The story I hate to tell: the dark history of obstetrics ~ Strike Two (part 5)

by faithgibson on March 8, 2016

in Contemporary Childbirth Politics, Historical Childbirth Politics 1820-1980

link back to part 4

part 5 ~ STRIKE TWO ~ 1910 to 1937

Strike Two started in the US in 1910 with the Listerizing of childbirth by the two most influential leaders of American obstetrics. The new policy was based on the best of intentions. Doctors De Lee and Williams and other professors of obstetrics hoped to eliminate or at least reduce the rate of maternal mortality from puerperal septicemia by treating childbirth in hospital settings as surgical procedure. This meant faithfully applying the newly discovered aseptic principles and rules for surgical sterility developed in 1865 by Sir Joseph Lister, Royal Surgeon to Queen Victoria. While the motives of the obstetrical profession were noble, these policies and practices were far from benign. In the end, Listerizing normal childbirth in healthy women did not achieve the stated goal of preventing or even reducing maternal mortality from puerperal sepsis.

In order to apply Dr. Lister’s ideas to normal childbirth, the second & third stages of labor were renamed ‘the delivery’ and declared to be a surgical procedure performed in an operating room by a physician-surgeon using the strictest of surgical sterility techniques. However, these ideas did not take the reality of laboring patients into account. A conscious woman was very different than the unconscious surgical patient lying still under the influence of the general anesthesia. However women in  the throes of expulsive labor could not normally lie perfectly still on the narrow OR table for the “one, two or more hours” that was typical for the pushing phase, especially in first-time mothers.

When laboring women naturally moved around, touched sterile sheets, even grabbed the hand of the obstetrician, it threw a monkey wrench into the idea of strict aseptic technique and the physician’s attempt to maintain a pristinely pure ‘sterile field’. As a result, influential obstetricians of the day (Dr. Williams and De Lee) decided that it was best to render the laboring woman unconscious and physically inert general anesthesia.  This brought the sterile surgical procedure of ‘vaginal delivery’ into alignment with the standard for all other surgical procedures.  In 1912, Dr J. Whitridge Williams (original author of Williams Obstetrics) said:

“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.

Unfortunately, anesthetic gases — chloroform or ether — were dangerous for both mother and baby. To reduce exposure to these harmful effects, doctors needed to speed things up by performing an episiotomy, using forceps to deliver the baby and manually removing the placenta. All of these additional interventions were risky and increased the mortality and morbidity associated with normal childbirth.

For babies, the problem was respiratory depression and anoxia (lack of oxygen) due to narcotic drugs and anesthetics given to its mother and physical birth injuries due to the traumatic delivery procedures including the use of high and mid-level forceps.

For mothers, the use of anesthesia, traumatic delivery and manual placental extraction techniques all predisposed them to hemorrhage and infection. Many invasive techniques combined with the effects of general anesthesia was an independent assault on the mother’s immune system, making her more likely to get an infection and less likely to survive it. Taken together, the routine use of these invasive procedures doubled the maternal death rate, sending it up from the already high level of 600 per 100,000 in the early 1900s to 1,200 by 1925.

Historical rates of MM for developed countries in early 20th century:

The MMR in the US at the beginning of the 20th century was 3-fold greater than Sweden and other European countries. As early as 1881 the Swedish government required all professional birth attendants (a category that included midwives and physicians) to learn and strictly apply the principles of asepsis and sterile techniques when attending to women during childbirth.

According to one informative source (1) “Maternal mortality in Sweden declined from 900 per 100,000 live births to 230 per 100,000 from 1751 to 1900. From 1900 through 1904, Sweden had an annual maternal mortality of 230 per 100,000 live births,while the rate for England and Wales was 440 per 100 000. For the year 1900, the United States reported 520 to 850 maternal deaths per 100,000 live births.3

In the US, the obstetrical strategy for providing aseptic care was to Listerize normal childbirth. This turned a normal biological process  into a risky surgical procedure that required general anesthesia and a host of invasive procedure, all of which greatly increased the iatrogenic and nosocomial complications. This constituted the most profound change in childbirth practices in the history of the human species.

In sharp contrast, physicians and midwives in Sweden successfully applied the principles of asepsis while maintaining the tradition of physiological care for normal labor and birth. By 1900, the MMR in Sweden had been reduced to 230 per 100,000 live birth, while at the same time maternal mortality in the US claimed an average of 650 mothers per 100K each year. When compared to the lower rates achieved inless prosperous European countries, the high maternal mortalityrate in the US was an acute embarrassment to American obstetrics.

Ref #1: The Decline in Maternal Mortality in Sweden: The Role of Community Midwifery ~ Ulf Högberg, MD, PhDAugust 2004, Vol 94, No. 8 | American Journal of Public Health 1312-132

The Official Party Line

The American obstetrical profession liked to blame the staggering maternal death rate in the US on American women — some fundamental flaw in maternity patients due to the effect of poverty or poor breeding or caused by the ignorance or meanness of midwives, which doctors claimed were untrained or inept or worse. However, none of the historical facts actually supported this self-serving narrative. By 1910, the already disproportionately high MMR in the US began to increase as the physiologically-based care of midwives and general practitioner physicians was systematically replaced by heavily medicalized labors under the effect of narcotics and other drugs and mothers who gave birth under general anesthesia with the routine use of forceps and episiotomy.

As the ‘new obstetrics’ model of case was extended to an increasingly large percentage of the childbearing population, the maternal mortality began climbing at 15% a year, until it hit the high water mark in 1925, with an astonishing 25,000 maternal deaths, which meant one mother died for every 80 live births. {ref.#2}

“As to maternal mortality, …during 1913 about 16,000 women died..; in 1918, about 23,000…and with the 15% increase estimated by Bolt, the number during 1921 will exceed 26,000.” [Dr. Ziegler, M.D. 1922-a]

The Awful Truth

This dismal state of affairs is still rarely acknowledged by contemporary authors. However, it did not go unnoticed at the time by people outside the medical profession. In 1931 the high-risk nature of medical and surgical intervention in normal childbirth became the subject of an official report by the White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care. These authors concluded that the care of midwives was safer than the care of MDs:

“… untrained midwives approach and trained midwives surpass the record of physicians in normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.” (original in emphasis)

In 1933 the New York Academy of Medicine published a study of 2,041 maternal deaths in childbirth. The 70-year old report by medical officials were described by contemporary physician-author Atul Gawande as “shocking”. In his 2006 New Yorker piece (“The Score”), he reported on the history of the “new obstetrics” as a surgical discipline and its record of maternal mortality during its first 20 years (1910-1930):

“The investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. …

At least two-thirds, the investigators found, were preventable. … newborn deaths from birth injuries had actually increased. Hospital care brought no advantages; mothers were better off delivering at home. … Doctors may have had the right tools, but midwives without them did better.” [emphasis added]

In a 1937 the well-known philanthropist and obstetrician, Dr. Alan Guttmacher (associate professor of obstetrics, John Hopkins Hospital) published a book entitled “Into This Universe”. In a chapter called ‘Safer Childbirth’ (p. 329), he describes a study by Dr. Louis Dublin, President of the American Public Health Association, Third Vice-president and Statistician of the Metropolitan Life Insurance Company. After analyzing the work of the Frontier Nurses’ midwifery service in rural Kentucky, Dr. Dublin made a public speech May 9th, 1932, saying:

“We have had a small but convincing demonstration by the Frontier Nursing Service of Kentucky of what the well-trained midwife can do in America. …. The midwives travel from case to case on horseback through the isolated mountainous regions of the State. There is a hospital at a central point, with a well-trained obstetrician in charge, and the very complicated cases are transferred to it for delivery.

In their first report they stated that they have delivered over 1000 women with only two deaths — one from heart disease, the other from kidney disease. During 1931 there were 400 deliveries with no deaths. The study shows conclusively that the type of service rendered by the Frontier Nurses safeguards the life of the mother and babe. If such service were available to the women of the country generally, there would be a savings of 10,000 mothers’ lives a year in the US, there would be 30,000 less stillbirths and 30,000 more children alive at the end of the first month of life {a total of 70,000 mortalities a year}.

What are the advantages of such a system? It makes it economically possible for each woman to obtain expert delivery care, because expert midwife is less expensive than an expert obstetrician. Midwives have small practices and time to wait; they are expected to wait; this is what they are paid for and there they are in no hurry to terminate labor by ill-advised operative haste.” [1937-A]

It must be noted that the death of 10,000 new mothers + 30,000 stillborn babies + 30,000 infants in one year is a preventable loss of life of 70,000 mothers and babies out of 4 million mothers and babies due to the lack of access to physiologically-based care for healthy women and lack of consistent and timely access to medical services for those with complications and lack of access to nurse-based pediatric care for infants . That would be 700,000 deaths every decade or  2.1 million during the period of time in question – 1910 to 1940.

A more contemporary and geographically pertinent example of this occurred in California as a result of a pilot nurse-midwife program established at Madera County Hospital from July 1960 to June 1963. The program served mainly poor agricultural workers. During the three-year program, prenatal care increased and prematurity and neonatal mortality rate decreased at the county hospital. Under the care of nurse midwives, the NNM rate was 10.3 % and prematurity rate dropped by 3%.

After the pilot program was discontinued by the California Medical Association, the neonatal mortality rate increased even among those women who had received no prenatal care. This suggests that the intrapartum care delivered by nurse-midwifes may have been far more skillful than that delivered by physicians. Prenatal care decreased while prematurity rose from 6.6 to 9.8% and neonatal mortality rose from 10.3 to 32.1 per 1,000 live births. It was concluded that the discontinuation of the nurse-midwives’ services was the major factor in these changes. [Levy, et al, 1971]

Historical sources for the US and Europe, as well as other studies to numerous to mention, all come to the same conclusion – Strike Two of the dark side of obstetric was the imposition of a strict obstetrical model in 1910 as the standard for healthy women.

It dramatically increased the maternal mortality rate over what it would have been if physiologically-based models of professional care were widely available and provide to this same healthy population with normal pregnancies. For all the derogatory opinions against the profession of midwifery espoused by the obstetrical profession, history records that childbearing women were considerably safer under the non-medical care of midwives – a safety expressly traceable to the fact that midwives did not routinely intervene or use invasive procedures to hurry up the process of normal childbirth.

Perhaps this quote by Dr. Alan Guttmacher sums it up best, as he addresses the question of why the operative intervention rate for European midwives and physicians was so much lower than doctors in the US:

What is responsible for this vast difference in operative rates?

Analgesics 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 functions which rarely requires artificial aid from steel or brawn. [“Into This Universe”,  1937] {emphasis added}

Continued part 6 ~ STRIKE THREE – 21st Century AUDACITY ON STEROIDS 

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