Quotable ~ obstetricians, AMA & a variety of other sources and topics
“The legalization of induced abortion beginning in the 1960s contributed to an 89% decline in deaths from septic illegal abortions (15) during 1950-1973.”
From a speech in 1911 by Dr. W. A. Evans, AMA operative and Health Commissioner for the city of Chicago, who gave these instructions to the doctors in their annual convention of the American Medical Association in 1911. This pronouncement was published in the Journal of the American Medical Association (JAMA) in September of that year:
“The thing for the medical profession to do is … to man every important health movement; man health departments, tuberculosis societies, housing societies, child care and infant societies, etc. The future of the profession depends on it. . .
The profession cannot afford to have these places occupied by other than medical men.”
“The 19th century model of normal childbirth as a pathology form of reproductive biology locks the obstetrical profession out of 21st Century science: Over the last couple of decades, the entire medical profession, except for obstetrics, has broadened its base by acknowledging and working with the mind-body continuum. The obstetrical profession has never revisited their historical relationship with birth as a pathological aspect of female reproduction.
As a result obstetrics focuses more and more tightly on the laboring uterus as a pathological organ, with obstetricians relating to the woman’s uterus as if it were a carburetor that needed to be tinkered with, the baby was a spark plug that needed to be removed and the mother’s physical experience and her social and emotional needs were nothing more than an inconvenient distraction to the real work of the obstetrician.”
Seek a beneficent ratio of interventions to good outcomes . .
“The skillful use of physiological management and adroit use of medical interventions as necessary provides the best outcome to for mothers and babies, with the fewest number of medical/surgical procedures and least expense.”
To promote “maximal results with minimal interventions”, which describes the skillful use of physiological management and adroit use of medical interventions as necessary to provide the best outcomes for mothers and babies with the fewest number of medical/surgical procedures and least expense.
This is the only model of maternity care that is worth pursuing, it is what we need to remain competitive in a 21st century global economy, it is what is most humane – the highest expression of concern for America’s mothers and babies, fathers and families and of course, those ‘third parties” who pay the bills for all this.
To fairly balance the practical needs of childbearing women and and their babies with the economic needs of obstetrical profession ….
“Early 20th century obstetricians believed that safety required that routine care for childbirth be reconfigured as into a new surgical specialty. These individuals were well-meaning and their plan to replace the old ways with better ways seemed logical under the circumstance of 1910.
Unfortunately, the time and place lacked the necessary information on the ‘natural’ or background dangers of childbearing. Without knowing the exact nature and precursor events that led up to childbirth emergencies, obstetrical policy makers didn’t actually know exactly what would make for a ‘safe and effective’ model of maternity care.”
“Birth-related morbidity and mortality can be time-shifted, place-shifted and person-shifted in ways that favor the mother at the expense of the baby or favors the baby at the expense of the mother, but it cannot be eliminated.
Furthermore, there is nothing that can be done or purposefully, or NOT done that would reliably reduce the risk to zero for both mother and baby 100% of the time with economically sustainability.”
“Physiologically-based care should be the universal standard for healthy women with normal pregnancies unless the mother herself requests medicalized care.
The form of care recommended by W.H.O. for a healthy population integrates the principles of physiological management with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. This standard should apply to all categories of birth attendants and in all settings and include the use of standard obstetrical interventions to treat complications or if requested by the mother.
When that is done, healthy women will no longer have to choose between an obstetrician and a midwife or between hospital and home. No matter who provides maternity care, they can be confident of receiving appropriate, physiologically-based care for a normal labor and spontaneous birth and having the best obstetrical services if or when they desire or require them.
for all our idealism, enthusiasm and sustained effort, we remain locked out of an integrated maternity care system by factors that are political rather than scientific. In the current configuration, we have to lose in order for them to win. The resurgence of independent midwifery and PHB was the result of our collective inability to make a positive impact on our hyper-medicalized system. We intended to meet just those specific needs the obstetrical profession couldn’t re address or wouldn’t acknowledge. None of us expected to create a free-standing parallel system of midwifery education and practice that remained permanently outside and separate from the health care system. Apartheid is never a satisfactory situation.
Any one who gets pregnant or provides services relative to pregnancy and childbirth knows all too well that it is impossible not to be drawn back into the political fray between obstetrics as the empowered class and midwives and mothers seeking non-interventive care as the disempowered and outlaw class.
Speaking as someone who has been doing this since the 1960s, when twilight sleep and episiotomy was still mandatory and universal, our activism has not been a happy or successful endeavor. Yes, we have won a few battles and I am grateful for that, but it is an illusion of progress. Added to our individual pain and collective experience is the expansive time frame for a dysfunctional system that manages to change but never actually fix the problem. For the entire 20th century and the first decade of the 21st, women and families have been swept along a conveyor belt that often took them to places they did not want or need to go.
The 95% rate of narcotics, scopolamine and general anesthesia in the1960s has simply been replaced by a 90% epidural rate; the routine use of forceps has been replaced by the liberal use of Cesarean, which is at 31% and still climbing. Birth is still conducted and billed as a surgical procedure. The monolithic obstetrical model continues to be characterized by routine interference in normal biology (such as routine inductions), unnecessary interventions mandated by liability issues or personal preference. Painful, invasive or humiliating procedures that we neither need or want continue to performed on ourselves, our loved ones or on our clients. We stand by helplessly as influential members of the medical profession and the media promote the idea of scheduled Cesarean as the 21st century standard of care. Ultimately we are losing the war.
As members of consumer and professional groups working for mother-baby friendly maternity care, it’s impossible not to get angry about this. Personally, it’s hard for me to be generous in the face of such daunting circumstances. But if we let our anger divide us into eternally warring camps, we will spend our time perpetuating instead of fixing an out-of-balance system.
What we need is a change of heart, starting with an acknowledgment that none of these groups – mothers, midwives or obstetricians — asked for these contentious problems. Contemporary obstetricians inherited a difficult situation not of their own making. They were schooled by a system that taught female biology as destiny when it comes to reproductive.
Childbearing is seen as an undependable patho-physiology that uses women up the way salmon are sacrificed during spawning. In must be remembered that without prenatal care and access to modern obstetrical services for those who develop complications during pregnancy or childbirth, high mortality rates are indeed the rule.
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- In 1900, the average married woman in the US had 17 pregnancies, 12 live births, but only 9 living children. Women expected to lose a tooth with every pregnancy. Poverty and high birth rate were associated with problem pregnancies, especially in very rural farming areas and for immigrants and ethnic minorities living in crowded urban tenements. Racial discrimination and economic inequities resulted in chronic ill-health, which made childbearing women vulnerable to childbirth serious complications that obstetricians could not predict, prevent or treat. In the poorer sections of town, one new mother died for every 100 births and one of 10 infants did not live to see their first birthday. Many of the life-threatening complications childbearing required surgical solutions, giving rise to the ‘new’ obstetrics for the 20th century as a surgical specialty.
In the decades before the discovery of antibiotics, Well-intentioned obstetricians had to respond to this grave situation any way they could. The highly medicalized style of care introduced in 1910 was an attempt to eliminate puerperal sepsis (childbed fever) in hospitalized maternity patients and by sheer happenstance, this ‘perfect storm’ of events resulted in the greatest change in childbirth practices in the history of the human species.
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In the decades before the discovery of antibiotics, Well-intentioned obstetricians had to respond to this grave situation any way they could. The highly medicalized style of care introduced in 1910 was an attempt to eliminate puerperal sepsis (childbed fever) in hospitalized maternity patients and by sheer happenstance, this ‘perfect storm’ of events resulted in the greatest change in childbirth practices in the history of the human species. Labor began to be managed as a medically emergency. For the first time ever, normal vaginal birth was defined as a surgical procedure. As a surgical procedure, the ‘delivery’ was to occur in a restricted, sterile environment, routinely conducted as an operation by a surgically-trained physician. Due to the difficulty of maintaining strict surgical sterility, it was necessary to anesthetize labor patients. Once anesthetized, the delivery need to be surgical included the routine use of episiotomy, forceps, manual removal of the placenta and suturing of the episiotomy or other perineal wounds.
To understand why this happened, you have to see this unique era of obstetrical medicine against the backdrop of what we know call “modern science”: 1840 to 1940 – were the time of the biggest change in the biological sciences and by extension, allopathic medicine.
The most pivotal year in the history of ‘modern’ medicine was 1881. It was a time marked by the lightening fast shift of medical thinking and practice. Overnight, humanity was taken from the B.C.G. era — ‘Before the Common knowledge of the Germ theory of infection’ — to the brave new world defined by the new scientific disciplines of microbiology, bacteriology. These biological sciences developed antiseptic practices, disinfectants and eventually aseptic principles and sterile techniques. Other scientific disciplines — anatomy, biology, chemistry, immunology, physics, and physiology – all contributed to the practice of medicine, including obstetrics, as a modern science.
For obstetrics, the most radical and extraordinary time was the last 2 decades of the 1800s and first 2 decades of the 1900s – 1881 to 1920. This forty years period was smack in the middle of a metaphorical earthquake — the San Andreas fault of bio-medical science. The paint was barely dry on most important discovery in the history of the biological sciences and medical practice, which had transformed human knowledge and medical practice at one and the same time.
The biological sciences were no longer B.C.G. – the invisible but nonetheless lethal power of germs had been unmasked and beaten back — but unfortunately, humanity was still in the Before Antibacterial Drugs (B.A.D) pre-ambulatory phase of the soon-to-be but not-quite-yet ‘miracle’ of modern medical science that arose in 1937 with the marketing of the first sulfa drug. The 50 years between the discovery of germs and the ability to selectively kill bacteria and other pathogens inside of a sick human being was still a no-man’s land, one peopled by doctors, public health officials and the lay pubic, all of whom did not yet know that the story had a happy ending.
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In addition to the many easily identifiable problems with our 1910 model of Listerized childbirth, there are an equal or greater number of real problems that real life obstetricians grapple with everyday. One major category is obstetrical emergencies – the kind of complications that kills one out of 57 women who don’t have access to or have decided not to make use of comprehensive obstetrical care, even when dangerously ill. These heartbreaking situations include very premature births, hemorrhage from placental abruptions or previa, high blood pressure, convulsions, stroke, amniotic fluid embolism, and a list of other equally rare but less dramatic life-threatening pregnancy problems.
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A different but also vexing problem for obstetrical providers are psychological issues — childbearing women who either cannot or will not take responsibility for their own and their baby’s wellbeing, whether this is due to substance abuse, alcohol addiction or other mental or emotional illness. Sometimes laboring women can’t or won’t cooperate at all with the physiological process of normal labor and spontaneous birth and must be heavily medicated or even anesthetized.
As a former L&D nurse, ER nurse, and now as a community midwife, I have witnessed situations were births attendants had to provide care to women who are hostile, totally uncooperative, even combative. But no matter how outrageous the mother’s behavior, the physicians and midwives are ethically and legally required to provide the same high standard of care they would to anyone else.
As consumer advocates, we assume that every mother wants what we want and knows what we know and can’t imagine a pregnant or labor women who isn’t totally informed about all the possible side effects of interventions and drugs. Sadly, that isn’t the norm. Many of the patients that obstetricians deal with just want the baby about and they don’t want it to hurt and don’t want it to take too long.
For birth attendants dealing will an undifferentiated population and high volume of labor patients, obstetrics is the art of dealing gracefully with unexpected, everything from simple failure to progress, to a variety of vexing emergencies such as cord accidents, fetal distress, shoulder dystocia, retained placentas, inverted uterus and PP hemorrhage. Obstetricians know any of these problems could trigger a lawsuit for them and the hospital, so the actual treatment of emergencies is complicated by political pressure from within the ‘system’.
One of the craziest things about litigation is that patients who actually got very good care for a very bad problem are often the ones that sue. They wrongly believe that whoever was present when a complication was discovered, was somehow responsible for having caused the problem. This is an irrational “guilt by association”, that is, the doctor and nurses were standing there when it happened, so somehow they must have don’t something wrong by not preventing it.
At the end of a week of dealing with all these high stress situations, an obstetrician might also get paged to deal immediately with a transfer from a planned home birth that end with a life-threatening emergency – cord prolapse, placental abruption, maternal hemorrhage, etc. Whether that problem is due to an unpreventable complication or poor judgment by someone – parents, midwives or even other professionals that did not respond appropriately – it sometimes very hard to discern. What is for sure is the grieving parents and an extremely difficult situation for everyone involved and certain fuels the on-going hostility between community-based midwifery and hospital-based obstetrics.
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19th century model of normal childbirth as a pathology form of reproductive biology locks the obstetrical profession out of 21st Century science: Over the last couple of decades, the entire medical profession, except for obstetrics, has broadened its base by acknowledging and working with the mind-body continuum. The obstetrical profession has never revisited their historical relationship with birth as a pathological aspect of female reproduction. As a result obstetrics focuses more and more tightly on the laboring uterus as a pathological organ, relating to childbirth as if the uterus were a carburetor that needed to be tinkered with, the baby was a spark plug that needed to be removed and the mother’s social and emotional needs were an inconvenient distraction to the real work of the obstetrician.
85 to 67 per 10,000 live births compared to maternal mortality rates of 48 to 44 per 10,000 in England and Wales and 23 to 33 per 10,000 in the Netherlands, where midwives
, between 1900 and 1910 infants in the United States died at higher rates than in 21 European nations.[8] Between 1915 and 1933, neonatal mortality in the United States ranged from 44 to 34 per 1,000 live births
Obstetricians seeking to develop the medical specialization of obstetrics[4-6] and public health nurses aspiring to establish a specialty in midwifery joined in a campaign to eliminate traditional midwives. Medical, public health, and nursing journals published articles accusing immigrant and African American midwives of being ignorant, dirty, and dangerous (these descriptors were believed as fact, widely used during this campaign, and appeared in print as late as the 1980s)[1] in an attempt to restrict and then eliminate traditional midwifery practice.
indicate that in the United States, the annual maternal mortality ratio * remained approximately 7.5 maternal deaths per 100,000 live births during 1982-1996.
In 1930, the national maternal mortality ratio was 670 maternal deaths per 100,000 live births (3). The ratio declined substantially during the 1940s and 1950s, and continued to decline until 1982. During 1982-1996, the annual maternal mortality ratio fluctuated between approximately 7 and 8 maternal deaths per 100,000 live births
: Since 1982 in the United States, no progress has been made toward achieving the Healthy People 2000 goal of 3.3 maternal deaths per 100,000 live births set in 1987 (objective 14.3) (4). The reason for this lack of improvement in maternal mortality is not clear.
some complications that can occur during pregnancy cannot be prevented (e.g., pregnancy-induced hypertension, placenta previa, retained placenta, and thromboembolism). Nevertheless, more than half of all maternal deaths can be prevented through early diagnosis and appropriate medical care of pregnancy complications (6,7). Hemorrhage, pregnancy-induced hypertension, infection, and ectopic pregnancy continue to account for most (59%) maternal deaths.
In this report, maternal mortality ratios are based solely on vital statistics data and are underestimates because of misclassification. The number of deaths attributed to pregnancy and its complications is estimated to be 1.3 to three times that reported in vital statistics records (6). Misclassification of maternal deaths occurs when the cause of death on the death certificate does not reflect the relation between a woman’s pregnancy and her death. In addition, the inclusion of deaths causally related to pregnancy that occur between 43 and 365 days postpregnancy can increase the number of maternal deaths identified by 5%-10% (6).
To identify interventions that may have an impact on reducing maternal mortality, approximately 25 states have reestablished maternal mortality review committees. These committees review various factors that may have contributed to maternal deaths, including the quality of medical care and systemic problems in the health-care delivery system. To assess the problem and develop appropriate interventions to reduce the number of maternal deaths, all states should implement active surveillance of maternal mortality, including maternal mortality review committees.
The proposed Healthy People 2010 goal for maternal mortality remains 3.3 maternal deaths per 100,000 live births. Unless investments are made in improving maternal health for all women, this goal will not be reached.
steady decline mortality in the west as sanitation, nutrition and general living standards improved. Medical science has little influence at first (McKeown and Brown, 1955).
The dramatic declines in maternal mortality were, in contrast, the direct result of mid-20th century improvement in obstetrical medicine.
The three most important factors in reducing U.S. maternal mortality rates have been (a) the educational influence of maternal mortality committees, (b) introduction of antibiotics and (c) the development of blood transfusions techniques (Klein and Clahr, 1958; Marmol et al , 1969; Llewllyn-Jones, 1974; Shapiro, et al, 1968
