The Dark Side of the Moon ~ The continuing failure of our national maternity care system to meet the practical needs of healthy childbearing women for more than a century!

by faithgibson on May 21, 2023

15,227 words ~ last edited Dec 1^st, 2022

by Faith Gibson, LM

Part 2_xyz-t1_The Dark Side of the Moon by Faith Gibson, LM

How and Why Interventive Obstetrics can be dangerous to the health of healthy childbearing women

Interventive obstetrics can and often does becomes dangerous whenever it fails to distinguish between healthy and high-risk populations of childbearing women. The reason the American obstetrical profession has been responsible for so much unnecessary harm to mothers and babies over the last hundred-plus years, accompanied by a disproportionately high maternal and perinatal mortality rate in the US, is the profession’s continuing refusal to formally distinguish between these two the major categories of childbearing women.

Healthy low-risk mothers who don’t need, want, or benefit from obstetrical interventions
Women with serious medical conditions, high-risk pregnancies or develop life-threatening complications that require obstetrical interventions and emergency surgery

Collapsing this important distinction between healthy low risk women and those with complications and high-risk situations resulted in a formalized system that routinely used of obstetrical interventions – drugs, anesthesia and surgical procedures — on childbearing women who do not need or benefit from them.

This failure to distinguish between these two health-related categories was originally the result of a formal pronouncement by influential and politically-involved obstetricians in the very early 20^th century in which they officially defined pregnancy and childbirth to be “pathophysiology”.

This is the wrong-headed idea normally pregnancy and birth are abnormal states. This resulted in pregnancy being formally defined as a “nine-month disease” that required a “surgical cure”.

The Clash of the Titans between Observable Reality and Imaginary States

Statistically, the great majority of childbearing women are healthy and have normal term pregnancies (over 70% of all births), while a very much smaller group of women (less than 30%) suffer from serious health problems or have high-risk pregnancies. The rational response by the obstetrical profession to this bifurcated demographic of childbearing women would be to modulate the care they provide to match the actual physical and psychological needs of each childbearing woman.

Instead, the obstetrical profession, as represented by organized medicine, chose to ridicule repeatedly reject this obvious state of affairs for the entire last century and well into the 21^st — that plain fact the childbirth in the vast majority of women is a normal biological event that can’t be made “better” by needlessly intervening in it.

At best, this reflects a history of “mixed” motives – a genuine desire to provide a life-saving services while also elevating the social and political status of their profession, and reaping substantial economic rewards by creating a total monopoly over all childbirth services. Unfortunately, positions of absolute power tend to be absolutely corrupting. In the case of obstetrics as a surgical specialty, that seems to have triggered self-serving motives that have more to do with politics and economic status than meeting the practical needs of childbearing women.

Historic figures set the stage for an obstetrical profession that is focused on obstetricians

A centuries-long bias by men towards the female gender set the stage in the early 20^th century for the profession’s most influential leaders to believe it was their God-given destiny to have a total monopoly over all childbirth services in the United States.

However, the formal politicization of obstetrics began in 1910 as an activity of the AMA that organized and funded the American Association for the study and preventing of Infant mortality. The AASPIM), which met for the very first time in 1910 in Baltimore, which is where the famous Johns Hopkins University Hospital, also employer of Dr. J. W. Williams, who was chief of obstetrics at the time and very soon to be appointed Dean of the JH School of Medicine.

The AASPIM was to meet annually for the next dozen or so years, functioning as a national convention of obstetricians who got together every year to, among other things, promote the obstetrical profession. Among the hundreds of these obstetricians were handful of particularly articulate and politically-talented who had become adept at using the “old-boys network” to help achieve the many goals of nascent obstetrical profession. Among these was Dr. J.W. Williams, one of the two most famous American obstetrician formally referred to as “Titians of American Obstetrics” i.e. Doctors Williams and Joseph Bolivia De Lee.

Their goal was to manipulate and re-configure public opinions by publicly demonizing midwives as dirty, dangerous, and dumb, and then use these negative images of midwifery as a springboard to “eliminate the midwife problem”. Interwoven with the practical dilemma for obstetricians of not having enough “teaching cases” to properly train all the midwifery, medical and nursing students, there also was a very deep prejudice against midwives that went way beyond their many rational (mostly irrational) arguments for abolition. Here are several examples of the denigrating opinions of obstetricians about midwives:

“the typical, old, gin-fingering, guzzling midwife, … her mouth full of snuff, her fingers full of dirt and her brain full of arrogance and superstition” Gerwin, 1906

“un-American”; Dr. Mabbott, 1907

“the overconfidence of half-knowledge, …unprincipled and callous for the welfare of her patients” Drs Emmons and Huntington, 1912

~ “The question in my mind is not “what shall we do with the midwife?” We are totally indifferent as to what will becomes of her… Dr. J. W. Williams, 1912-B, p.225]

~ “The midwife is a relic of barbarism. In civilized countries the midwife is wrong, has always been wrong. The greatest bar to human progress has been compromise, and the midwife demands a compromise between right and wrong. All admit that the midwife is wrong.” Dr. DeLee, 1915-C p. 114

Here are a few comments that reveal the underlying motives of these influential obstetricians, and the motives and methods of the obstetrical profession to achieve its economic and social goals of supremacy:

“Any scheme for improvement in obstetric teaching and practice which does not contemplate the ultimate elimination of the midwife will not succeed. This is not alone because midwives can never be taught to practice obstetrics successfully, but most especially because of the moral effect upon obstetric standards.” ~ The Teaching of Obstetrics” by American Association of Obstetrics and Gynecologists

“I should like to emphasize what may be called the negative side of the midwife. Dr. Edgar states that the teaching (i.e. “clinical”) material in NY is taxed to the utmost. The 50,000 cases delivered by midwives are not available for this purpose. Might not this wealth of (clinical teaching) material, 50,000 cases in NY, be gradually utilized to train physicians?” [1911-D, p 216]

“Another very pertinent objection to the midwife is that she has charge of 50 percent of all the obstetrical material [i.e., teaching cases] in the country, without contributing anything to our knowledge of the subject. As we shall point out, a large percentage of the cases are indispensable to the proper training of physicians and nurses in this important branch of medicine.” [1912-B, p.224]

“In all but a few medical schools, the students deliver no cases in a hospital under supervision, receive but little even in the way of demonstrations on women in labor and are sent into out-patient departments to deliver, at most, but a half dozen cases.

When we recall that abroad (i.e. Western Europe) the midwives are required to deliver in a hospital at least 20 cases under the most careful supervision and instruction before being allowed to practice, it is evident that the training of medical students in obstetrics in this country is a farce and a disgrace. It is then perfectly plain that the midwife cases, in large part at least, are necessary for the proper training of medical students.

If for no other reason, this one alone is sufficient to justify the elimination of a large number of midwives, since the standard of obstetrical teaching and practice can never be raised without giving better training to physicians.” [1912-B, p.226] {emphasis added}

Obstetrics as a monopoly over all forms of pregnancy and birth-related services

As articulated by Drs Williams and other politically and economically motivated colleagues, the goals of the obstetrical profession were perfectly clear – completely eradicate of the “competition” by passing laws that would make the practice of midwifery illegal. Thanks to the political clout of organized medicine, which meant regularly greasing the back door to state legislators with lots of campaign donations, midwifery was successful criminalized in about half of the states. This gave obstetrics in a functional monopoly over all pregnancy and childbirth-related care in most of America and that in turn forced many women to have forceps deliveries in hospitals under Twilight Sleep drugs and general anesthesia.

“For the sake of the lay members who may not be familiar with modern obstetric procedures, it may be informing to say that care furnished during childbirth is now considered, in intelligent communities, a surgical procedure.” [1911-D, p. 214]

“Engelman says: ‘The parturient suffers under the old prejudice that labor is a physiologic act,’ and the profession entertains the same prejudice, while as a matter of fact, obstetrics has great pathologic dignity —it is a major science, of the same rank as surgery”.
[1915-C; Dr. DeLee, p. 116]

This was the opening salvo in coming “Hundred Years War between Midwifery and Medicine”. Speaking of long-ago historical times, people should know that midwifery is unique in regard to preventative health care. Midwifery as provided by formally trained and experienced midwives is the very first preventative health care discipline, as was recorded in 5,000-year-old Egyptian hieroglyphics.

This sentence literally takes us back to the gender-centric roots of childbearing as a personal aspect of our gender and while always remaining a foreign experience to the male of the species. Both the pregnant woman, and the care provided to her by women as experienced midwives, speaks of a future in which the care of healthy women is extracted from the purview of obstetrical medicine to become again what it always fundamentally was “maternity” care.

The derivation of the word “maternity” is “maternal” and refers to a woman who is or has given birth to children. Maternity care is mother-and-baby-centric and focuses on and providing practical real-time supportive services to healthy pregnancy women during the many long hours of labor, a normal birth and continuing postpartum care for the first year of the new mother and her new baby’s life.

Unlike obstetrics, which is organized around the professional needs of obstetricians, midwifery if organized around the practical needs of childbearing women and their newborn babies.

Historical prejudice by male doctors against obstetrics as “women’s work”

Apparently prejudice by one person or group against another person or group is as “American as Apple pie”, especially when it comes to professional groups, particularly affecting practitioners of allopathic medicine. Today everyone would agree that obstetrics currently enjoys great professional status, helped out mightily by the king-maker role of obstetrical departments as the economic cash cow of American hospitals. But we must remember that “man-midwifery”, as it was called all throughout out the 17th, 18th and 19th centuries. As such, man-midwives was considered to occupy the very lowest rung of the ladder, as the poor stepsister of ‘modern-medicine’. Attending birth was cast aside as a dubious form of “woman’s work” that was not worthy of the professional attention of formally-educated “medical men”.

As a Dr. Moran wrote in 1915:

“Obstetrics is the most arduous, least appreciated, least supported, and least compensated of all branches of medicine”.

So the grand plans being generated by influential obstetricians in 1910 was for American obstetrics to be seen as new surgical specialty, for childbirth to be referred to as the surgical procedure of “delivery” (in which the doctor and not the mother was seen as the active agent in the child’ birth) and thus for surgeons to take control of women’s reproductive biology. Yes, this was both audacious and in the final frame as judged in the third decades of the 21^st century, with a surgical delivery rate for American mothers attended by obstetrical being 32%, this was smashingly effective from just about every angle!

While influentical obstetricians of the early 20^th century had no clue of just how successful they would eventually be, clearly the obvious place to start in 1910 was by getting rid of “female practitioners”, an idea that trances directly back to an 1820 publication called

”Remarks on the Employment of Females as Practitioners in Midwifery”; Cummings & Hilliard, Boston, 1820”

Its physician authors objected to women being formally trained as midwives based on a series of erroneous and/or self-serving ideas. The rejection of women as “practitioners” claiming that members of the female gender were intellectually incapable of being educated, that the emotional nature of women would make them incapable of responding rationally in an emergency and even if it was possible to sufficiently educate women, the indelicate nature of medical knowledge would corrupt their morals.

Its author insisted that labor and birth were biologically “simple”, but the potential for systemic complications made childbirth into a medical event that should only be attended by fully “qualified” physicians. He pointed out that if midwives were educated and formally trained, the better classes of women (who could pay) might preferred these educated women practitioners while spreading the rumor that it was “indelicate and vulgar to suffer the attendance of a physician”.

However, the real argument by physicians was economic – they saw providing maternity care as the key to a successful general medical practice. It was assumed that the mother’s gratitude would result in loyalty to the physician, thus generating “return business” as the mother called on the doctor who delivered her baby for other kinds of medical care for herself and family members and was sure to recommend him to friends, neighbor, members of her church and any pregnant woman she met in the street!

In the words of the 1820 publication:

“Women seldom forget a practitioner who has conducted them tenderly and safely through parturition…”

“It is principally on this account that the practice of midwifery becomes desirable to physicians. It is this which ensures to them the permanency and security of all their other business.”

The pamphlet ends by congratulating “distinguished individuals” in the medical profession for being so successful in excluding midwives from the practice of midwifery.

“It is one of the first and happiest fruits of improved medical education in America, that they were excluded from the practice (of midwifery) and it was only by the united and persevering exertions of some of the most distinguishes individuals our profession has been able to boast, that this was effected.”

So in addition to the midwife’s obviously fatal biological flaw – i.e. not being male — midwives were also ‘guilty’ of being in economic competition with the obstetrical profession. Every time a midwife attended a birth, a “medical man”/ obstetrician felt that he was personally being cheated out of his professional fee. And since “confinements” (i.e., the lying-in period during which the baby was born) attended by midwives and the old-fashioned “country doctor” occurred in the family’s own home, each of these out-of-hospital birth meant lost income for the hospital’s obstetrical department and new mother’s 14-day postpartum stay in the maternity ward, and her baby’s 14-day stay in the hospital’s newborn nursery.

And as mention earlier, one of the most effective ways for the obstetrical profession to keep midwives from becoming an integral part of the country’s maternity care system was to refuse to acknowledge the practical difference between healthy and high-risk pregnant women. Obstetricians simply decreed that ALL childbearing was potentially “high-risk”, therefore each labor or birth was a dangerous emergency just waiting to happen. Defining childbirth as a ‘medical emergency” made it much easier for the obstetrical profession to insist that “logically” all aspects of childbearing were the rightful purview of surgically trained obstetricians as a restricted practice of medicine solely under its legal control. Anyone attending a home birth who wasn’t a doctor could, and often would, be charged with illegally practicing medicine without a license, which is a felony in most states.

For several decades, its influential leaders participated in national meetings that met annually (the Association for the Study and Prevent Infant Mortality or ‘ASPIM’) to discuss the “midwife problem”. This referred to the problem obstetricians were having in eliminating midwives. In today’s world, we can easily recognize this the same abuse of power that seemingly benign word “problem” was used to define the “Jewish” problem, the “race” problem, or the “immigration” problem, ad nauseum.

As is always the case of smear campaigns against racial, religious, ethnic “problems” — in this case, midwives – this included a decades-long blitzkrieg of propaganda published in newspapers and women’s magazines and broadcast in radio programs that denigrated midwifery while promoting obstetrics and hospital-based childbirth for healthy women. One popular PR slogans was: “Always a physician, never a midwife”.

Midwives were portrayed as uneducated, dirty, probably drunk and their care as dangerously “old-fashion”. Meanwhile obstetricians sang the praises of doctor-attended hospital birth as “scientific” and “much safer”, describing childbirth in the hospital as “painless” due to Twilight Sleep drugs and general anesthesia. Normal childbirth as a surgical procedure conducted under chloroform officially became the new, modern, much better way for the new “modern” woman to have a baby.

Incidentally, it also was the most profound changed in childbirth practice in the history of the human species!

The Dirty Little Secret – most doctors who attended births were less skill and more dangerous than the midwives they displaced

The majority GPs and significant number of obstetricians that has so thoroughly displaced the non-interventive care of midwives, were dangerously inept. While not knowing how to manage a normal childbirth or respond to an obstetrical complication, they didn’t hesitate to use painful or dangerous interventions such as episiotomies and high forceps!

However, the widespread incompetence of young doctors was not secret to politically influential obstetricians during the first part of the 20^th century (1910 to 1940). The leaders in the obstetrical profession had long ago recognized (and written extensively about!) the poor quality of the average doctor that attended “midwifery cases”, as normal birth was still referred to by the obstetrical profession. This immediately pointed back to the poorly on the state of obstetrical education in US, especially as compared to two centuries clinical training programs in obstetrics provided by medical schools in Western Europe.

Both Doctors Williams and DeLee were aware obstetrics was (and still is) an “elective” class in many medical schools (including California) which was both directly and indirectly responsibility for the very poor record and embarrassingly high MMR in the US compared to Western European countries.

One outspoken obstetricians of this early period (Dr. Hardin) was quoted as saying that:

“Maternal mortality in the country when compared with certain other countries, notable England, Wales and Sweden is, according to Howard, “appallingly high and probably unequaled in modern times in any civilized country ….

… in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile.” 1925-A; Dr. Hardin, p. 347

“The story of medical education in the country is not the story of complete success. We have made ourselves the jest of scientists throughout the world by our lack of a uniform standard. Until we have solved the problem of how NOT to produce incompetent physicians, let us not complicate the problem by attempting to properly train a new class of practitioners. The opportunities for clinical (i.e. “bedside”) instruction in our large cities are all too few to properly train our nurses and our doctors; how can we for an instant consider the training of the midwife as well?” [1911-C, p. 207]

No one can read these figures without admitting that the situation is deplorable, and that the vast majority of our schools are not prepared to give the proper clinical instruction to anything like the present number of students. ….

The paucity of material (i.e. teaching cases) renders it probable that years may elapse before certain complications of pregnancy and labor will be observed … to the great detriment of the student.

Moreover, such restriction in [teaching] material greatly hampers the development of the professor and his assistants by the absence of suggestive problems and his inability to subject his own ideas to the test of experience.” 1911-B; Williams, p.171

If such conclusions are correct, I feel that …[we must] insist upon the institution of radical reforms in the teaching of obstetrics in our medical schools and upon improvement of medical practice, rather than attempting to train efficient and trustworthy midwives.” 1911-B; Dr. Williams; p.166

~ “We can get along very nicely without the midwife, whereas all are agreed that the physician is indispensable.” [1912-B, p. 222 ]

Dr. Whitridge Williams, original author of “Williams Obstetrics” was highly critical of this situation:

“The generally accepted motto for the guidance of the physician is ‘primum non nocere’ (in the first place, do no harm), and yet more than 3/4 of the professors of obstetrics in all parts of the country, in reply to my questionnaire, stated that incompetent doctors kill more women each year by improperly performed operations than the … midwife….” 1911-B; Dr. Williams, p.180

“In 1850, Dr. James P. White, introduced into this country clinical methods of instruction in obstetrics. Yet, during the following 62 years … our medical schools have not succeeded in training their graduates to be safe practitioners of obstetrics.” 1911-B; Dr. JW Williams, MD

“After 18 years of experience in teaching what is probably the best body of medical students every collected in the country — the student body at the Johns Hopkins Medical School for the years 1911-1912 …. — I would unhesitatingly state that my own students are absolutely unfit upon graduation to practice obstetrics in its broad sense and are scarcely prepared to handle the ordinary cases.” [1911-B; Dr. JW Williams, p. 178]

“In 1911, the great American obstetrician, J. Whitridge Williams, (original author of “Williams Obstetrics”), completed a survey of obstetrical education in United States medical schools. Williams found that more than one-third of the professors of obstetrics were general practitioners. ‘

Several accepted the professorship merely because it was offered to them, but had no special training or liking for it, 13 had seen less than 500 cases of labor, 5 had seen less then 100 cases and one professor had never seen a woman deliver before assuming his professorship. Several professors of obstetrics were not able to perform a Cesarean section. [DeVitt, MD, 1975] {*}

Dr. Williams reported on the inadequate clinical training of medical) students, noting that:

“the actual figures show that in 25 schools, each student sees 3 (deliveries) or less, in 9 schools, 4-5 cases and in 8 others, 5 or more cases, while in some of the smaller hospitals this is possible only by having 4-6 (medical students) examine each patient…”

Second only to the profession’s fixation with the “midwife problem” was the on-going distress by its leaders over the near total and very obvious failures of obstetrical education and practice during the first 4 decades of the 20^th century.

In particular was the issue of hospital-based clinical training programs was the biggest problem which required obstetrical patients and obstetrical professors. The patients of private obstetricians were never used as teaching cases. Many hospitals in the US didn’t have enough “clinical material” (teaching cases”(sufficient daily census for deliveries that would have allowed med students to at least manage a at least a couple dozens of labors and births. Officially referred to as “clinical material”, more often shortened to just the word “material”, referred to medically-indigent pregnant women, who were received free hospital care in return for agreeing to be teaching cases i.e. “obstetrical material” for medical students during for “lying in period”, which usually was two weeks before the due date and two to four weeks afterwards.

At that time, medical students only attended 5 or 6 births under the supervision of old, wiser obstetricians before graduating from medical school. This complete lack of information about birth and hands-on skills necessary to respond to an obstetrical problem made all new graduates doctors very dangerous, as they had no actually experience or expertise, but nonetheless, wielded the power, respect and economic compensation that come with that magic word “doctor”, who we normally assumed knows what he is doing.

The one of the reasons for that obstetrical training was so poor was a dearth obstetrically-trained professors to run hospital-based “clinical” (i.e. hand-on) training programs. Today these programs are known as obstetrical residencies. In the early 20^th century, the vast majority of doctors only watched a half dozen births as a medical student and only “caught” one or two babies themselves before graduating. Nonetheless, they hung out their shingles and went into private practices as full-fledged doctors. Dr. J. Whitridge Williams lamented on many occasions that newly graduated doctors did not even have the skills of the average midwife, but nonetheless thought nothing of using the most dangerous types interventions, such as high forceps deliveries and surgical procedures such as cutting the mother’s public bone in half to make her pelvis bigger.

In add to the egregious lack of “common sense” in newly minted doctors, there was a similar set of problems with the few clinical training programs that did exist. Often the “medical men” hired to run obstetrical clinical training programs had only attended a handful of births during medical school and often only as an observer. Dr. Williams noted that one new “supervisor” of a clinical program admitted to never having seen a woman give birth before he took his current post as its director.

Feb 21 @ 4:43 pm
???? maybe below as part 3 ????

The cataclysmic decimation American midwifery as an “extinction event”

“A recent article in the American Magazine on census taking stated that there was only one occupation that men were not listed for, and that was “midwife”. 1925-A p. 348 ^86

??? Dr. DeLee is speaking about the common medical prejudice that male doctors would be “naturally” superior birth attendants (compared to women midwives) if only they had sufficient clinical material available to them during medical training. Once doctors had these “superior skills”, midwives should be eliminated. In order to accomplish this dubious goal, Dr. DeLee is arguing against the establishment of formal training schools for midwives, even though such training would improve the care of midwives, thus reducing the risk to mothers and babies.???

Feb-22-2023 @ 12:08 am In other words, the training of midwives would “waste” clinical material and give the midwife “to much dignity and importance”. Therefore, Dr. DeLee was seriously recommending the unnecessary deaths of mothers and babies was a “reasonable” price to pay for the “greater good” of his “Ideal Obstetrics”. \

??????that would have been prevented by mfry school education and additional skills developed during the clinical training period — ?????

Between 1910 and 1930, midwifery in the America as the traditional standard of care for healthy women suffered a cataclysmic decimation best descried as an “extinction event”. After thoroughly besmirching their reputation, midwives were essentially wiped off the map except for black midwives in segregated areas of the country where black women were not allowed to be admitted to all-white labor wards.

An article published in 1975 in the New York Times Magazine characterized physicians as saving mothers from the “dangers” of midwifery care by forcing midwives out of the “childbirth business”. The article described this power grab by the obstetrical profession, saying:

“In the United States … in the early part of this century, the medical establishment forced midwives — who were then largely old-fashioned untrained “grannies” — out of the childbirth business. Maternal and infant mortality was appallingly high in those days…

~ “As the developing specialty of obstetrics attacked the problem, women were persuaded to have their babies in hospitals, and to be delivered by physicians…. Today it is rare for a woman to die in childbirth and infant mortality is (low)…” [NYTM; Steinmann, 1975]

Note the linguist trickery use in each of these paired statements. Each one links two unconnected facts together by simply have the two statements follow one another; reader will naturally connected the subject of the first (midwives) as being responsible for the bad outcomes (“maternal and infant mortality was appallingly high”) that are reported in second sentence.

This is what happens when the statement “medical establishment forced midwives …. out of the childbirth business” is followed by: “Maternal and infant mortality was appallingly high in those days…”. It happens again when “ women were persuaded to have their babies in hospitals, and to be delivered by physicians….” is followed by: “Today it is rare for a woman to die in childbirth and infant mortality is (low)…”

Based on this sentence structure, newspaper readers would assume that midwives were directly to blame for “appallingly high” maternal mortality and their replacement by obstetricians is the reason that today it is “rare for a woman to die in childbirth”.

~ “The midwife has been a drag on the progress of the science and art of obstetrics. Her existence stunts the one and degrades the other. For many centuries she perverted obstetrics from obtaining any standing at all among the science of medicine.” Dr. DeLee, 1915,-c, p. 114

~ “Obstetrics is held in disdain by the profession and the public. The public reason correctly. If an uneducated women of the lowest class may practice obstetrics, is instructed by doctors and licensed by the State, ( attendance at a birth) certainly must require very little knowledge and skill —surely it cannot belong the science and art of medicine.”

~ “If the profession would realize that parturition, viewed with modern eyes, is no longer a normal function, but that it has imposing pathologic dignity, the midwife would be impossible of mention.”[1915-C; DeLeeMD p.117]

~ “The midwife never has and never can make good until she becomes a practicing physician thoroughly trained; that midwives should not be licensed save in those states where they are so numerous that they cannot be abolished at once; and concluding with the third question by showing how midwives can be gradually abolished.” [1911-C; Emmons & Huntington,MD, p. 199

@@@ barking lot @@@ and very good luck as “medical men” (the term doctors referred to themselves at the time)

Part 3 ~ “Lock her up” was the obstetricians plan eliminating midwives

Starting in 1910, there was a sustained and usually successful effort by organized medicine to convince the lay public that childbirth should not be thought of as just a “normal” part of life, but as a potential medical emergency that needed to be managed minute-by-minute by a bevy of specially-trained labor and delivery room nurses and obstetrically-trained surgeons in an acute-care hospital. Over the following decades, this gave rise to an ever-increasing rate, and increasing level of invasiveness, of obstetrical interventions, as well as a growing dependence on technology and the supplanting of normal spontaneous childbirth with elective Cesarean surgery.

When used appropriately, medical and surgical interventions such as breaking the water, induction of labor, use of IV Pitocin to make contraction longer and stronger, and Caesarean sections can all be life-saving. But as already noted, obstetrical interventions are not risk-free for the childbearing woman or her baby. All interventions can result in further complications. Obstetrical complications can easily become emergencies and childbirth emergencies often result in permanent or damage death for both mothers and babies.

It will come as no surprise that these anti-midwife propaganda campaigns did not end with a few famous obstetricians singing the merits of hospital-based obstetrical care on the radio and in women’s magazines. It included the industrial-strength lobbying of legislatures underwritten by the AMA, which prodded states to pass laws that defined the practice of midwifery to be an illegal practice of medicine. That was the charge used against me in 1991 when I was arrested in my home on Friday afternoon in the presence of my youngest daughter, handcuffed and jailed by the Medical Board of California.

Law-enforcement agents typically arrest people on Friday afternoons because all the judges leave their chambers at noon that day. If Incarcerated individuals can’t afford bail (mine was for $50,000) they must spend the weekend in jail before a judge can decide whether or not to free them on them on their own recognizance. Luckily for me, a former client paid my non-refundable $5,000 bail, and I was released at 2am that morning. Unfortunately, this was also followed by criminal prosecution over a course of 20 months, with 16 pre-trial hearings before the charges against me were dropped. Like the $5,000 cash bail, the system also did not refund the $40,000 in legal fees.

The political “lock her up” chant so popular with the far-right is the kind of thing that happens in a dystopian world in which intelligent, educated and mentally-competent adult women do not have a right to control their own reproductive biology, either as individuals or as practitioners who provide healthcare services outside our frequently misogynist and/ or politically and economically corrupted, mainstream system. Whether the issue is OOH childbirth, access to contraception or safe and legal abortion services, it’s always the same kind of gender-specific prejudice, even when the obstetrician is herself a woman. Women who don’t agree to drink the medical school Kool-aide get washed out of their residencies and don’t get to become obstetricians.

Locking Her Up as the norm for obstetrical care

All over the United States, many midwives have been locked up for attending normal births. In a post Roe world, many more of use will be locked up for helping to facilitate the termination of a pre-viable pregnancy. I’ve only been “hand-cuffed” three times in my life, but always in relation to the reproductive functions of my gender. The first two occasions were the leather wrist restraints that tied each of my arms to the side of the metal delivery-room table while I pushed out babies number one and two out. I should mention that baby number one (my eldest daughter) was born in the back seat of our Renault in 1964 in my effort to avoid the mandatory obstetrical interventions of Twilight Sleep drugs, general anesthesia, episiotomy, forceps delivery and lots of stitches by giving birth just before (four blocks) my husband turned into the hospital ER entrance. This is similar in purpose to eating before you out to a restaurant to avoid the ptomaine poisoning that they are “famous” for!

The third and last time I was handcuffed was for helping healthy childbearing women give birth normally in their own homes. While this kind of obstetrical misogyny pre-dates the “me-too” movement by half a century, the issues are all the same – prejudice, sexism, lack of empathy, and a false sense of entitlement that makes it OK for men in position of power or control to get what they want at the expense of others!

For those of us who have already been snatched up by the long arms of our misogynist laws, the bell can’t be un-rung. But by virtue of being female gender, we all “have a dog in that fight”, and so we must keep working to correct these gender and reproductive-related problems. I often use the example of being in labor – yes, it’s inconvenient and a lot of work, seems to take “forever”, but no one else can do it for us and failing to do it is unthinkable.

Likewise, in the realm of gender politics, we must do the work, put our shoulder to the wheel, and “push” until the job is done and women as a gender are no longer being legally discriminated against, at least not without impunity!

Finished for now @3:45 am 10-03-2022 %%%%%%%%%%%%%%%%%%%%%%%%%%%%

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???? The obstetrical process of “delivery”, which in the United States was (and still is) legally defined as a ‘surgical procedure’, these healthy mothers were taken by stretcher to our OR-type delivery room and given a general anesthesia. After they were unconscious, a ‘generous’ episiotomy incision was done, and then an extremely dangerous form of fundal pressure was provided by one of the L&D nurses who would stand on a foot stool next to the delivery table and to press hard on the top of the mother’s uterus in an attempt to push the unborn baby down deeper in the pelvis in an effort to help the doctor pull the baby out from below with obstetrical forceps.

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I spend my entire professional life fighting to fix our dysfunctional obstetrical system. I’ve never forgotten the years I spend as an L&D nurse (1963-76) actually being the person who directly implemented the corrupt policies and practices of a system is historically characterized as “knock’em out, drag’em out” obstetrics (1910 to 1980s). I know this because I worked for more than a decade in racially-segregated hospital in what is best described as the “Dark Ages of the Deep South”. Our hospital provided two separate and very “unequal” accommodations for labor patients, depending on whether the mother-to-be was white or black.

Our white women were admitted to the all-white maternity department on 5 North. All our labor patients were immediately and repeatedly drugged with Twilight drugs (narcotics and amnesic drug scopolamine). Normal childbirth was conducted as a surgical procedure that began with general anesthesia. As soon as the mother unconscious the doctor performed a series of surgical procedures that included a “generous” episiotomy, forceps delivery, manual removal of the placenta and extensive suturing of the episiotomy incision. Due to the drugs given the mother during labor and the anesthetic gases given during the labor, and a traumatic forceps delivery that included a dangerous form of “fundal pressure” (more about later), many of these babies were born with a profound respiratory depression requiring us to resuscitate them. It was not uncommon for these babies to be unable to stillborn.

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Why access to non-interventive maternity care matters so much to healthy childbearing women

Maternity care is very different from other forms of healthcare in several ways and also different from the American model of interventive obstetrics. This difference is so central that I think we should acknowledge that distinction in our vocabulary – the nouns we use to describe these two very different processes for providing pregnancy and childbirth-related care.

Logically-speaking, the term “maternity care” should refer to the art and science of providing supportive and non-interventive care ot healthy childbearing women, while “obstetrics” is and always has been a surgical specialty, in which medical doctors are trained to use various medical and surgical interventions treat the complications of pregnancy, childbirth and postpartum period.

The most obvious and important distinction between maternity care and other medical services is that childbearing women are not “sick” and childbirth is generally a normal biological function. In the US, the vast majority of childbearing women (over 70%) have healthy pregnancies and give birth to healthy babies. One reason for that is reliable access to high-quality maternity care. Whether provided by an MD or midwife, maternity care providers continually screen pregnant and laboring women for risk factors or possible complications and refer them to appropriate medical services as needed. Regularly scheduled prenatal visits and the presence of a professionally-trained birth attendant (physician or midwife) during active labor and birth makes childbirth safer for both mother and infant.

In addition to its physical aspects, having a baby is also a psychologically important event in the lives of women. The kind of maternity care a woman receives will affect how she experiences these important life events. Her experience during pregnancy and birth affects how she feels about herself and her baby, which in turn influences her role as a mother and her relationship to her family. Providing effective and comprehensive care during pregnancy and childbirth improves the lives of women and their children. The stability of society is greatly benefited by stable and reliably affectionate relationships between parents and children. For that and other compelling reasons, evidence-based childbirth options should never be withheld from pregnant women who have been fully informed and provide legal consent.

Ample scientific evidence long ago established that it was impossible to reduce all childbearing risks to zero 100% of the time for both mother and baby, regardless of the place of birth or the category of birth attendant — obstetrician, family practice doctor, professional midwife, hospital, home or birth center. There is nothing that can be done, or purposefully not done, that will reliably, ethically, and with economically sustainability, assure a good outcome for every mother, every baby, every time.

However, some types of birth-related morbidity and mortality can be temporarily time-shifted, place-shifted and person-shifted. One example of this is what happens when the obstetrical profession promotes both elective induction of labor in healthy women with normal pregnancies and elective Cesarean deliveries as “safer” than awaiting the spontaneous labor and normal vaginal birth.

Occasionally a bad “outcome” will be averted, but statistically it’s more likely that would otherwise have been normal a birth that for both mother and baby, is suddenly turn by those interventions into a life-threatening complication that will require blood transfusions, an emergency hysterectomy and weeks in the ICU. Sometimes it results in a preventable maternal death (ref. maternal death of Kira Johnson after a repeat CS).

As proclaimed by one popular TV commercial “It’s not nice to fool Mother Nature”. The bottom line is simple: No matter how much risk-shifting and cost-shifting is done, bad outcomes can never be totally eliminated and in actual fact, often are increased in frequency and severity due to ill-considered efforts to protect hospitals and obstetrical staff from possible malpractice litigation by throwing childbearing women under the bus.

Historically and in contemporary times, the vast majority of maternity care practitioners are midwives. Professional midwifery training programs teach students a variety of valuable “truisms” about normal labor and birth. These include being careful not to disturb the normal process, making “right use of gravity”, avoiding anti-gravitational positions, how best to meet the practical needs — biological, psychological, as well as emotional and social – that pregnant and laboring women commonly have. This non-interventive and supportive form of physiological management has already been tested and found to work by billions of times by women giving birth all over the world and spanning the many thousands of years of our species existence.

For an essentially healthy population, the most efficacious form of maternity care is always the method that provides “maximal results with minimal interventions”.

This is defined as a beneficial ratio of interventions to outcomes for each childbearing woman.

The ideal maternity care system seeks out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome with the fewest number of medical/surgical procedures and least expense to the health care system.

Pasted in “Outtakes – Sylvie file

Integrate physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women.

The form of care provided needs to be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than by the occupational status of the care provider (physician, obstetrician, midwife).

Ultimately, all maternity care is judged by its results — the number of mothers and babies who graduate from its ministration as healthy, or healthier, than when they started.

We need to use our energies to transform our national maternity care policies and reconfigure the system at its most basic and practical level by promoting :

Maximal results with minimal interventions
Skillful use of physiological management
Adroit use of medical interventions as necessary
Fewest number of medical/surgical procedures
Least expense
Best outcome for mothers and babies
Value to families – meeting their social, psychological and developmental needs as defined by the mother, father and others members of the family

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 appropriate access to the best obstetrical services if or when they desire or require them.

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Problems associated with interventionist obstetrical services for a healthy population is

drastically increased cost and nosocomial and iatrogenic complications without statically significant improvement in outcomes. Routinely medicalizing normal childbirth in low and moderate risk mothers dramatically increases the rate of medical interventions, operative deliveries, re-hospitalization, nosocomial complications (such as MRSA infections) and 2 to 13-fold increases morbidity associated with the high rate of cesarean surgery. This includes anesthetic accidents, surgical injury, hemorrhage, emergent hysterectomy, infection, cerebral stroke and maternal death. Downstream complications of post-Cesarean reproduction include secondary infertility, tubal pregnancy and miscarriage. Delayed risks in post-Cesarean pregnancies includes increased rate of breech babies, placental abnormalities (previa, percreta & abruption), stillbirth and uterine ruptures prior to labor and/or before a scheduled repeat C- section can be carried out.

This is a night-and-day different from the obstetrical model, which is a surgical specialty. Obstetricians are trained to provide the type of medical and surgical services needed by the 20% or 30% of pregnant women who have high-risk conditions, develop serious complications or experience a obstetrical emergency that requires an operative delivery (forceps, vacuum e or Cesarean section. However, a surgical specialty, the formal medical school education and hospital-based clinical programs for its obstetrical residents do not teach, or even acknowledge, the existence of non-interventive care for “normal childbirth” as distinct from obstetricalized interventions and surgical procedures.

At the same time, the obstetrical profession must refrain from the routine use of interventions originally developed to treat life-threatening complications. When “life-threatening” medical treatments and procedures are used on a healthy childbearing population that do not have themselves have any life-threating conditions, those treatment themselves become dangerous and life-threatening.

Changing unhelpful or harmful behaviors within the medical profession will

never be able to normalize the care of healthy childbearing women unless we first address and change the erroneous belief that normal childbirth is a pathology, i.e, a potentially dangerous equivalent to a hand-grenade with the pin pulled.

Beliefs behind the behavior trace back to the pre-antibiotic era

Prologue

Beginning in 1910, leaders of obstetrical profession in the US embarked on a self-serving propaganda campaign to spread misinformation about the nature of childbirth, which they officially as described as “pathophysiology” and re-defined a “nine-mouth disease that required a surgical cure”.

This was accompanied by glowing descriptions of the wonderful new surgical specialty of obstetrics and new idea of electively hospitalizing healthy middle-and upper class maternity patients as paying customers. This was promoted as the new “modern” (i.e. scientific) way to have a baby, which was also accompanied by a startling new promise of “painless childbirth”. As late as the 1976, which is when I retired from labor and delivery room (L&D) nursing, our obstetricians were still assuring soon-to-be-new mothers that they:

“won’t feel a thing, won’t remember anything, you’ll just wake up with a new baby in your arms”.

The public was repeatedly barraged in newspaper, radio broadcasts and women’s magazines with dark ideas about the dangers of childbirth in the hands of midwives and old-fashioned “country doctors”. This was quickly followed by claims that every mother and every baby would “safe” in the hospital under the care of an obstetrically-trained surgeon. However, all these claims were equally false and the obstetricalization of normal childbirth healthy women was accompanied by an increase in maternal and infant morbidity and mortality.

Nonetheless, the public believed, shared, trusted and elevated this information to the status scientific fact, which it certainly was not. Nonetheless, the obstetrical profession continued to publicly portray elective hospitalization and routine use of medical and surgical intervention as a scientifically-rigorous process for providing the very latest and best childbirth services to a healthy childbearing population. Having defined normal childbirth pathology, they were happy to now offer a Pandora’s box full of medical and surgical “cures” that were risky at best and too often life-threatening.

This new and supposedly ‘scientific ‘obstetrical process began with her husband being sent home and the laboring woman being admitted to a “No Admittances” labor and delivery unit. She would have her all public hair shave off and given a large soapsuds enema. After she got out of the bathroom, she’s be put to bed and receive the first many frequently-repeated injections of Twilight sleep drugs (morphine and scopolamine).

Scopolamine is both an amnesic and hallucinogenic drug, which reduces the mother-to-be to a semi-conscious and pseudo-psychotic state. As a result, it was often necessary to use four-point restraints in which the mother’s wrists and ankles were tied to the respective four corners of the bed. This meant the laboring woman spent her entire labor in the worst of all position for her and her baby, which is lying flat on her back.

In the gender-related rhetoric of our currently dysfunction political system, I would call this as the “lock her up” phase. When it was time came for the baby to be born, the mother was taken by stretcher to an OR-style “delivery room” and given chloroform or other general anesthetics. Then her wrists were put in leather restraints (the kind used in psychiatric units) strapped to the side of the delivery table, and her legs put up in obstetrical stirrups, which mean she again was forced to give birth while lying flat on her back. No wonder doctors thought forceps were a necessary aspect of vaginal birth.

The obstetricalized version of childbirth was formally known as the surgical procedure of “vaginal delivery”, which was something ‘performed’ by the doctor on an unconscious woman. After the mother was “put to sleep”, the doctor cut a large episiotomy and instructed the L&D nurse to provide a dangerous form of fundal pressure. This required the nurse to stand on a foot stool next to the delivery table, while pushing with the whole weight of her body on the top of mother’s uterus in an effort to shove the baby down from above while the doctor pulled from below with forceps.

When Chickens Come Home to Roost ~ US has highest maternal mortality rate in the industrialized world!

When obstetrical interventions and surgical procedures originally developed to treat life-threatening complications were routinely applied, decade after decade, to healthy women with normal pregnancies, the results were an unmitigated disaster that resulted in the US having the highest maternal mortality rate in the industrialized world and equally disastrous rate of dead and permanently brain-injured newborns.

But in the insular “Alice in Wonderland” world of obstetrics, it policies and practices were never came under the scrutiny of “disinterested” scientific observers or those doing science-based research. If they had, the US would have a maternity care system based on physiological practices as provide by midwives and family practice physicians that normalized childbirth in healthy women with normal term pregnancies.

Obviously, that is NOT what happened. Instead obstetric became the “cash cow” of hospital economics and as a consequence, was and continues to be virtually “untouchable”, year after year, decade after decade. Based on my experience as an L&D nurse, my best estimate is that about 20% of new mothers and/or their babies were negatively affected by these many layers of ‘routine’ interventions and artificially-elevated rate of operative and Cesarean deliveries. In far too many instances, new mothers or their babies were permanently damaged or died as a result of unnecessary and often unwanted obstetrical interventions in the labors of women who otherwise would have just given birth spontaneously and safely and had a normal healthy baby that breathed spontaneously after being born.

Backstory ~ Historical Obstetrics as a “life-saving miracle”
that so far has missed the mark

As a surgical specialty, obstetrics was originally developed as a method for providing life-saving care to women suffering from the many different life-threatening complications of pregnancy, childbirth and the postpartum period. Obstetrical surgeons were able to eliminate unnecessary pain and suffering, respond to serious complications and provide emergency interventions associated with childbearing, such surgery to remove an ectopic pregnancy, Cesarean delivery of women who had a deformed pelvis due to having rickets as a child, removal of a retained placenta or emergency hysterectomy for a life-threatening hemorrhaging in a newly delivered mother. These all represent the “right use of obstetrics”, and no question about it, we are incredibly and eternally grateful.

Unfortunately, when that same life-saving intervention-based, ‘pre-emptive strike’ model of obstetrics was universally applied to all childbearing women, 75% of whom were healthy and had normal pregnancies, obstetrics took on the karma of the ill-fated ocean liner Titanic. The Titanic was new and technology impressive, and its promoters promised the moon, claiming that it was virtually unsinkable. However, it was unable to deliver on that promise and became a deadly catastrophe.

Twenty-century obstetrics is also big and showy, but it also is like armada of tiny Titanics, each one occupied by a healthy woman with a normal pregnancy heading straight into the iceberg that is obstetrical intervention. On the surface, ice bergs don’t look particularly dangerous, but 5/7^th of their mass is below the water line. Obstetrics as provided to a healthy population mirrors this, as each intervention doesn’t necessarily look menacing by itself, but is part of an highly medicalized process that virtually destroys the normal biology of spontaneous labor and birth and a baby able to breathe on its own at birth.

Every year from 1910 to 1950, two million childbearing women (T. 80 million) were exposed to the routine use of multiple dangerous interventions. After WWII, the annual number of births doubled to four million (T. 120 million), while unnecessarily-obstetricalized childbirth as a surgical procedure continued to be “performed” on many millions of anesthetized women well into the late 1970s and early 1980s, depending on where in the country the mother lived. Over this three-quarters of a century, 200 million women were needlessly exposed to the serial dangers of Twilight Sleep drugs, chloroform, ether, and other types of general anesthesia, routine episiotomies, forceps deliveries, manual removal of the placenta and extensive suturing of the episiotomy incision.

For many millions of mothers and unborn babies, this was catastrophic. Women whose bodies were exposed to these abusive practices suffered silently and for the rest of their life from humiliating “female troubles”, a euphemism for being incontint or a uterine prolapse that eventually required a hysterectomy for those who could afford such major surgery.

For babies, the systemized “obstetrical incontinence” resulted in various kinds of permanent brain damage – babies born with cerebral palsy, Erb’s palsy, other types of paralysis, and a spectrum of mental retardation. This was the neonatal consequence of narcotic drugs given to their laboring mother, in combination with the severe respiratory depression caused by the use of chloroform and other general anesthetics in combination with and a very dangerous form of “fundal pressure” in which the doctor instructed the L&D nurse to push down very hard on the top of the mother’s uterus while he pulled with forceps from below.

During the first half of the 20^th century, the public in general did not understand the causal relationship between the use of narcotic, anesthetics, obstetrical interventions and invasive surgical procedures such as the use of forceps and the large number of brain-injured babies being born every year in the US. Unlucky families who had a child with cerebral palsy or profound mental retardation often felt feel ashamed and humiliated by their child’s disabilities and hide them away in a back bedroom so the neighbors wouldn’t know, or at least avoid the mutual embarrassment of would seeing their distressingly disabled child.

We, the People, pay the piper while obstetricians take a powder

The institutionalized use of obstetrical interventions in the United States was responsible for a disproportionally high rate of maternal mortalities and crippling life-long disabilities for both mothers and babies. It’s no surprise that the obstetrical profession wants to ignore and sweep this period of its history under the rug by pretending that a century of institutionalized iatrogenesis actually never happened.

Even more galling is their portrayal of themselves as the “saviors” of childbearing women, claiming to save childbearing women from the horrors of labor pain and nasty brutish work of pushing a baby out their vagina. Why not just lie on an OR table and watch while the doctor does the work (and takes all the credit!) by performing a nice Cesarean and delivers the baby “from above”? We all know that a sanitized “above” is better than a “below” that includes a vagina, with all its various secretions and sexual connotations!

As an L&D nurse, I used to read old obstetrical textbooks that had a whole chapter on “obstructed labor” and how to “get the baby put” by first decapitating the baby (preferably after it died!) and then taking its body out in pieces. No one wants to live in a world with the modern, life-facing practice of obstetrics!

If obstetrical profession had continued to define its surgical specialty as concerned with the treatment of abnormal conditions and emergencies, my historical account of the “bad old days” and concerns about the “wrong use of obstetrics” would be unnecessary. I wish to God that was the case, as I’ve spent the entirety of my professional life attempting to right this grievous wrong, all to no avail.

So far stubbornness has ruled the day (actually more than a century, in which obstetricians just “assumed” that they, as MDs, always “know best”. These regrettable character flaws were combined with generous serving of professional hubris, aspirations to ever greeter social status and wealth, and highly influenced by the incendiary ideas of Dr. J. Whitridge Williams (most influential obstetrician of the 20^th century, but more about him later) and all mixed with the natural tendency of the professionals to want to use their professionals skills. The result was in “a perfect storm” that turned healthy childbearing women into the patients of a surgical specialty, and normal childbirth into a surgical procedure. This was, and continues to be, the most profound change in childbirth practices in the history of the human species.

Mind the Gap!

Reconciling the Irreconcilable — Learning to “love” the bomb

Yes, we need to learn to love our maternity care system, dysfunctional as it seems to us. We need to own it, to think of it as ‘ours’, believe it can again be based on rational logic and returned to balance by meeting the needs of all stakeholders – mothers, babies and all categories of birth attendants.

We need to use our energies to transform our national maternity care policies and reconfigure the system at its most basic and practical level. We need to promote ideas like:

Maximal results with minimal interventions
Skillful use of physiological management
Adroit use of medical interventions as necessary
Fewest number of medical/surgical procedures
Least expense
Best outcome for mothers and babies
Value to families – meeting their social, psychological and developmental needs as defined by the mother, father and other members of her family

We rabble rousing childbirth activists believe that physiologic care, which is the scientifically-based standard of care, should be universally provided to healthy women with normal pregnancies unless the mother herself desires or requires medicalized care. The philosophy, principles and practices that permit the wise management of childbirth are based on not disturbing the normal process unless it becomes necessary, and even then, the standard of care calls for using as few interventions as possible.

I have worked my entire adult life to transform the narrow focus of our dangerously interventionist obstetrical system into a safer and broad-based maternity care model able to respond to the practical needs healthy childbearing women. In our era, this is known as mother-baby-father friendly maternity care, (thanks to the Coalition for Improving Maternity Services (CIMS), but in actual fact, it is just biologically normal, socially-based supportive care as provided to our species by our species for hundreds of thousands of years.

Still no Joy in Mudville!

But for all our idealism, enthusiasm and sustained effort, we remain locked out of the system by a century of institutionalized decisions that are based political rather than scientific factors. In the current configuration, mothers and midwives have to lose in order for the ‘system’ to win – i.e. an interventive form of obstetrics as a surgical specialty that continue to define childbirth as a patho-physiology.

By pathologizing normal childbirth, the obstetrical profession dominates and controls the standards of care as hospital-based discipline organized around the routine use of a dozen or more intervention that begin with the continuous EFM and far too often end in Cesarean surgery. Not only is “history” written by the “winners”, but so are the textbooks, our laws and legally-binding standards of practice.

As an “expert” system, obstetrics fails in the very area it was supposed to have the most mastery and expertise — preserving the health of already healthy mothers and babies by protecting them from harm, including serious iatrogenic and nosocomial complications and preventable mortality. With medical intervention and surgical procedure rates of over 70% (ref: Listening to Mothers surveys) confirms that the introduction of harm has been systemized and institutionalized. As a result, the obstetrical profession has failed to carry out its most basic of all its responsibilities — “in the first place, do no harm.”

Even more than our frustration as activists attempting to normalize normal childbirth, we continue to be personally affected by the painful schism between our values and our on-going experience of interventive obstetrics as it is being applied to healthy women, which is often like watching a slow-motion car crash! Speaking as someone who has been doing this since the 1960s, when Twilight Sleep drugs, episiotomy, general anesthesia, a dangerous form of “fundal pressure” and forceps deliveries were 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 mostly it’s an illusion of progress. General anesthesia was replaced by epidural, forceps deliveries exchanged for Cesarean section, but in actual fact, the routine use of anesthesia – general or epidural – are unnecessary, ditto for forceps and Cesarean. For each of the dangerous or unnecessary protocols or procedures that were eliminated, one or more have been added, the most recent being the routine induction of labor before the mother’s due date.

This new pre-term or EDC induction protocol is a statistically-based strategy to prevent the very small possibility of fetal distress or unexplained stillbirth should the mother not have given birth spontaneously before reaching 41 weeks and 3/7^th days of pregnancy. There is no logical reason to induce 100% of the childbearing population at 39 weeks to prevent a possible negative occurrence at 41. 3/7^th, since the vast majority of pregnant women have already delivery spontaneous by the end of the 40^th week.

As activists, our individual pain and collective experience is the extremely long-time frame for a dysfunctional system that manages to make minor and superfluous changes from time to time, but never actually fixes the core problems. There never is any public acknowledgement by the obstetrical profession or the wider scientific community of the irrefutable scientific evidence that identifies the routine use of obstetrical protocols based on hospitalization, medical interventions and surgical procedures to be both unnecessary and harmful – iatrogenic.

The origin of our currently dysfunctional system are the historic policies and practices of the last century, which were both unnecessary and extremely harmful to both mothers and babies. However, that system – on based on the obstetrical claim that pregnancy was a “nine-month disease” that required as “surgical cure” – was the foundation and building blocks for our current obstetricalized, and plainly dysfunctional model of care.

Because the obstetrical community has never, ever acknowledged its historical or its contemporary problems, the profession has no reason to change its practices. As currently configured, they continue to ignore the science-based principles of physiological management of normal labor and birth which, from a legal standpoint, is the actual standard of care for healthy women with normal term pregnancies. continue to let them get away with it.

For the entire 20^th century and two decades into the 21^st century, healthy women and their families have been swept along a conveyor belt that took them to places they did not want or need to go. Even more alarming, the consequence of organizing obstetrical practice around protecting hospitals and obstetricians from lawsuits, is a dysfunctional system that doesn’t serve the vast majority of the childbearing population (75-80% of all births) and does result in a two-to-three fold higher rate of preventable maternal deaths than other developed countries. Historically (1910-1975) and in our own time, the US has the highest MMR in the developed world! (Commonwealth Club online publication)

In a perfect world, the resurgence of traditional (non-medical) midwifery and out-of-hospital birth should never have been necessary. The reason it happened was the collective inability of childbearing women and midwives to make any substantial impact on our hyper-medicalized system. We intended to meet just those specific needs the obstetrical profession couldn’t 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. But similar to the limited choices available to groups battling institutionalized segregation based on race, religion or ethnicity, all we could do is build an “equal but separate” system.

But apartheid is never a satisfactory solution to any situation. Anyone who gets pregnant or provides services relative to pregnancy and childbirth knows two things – (a) the safety of childbearing women and their unborn babies depends on having appropriate access to obstetrical services when needed, and (b) it’s impossible for mothers and midwives not to be constantly drawn back into the fray at the political level. Simultaneously with fighting to fix a dysfunctional, we must never say or do things that would make pregnant women distrust or afraid to go to the hospital when they or their unborn babies need medical, obstetrical or surgical interventions. This is quite a balancing act!

Reconciling the Irreconcilable — Learning to “love” the bomb

We need to use our energies to transform our national maternity care policies and reconfigure the system at its most basic and practical level. We need to promote ideas like:

Maximal results with minimal interventions
Skillful use of physiological management
Adroit use of medical interventions as necessary
Fewest number of medical/surgical procedures
Least expense
Best outcome for mothers and babies
Value to families – meeting their social, psychological and developmental needs as defined by the mother, father and other members of the family

Childbearing women are not sick!

We must never forget or ignore the fact that childbearing women are not sick. The fundamental purpose of maternity care is to protect and preserve the health of already healthy women and reduce or eliminate preventable mortality and morbidity for mothers and babies. This is why maternity care for healthy women with normal term pregnancies is fundamentally different from medical care and all other forms of healthcare.

Mastery in normal childbirth services means bringing about a good outcome without introducing any unnecessary harm or unproductive expense. For an essentially healthy population, the safest and most cost-effective form of maternity care provides “maximal results with minimal interventions”. According to the scientific evidence, the ideal maternity care system seeks out the point of balance where the skillful use of physiological management and adroit use of necessary medical interventions provides the best outcome with the fewest number of medical/surgical procedures and least expense to the health care system.

However, pregnancy and childbirth are major developmental events in the lives of women. The kind of maternity care a woman receives will affect how she experiences these important life events. Her experience during pregnancy and birth affects how she feels about her baby, herself as a mother, her family and other relationships. Providing comprehensive care during pregnancy and childbirth improves the lives of women and their children at the time and over the span of their lifetimes. This form of maternity care is not only the safest and most cost-effective, but its intergenerational “mother-baby” model supports and protects the mother-baby bond. Practices that make mothering more difficult are by definition also baby for her baby. A strong and stable mother-baby bond is the ‘gift that keeps on giving’, as it provides the highest likelihood that the child will be able to get its emotional needs met and grow up to be mentally and physically healthy adult.

For Healthy Childbearing Women, Simple is Safer

Childbearing women cared for by professional birth attendants who provide physiologic support for normal childbirth have 2 to 10 times less obstetrical intervention than the current medicalized form of hospital childbirth. Physiologic support is also associated with a dramatically reduced rate Cesareans surgeries from over 30% to under 10%.

As measured by outcomes of the four main categories of birth attendants …

unattended births
lay midwife-attended
OOH professional midwife-attended
Hospital-based obstetrician care

Irrespective of the category of birth attendant, a statistics that includes lay and “granny” midwives, the best strategy for preventing maternal and perinatal mortality and morbidity is a model of that balances safety and cost-effectiveness by providing:

(1) Unfettered access to regular prenatal care that includes risk-screening and referral to medical careproviders and other healthcare services as needed
(2) An experienced birth attendant who is skilled in physiological management, trained and equipped to deal with rare emergencies, and is physically present during active labor, birth and the immediate postpartum-postnatal period

(3) Access to hospital-based services for unexpected complications or if medicalized care is requested by the mother

Second copy of same material
My personal experience and professional role in this intergenerational saga

I spend my entire professional life fighting to fix this dysfunctional system and am still at it at the age of 79! I’ve never forgotten the years I spend as an L&D nurse actually being the person who directly implemented the corrupted system historically referred to as “knock’em out, drag’em out” obstetrics. Mothers and babies died because I was a “good” nurse who followed “doctors’ orders”, even though I knew what I was doing was, scientifically-speaking, “wrong” and so dangerous that it result in the birth of babies that would never breathe due to the narcotics medication and anesthesia we gave to their mothers. Unfortunately, I personally understand how and why “good” people follow “bad” orders. I’m only relived that wasn’t my fate to have been born in Germany during Hitler’s reign of terror.

Many decades later I have finally forgiven myself but. I can never give up trying to change the system so that it actually does what it claims, which is to make childbirth safer through the appropriate use of obstetrical interventions and necessary surgical deliveries. At the same time, the obstetrical profession must refraining from the routine use of interventions originally developed to treat life-threatening complications, which become life-threatening when they are routinely used on a healthy childbearing population.

In the meantime, I lie in waiting for long stretches of time, patience being a handy attribute for midwives, laboring women and their families. Unfortunately, medical schools still aren’t teaching future obstetricians to be patient.

Metaphorically, I aspire to be a cross between Harriet Tubman, Anne Frank and a hundred-year-old daughter of a slave living in North Carolina that I knew very well (Maggie Nichols) by ending the systematized and institutionalized “wrong” use of obstetrics as the standard of care for childbirth in America. By that, I’m pointing to a systematized and institutionalized form of obstetrics as an aggressively interventive surgical specialty adopted more than a hundred years ago (1910).

Unfortunately, the historic idea that childbirth was a basically pathological process meant that obstetrical practices were organized around the “preemptive strike” – using procedures developed and designed to treat serious complications “prophylactically”, such as not allowing women to eat or drink during labor, then giving IV fluids to keep the labor patient from becoming dehydrated or in case they bleed excessively later on. Relative to normal pregnancy, the pre-emptive strike means scheduling an induction instead of waiting for labor to start. During childbirth, it’s “when in doubt, cut it out” (i.e. doing a Cesarean). In addition to the unproductive cost of prophylactic medicalization is a high level of iatrogenic and nosocomial complications triggered by this “can’t be too careful” philosophy.

But the routine use of all these interventions is directly in opposition to supporting the biology of normal childbirth in healthy women with normal term pregnancies. This “shoot first, ask questions later” philosophy still shapes and defines obstetrical services of normal childbirth in the 21^st century except, that childbirth is rarely ever allowed to be “normal” in this profoundly dysfunctional and interventive system.

The problem with American obstetrics is that it is all about the obstetricians.

Defining, conducting and billing for normal childbirth as a “surgical procedure” (still true in 2022!) is a fluke of history that traces back to policy decisions made 1910 by the founding fathers of American obstetrics. Obviously normal childbirth as a natural function of human biology is not normally an operation ‘performed’ by a surgeon. But in 1910, the obstetrical profession decided to define itself as a hospital-based surgical specialty, re-define healthy childbearing women as “surgical patients” and normal childbirth as a “surgical” procedure. This is the most profound changes in normal childbirth practices in the history of the human species!

This was part of a campaign to distance and distinguish themselves from midwives and “old-fashioned” country doctors, as well as their political and strategy economic to take over all facets of pregnancy and childbirth as the sole domain of the obstetrical profession.

The decision to conduct normal birth as a surgical procedure was actually an attempt to prevent puerperal sepsis in hospitalized maternity patients in a pre-antibiotic world. ‘Childbed fever’, as puerperal sepsis was called by the general public, was a potentially-fatal hospital-acquired infection. Until the discovery of Pasteur’s germ theory of infectious disease in 1881, it was responsible for repeated pandemics that killed from 5 to 50% of childbearing women in the “lying-in” ward of 18^th and 19^th century “charity” hospitals dotted across the European continent.

The problem with obstetricians is never admitting their mistakes, never learning from their mistakes, never saying “sorry”, and never promising to fix the problem and play ‘nice’ in the future

Since 1910 the obstetrical profession has legally defined the all terms for childbirth practices and all forms of maternity care. By characterizing childbirth as a dangerous and dysfunctional form of biology, the obstetrical professions was able to get policies and legislation passed that made midwifery care illegal, and adopted national policies and practices for childbirth that left childbearing women out of the equation. Childbearing women were treated like objects without a voice, or any opportunity to control what was being done to them or their babies.

Beginning in 1910, women no longer gave birth under their own power, but were “delivered”. The “delivery” was a solo performance by the doctor, in which the mother, father and nurse are both the audience and cast members, while the obstetrician was clearly the star of the show.

This system got cemented in places in the early 20^th century without any prior input from the wider scientific community. It’s hard to imagine, but the American obstetrical profession never conducted any studies that compared mother-baby outcomes for healthy childbearing women based on these two very different systems – supportive physiologic care provided by midwives and general practice doctors, compared to the standard (i.e. pre-emptive) model of obstetrical and surgical interventions.

From 1910 to the 1980s, hospital-based obstetrics had a “no admission” policy for husbands and other family members during the labor because labor patients were routinely injected with large doses of morphine and the Twilight Sleep drug scopolamine every 2-3 hours. Normal childbirth was conducted as a surgical procedure that began by rendering the mother unconscious under general anesthesia. The surgical procedure of “vaginal delivery” began with routine use of episiotomy, flowed by a forceps delivery, manual removal of the placenta, suturing of the episiotomy incision and then separating the newly delivered mother and her newborn for 12 (or more) hours.

Historical Obstetrics as it was meant to be: A Life-saving “Miracle”

As a surgical specialty of obstetrics was originally developed to provide life-saving care to women suffering from the life-threatening complications of pregnancy, childbirth and postpartum. Obstetrical surgeons were able to eliminate unnecessary pain and suffering, respond to serious complications and provide emergency interventions associated with childbearing, such surgery to remove an ectopic pregnancy, Cesarean delivery of women who had a deformed pelvis due to rickets when she was a child, removal of a retained placenta or emergency hysterectomy for a life-threatening hemorrhaging in a newly delivered mother. These all represent the “right use of obstetrics” for which we are all incredible grateful.

So far stubbornness has ruled the day (actually more than a century!, in which obstetricians just “assumed” that they, as MDs, always “know best”. These regrettable character flaws were combined with generous serving of professional hubris, aspirations to ever greeter social status and wealth, and highly influenced by the incendiary ideas of Dr. J. Whitridge Williams (most influential obstetrician of the 20^th century, but more about him later) and all mixed with the natural tendency of the professionals to want to use their professionals skills. The result was in “a perfect storm” that turned healthy childbearing women into the patients of a surgical specialty, and normal childbirth into a surgical procedure. This was, and continues to be, the most profound change in childbirth practices in the history of the human species

The modern-version version of American obstetrics as a surgical specialty

The elevation of operative obstetrics while criminalizing physiologically-based care turned the 20^th century into Dark Ages. The traditional principles of physiological management for normal childbirth were denigrated and abandoned. The non-intensive care of midwives was ridiculed by influential obstetricians, quickly becoming the target of an aggressive publicity campaign in that planted anti-midwife articles in newspapers, women’s magazines and radio programs. In many states, organized medicine has no trouble getting laws passed that criminalized the practice of midwifery. Obstetrical training programs stopped teaching medical students how to physiological manage normal childbirth, and instead taught the routine use of anesthesia, episiotomy, forceps, and other invasive techniques.

Instead of being based the scientific principles, this aggressively interventive model of obstetrics was based on a cult of personalities of a handful of professionally influential obstetricians during the two decade of the 20^th century who were promoting their personal and peculiar theories. The problem with obstetrics is that it is all about obstetricians – their own prestige and social standing – instead of what best served the needs of a healthy childbearing population.

Eventually these prejudiced policies were institutionalized as the American standard of care for childbirth. This legally restricted the scope of practice to hospital-based obstetrics. The hospital’s malpractice carriers require OBs and nurse-midwives to abide by obstetrically-defined policies, practices and protocols. They call for the routine use of interventive technology (EFM, IVs, Pitocin, epidural, etc.) and restrictive policies that limit the mother’s mobility and impose artificial time restraints during active labor and 2^nd or pushing stage of labor and birth.

The politics of the system – ideas that obstetricians enjoy a naturally elevated social status and political clout via the organs of organized medicine, combined with the self-serving restrictions imposed on obstetrical practice by medical malpractice carriers, prevents healthy women from having a normal vaginal birth via “hospital policies” that required doctors to do Cesarean deliveries on women with a previous Cesarean, breech baby, “big” baby, twins or a post-term pregnancy. Using conservative statistics, the maternal morbidity rate (serious complications) following a Cesarean is 70 times greater than those associated with a vagina birth, and the maternal mortality rate is 3.5% greater. Protocols for protecting doctors and hospitals from lawsuits are literally killing women via medically unnecessary Cesarean surgeries.

Systemizing and institutionalizing the “wrong use” of Obstetrics

At the center of this profoundly dysfunctional self-serving system is a century-long refusal by the obstetrical profession to admit that what they’ve been doing for the past 120 years – the decision to treat normal childbirth as a hand grenade with the pin pulled – has never been of benefit to healthy childbearing women or their newborn babies. This is not merely unnecessary but fundamentally and scientifically wrong and dangerous for both mothers and babies. Complications and preventable deaths caused by the action or omissions of a medical doctor are technically known as “iatrogenic”. The list of iatrogenic practices begins in medical schools, which haven’t taught physiological management of normal birth since the early 1900s. It continued with the criminalization and elimination of traditional midwifery practitioners and hospitalization of all childbirth services, beginning in 1910. This highly medicalized and interventive system included routine use of general anesthesia and operative deliveries in the first 75 years of the 20^th century.

Since the introduction continuous EFM in the mid-1970s, “normal” birth under obstetrical management means putting a laboring woman to bed and hooking her up to an EFM system as soon as she arrives in the L&D unit. Over the next hours, the vast majority of laboring women will wind up with a Pitocin IV to speed up their labors. In order to tolerate the suddenly intensified pain of Pitocin-induced contraction, she’ll need to have epidural anesthesia. This includes the use of an automatic blood pressure cuff that goes off every 15 minutes, and a pulse oximetry device on one of her fingers to be sure she doesn’t have a dangerous drop in her blood pressure due to the effect of epidural anesthesia.

Another side effect of epidural is inability to spontaneously empty her bladder, so a Foley or “in-dwelling” urinary catheter inserted into her bladder and hooked up via plastic tubing with a bad hanging on the bottom of her bedrails.

When the time comes to push, she will being laying on her back. In this position, the natural course of the birth canal – technically referred to as the “curve of Carus” — is a 60 degree arc that bend up hill. Laying on her back, numb from the waist down, someone else (husband, nurse, or obstetrical stirrups) will have to hold her legs up for her as she attempting to push her baby around the 60 degree pelvic curve and straight up hill against the forces of gravity toward the ceiling.

When her efforts fail to do this at the rate thought necessary by the hospital staff or her OB, a “vacuum extractor” (similar to a miniature toilet plunger) will be used to pull the baby out. However, the statistically more frequent situation is concern over some irregularity in the fetal heart rate that may or may not be a sign of fetal distress. As noted earlier, “when in doubt, cut it out” is the obstetrical response to mere possibility (i.e. not probability) that the baby is not doing well. The reason performing a Cesarean is recorded on the operative record as a “non-reassuring fetal heart rate tracing”. Note that it doesn’t say the baby was in distress, just that the EFM record was “non-reassuring”. This scenario, which I describe of “obstetrical-staff-distress”, is the second most frequent “diagnosis” used to explain why a first-time mother had an unexpected Cesarean delivery.

Banging the drum harder – more is not the same as better!

The current system suffers from two fatal flaws. The first was an unquestioning adoption in 1910 of an unscientific system built on the idea of eliminating the natural risks of childbirth through the use of the preemptive strike – exercising total control via the routine use of “knock’em out, drag’em out” drugs during labor, and conducting childbirth a series of surgical procedures. The second was the profession’s fantasies of taking over and ultimately having total dominion over the all aspects of female reproduction as a surgical specialty under the control of obstetricians and gynecologists. Unfortunately, the least important persons in this grand plan was the individual laboring woman and her baby. Eventually (1976) a sudden and meteoric rise in medical malpractice suits would make the baby (but not its mother) the central issue for hospitals and obstetricians.

As activists for normalizing normal childbirth and preventing preventable morbidity and mortality for both mothers and babies, our job is to see that both mother AND baby are the “central” issue for the “system” and that the “system” is solidly evidence-based. This is an inclusive model that accounts for the emotional, psychological and sociological aspect of mother-baby wellbeing. As a science-based model of maternity care for healthy women with normal term pregnancies, its practitioners and birth attendants (midwife or physician) would be educated and experienced in physiological management and support, including the right use of gravity, for normal vaginal birth.

Hospitals can still hawk the “wonders” of epidural, but only if it includes “fully informed consent”, which means identifying how it interferes with normal physiology of spontaneous birth, which is the evidence-based model of care. They can offer access to continuous EFM but only after the informed consent process has thoroughly debunked its claims “greater fetal safety” and includes the inescapable reality that it (a) does not benefit the baby; (b) interferes with the spontaneous physiology of labor (right use of gravity, frequent change of position, being upright and mobile). This is associated with a three-fold increase in the C-section rate, which more than tribbles the risk of maternal death and increases the likelihood of morbidity (serious complications) by a factor of 70.

OBs can still hawk the “convivence” of Pitocin-induced labors and ‘elective’ Cesarean, but only after acknowledges all these increased risks and admitting that routine inductions and elective Cesareans are both more dangerous than awaiting the spontaneous onset of labor.

Stop feeding the Big Blue Elephant in the middle of the room!

What is missing in our automated 21^st century obstetricalized, electronically-monitored system of multiple interventions in the labors and births of healthy women is plain old-fashioned honestly and common sense. We currently have “willful blindness” on an industrialized scale. Many wonderfully compassionate obstetricians are locked into a system that forces them to serve the gods of hospital policies that promote the routine use of interventions in general (interventions translate into “billable units”) but are particularly aggressive about speeding up labors (or doing C-sections) so the unit can “process” more “deliveries in each 24-hour day.

Among dozens of unnecessary interventions and other bad ideas, the one that makes me see scream into my pillow was reported in a Wall Street Journal article (07-12-2006) as “Pit to distress” (copy included as email attachment). This was, in my opinion criminal hospital policy that required L&D nurses to constantly increase the drip rate of IV Pitocin until the mother either delivers vaginally, OR the baby goes into fetal distress and the OB can ‘fix’ the problem that system created by doing a crash emergency C-section.

The only way to end this institutionalized madness is to replace a century of willful blindness (i.e. obstetrician-centered care) with a scientifically-based mode of care organized around the practical needs – biological, psychological, emotional, and social – of the childbearing woman, her unborn and newborn baby and her family. This describes an evidence-based system that supports the normal spontaneous biology of childbearing, and an educational process that trains practitioners –professional midwives, family practice physicians, and a few rare obstetricians – in the art and science of physiologically-based childbirth. This is 100% absent from the current system.

Exchanging willful blindness and silence with dialogue, science and change

The obstetrical profession needs to acknowledge the insular and iatrogenic nature of both historical and contemporary obstetrics as practiced over the last half dozen decades (1910-2022) by policies and practices that specifically distinguish between the practical and normal biological needs of heathy women, as contrasted with women or unborn babies who have high-risk circumstances. They the obstetrical profession as a whole (ACOG, etc) needs to acknowledge the sequential failures of the past and sincerely apologize.

Then the obstetrical profession, directly and via organizations such as ACOG, can enter into a genuine dialogue with childbearing families, their midwife-birth attendants, and with “neutral” 3^rd parties, such as scientists in many other fields including psychology, sociology, ethics, and experts in PTSD) as well as the participation of the general public. The ultimate goal is an “honest” effort and willingness to fix the problem (distinguish btw standards of care for healthy women with normal pregnancies and those with abnormalities or that develop complications) and that they agree to “play nice” from here on out.

At the same time, we must scrupulously promote the “right use” of obstetrics and be very careful not say or do things that would predispose pregnant women to resist or refuse seeking necessary obstetrical services and hospitalization when needed. We need end the Hundred Years War between midwives and midwifery, kiss and make up, and officially reconcile our two disciplines, as is the norm in most of Western Europe and many other parts of the developed world.

The Dark Side of the Moon ~ The continuing failure of our national maternity care system to meet the practical needs of healthy childbearing women for more than a century!

The Clash of the Titans between Observable Reality and Imaginary States

Historic figures set the stage for an obstetrical profession that is focused on obstetricians

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