Historical Context for Contemporary Obstetrical Policies – a work-n-progress

by faithgibson on January 8, 2013

in Contemporary Childbirth Politics, Historical Childbirth Politics 1820-1980

Part 1 ~:~ The most profound change in childbirth practices in the history of the human species

The Invention of the American Way of Birth:

How healthy childbearing women became the patients of a surgical speciality and normal childbirth was turned into a surgical procedures ‘performed’ by medical doctors under general anesthesia 

Most people assume that the way obstetrics is practiced today is the way it always was, but our so-called ‘modern’ American obstetrics (as it reflects the policies of ACOG) is a relatively resent invention. Through out the 19th century, obstetrics was part of a non-specialty practice of medicine often referred to as ‘man-midwifery’. This was a hybrid form of midwifery practiced by GPs, who mainly used physiologic management but frequently added the use narcotics for pain, episiotomy and forceps for prolonged labor or ‘big’ baby or first-time mother, and the manual removal of the placenta to shorten the third stage of labor. By 1910, this classic view of obstetrics as a medicalized practice of midwifery was replaced by the ‘new obstetrics’ as a brand new surgical specialty. This was an American invention promoted by a handful of influential American obstetricians, with Dr J. Whitridge Williams and Dr. Joseph De Lee  leading the way.

The new obstetrics as a surgical discipline was a whole new ball game. Obstetricians saw this drastic reshaping of childbirth practices as the exciting and modern solution to the age-old problem of unexpected, unexplainable complications seen so frequently in a pre-antibiotic era. At the same time, these obstetrical leaders realized that what they were proposing would require that all medical students be educated in these new ideas and clinically trained in the art and science of obstetrical surgery.  As a surgical discipline, that meant had a hospital-based medical training that could provide a steady stream of ‘clinical material’ — that is, access to large numbers of maternity patients to be used as ‘teaching cases’ .

Hospital-centric training created, at least a temporary, an impediment to professional development of the new surgical speciality.  At that time in history (1900-1930), a third of all maternal deaths in hospitalized maternity patients were the result of deadly infections — ‘childbed fever’ or puerperal sepsis — in the days following a normal birth. If the leaders of the new obstetrics couldn’t find a way to reduce the incidence of maternal mortality, doctors would never be able to convince healthy women to seek out hospital maternity care, which in turn would hobble the ability of to clinically train physicians and to advance the new profession of obstetrics.

To reduce the risk of maternal deaths from childbed fever, influential obstetricians of the era decided to ‘Listerize’ childbirth. This meant adopting the principles of surgical sterility developed by Sir Joseph Lister (Royal surgeon to Queen  Victoria) to prevent post-op infections referred to as ‘hospital fever’.  Normal childbirth as a sterile surgical procedures was originally introduced during a pre-antibiotic era in an effort to reduce the frequency of deadly childbirth-related infections, which were particularly risky for maternity patients giving birth in an institutional setting.

An important obstetric textbook of the period flatly rejected the idea of childbirth as a normal or healthy function of female reproduction. Pregnancy was officially referred to as a “nine-month disease requiring a surgical cure”. Its author, Dr. Joseph DeLee, was a skilled and compassionate obstetrician with many admirable personal traits. He owned a small private lying-in hospital in inner city Chicago that served an immigrant population. He was known to provide care to the poorest of these women without charge.

However, his 1913 textbook he states that labor and birth, if viewed properly, are pathologic processes that damage both mothers and babies “often and much.” In the first issue of the American Journal of Obstetrics and Gynecology, Dr DeLee proposed a sequence of interventions designed to save women from the “evils natural to labor.”

No less a historical figure than Dr J. Whitridge Williams, chief of obstetrics at Johns Hopkins from 1911-1923, likewise believed there was no place for physiologic care (non-medicalized man-midwifery) in the modern practice of obstetrics: He said, “That word ‘physiological’ has all along stood as a barrier in the way of progress.” 

This perspective gave us a pathology-oriented model of childbirth in which healthy women with normal pregnancies became the patients of a surgical specialty. Labor was seen as a pending emergency to be managed as a medicalized event by professional nurses. Normal childbirth was to be conducted as a surgical procedure by an obstetrically-trained surgeon. The focus of health care during childbirth changed from “responding to problems as they arose to preventing problems” [ref: Judith. Rooks], which gave rise to the ‘pre-emptive’ use of medical interventions, anesthesia and surgical procedures.

Based on a perspective that often characterized pregnancy as a ‘nine month disease that required a surgical cure”, obstetricians were taught to control the course of labor and birth through the routine use of interventions, a policy that was applied equally to women who were healthy and had normal pregnancies as it did to high-risk patients. These policies normalized the pre-emptive use of obstetrical intervention, made medicalized care the standard for labor and turned normal spontaneous birth into a surgical procedure performed by physicianson women rendered unconscious by general anesthesia.

This policy was directly responsible for the most profound change in childbirth practices in the history of the human speciesIt was implemented all across America without first having tested the fundamental hypothesis — that of replacing physiological management of normal childbirth in healthy women with the routine medicalization of labor and the conduct of normal childbirth as a surgical procedures. Neither to general idea or  individual elements (such as right use of gravity vs. routine use of low-forcepts) by conducting clinical studies, RCTs or any other form of scientific analysis that contrasted outcomes associated with strict obstetrical management in a healthy population to outcomes of physiologically-based model of care in a matching cohort.

No scientifically-conducted studies or statistical research was ever done that identified surgeons as the preferred choice for providing primary care for a healthy population or that supported the routine use of obstetrical interventions and invasive procedures as a better model of maternity care. Nor was there any established scientific basis for re-assigning laboring women to a passive role, one that routinely rendered them unconscious under general anesthesia while the doctor delivered their baby, often assisted by episiotomy and forceps.

“In Johns Hopkins Hospital,” said Dr. Williams, “no patient is conscious when she is delivered of a child. She is oblivious under the influence of chloroform or ether. [Twilight Sleep: Simple Discoveries in Painless Childbirth, Dr. H. Smith Williams; 1914, p. 67]

It is just a fluke of history that a hundred years later we are still using the idea of normal birth as a surgical procedure, one that is still billed under a surgical code. This idea was originally introduced during a pre-antibiotic era in an effort to reduce the frequency of deadly childbirth-related infections, which were particularly risky for maternity patients giving birth in an institutional setting.

AUTHORITY-BASED MEDICINE: For two thousand years,  the “art and science” of western medicine (a history traceable to Hippocrates in ancient Greece) was conducted as an authority-based discipline. No one had ever heard of ‘evidence-based’ medicine or ideas about applying rigorous research techniques to all aspects of health care prior to adopting them. Instead, advances in medical policies and practices were implemented on the direct authority of influential doctors and other leaders in the field who claimed to have a new or better idea. In a less technologically developed age, choices were often limited and drastic measures were simply accepted as the best choice among a host of lesser options.

EXPERIMENTAL MEDICINE: By today’s standards it seems irrational and unacceptable not to predicate important medical practices on strong scientific evidence, but this was normal until just 30 or so years ago. In 1976, the 2,000 year history of unchallenged authority of medical practitioners fell victim to its own excesses and simultaneously, to the inexorable momentum of modern science. In the wake of a scandal about 30 years  of experimental research on syphilis done on a black population in Tuskegee, Alabama, President Carter appointed a federal Commission on Bioethics. This engendered a paradigm shift in thinking that is still re-shaping the dynamic field of healthcare.

This new perspective spurred the passage of federal laws that defined any new medical practice, drug or treatment for which safety and effectiveness had not yet been scientifically established, to be an ‘experimental’ practice of medicine. No longer was society willing give away its responsibility for its own well-being by blindly trusting doctors to always know what was best for their patients. For the first time, their were laws that required physicians and other practitioners to provide full disclosure and obtain the patient’s fully-informed and voluntary consent before the patient could receive unproven medical treatments or be enrolled in a clinical trial.

Unfortunately, these insights made no difference in childbirth practices. The 1910 configuration of obstetrics as a new surgical specialty for a healthy population — and all the interventions and invasive procedures associated with the obstetrical model of care — was never thought of as an experimental practice of medicine, not at the time and not since. So in 1976, no one thought to question the authority of the obstetrical profession to continue using an unproven interventionist model of obstetrics as the universal standard of care. By default, the ‘new obstetrics’ was grandfathered in to mainstream medicine by assuming that obstetrical policies and practices of intervention in normal childbirth had been put to the test and determined to be based on type 1 & 2 scientific evidence. That was not the case.

However, the classic principles and practices of physiologically-based care used routinely before 1910 — physical and psychological support, taking care not disturb the normal biological process, non-drug methods for coping with pain, an upright and mobile mother who moves around during labor and makes right use of gravity during second stage, the idea that it was the mother how gave birth under her own powers and that the proper role of the birth attendant was to assist and help her. Instead these non-medical activities, philosophies and supportive forms of care were no longer seen as time-tested ‘traditional’ ways, used successfully  for millennia. In the post-1976 world, physiological management was now described as an unproven “alternative” method, the use of which was in violation of the new ideas of evidence-based medicine.

By not acknowledging these traditional methods to be a proven aspect of midwifery and instead re-labeling them as an unproven and experimental form of medicine, the principles of physiological care were easily dismissed by the obstetrical profession. This permitted the historical anti-physiological bias of the obstetrical profession to continue on as before and translated into an aggressive,  even hostile rejection of physiologically-based care. These ideas and techniques were defined as having NO legitimate place in the  practice of medicine. In recent years, ACOG has taunted consumer groups and the midwifery profession to ‘prove’ the legitimacy of each and every elements of physiologically-base care via by RCTs.

EVIDENCE-BASED MEDICINE — EXCEPT FOR ACOG: In the 34 years since the controversial issue of experimental medicine came to light, both the medical profession and society has recognized the value and embraced the benefits of evidence-based medicine. In spite of this, ACOG has still not reevaluated the historical assumptions about childbirth practices made during a pre-antibiotic era, even though these outdated ideas were implemented without being  established as safe and cost-effective and continue to underpin contemporary care during normal childbirth in the US.

Nor has ACOG put policies in place that require RCTs to be conducted on all new obstetrical interventions before they are allowed to become standard practice. This is particularly relevant to the introduction of continuous electric fetal monitoring (EFM) in the 1970s and the current high-level of elective use of induction (33%) and operative delivery, which underpins our current 32% Cesarean rate. This highly interventive form of maternity care for a healthy population is an unproductive expensive that entails immediate, delayed and downstream risks of complications that affect a woman’s contemporary health, future childbearing ability and her wellbeing as she ages.

As an “expert” system, obstetrics has failed in the very area it was supposed to have the most mastery and expertise — preserving the health of already healthy mothers and babies.

Physicians Spokespersons for Medical Science

Physicians are the natural spokespersons for the scientific discipline of medicine. While that status bestows many privileges, it also comes with additional responsibilities. The very fact that Doctors of Medicine (MDs) are holders of a doctorate (equivalent of a PhD) in the science of medicine gives the public and the press every good reason to believe that formal statements made by physicians about matters of health, safety and medical care are unbiased, scientifically-based and factually correct.

This places a unique social burden of both candor and accuracy on doctors by virtue of their advanced education and license to practice medicine, with its legal power and elevated level of trust and respect. This results in a higher standard of ethical conduct for MDs than the mere recitation of personal preference or professional self-promotion. This high ethical standard would include a duty to communicate only scientifically valid information in a public forum unless such statements are identified as a personal, political or corporate opinion.

As amply demonstrated by the literature, many of those with a doctorate in medicine are not living up to their obligation to speak and act on the best scientific evidence. This has recently as been argued by state medical boards in regard to ‘expert witness testimony’ by MDs in disciplinary cases and other litigation that licensed physicians have a legal or “due diligence” obligation to provide “honest, complete, and impartial” information in their field of expertise. I suggest this would extent to the obstetrical profession in regard to press conferences and other public statements provided to the media.

Next post on this topic –>Developing “Standard Characteristics” for OOH Studies of Intrapartum Care ~ Current assumptions about OOH birth are not fact-based on either side (medical profession OR consumers and many midwives) 

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