Word count 1824
Chapters Five
Twentieth-Century Birth ~ An Unofficial century-long Medical Experiment with more than a 100-year run
The 20th century medicalization of labor and birth in the US was remarkable more for scale than substance. It systemized the complete loss of physiological management and eliminated important attributes such as ‘patience with nature’ and ‘right use of gravity’. Implementing this form of obstetrical management as the ‘standard of care’ triggered the most dramatic changes in the history of normal childbearing during the 20th century. For women with complicated pregnancies these changes were often positive. For the 70% of women who were healthy, normal pregnancies, the change was not good. The thesis of this medical experiment was the idea (more correctly a hypothesis) that medicalized childbirth would eliminate dysfunctional labor, obstructed birth, perinatal deaths and cerebral palsy.
However, there was no solid evidence to support this hypothesis. The high level of very serious intervention was further complicated by the suddenness of it all. The really accelerated curve for taking over the “obstetrical material” of midwives and reconfiguring them as obstetrical patients was from 1910 to 1920. That is a very short time to work out the bug of something so big and complicated as eradicating the biology of normal childbirth. But the obstetrical profession rose to the occasion by developing a variety of methods they hoped would reduce these problems including the routine use of anesthesia, episiotomy, forceps, manual removal of the placenta, perineal suturing and drugs to treat hemorrhage and eventually, drugs for infection.
What this meant to the childbearing population was that they were no longer cared for at home by their midwife or family physician but instead admitted to hospitals where their labors were managed by professional nurses (whom they did not know) as a ‘medical’ condition. Normal birth was no longer a process of biology belonging to the laboring women, for which she engaged the help of others to assist her, but which was clearly her own accomplishment. Instead birth was now something accomplished by doctors and nurses, a commodity or a product of the medical profession — something you couldn’t do yourself. It was like engaging the services of a surgeon to remove your appendix, only now doctors took you to the delivery room to “remove” your baby. Had you asked to see the studies on this new ‘surgical procedure’, you’d have found out that medicalized childbirth was a ‘hypothesis’ still in the ‘experimental phase’.
That said, it is only fair to also acknowledge the many important new discoveries and inventions during the first forty years of the 20th century as the science of obstetrics. Ways to artificially induce labor, such as balloons or ‘boogies’ inserted into the cervix to pry it open and drugs injected into the mother to start or speed up labor were developed and used. The design of forceps was improved (several times), the fetascope for listening to heart tones was invented and became indispensable, the basic understanding of the effects of labor on fetal heart rates (which eventually lead to the invention of the electronic fetal monitoring in 1960s) was published by Dr DeLee in 1924, ‘twilight sleep’ was introduced (narcotic and amnesiac drugs) and first use of a crude form of oxytocin (labor-stimulating hormone) and ergotamine occurred. Surgical techniques and anesthesia administration were improved, making Cesareans many time safer that before. However, C-sections were still only performed as a ‘last resort’ because of the risk of serious complications from anesthesia, hemorrhage and infection.
As for the experience of laboring women, that was not improved. Mothers-to-be were kept in bed, heavily medicated with narcotics and isolated from family members. Normal childbirth (now called ‘the delivery’) was to be conducted by a physician as a surgical procedure, ‘performed’ in a sterile operating room on an unconscious women. Of course, fathers (or other family members) were not allowed. This style of medicalized management resulted in a host of difficult labors, including failure to progress and the need to narcotize mothers since the pain of laboring in bed on one’s back was too great to tolerate without medication. For no apparent reason newly delivered mothers suffered massive hemorrhages and some still got fatal infections or infected episiotomy incisions. Other unexpected difficulties included babies that appeared to develop ‘fetal distress’ for no discernable reason, who were stillborn or so depressed at birth they required resuscitation.
Despite what it appeared to be powerful tools to control labor and birth, there was in the background the really dark side of everyone’s worse fears – babies inexplicably born with permanent neurological damage, cerebral palsy and other severe mental and physical problems sometimes referred to as ‘birth injuries’.
All these interventions were a valiant and well-meaning attempt to eliminate the tragic complications of childbirth including stillbirth, brain damage, cerebral palsy and damage to the mother’s pelvic floor. Doctors did not intervene to be mean or out of a disregard for the health of their patients. They were good people who had high hopes, they believed in what they were doing. The question (both unanswered and unasked) was could the medical model delivery on its promise?
The Fix is a Failure
Unfortunately for obstetricians, the same measures of safety that lead to the original condemnation of medical education in 1910 — poor outcome statistics and a high level of maternal and infant mortality and morbidity — revealed the ‘fix’ to be a miserable failure. One physician of the era (Dr. Bolt) identified an increase in maternal deaths of 15% per year for more than a decade and a 44% rise in birth injuries during exactly the same period (1910 to 1935) that coincided with the displacement of midwives by physicians and healthy women became obstetrical patients.
According to a contemporary paper entitled “The Elimination of Midwifery in the United States — 1900 through 1935” by Dr. Neal DeVitt :
‘“The Committee on Maternal Welfare of the Philadelphia County Medical Society (1934) expressed concern over the rate of deaths of infants from birth injuries increased 62% from 1920 to 1929. This was simultaneous with the decline of midwife-attended birth and the increase in routine obstetrical interventions, due in part to the influence of operative deliveries.”
In 1937 Dr Guttmacher pointed out the problem with the following comments about maternal-infant mortality in the US:
“Let us compare the operative rates of these relatively dangerous countries (USA, Scotland) with those of the countries which are safer. In Sweden the [operative] interference rate is 3.2 percent, in Denmark it is 4.5, while in Holland …. it is under 1 percent.” “What is responsible for this vast difference in operative rates? … Analgesics [narcotic drugs] and anesthetics, which unquestionably retard labor and increase the necessity for operative interference, are almost never used by them in normal cases; and more than 90 percent of their deliveries are done by midwives unassisted. And midwives are trained to look upon birth as a natural function which rarely requires artificial aid from steel or brawn. [emphasis added, 1937-A]
NOTE –> The problem was that physicians took over the practice of midwifery without any idea of the philosophy, principles or techniques required for the practice of midwifery — the ‘social’ or physiological model of birth.
They coulnd not bring themselves to acknowledge the psychological and social needs of laboring women or appreciate the greater safety and other benefits afforded by respect for and strict adherence to physiological management. Most important of all, they had no understanding of the dangers introduced by medical interference and surgical interventions.
Instead physicians saw the care of healthy childbearing women primarily as an educational opportunity for them to develop better skills in interventive obstetrics. This was done by routinely using chloroform, episiotomy, forceps and manual removal of the placenta at every normal birth. This reflected the idea that medical students needed to learn these surgical techniques and graduate physicians needed to keep current on these skills, so that when forceps were actually necessary, they would be proficient. The lay public doesn’t appreciate how hard it is to use any instrument of force in the “J” shaped birth canal of a childbearing woman. Since babies don’t come out like a train comes out of a tunnel, you can’t just “pull” them out with the medical equivalent of tongs or a toilet plunger. Learning how to navigate that 60-degree angle, officially called the “curve of Carus” after professor of anatomy and obstetrician Carl Gustav Carus who first described it as the “parturient axis” in 1789, is a difficult skill.
Much of obstetrics is the story of how hard it is to fool (or fool with!) ‘Mother Nature’. The history of forceps is the record of the various ways the medical profession has tried to “work around” the problems caused by that 60-degree angle. In particular, how hard it is to get an undamaged baby out of the unconscious, anesthetized (or numb) body of a laboring woman who can’t push her baby out (perhaps because of the anesthesia) or for whom the anti-gravitational position and weight-bearing on the pelvis works directly against the natural (and necessary) characteristics of pelvic mobility.
Hard as it is for a mother lying on her back to push her baby uphill around a 60-degee angle, consider how much more difficult it would be for the doctor to accomplished the same things by pulling on the fragile skull of an unborn baby “from below” (standing on the floor in front of the pelvis), with enough force to get the baby to go around the corner and emerge at an uphill angle (i.e., baby’s head pointing towards the ceiling). The many bad maternal-infant outcome statistics of the era reflected the poor outcomes that resulted from pulling heavily narcotized babies out from below with forceps.
The Obstetrical Profession Confuses ‘Cause’ and ‘Effect’
In a systemized effort to “fool” Mother Nature, anesthesia, episiotomy, forceps, manual removal of the placenta and stitching up the episiotomy not only became ‘routine’ but quickly also became the “standard of care”. Unfortunately, anesthetic deaths, postpartum hemorrhage, infection, newborn brain damage, stillbirth and long-term gynecological complications associated with the use of forceps (such as incontinence) followed in the wake of this ill-conceived and unscientific model of care.
Equally sad for the obstetrical profession, the actual cause of these poor outcome statistics turned out to be the very thing that the obstetrical profession considered to be the ‘big deal’, the brightest hope of its profession, its best talent, its raison d’etre – the ‘creative’ and prophylactic use of drugs, anesthesia and surgical interventions. However, the interpretation by medical professionals was an exactly inverted opinion. In their minds the bad outcome statistics only proved that birth was even more pathological than they already imagined. They were (and remain) convinced that what was (and is) needed to correct the problem was (is) ever more drastic interventions, done sooner and applied to more and more cases of otherwise healthy pregnancies or normal labor.
(When I retired from L&D nursing in 1976, this was still the obstetrical standard of care, except that general anesthesia was slowly being replaced by spinals or epidural anesthesia)
