still have dismal maternal-infant outcomes — we rank 42nd in maternal deaths and 50th for infant mortality.

This is a peculiarly American problem that developed over the last hundred years. During the early 1900s the medical profession didn’t fully understand which childbirth practices reliably made things safer, and which had serious side-effects that increased the frequency  and seriousness of complications.

Compared to other developed countries, maternal and infant mortality rates in the US were shockingly high during this era, with at least 10,000 new mothers dying every year (MMR 1910). During the pre-antibiotic era of early 20th century maternity care,  3 times more mothers died in the US than in Western Europe (200 vs. 675 per 100,000 live births). This embarrassing international situation had both the public and the medical professional looking for an immediate solution.

Unfortunately the abilities of medial science in 1910 were still very rudimentary.  It would be another 40 years before antibiotics were discovered. Doctors were not yet able figure out which women and which pregnancies were high risk, as many modern diagnostic tests and ultrasound imaging had not yet been invented. For pregnant women with Rh-negative blood types there was no way to eliminate the potentially-lethal complications for their unborn babies. There were still no safe blood transfusions for women with other serious medical complications. Safer anesthetics and better surgical techniques weren’t available until after World War II.

Given the limitations of medical science, the experts of the time concluded that the best way to reduce maternal mortality was to dramatically change the way the medical profession treated normal childbirth. Their recommendation was a highly-medicalized system of obstetrical care to be uniformly applied to the entire childbearing population — healthy women as well as those with medical problems.These grand ideas were dramatic and bold, as well as drastic in their effect AND magnitude, affecting over 2 million mothers-to-be every year and represented the most profound change in childbirth practices in the history of the human species.

These policies called for the elective hospitalization of laboring women. However, the hospitalization of maternity patients on a large scale introduced its own problems. During this pre-antibiotic era (prior to 1937) the leading cause of death in new mothers was infections — childbed fever (i.e. puerperal sepsis). Without access to antibiotic drugs, this one complication caused  a third of all maternal mortality.

The vast majority  of these deaths from sepsis occurred in hospitalized maternity patients. In the very early 1900s, hospitals had a very bad reputation and were seen as places of last resort. The majority of hospitalized maternity patients were homeless, mentally ill, petty criminals or very poor who couldn’t pay a doctor or midwife to provide care in own their home. Medically-indigent women received free care in teaching hospitals by agreeing to become ‘clinical material’ for medical students. People of means avoided hospitals like the plague (bun intended).

To make this new plan work, the obstetrical profession had to address the bio-hazards and contagion that naturally occurred whenever large numbers of childbearing women were aggregated together. Influential obstetricians decided the most effective method for preventing the spread of puerperal sepsis to treat normal birth as a surgical procedure. That meant the same sterile protocols that doctors used when performing abdominal surgery. The obstetrical profession was confident these new protocols would eliminate, or at least dramatically reduce, the majority of potentially-fatal birth-related  infection.

The principles of aseptic technique and surgical sterility were originally developed in England by Dr. Joseph Lister in the 1870. For obvious reasons, “Listerization” referred to the use of these protocols.  In order to Listerize normal childbirth, the very last few minutes of 2nd stage labor (when the baby was expected to be born very soon) was re-defined as a surgical procedure to be performed by physicians. This surgical activity was re-named the “delivery” and provided with a surgical code used for billing and the daily hospital census.

These new childbirth practices included the routine use of ‘Twilight Sleep” during labor. Women were given a injections of narcotics for pain and the amnesic-hallucinatory drug scopolamine to block the mother’s memory of the labor. Administration of these drugs was repeated every few hours until the birth was imminent.  At that point general anesthesia (ether or chloroform) was used to render the mother unconscious during the surgically-conducted delivery. This consisted of a series of surgical procedures that included the routine use of episiotomy, forceps, manual removal of the placenta and suturing of the perineum.

Doctors of that era expected the pre-emptive use of these medical and surgical interventions to dramatically and permanently reduce birth-related complications, resulting in a vastly improved mortality statistics. For the first time, the United States would be on a par with England and other comparable European countries.

These unprecedented changes in childbirth practices were the product of a remarkable different decision-making process than we are use to today. Modern standards for implementing  untested medical treatments or new policies are generally based on scientific research.

But in the early 20th century, the concept of evidence-based medicine (EBM) did not yet exist. At that time the general standards for new forms of medical care were based on the opinion of medical experts — in the case, influential obstetricians of that era.

It is a mere happenstance of history that modern obstetrics in the United States developed during the first half of the 20th century, in a pre-antibiotic world that lacked so many of technologies we think of as “modern medicine”.  As a direct reflection of this experience our modern model of obstetrical care was molded by the grim realities and 19th century thinking they produced.

This kind of thinking both rejected physiologically-based care for normal childbirth (they claimed birth was intrinsically pathological) and abhorred the practitioners that provided it – midwives. The intrinsically fearful attitudes it spawned turned healthy childbearing women into the patients of a surgical specialty, labor into a potential medical emergency, and normal childbirth into series of surgical procedures ‘performed’ by physicians in hospitals.

Our modern system has dutifully maintains all these traditions, and added undreamed of interventions, dozens more medical treatments, encourages the casual use of surgical procedures and the ‘normalization’ of Cesarean surgery as an equally safer and therefore a better way to have a baby, since it saves the mother and baby the time and trouble of having to labor.

This system systematically attempts to control midwifery our of existence, and when that doesn’t work, to be as adversarial and uncooperative as possible. The legacy of it all is an unaffordable, not cost-effect, not safe system that significantly affects childbearing families, midwives, taxpayers, state budgets and the federal deficit.

Topic continued ~ part 2-a ~ The impact of these new policies on the historic profession of midwifery in the US (link right below)