Part 1 (of 2) 01-28-2020
How 19th-century obstetrical thinking still dominates childbirth practices in the United States
Why understanding the history of obstetrics is the first step in creating a 21st-century maternity care system for healthy women based on the principles of physiological support for normal childbirth
The Basic Problem: Misplaced fear, lack of trust, inadequate or incorrect information about normal childbirth
There has been a wide-spread misunderstanding about the actual dangers of normal childbirth in the United States for more than a century. The lay public and American medical profession often see dangers where there are none, while at the same time they also fail to appreciate the substantial dangers introduced by the routine medicalization of normal childbirth in healthy childbearing women with normal pregnancies.
Historical Circumstances ~ Part One: Obstetrics in America
The historical practice of obstetrics in late 19th century America was part of the general (i.e. non-surgical) practice of medicine as provided general practitioners (GPs). If the patient of a GP needed an operative delivery, he was forced to call on the services of a gynecological surgeon. This often caused delays and other practical problems; it also was frequently accompanied by a difference of medical opinion between these two doctors that caused contention and even hard feelings.
To eliminate these professional problems and advance this field of medicine, the surgical specialty of gynecology combined with the medical discipline of obstetrics in the early 1900s to form the surgical specialty known today as “obstetrics and gynecology”. As surgical specialists, the role of Ob-Gyn doctors has always been to treat life-threatening complications of childbearing by using various medical and surgical interventions developed specifically for that purpose.
Because these early 20th-century obstetricians were only called in emergencies, they experienced childbirth as fought with danger. Just as police officers who deal with criminals all day-every day tend to see lawlessness everywhere look, so obstetricians tended to see normal childbirth thru a lens that focused tightly on its dangers. Given the life-threatening complications that doctors saw with such disturbing frequency in the early 1900s — long before birth control was available to married women and 40 years before the development of antibiotics, safer anesthetics and blood transfusions — it was logical for doctors to assume that childbirth itself was fundamentally defective and dangerous.
In fact, early 20th-century textbooks identified normal childbirth as a pathological aspect of female reproductive biology. Dr. Joseph DeLee, a famous obstetrician of that era and his contemporaries, erroneously concluded that normal childbirth was actually a cruel trick of Mother Nature, who had crafted a sacrificial process for human females similar to that of salmon that always die after spawning. Quite naturally, these assumptions applied to all childbearing women, included the great majority of healthy women with normal pregnancies.
Dr. DeLee and his contemporaries saw all childbirth services as a fight btw a vicious Mother Nature, who historically did her best to kill each and every new mother, and the obstetrical profession. In this perspective, the only way to stop the biologically-programed sacrifice of new mothers was the early and frequent use of obstetrical interventions. Each and every time a doctor was called a so-called ‘normal’ labor and birth, he was grateful for the weapons lent to him by modern medicine — forceps to pull the baby out quickly before the mother died, and in dire situations, a scalpel to perform an emergency Cesarean (itself a very dangerous intervention during the pre-antibiotic era).
Under such circumstances, it was also logical to assume that the same medical and surgical interventions that so successfully treated obstetrical complications would, if used prophylactically, correct for all Mother Nature’s obvious mistakes.
Obstetrical care became the default standard for all childbirth services in the US specifically because it routinely medicalized all phases of normal childbirth in all childbearing women. It is a process designed to get the results it produces.
It is a process designed to get the results it produces.
The Problem ~ Part two ~ Physiologic Childbirth practices & midwives
Because obstetricians saw labor and birth as a pending emergency, the idea of physiological care as provided by midwives and country doctors was seen as so inadequate and old-fashioned that it constituted substandard or negligent in the new world of scientific medicine.
This early 20th-century bias against physiologic childbirth was institutionalized in medical school curriculums, as successive generations of medical students were faithfully taught that normal childbirth was a pathological form of female physiology. This gave rise to a comment still used today that characterizes “Mother Nature” as a “bad obstetrician“, therefore equating the natural biology of childbirth as undependable and potentially dangerous.
As a result, the aggressive or “preemptive” use of obstetrical interventions has been seen as the superior model of care for the last century. As noted earlier, obstetrics became the standard form of maternity care specifically because it routinely medicalized all phases of normal pregnancy and childbirth in all childbearing women. A fundamental misunderstanding and disdain for the appropriate use of physiologic childbirth practices dominated the practice of obstetrics throughout the 20th century and it continues to define the obstetrical perspective in the 21st century.
When obstetrical medicine is used to diagnose and treat abnormal conditions and the complications of childbearing, the results are unprecedented in their effectiveness, and truly are ‘miracles of modern medicine’. It goes without saying that we are all grateful for the ability of obstetricians, in conjunctions with other modern medical services, to save lives and relieve suffering of childbearing women with serious complications.
This is indeed the ‘right use’ of obstetrics and we wouldn’t want it to be any other way.
But the surgical specialty of obstetrics and gynecology went way beyond this appropriate role. They genuinely believed that the prophylactic use of obstetrical interventions could and would eliminate, or at least drastically reduce, all serious complications of childbearing. Unfortunately these same obstetrical interventions and surgical procedures, when used pre-emptively as a routine aspect of standard care for healthy childbearing women with normal pregnancies, introduce unnecessary risk and are associated with a long list of iatrogenic complications.
In military terms, this is described as “right tactic, wrong terrain” — that is, the idea has merit but it is being applied in the wrong circumstances. Routinely using obstetrical intervention as the standard of care for healthy women is a ‘wrong use’ of obstetrics. In other words, the idea itself has great value, but is being applied in the wrong circumstances. In this case, the universal application of these interventions to healthy women can also represent another military phenomenon known as “mission creep“.
But historically the obstetrical profession did not see any problem with its medicalizing of normal childbirth. From its perspective, it was clearly able to outsmart “Mother Nature”; the only thing standing between them and their ability to make these life-saving services universally to all childbearing women was the midwifery profession. In obstetrical terms, this was known as “the midwife problem”, which was soon attacked by its best and brightest minds. By 1910 these influential obstetricians began to formally lobby state legislatures all across the country for obstetrics to be defined as the universal standard of care for all childbirth services under all circumstances and for the lawful practice of midwifery to be ‘phased out’ as quickly and quietly as possible.
To help sway public opinion to their side, leaders in the obstetrical profession implemented a public relations campaign in newspapers, radio programs and women’s magazines. It enthusiastically promoted obstetrics as the new, better, smarter — in fact the ONLY way — for a “modern woman” to safely have a baby. This was also accompanied by a barrage of articles portraying midwives as ignorant and dirty and their care as outdated and dangerous. Many of these articles urged women not to choose a midwife and husbands not to allow their wives be attended at home by a midwife.
The same uncritical acceptance of the same unscientific premises that began in 1910 (the notion that physiological childbirth practices are dangerous) has continued unabated and unchanged for a hundred years. The nature of this problem “right tactic, wrong terrain” is with us to today as the contemporary problems and iatrogenic-nosocomial complications of an obstetrically-based maternity system routinely using obstetrical interventions on healthy women with normal pregnancies.
What really is the problem?
What kills childbearing women and their unborn/newborn babies and causes a life-time of disability and social ostracism has been the same throughout all history periods and all over the world.
The five most important dangers of childbearing
The five most important dangers of childbearing have far more to do with contemporary social and political barriers that reflect pre-scientific periods of history, geography, economics, social prejudice, and personal mental problems than the basic biological characteristics of normal childbirth.
The historic danger of childbearing was to live before the development of scientific medicine. The geographical danger of childbearing is to live in parts of the world that don’t have a functional (scientifically-based and effective) healthcare system. The economic danger of childbearing is to live in a country with a profit-based medical system that is so expensive the family can’t afford necessary care. The social danger of childbearing is to belong to an ethnic or religious culture that rejects the use of modern medicine. The personal danger of childbirth is to be a pregnant woman unlucky enough to have mental or emotional problem that causes her to reject life-preserving maternity services.
While the biological dangers of childbirth for mothers and their unborn/newborn babies are real, risk of death and long-term disabilities become vanishingly small when childbearing women have access to a healthcare system that provides effective maternity services and necessary medical services.
Currently, the most dangerous place in the world to be a childbearing woman has a MMR of 2,000 per 100K live births – that is one death for every 50 births. If you have 7 or more children, your chances of dying in childbirth are as high as 1 out of 8.
In a 21st century world, 99 times out of a hundred the problem is not the biology of pregnancy and childbirth but the inability, for whatever reason, to access to life-sparing maternity care and perinatal services.
Whether that is because a woman can’t afford care, it geographically unavailable to her, or prejudiced individuals deny care to people of your color or ethnicity, your husband who won’t ‘allow’ you to use medical services under any circumstances – childbearing is a potentially deadly condition that results in tragic deaths of mothers and babies because normal childbearing was isolated from the modern maternity care process and appropriate use of elective and emergent medical services when needed.
So the 4-part answer is so simple it may shock or even anger the reader:
it is lack of access to a modern (i.e. scientific and effective) healthcare system that provides maternity care to all childbearing women (regardless of ethnicity or ability to pay) by that is:
- Accessible, affordable and acceptable to the women it services
- provided primarily by non-obstetricians (midwives and GPs)
- includes referral to scientifically appropriate medical services as needed
- these medical, obstetrical & perinatal services are provided in a safe, timely and effective manner
This universal safety net includes initial and on-going screening for abnormal conditions and complications (with appropriate referral to medical services), routine prenatal care, a train birth attendant (midwife or physician) present throughout active labor, birth and immediate postpartum-neonatal period, with follow-up care routinely provided to new mother and baby and appropriate use of medical services any time a complication develops or the mother requests medical care.
What is vitally important – the core issue — is that modern and comprehensive healthcare systems exist, that childbearing women have access to it (i.e. no racial, ethnic discrimination and family is able to pay for needed services) and the childbearing family is willing to use such services (i.e. no religious beliefs that preclude medical care or introduce gender-related barriers to receiving such care).
Concepts of “safety” in regard to maternity care must factor in its acceptability to childbearing families. Relative to regulations about the practice of California licensed midwifery, any regulation that leaves pregnant women without the legal options of midwifery care and thus forces them into highly-medicalized but unwanted hospital obstetrics or lay mfry or unattended labor and birth, is functionally a denial of services that introduces totally unnecessary risks for both mother and baby. Many of these women have very real, very respectable reasons for declining hospital-based obstetrical care as a ‘risk-reduction strategy that
Many of these women have very real, very respectable reasons for declining hospital-based obstetrical care as a ‘risk-reduction strategy that unfortunately does NOT in their particular case actually reduce the risk to them, or it exchanges one set of risks (ones acceptable to the family) for a set that are may actually higher (ex. unwanted repeat Cesarean) and/or otherwise unacceptable to that particular family. This is particular an issue for women with PTSD as a result of prior physical or sexual abuse or a previous traumatic birth experience.
Any law or regulation that creates an ipso-facto denial of services represents a one-dimental definition of ‘safety’. Whether this happens as a result of politics or genuine concern, any law that prevents childbearing women from receiving the care they need is a bad law. Time for a little Nancy Reagan “Just say No”.