word count 3933 as of Jan 17-2025
Chapter Two ~ Birth Dangers in a Pre-scientific World
However, not all problems associated with childbirth can be prevented by patience or correct positioning. In a pre-scientific, pre-technological world, the normal support of midwives was often not enough if the childbearing woman suffered from a serious disease, became ill during the pregnancy, the labor became abnormal or the birth was otherwise complicated. In such cases, childbirth could and often did become dangerous.
As the centuries passed, more and more people left their safer natural environments and healthy life styles migrated to big cites where poverty and crowded unsanitary living conditions resulted in malnutrition and diseases for which there was no treatment at that time.
By the early Middle Ages, an increasing percentage of childbearing women were unhealthy. This resulted in many complicated pregnancies and a high mortality rate that were not the result of any deficiency in “normal” biology but rather reflected a negative impact of civilization on childbirth as a result of social forces including ignorance, superstition and unnatural circumstances imposed by city life and crowded urban environments. Untreated complications meant that mothers and newborn babies with serious problems could and did die.
By the Middle Ages, people began to think of childbirth itself as generally dangerous. Unfortunately, they were confusing ‘cause’ with ‘effect’. Nonetheless, it poisoned the water of public opinion. This set the stage for the next four centuries of the most drastic changes in childbearing practice to ever occur in the history of the human species.
The Renaissance – 16th and 17th century Europe
It was not until the “Age of Enlightenment” that the fledgling concept of “scientific inquiry” began to root. The scientific method is usually described as a systematic approach consisting of observation, testing and evaluation that forms the basis of telling the scientific from the superstitious. The scientific method follows a series of steps:
- identify a problem you would like to solve,
- formulate a hypothesis,
- test the hypothesis, (4) collect and analyze the data,
- make conclusions.
Other authors add the comment that the scientific model is inefficient but highly successful method of knowledge construction based on experimental testing of hypotheses. These definitions all add that no theory is worth its salt until it has been rigorously ‘tested’ by these method and thus can be said to be scientifically validated.
In regard to the field of medicine, the “new science” of obstetrics was still in its very early infancy in the 1600s. By today’s standards, it was also mostly ineffective. Inexperienced doctors inadvertently caused harm on many occasions. However, in the case of an obstructed labor “medical men” or barber-surgeons were called on to remove the dead child through the use of surgical instruments. In a pre-technological world, the cause of this all-too-frequent birth complication was a common pelvic deformity known as rickets, in which fragile, decalcified bones of the pelvis collapse in on one another, trapping the fetus inside. Rickets is the result of malnutrition and inadequate exposure to sunshine, both well-known hazards of poverty in a smoky urban environment.
Once medical men were invited into the birth chamber, the 5,000 year-old relationships between midwives and doctors was permanently destabilized. Ideas began to percolate in the minds of doctors, and especially professors of medicine, that doctors (who indeed were called in when things went wrong) should be more involved in the process of childbirth. In particular, childbirth should be taught to medical students, since such knowledge was vital to the ability of graduate physicians to provide care in complicated cases.
There were some problems with this plan, since it was a crime and a scandal in many parts of Europe during the Middle Ages for male physicians to be present during labor and birth. Because of this the medical profession had to depend on midwives for their information.
Original Obstetrical Knowledge Gleaned from the Midwifery Profession
While the goal was a noble one, the way doctors went about it was far less so, colored as it was with the natural chauvinism and class prejudice of the times. Instead of mutual effort by physicians and midwives to reciprocally share knowledge with one another, it became a one-sided arrangement that consisted primarily of a century-long appropriation of the intellectual property of midwifery by the medical profession.
For thousands of years the technical understanding of the normal course of labor and birth resided in the hands and heads of midwives as the intellectual property of their profession. This knowledge included the evaluation of unusual or abnormal situations and development of special skills to be used by the midwife when abnormalities arose and eventually teaching this specialized knowledge to the next generation of midwives.
From Time Immemorial to the 15th century this body of knowledge was passed down from one generation to the next as an oral tradition. Only after the invention of the printing press (the direct antecedent of the Internet in function and scope!) could this knowledge base be committed to paper and transmitted widely as textbooks on the practice of midwifery*. But a century after publication of the first textbooks on midwifery, intellectual property developed by midwives over many millennia was quietly incorporated into obstetrical textbooks. The original source for the obstetrical knowledge base on normal childbirth was gleaned from the discipline of midwifery.
* the word ‘midwifery’ continued to be used for 3 more centuries to describe normal maternity care, whether provided by a female midwife or male doctors. The use of the word ‘obstetrics’, which now refers only to the medical practice of obstetrics by physicians, did not uniformly replace the classical meaning of midwifery until the 1920 in the US and 1960s in the UK.
Scientific Study of Anatomy
Simultaneously with access to midwifery textbooks there arose a whole new process for learning vital information about the human body. This was the study of the anatomy of childbearing through the new science of anatomical dissection. This unique information was added to the totality of what was known about the field of childbirth. Texts on midwifery and knowledge of anatomy from vivisection permitted physicians, with no professional experience or first-hand information on childbearing, to learn, teach and eventually practice, using the combined knowledge of both traditions.
While the medical community was only too happy to benefit from the intellectual property of midwifery, the physicians of the day did not play well with others, nor share with midwives the knowledge learned from dissection or other insights leading to a better understanding of the normal process of childbearing and more effective treatment of complications. A modern-day researcher, writing in 1975 on the issue of medical advances not shared reciprocally with midwives remarked that:
“The passage of midwifery into the mature stream of medical advances has resulted in the parturient [childbearing] women gaining the benefits of (fetal) auscultation, a more complete knowledge of anatomy and asepsis as it developed. Yet, due to the status of women, these advances were kept largely within the circle of male practitioners and thus did not influence the care of the many uncomplicated confinements [managed by midwives] which the physician did not attend.
Conversely, at least in the US, physicians had little contact with midwives and never learned their useful traditions, among them patience with nature. During the 19th century, obstetricians in England and the US wished to show the scientific nature of their profession. Moreover, in the United States, the dignity of the [obstetrical] profession was thought to be threatened by the practice of midwives.” [DeVitt, 1975]
However, obstetrics did do quite a stellar job of franchising this hybrid form of obstetrical knowledge all across Europe as it slowly synthesized knowledge from these dual sources and improved its ability to successfully intervene in complicated births. At its most rudimentary level, the earlier generations of doctors could not save both mother AND baby, but rather were forced to choose between either mother or baby. The invention of forceps and other improved medical and surgical interventions meant that doctors were eventually able to preserve the life of both mother and baby in many cases of obstructed labor.
Institutionalizing Medical Education
The earliest version of hospitals, as we know them today, was in Western Europe and those early hospitals also became a place for both treatment and the clinical training (i.e. hands-on) of medical students. However, 400 years ago hospitals were dramatically different in form and function from modern-day acute-care institutions.
Originally they were charity hostels (often run by Catholic nuns) that arose during the Middle Ages in Europe to house the indigent. They were the perfect place for medical schools to teach students, as they provided a steady stream of ‘clinical material’. In a fairly short time hospitals became organized around medical education. In exchange for room, board and medical care, street people who were sick become ‘teaching cases’ for medical students.
In these charity hospitals unmarried pregnant women who were unable to work (and without family or friends) would find shelter and care in the maternity wards, living on this ‘hospitality’ for 2 or 3 months before their babies were born. While no money was exchanged, the price for this free care was very steep. Even in the best institutions, an average of 1 out of every 128 childbearing women died. In the ‘average’ charity hospital, the number of maternal deaths was more like 1 out of 50 and sometimes, for months at a time, the number rose to 1 out of 3 mothers.
Physicians recognized early on that aggregating childbearing women together in an institutional setting resulted in a drastic increase in maternal and infant mortality. They also observed that indigent women who gave birth on the doorsteps of the hospital, prior to admission to the maternity wards, were remarkably free from this scourge, as were their newborn babies. All of these facts were well known to both hospital staff and townspeople. However, no one could provide a good explanation of why.
The epidemic killer of healthy women had little to do with pregnancy complications or the normal biology of labor or birth. Newly delivered mothers were dying of puerperal sepsis, or childbed fever, acquired from contaminated bedding, dirty instruments or the unclean hands of medical students and physicians. This was an unintended consequence of carrying the potentially fatal bacteria of hemolytic streptococcus on their ungloved and unwashed hands from autopsy room of women who had just died from puerperal sepsis to the vaginas of healthy laboring women. Medical students fresh from the dissection lab routinely went from one bed to the next, examining the entire line of laboring women one after another, and thus spreading infection from mothers who died from puerperal sepsis to every woman who was in labor that day.
All this occurred before there was any scientific knowledge of the role of microscopic organisms (bacteria or germs) in causing of childbed fever and other infections. The concept of contagion between two or more infected patients was not understood, nor the idea of hands, instruments or equipment becoming contaminated with purulent organic material. Sterile technique had not yet been developed yet. But even more important, this was before the invention of exam gloves and at a time when hand washing by physicians and med students was considered to be absurd and insulting.
Even after the role of bacteria and contagion was more widely understood as the cause of childbed fever, many obstetrical professors laughed at the idea of prophylactic hand washing in chlorinated lime or a weak solution of carbolic acid (aseptic techniques developed by 19th century physician-scientists Doctors Lister, Semmelweis and Pasteur). Decades later, after the bacterial cause of puerperal sepsis was generally agreed upon by thoughtful scientists around the world, many of these same professors continued to insist that ‘the healing hands of a physician could never be a source of harm’.
As a result of this dangerous practice undelivered mothers became contaminated with the haemolytic streptococcal bacteria during labor and developed a virulent septicemia that caused death within 72 hours. Before the discovery of antibiotics this high mortality was inevitable. During the 18th and 19th centuries ten to fifty percent of maternity patients (both mother and baby) died in the teaching hospitals of Europe from hemolytic septicemia. In the large institutions, this meant two or more deaths a day. One historical account describes the tolling of the bell by the monks as they carried out the body of another mother who had died and the eerie effect that the sound of the tolling bell had on everyone.
According to historical records, the all-time worst epidemic of contagion occurred at the University of Jena, when not a single mother left the hospital alive for four years in a row. Of course, it was these lethal infections from iatrogenic sources that accounted for the observation by doctors and maternity patients alike that it was safer to give birth on the doorstep of the hospital than in its delivery rooms. As would be expected, this horrific rate of death from puerperal sepsis also gave rise to some very wrong theories about the origin of this infection, most of which blamed childbearing women for somehow being “dirty”. This mistaken theory of “autogenic infection” was the origin of the 20th century OB prep (shaving off public hair and administering enemas to laboring women), a practice that continues today in some places.
Home Versus Hospital, 1881
In regard to epidemic levels of maternal-infant mortality from infection, obstetricians also had formal discussions among themselves on the vastly higher death rate for hospital births versus “private practice” (women attended in their own homes). A renowned professor of obstetrics from Edinburgh, Scotland lamented in 1881 that: “…maternal deaths or deaths during childbed – by which is meant death occurring within four weeks after delivery, — have been shown to be striking in their frequency” … “The present Maternity Hospital, being a necessity, and puerperal fever having been shown to exist there, and to have been the direct cause of death in 1 out of every 32 women …. ”
Academic papers on the topic were published in professional journals. In a paper published by the Edinburgh Obstetrical Society in 1881 about the use of aseptic techniques in childbirth, this same professor wrote that: “ …. the mere aggregation of lying-in women [in hospitals] is itself a cause of danger”. He went on to say:
“What I believe to have been the origin of the disease, [is the] the want of a separate mortuary and the performance of post-mortem examinations in the hospital. Since that report, the fault has been remedied and the hospital thoroughly and repeatedly disinfected. Notwithstanding all this, the deaths from puerperal fever have continued. Yet during that period there has not been recorded a single case of death from a similar cause in the extern practice [i.e., births occurring at home]… although the births at ….. home are double, amounting to 625, and the general death rate is only 1 in 156 [compared to 1 in 32 for the Edinburgh Maternity Hospital].”
Despite the high mortality associated with hospitalization of maternity patients, the conclusion arrived at by medical professionals was that hospital birth was a necessity, as it was the only place for indigent women and the training of medical students.
“… 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 [birth occurring in hospitals instead of the family home] 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 … specially liable to be quickly and gravely affected by any septic influence under which they may be brought.”
The Germ Theory & Surgical Sterility ~ Barely a Hundred Years of Enlightenment.
Few people realize what a short time separates us and the ‘bad old days’, when the pathogenic role of bacteria and the behavior of germs were invisible and unknown. The idea of surgical ‘sterility’ itself is little more than a 100 years old. It was not until 1881 that a French physician, Dr. Louis Pasteur, established the central role of microbes — commonly known as ‘germs’ or ‘pathogens’– in causing illness and infection.
On a chalk board at a prestigious medical meeting Dr. Pasteur drew a graphic representation of what the streptococcus bacteria looked like under a microscope — rectangular microbes that resembled a string of box cars on a train track — and said “This, gentlemen, is the cause of Childbed Fever”.
With this discovery, Dr. Pasteur delivered the fatal blow to the erroneous and dangerous doctrine of ‘spontaneous generation’ — the theory held for 2000 years that life could arise spontaneously in organic materials. Understanding microorganisms was a natural discover for Louis Pasteur as his father was a vintner and techniques to achieve bacteria-free surfaces are basic to wine making. In order to prevent mold from growing on the fermenting wine, the wine bottles must be sterilized by boiling and their sterility maintained until filled and sealed. Dr Pasteur also developed “pasteurization”, a process by which harmful microbes in perishable food products are destroyed using heat, without destroying the taste or nutritional value of the food.
It was not until the discovery of anesthesia in the 1840s to control the inevitable pain of surgery and then 40 years later, the germ theory of disease and use of sterile technique to control the infection, that surgery became a reasonably effective form of medical treatment. According to history, the first-ever obstetrical operation — a Cesarean — was done in first century Rome to extract a living child from its dead or dying mother. Chloroform anesthesia made it possible to do Cesareans on living women and sterile technique made it possible for women to survive the operation. Other obstetrical surgeries such as episiotomy and the use of forceps were greatly enhanced by anesthesia and sterile technique. It did not take long for operative obstetrics to become the new “wave of the future”.
The A to Z of Childbirth Under Conditions of Surgical Sterility
Birth as a surgical procedure actually describes an organizing principle related to the guarantee of an absolutely germ-free or ‘sterile’ state. Since sterility is a recognized precursor for surgery, the medical profession typically refers to this as ‘surgical sterility’ and to any ‘procedure’ that requires sterility as a ‘surgical procedure’. However, conducting birth under conditions of surgical sterility does not automatically mean that actual surgical ‘operations’ — such as episiotomy, forceps or manual removal of the placenta — are being performed. One can technically conduct normal birth under totally sterile conditions without using instruments to cut or penetrate human tissue or inserting the surgeon’s hands into a sterile body cavity (such as the uterus).
However, ‘conditions’ of surgical sterility remain the same, which is to say, it still requires a special germ-free environment (special cleaning and restricted access), all surfaces and materials must be sterilized and the birth attendant must do a proper ‘surgical scrub’ of hands, don a 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. The mother likewise must be “scrubbed”, 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 throws of a natural, unmedicated labor, pushing hard with every contraction, lying on her back while working to get their baby uphill and around that infamous corner (Curve of Carus), will be able to lie perfectly still, not moving or accidentally touching any of the surgically sterile drapes, Since the mother isn’t wearing sterile surgical gloves, her touch would technically “contaminated” the any sterile surface or material she touched. If the physician’s sterile glove were then to comes in contact with any of these “contaminated’ surface, it would officially ‘breaks’ sterile technique, which is of course a real ‘no-no’. So to preserve the sterility of the physician’s gown and gloves, it is imperative that everything else be maintained in its most absolutely sterile state.
In order to keep women from touching anything sterile, nurses routinely restrain the mother’s hands in heavy leather wrist restraints (same as used in psychiatric wards). Then the mother was put to sleep with general anesthesia, all as a part of the process of protecting the sterile field. More recently, epidural anesthesia has taken over the role of making a childbearing woman into a suitable surgical patient who can stay still and not touch. As a result, wrist restraints are now seldom used. And some institutions have relaxed, the definition of “proper” sterile barb, permitting the obstetrician to omit some part of the usual regime, such as gown but no scrub cap, or surgical mask but no sterile gown, etc.
The Law of Unintended Consequences
The point of all this detail is to make it easier to see why the tail wags the dog in regard to the surgical procedure of birth. These technical requirements for sterility, which are perfectly correct for the performance of actual surgery, are absolute and by their very nature must dominate the entire process. The biological, psychological and social needs of childbearing parents – all else – must be subsumed under the rules of surgical sterility and surgical technique. Unfortunately this virtually erased the parents and the social nature of childbirth from the picture for the first seventy-five years of the 20th century.
This didn’t happen because obstetricians didn’t like childbearing women. It happened because doctors were afraid that if they didn’t impose this strict sterility on childbirth, this perfectly lovely young mother, in the bloom of good health, would get infected and die. And certainly for indigent women giving birth in the charity hospitals of Europe in the 16th century, this sterile technique would indeed have been life-saving. It is just a fluke of history that the epidemic nature of puerperal sepsis in hospital settings of the 18th and 19th centuries has so influenced and defined the development of maternity care for healthy women in the US in the 20th and now the 21st century.
The Other Way – Aseptic Technique
Normal birth can also be successfully conducted as an “aseptic” event. In fact, aseptic technique is the statistical standard used around the world by midwives and physicians in both home and hospital births. The conditions for aseptic technique do not overshadow the mother’s psychological and social needs and it is less expensive than surgical sterility. Aseptic technique entails the use of materials and supplies that are guaranteed clean and dry (technically ‘aseptic’). That means that nothing ever touches the mother that has ever come into contact with the body fluids of another person, or sources of ordinary dirt, such as the floor.
Under aseptic conditions, sterile supplies are used anytime an instrument or gloved hand must enter into a sterile body cavity or touch tissues that have been cut or lacerated. However, the doctor or midwife do not have to be “gowned and masked”, the mother does not have to be in a ‘special’ place, the family including other children can be present. When it comes to bio-hazards, the safest place (most free of pathogens that would make the mother or baby sick) is the family’s own home. Necessary sterile supplies are a pair of sterile gloves, a sterile scissor to cut the cord and a sterile clamp to tie it off. Accompanying this short list is the use of lots of clean linens, paper towels, plastic-backed disposable underpads and half dozen disposable diapers, sanitary napkins and appropriate trash receptacle.