Chapter one ~ The Obstetrical Franchise In America and the 20th-century Gender War btw Midwifery and Obstetrics (spoiler alert – obstetricans won, midwives and childbearing women lost!)

by faithgibson on January 1, 2025

in Contemporary Childbirth Politics

Complied by Faith Gibson, LM, 2007
word count 5575 ~ 01-25-2025

Historical & Contemporary Background on
the 20th-century practice of  “obstetrics”
for healthy women, the profession of
midwifery and its relationship
with organized medicine

The unfortunate truth about America is that we have the highest maternal mortality rate  (MMR) of any wealthy industrialized country in the world, which has been true since 1900, or 125 years and counting.

Also, we are one of the few countries in the entire developed world that doesn’t have a national midwifery service, and very few states have incorporated professional midwifery into their public healthcare system. Instead of training and licensing professional midwives, they prefer to be egged on by ACOG and the AMA to criminally prosecute midwives.

Note: More recent versions of this post describes the obstetrical profession as having granted themselves an exclusive “franchise” (i.e. monopoly) over all aspects of childbirth, as well as related maternity care during pregnancy and the postpartum period

It not so much what you say, as what you repeat over and over again” —
PBS News Hour, 6/28/2005, in relationship to the war in Iraq.

Chapter One 

Few people in the US are aware of the highly controversial nature of midwifery and the historical tension between the professions of medicine and midwifery.

This controversy has nothing to do with the appropriate use of obstetrical medicine to treat the 30% of pregnant women who develop various problems.  Obstetricians and midwives both agree that complications of pregnancy and childbirth should be treated promptly and appropriately by the obstetrical profession.

The question is whether these same obstetrical interventions should be used routinely, or “prophylactically”, on the 70% of healthy women with normal pregnancies.

What would we think if the fire station in our neighborhood showed up at our house, and used an axe to break down the back gate? Then four firefighters in flame-proof jackets festooned with reflective tape and wearing big helmets rushed into our kitchen with a great big water hose and started spraying water at the stove just in case we might have a grease fire later in the night.  Personally I would really wonder what kind of training they got that would have taught them to do something so irrational, harmful the kitchen gate that got axed and very unnecessary and wasteful of time, money and other resources.

It is the 70% category of healthy women with normal pregnancies that has always been the traditional focus of midwifery care. Formal midwifery training has a history almost as old as the human species itself. The record of midwifery can be traced back to ancient Egypt, where formal training and the organized practice of midwifery go back more than 5,000 years. In ancient Greece, there were three different categories of midwives, depending on how much formal training they each had.

For as long as humans have occupied Planet Earth, older and more experienced women who had given birth themselves have naturally helped younger women during labor, birth, and the immediate postpartum period.

After the baby was born, these experienced women helped the new mother breastfeed for the first time, made sure she had water to drink, was able to empty her bladder, and helped her deal with the rather substantial bleeding that naturally occurs after the birth.

This naturally included food for the new mother and tips on how to care for herself and the new baby. Last but not least, she made sure the new mother got a good nap, and while she slept, the father and other family and close friends got to see the newborn baby for the first time.

Childbearing and child-caring have always been, and will always be “women’s work“.

Marriage of American obstetrics and hospital childbirth as the “new norm”, circa 1910

But early in the 20th century, the American obstetrical profession decided that “delivering babies” was rightfully a medical practice. This was based on the idea that (a) obstetrics as taught in medical school, (b) that the surgical discipline of obstetrics was mostly about delivering babies, and (c) therefore childbirth was the rightful work of “medical men” (as doctors preferred to be called in the early 20th century).

As “medical men” they concluded that healthy childbearing women were also a rightful part of their patient population, so they began hospitalizing healthy white middle and upper-class childbearing women, whose social status had now reduced to being a “maternity patient”.

However, this was a critically important turning point for the American obstetrical profession, as for the first time its hospital’s maternity wards were being generously monetized by its electively hospitalized maternity patients. Previous to this, only indigent patients were delivered in hospitals, and charity cases paid little or nothing. This is one reason that having a baby in the hospital in the early 1900s  was seen by some as indicating that you were poverty-stricken and homeless. However, the public’s relationship with hospitals as a place for childbirth changed dramatically and very quickly between 1910 and 1915,

But the amnesic-hallucinogenic drug scopolamine recently began to be used in German labor wards and word quickly that this drug obliterated the labor patient’s memory of having had any pain.  Newspaper articles and women’s magazines printed testimonies from “satisfied customers”, who shamelessly sang the praises of painless childbirth under the influence of the miracle drug scopolamine.

This news quickly spread to the United States and changed everything about childbirth in American hospitals. It started with the aggressive promotion of “painless childbirth” for all labor patients who agreed to come immediately to the hospital when their labor started. These labor patients were promised that under the influence of the Twilight Sleep drugs (scopolamine and morphine) wouldn’t remember having any labor pains.

When the time came for the babies of these heavily drugged labor patients to be born, the labor patient would be moved by stretcher to an obstetrical operating room (later called “the delivery room”) and she would be rendered under chloroform or other general anesthetics.  Since she was unconscious and unable to “push”, her baby would be delivered by obstetrical forceps.

Having been unconscious for the delivery of their baby, they really couldn’t remember anything at all, which in a convoluted and perplexing way produced the quintessential  “perfectly painless childbirth”

Once word was out, the rush was on, with everyone singing “To the hospital we must go!”

Word spread very quickly, so it wasn’t a surprise when the white upper classes of maternity patients as ‘paying customers’ (a new concept!) were eager to be electively hospitalized and quickly injected with Twilight Sleep drugs that would (to quote the famous and influential obstetrician Dr. J. Whitridge Williamns) “brought on the waters of forgetfulness“.

For the demographic of white women whose families could pay to have the baby born in the hospital, the labor and birth was not the end of their hospital birth story. Postpartum care that included the traditional 14-day “lying-in-period” was also provided to the new mother. 

With the help of organized medicine (AMA), influential obstetricians launched an extensive and largely successful campaign to “eliminate the midwife” in the early 1900s. The goal was to abolish the practice of midwifery in the United States by using various legal and legislative strategies that essentially made it illegal for anyone other than a state-licensed MD to “attend cases of childbirth”.

The result was immediate and dramatic. The percentage of births attended by midwives in 1910 was 40 to 60%; by 1920, it had dropped like a stone to only 13%, and nearly all of those were black “granny” midwives in the South who only provided care to other black women.

While a tiny remnant of the midwifery profession continues to be practiced in the United States, the historical prejudice of the medical profession and the legal and legislative barriers that such a gender bias generated over the last 100 years, make it virtually impossible for midwives to take their rightful place in the spectrum of health care services available to healthy women.

Questions, questions, more questions than answers!

Has the obstetrical knowledge gleaned over the 20th century changed how we see pregnancy and childbirth? They still are natural biological acts, but has “modern” medical science fundamentally changed the categorization of spontaneous childbirth from a normal biological process just another form of pathology in the same category as disease, deformity and accidental injury?

Are we to believe that modern obstetrics has scientifically identified childbirth in contemporary American women to be such a fundamentally dangerous aspect of female biology that is much safer to schedule elective Cesarean surgery, thus saving the mother from possible death or disability?

In 1985, a paper titled “Prophylactic Cesarean Section at Term?” by two obstetricians was  published in the nationally prestigious New England Journal of Medicine identifying human childbirth as a “pathophysiology”

These authors made a very strong case for the routine use of “prophylactic” Cesarean at term (also referred to by the obstetrical profession as “vaginal by-pass surgery”) as an effective way for the obstetrical profession to permanently eliminate the danger that vaginal birth can at times pose to the unborn and newborn baby.

The authors claimed this method for providing safer births to babies would entail only a small increase in the number of “excessmaternal deaths and “extra maternal mortality”. (p. 1266)

“….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000… [emphasis added]

… if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of healthy infants at a relatively low cost of excess maternal mortality.” [emphasis added]

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 ….

Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure? [emphasis added]

….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached? [emphasis added]

If a patient considers the procedure (i.e. routine CS @ term) and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery?” p. 1267 [emphasis added]

The statement that strikes me as most absurd is the “probably” in this sentence:

“We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10…? ”.

The Facts, just the Facts, and nothing but the Facts!

There continues to be much disagreement about the contemporary relationship between physicians and midwives. At the core of the question about the modern role of midwifery is yet another question — what is the right relationship between “modern medicine” and “modern” childbearing?

Has the obstetrical knowledge of the 20th century fundamentally profoundly changed the nature of childbirth (a natural biological act) the same way that medical science has fundamentally changed the course of illness, injury, disease, and deformity, which are all forms of pathology?

In the present time there is still a great deal of disagreement about the contemporary relationship between physicians and midwives. At the core of the question about the modern role of midwifery is yet another question — what is the right relationship between “modern medicine” and “modern” childbearing?

Has the obstetrical knowledge gleaned over the course of the 20th century changed how we see pregnancy and childbirth, which of which are natural biological acts, the way medical science has fundamentally changed the course of human illness, disease, deformity and accidental injury, which are all forms of pathology?

Are we to believe that modern obstetrics has scientifically identified childbirth in contemporary American women to be such a fundamentally dangerous aspect of female biology that is much safer to schedules elective Cesarean surgery, thus saving the mother from possible death or disability?

In 1985, a paper titled “Prophylactic Cesarean Section at Term?” by two obstetricians was  published by in the nationally prestiageous New England Journal of Medicine identified human childbirth as a “patho-physiology”

These authors made a very strong case for the routine use of “prophylactic” Cesarean at term (also referred to by the obstetrical profession as “vaginal by-pass surgery”) as an effective way for the obstetrical profession to permanently eliminate the danger that vaginal birth can at times pose to the unborn and newborn baby.

The authors claimed this method for providing safer births to babies would entail only a small increase in the number of “excessmaternal deaths and “extra maternal mortality”. (p. 1266)

“….the number of extra women dying as a result of a complete shift to prophylactic cesarean section at term would be 5.3 per 100,000… [emphasis added]

… if it could save even a fraction of the babies at risk, these calculations would seem to raise the possibility that a shift toward prophylactic cesarean section at term might save a substantial number of healthy infants at a relatively low cost of excess maternal mortality.” [emphasis added]

We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10 ….

Is there some ratio of fetal gain to maternal loss that would unequivocally justify a wider application of this procedure? [emphasis added]

….is it tenable for us to continue to fail to inform patients explicitly of the very real risks associated with the passive anticipation of vaginal delivery after fetal lung maturity has been reached? [emphasis added]

If a patient considers the procedure (i.e. routine CS @ term) and decides against it, must she then be required to sign a consent form for the attempted vaginal delivery?” p. 1267 [emphasis added]

The statement that strikes me as most absurd is the “probably” in this sentence:

“We probably would not vary our procedures if the cost of saving the baby’s life were the loss of the mother’s. But what if it were a question of 2 babies saved per mother lost, or 5 or 10…? ”.

 

The Facts

The short answer is that the scientific literature – research published in medical journals, textbooks, and the measures of maternal-infant well-being as provided by birth registration data – all identify statistically increased risk and unnecessary expense when drugs and surgery are compared to normal or ‘spontaneous’ birth in a healthy population.

These scientific sources all make it clear that the routine use of obstetrical interventions, and electively conducting normal birth as a surgical procedure, are always more dangerous for healthy women with normal pregnancies than the use of physiological principles. Scientifically speaking, this is not a controversial finding. Reliable scientific evidence of increased complication and maternal and infant mortality is not unavailable nor incomplete; nor is this statistical evidence the subject of methodological disputes.

For healthy women who are well-fed, well-housed, well-educated and receive good prenatal care during pregnancy, the greatest realistic danger today is obstetrical over-treatment and the cascade of complications associated with the routine use of obstetrical interventions — induction of labor, intrapartum administration of narcotics, anesthesia, episiotomy, forceps, vacuum extraction or Cesarean surgery.

A contemporary example of just one of the problems associated with obstetrical interventions can be found in a June 1st, 2005 report entitled “Routine Episiotomy Offer Women No Benefits or Relief” [Ob.Gyn.News, Vol. 40, No.11]

It stated that:

“the routine use of episiotomy for uncomplicated vaginal births provides no maternal benefits…” and that women without episiotomies were “more likely to have an intact perineum and to resume sexual intercourse earlier”.

In spite of this, and dozens of earlier studies with similar conclusion published over the last 30 years, about a million of episiotomies are done each year, at least 95% of which serve no medical purpose.

Important Update on Hospital Episiotomy Rates in the US

A very recent and appreciated improvement in obstetrically-managed childbirth is a sudden drop in episiotomy rate from 63% to 5% or lower since 2012

  • When the Leapfrog Group began publicly reporting on episiotomy rates in 2012, the rate in the US was 63% 
  • By 2022, the average episiotomy rate in the United States dropped to only 4.6%, which was a 63% decline
  • Teaching hospitals have lower episiotomy rates than non-teaching hospitals. In 2022, the average episiotomy rate in teaching hospitals was 4.2%, compared to 5.1% in non-teaching hospitals. 
  • The episiotomy rate has declined due to a decrease in routine episiotomies and a decrease in anal sphincter laceration rates. 
  • {Editor’s note — episiotomy incisions frequently extend beyond the perineal incision and cause the deeper layers of the mother’s perineum to tear.  These tears are directly responsible for anal sphincter lacerations that cause the new mother to become incontinent (unable to control her bladder and/or bowel).   

Indisputable as the facts about obstetrical interventions are, the style of maternity care or the methods by which it is provided to healthy women in the United States for almost a hundred years has not been defined by science-based parameters. This slip ‘twix cup and lip’ is usually referred to as ‘cognitive dissidence’.

This is a particular problem because physicians are the natural spokespersons for the scientific discipline of medicine, a circumstance that places a societal burden of candor and accuracy on doctors by virtue of their advanced education. The obligation intrinsic in this education creates a higher standard of conduct than mere recitation of personal preference or professional self-promotion.

The very fact that physicians are the holder of a doctorate (equivalent of a PhD) in the science of medicine gives the public every good reason to believe that statements made by physicians about matters of health, safety and medical care are unbiased, scientifically-based and factually correct. This would include the duty to communicate only scientifically valid information in a public forum unless such statements are identified as merely a personal opinion.

However, little in the public discourse addresses, corrects or even acknowledges the century-long disconnect between the science and the practice of obstetrics.

Exploring the conundrum between science and practice is what the rest of this document is about. Before beginning on that endeavor, I want to state for the record that the following discussion, which includes the early politics of the obstetrical profession, is historical in nature and not mean to cast aspersions on individual obstetricians practicing today.

I count many of these hard working obstetricians among my friends and frequently depend on their expertise when midwifery clients develop problems that require obstetrical solutions.

I am profoundly grateful for the modern science of obstetrics and apologize in advance for any offense that may be taken by anyone. I offer, in my defense, the possibility that we as a society could finally, after nearly 400 years of misdirection, correct a pervasive and troubling problem to the mutual benefit of all.

But unfortunately, an in-depth exploration of these historical events includes information that is unflattering to the medical profession. While many would prefer that this information be left out, it would be impossible to really understand the modern-day topic of normal birth and midwifery without these historical antecedents.

Furthermore, my conclusion is that it is we, the public, who have been asleep at the wheel for much too long, therefore not doing our job of making sure that obstetrical services were safe and as a surgical discipline, only used when medical and surgical were necessary to prevent unnecessary suffering, physical harm and preventable morbidity and mortiality.

The good news however is that this “problem” is one that we already understand and know what to do about. We have not been set adrift without a compass and a swift current that will carry us forward.

In the shadow of September 11th, 2001 the American public has, with good reason, become tired of being bombarded by the “crisis” of the month – hysteria over toxic dumps, bad schools, divorce, defective tires, dishonest accounting methods and corporate fraud.

The list of things that needs ‘fixing’ is endless and growing daily. We don’t want to hear that there is yet another reason to worry about something that no one knows what to do about. Or worse yet, someone is proposing that we spend huge sums of money on research for a solution that will, no doubt, take decades to find and include some painful, far-fetched remedy or expensive drug with horrible side-effects.

But unlike war, global warming, bio-terrorism and incurable diseases, we know what to do about this “problem” – the lack of science-based birth care as it applies to healthy women with normal pregnancies.  The solution is no secret and there are lots of resources – sound scientific evidence, textbooks and knowledgeable, experienced people  (midwives and midwifery-friendly doctors) who can teach the principles and demonstrate skills of physiological management. This will reduce our Cesarean rate by more than 50% while making for happier mothers and healthier babies and freeing up an additional 10% of the health care budget to spend on people who are genuinely ill or injured.

In the long run this is a win-win solution, as obstetricians will get to do what they are trained for — focus care on those suffering from the diseases and dysfunctions of fertility and childbearing.  And should a terrorism event (biological or otherwise) occur and hospitals become overwhelmed with the injured or ill (perhaps with contagious diseases), both physicians and midwives will be able to provide safe, community-based maternity care without having to waste the precious medical resources of doctors and hospital beds on the care of healthy mothers and babies in the midst of a life/death national emergency.

A Question of Intellectual Property, circa the Fifteenth Century 

This controversy between midwifery and medicine may well be one of the first organized conflicts over “intellectual property”, occurring long before that concept found a voice in the late 20th century.

The intellectual property in question belongs communally to childbearing women and their midwives. Midwifery as an organized body of knowledge and set of technical skills preceded the modern discipline of medicine by more than 5,000 years. From an ethical standpoint, one could argue that it rightfully belongs to humanity and should remain far above the idea of a proprietary knowledge that is restricted to the few, at the expense of the many.

To characterize the issue in techie-talk, it’s a bit like Microsoft appropriating the hard and software for the graphical interface developed by Apple (the mouse and iconic menus) with neither compensation or acknowledgment by MS of its original source. Then, after re-naming the concept as “Windows”, pretending that Microsoft alone had invented the system and subsequently devoting massive amounts of corporate time, money and political influence to trashing the reputation of Apple. With sufficient repetition, perception becomes reality.

Having amassed such an effective, well-financed political machine, Microsoft would then be able to get MS-friendly/Apple-hostile legislation passed, allowing Microsoft to use the court system to harass Apple and eventually tie Apple’s business up in legal knots.

And having “won” the OS war, the final blow would be to re-write history so that for the next entire century generations of school children (who would soon enough be adult citizens/consumers) would hear that MS invented all good things in the computer world and that Apple was a dangerous infidel, vanquished by Microsoft as a selfless act of concern over the safety and satisfaction of your computing environment.

The Alpha and Omega of Midwifery

Historically childbearing women themselves were the best (and only!) source of information about the biology and physiology of pregnancy and normal childbirth. For thousands and thousands of years, women gave birth normally with the support of their extended families and the help of experienced older women.

For healthy women in safe surroundings, pregnancy and birth was generally successful for both mother and baby. We know this statement is true because the human species has survived (and in fact, thrived) into the 21st century. Anyone alive in the 21st century is a direct descendent of women who were successful at giving birth normally — without the need for forceps or cesarean surgery.

From the get-go of the human species (Eve 2.0!), older, experienced women always helped younger, inexperienced women during the hours of labor, at the moment of birth and to help care for the new mother for some days afterwards as she learned to care for her new baby.

Eventually, this type of experienced help become known as “midwifery”. Those women caregivers who developed specialized skills in managing childbirth and dealing with the needs of new mothers and babies were known as “midwives”. In old English ‘mid’ = “with” & ‘wife’ = “woman”, thus a ‘midwife’ is someone who is ‘with woman’ during the events of childbearing.

The first record of midwifery as an established discipline can be found in the hieroglyphics of ancient Egypt in 3000 BC. The first mention of midwives in Western culture (perhaps prophetically) is a story in the Old Testament of political intrigue and civil disobedience. The book of Exodus records the clash between the Egyptian Pharaoh who ordered the midwives to kill all the first-born sons of the enslaved Hebrew population. The Egyptian midwives to the Hebrews, at the risk of their own lives, declined to carry out such orders.

Dr. Hardin, 1925: “The practice of midwifery is as old as the human race. Its history runs parallel with the history of the people and its functions antedate any record we have of medicine as an applied science. Midwives, as a class, were recognized in history from early Egyptian times.” [1925-A; p. 347]

Care provided to childbearing women during labor and birth was uniformly in the hands of midwives until the 17th century, a span of nearly 500 centuries. Since Time Immerial (approximately 40,000 years ago) care during and after childbirth was provided by older women who had them themlves given birth and therefore knew the from “inside” the obviously somewhat painful and often stressful experience.

For that reason, the discipline of midwifery was empirically-based (i.e. not academically based  as something one read about in a book). Instead the practice of midwifery grew as an organic effort to meetthe practical needs of laboring women, which are primarily psychological, emotional, and social and to provide care and at times intervention to the newly delivered baby.

The care of midwives included ‘patience with nature’ and a commitment not to disturb the natural process. Again, we must accept as fact that this was a successful strategy, as the human species has survived and thrived under the care of their midwives. No medical drug or devise or surgical instrument or procedure developed over the millennia of western culture has been able to make birth better or safe in healthy women with normal pregnancies than spontaneous labor and normal birth.

1932 “…that untrained midwives approach and trained midwives surpass (emphasis in original text) the record of physicians in  normal deliveries has been ascribed to several factors. Chief among these is the fact that the circumstances of modern practice induce many physicians to employ procedures which are calculated to hasten delivery, but which sometimes result in harm to mother and child. On her part, the midwife is not permitted to and does not employ such procedures. She waits patiently and lets nature take its course.”
1932 White House Conference on maternal and infant health

These protective methods are what we now refer to as “physiological management” – that is, “…in accord with, or characteristic of, the normal functioning of a living organism”. Its classic principles include a basic trust in biology and support for the normal process of labor and birth and a tradition that restricts the use of interventions to abnormal situations only.

This non-interventive approach recognizes the mother’s need for physical and psychological privacy and to feel safe from unwanted intrusions and the prying eyes of strangers. Physiologic care encourages the mother to walk around at will and to be upright and mobile during both labor and birth. It also includes continuity of care by individuals known to the mother, one-on-one social and emotional support, non-drug methods of pain relief (such as movement, touch and warm water) and the right use of gravity.

Gravity – What a concept!

Even though traditional midwives had no formal training in the science-based study of anatomy as we think of it today, they had ample opportunity to observe that childbearing women, when left to their own devices, almost universally chose to be mobile during labor and to assume some form of upright position during the birth of the baby.

Midwives also noted that, on those rare occasions that women chose or circumstances required them to be lying down, the labor was much slower and the mother had to push longer and harder to get the baby out. Sometimes she wasn’t able to deliver unless or until she got back up into a gravity-friendly position. For a laboring mother, lying down is an anti-gravitational position that can reduce the pelvic outlet by almost a third, while simultaneously requiring the mother to push her baby up hill around a 60-degree bend. It’s no surprise that it is harder and takes longer and sometimes doesn’t work at all.

The childbearing pelvis – that is, the internal bones that the baby must pass through — normally creates a hollow space shaped like a lower-case letter “j”. Most people erroneously think of the birth canal as a straight chute (lower-case ‘l’), going straight down thru the lower half of the mother’s body; in other words, if the mother was lying down and you were watching from the side, her baby would pass through the pelvis and out of her body the same way a train comes out of a tunnel – a straight cylindrical object passing thru a straight cylindrical container.

But this is not anatomically correct. Imagine instead that you are looking at an upright pregnant woman from the side as she labors and gives birth while still in an upright posture. If you had x-ray vision, you would see that the long stem of the ‘j’ tracks with the mother’s lower spine and the curved foot of the letter bends forward to track with the lower half of the birth canal.

What this means is the pelvic outlet — last 1/3 of the journey – bends at a 60-degree angle, which requires that the baby to go around a corner and emerge into the world going forward (into its mother’s arms!) instead of down (where it would be hard to reach and might be injured as it fell to the floor). Not doubt this “frontal delivery” is an important survival characteristic, as for 99.99% of human history predates hospital obstetrics, which meant it was the mother herself who was responsible for catching her own baby.

Were you to look down into the pelvis from the top, you would notice that the big triangle-shaped bone of the lower spine — the sacrum and coccyx — encroach forward into the pelvic outlet about an inch or so. In this regard, the pelvis is like a hollow bowl with smooth walls on three sides but the fourth side is bent in, making it impossible for anything that is the same size and shape as its circumference to pass through.

However, in the second stage of labor, after the baby is squeezed out of the uterus thru the cervix and starts its trek down into the birth canal, you would see something remarkable happen. In pregnancy the sacrum and coccyx are able to move somewhat and are actually pressed back out of the way by the baby’s head as it descends lower and gets closer and closer to being born. The hormones of pregnancy also make the cartilage that holds the two sides of the pubic bone together become very elastic. Thus the pelvis can stretch and widen side to side, which can give the baby an extra 1-2 centimeters of room to negotiate its passage into the world.

Of course, this nifty trick ONLY works if the mother is standing, squatting or is in some other position that makes ‘right use’ of gravity and allows her sacrum to move back out of the way (similar to the way a pet door is pressed open by the dog or cat as it passes through).

However, if the mother is bearing her own weight on her lower back, such as lying down with her legs held up in stirrups, the sacrum cannot move out of the way, and sometimes the trap door gets stuck in the closed position. When a woman tries to give birth lying down, not only must gravity be defied in order to push the baby uphill and around a corner, but she must do this with the doorway partially blocked, reducing the aperture of the pelvis by as much as a third.

If the baby is small or the mother’s pelvis is big, the forces of labor and extra effort on her part can overcome this impediment. However, for a mother who lying down, the baby will still have to be pushed uphill and will emerge in an upward angle (towards the ceiling).

This is obviously a lot harder and may require the use of forceps or vacuum if the mother has had anesthesia.  Unfortunately, if the reverse is true (a relatively big baby and/or small pelvis) the baby can get stuck – the ‘obstructed labor’ of Old World fame but with a New World reason. In modern life, this would require a forceps delivery or a Cesarean.

In the ancient world or for women in poor countries without access to obstetrical services, cephlo-pelvic dystocia (CPD) eventually results in the death of the baby and may cause the mother to develop a fistula between her bladder or rectum or other debilitating forms of incontinence due to obstructed labor or associated with the use of episiotomy and forceps.

It should be noted however, that CPD caused by positioning the mother on her back or other “wrong uses of gravity” in modern societies and the damage it may cause to the baby or the mother’s pelvic floor, are iatrogenic in origin and therefore preventable complications.

In times and places where obstetrical interventions, cesarean surgery, safe anesthetics and modern antibiotics were not available,  the “complications” of CPD were not simply a transient problem, but a death sentence for both mother and baby.

Right Relation with the Obstetrical Profession

This is an appropriate occasion for me to express my own great personal and professional appreciation for the modern discipline of obstetrics and gynecology.

One of the reasons the topic of a functional obstetrical profession in the United States, which hasn’t been the case for the last 300 years)  is so near and dear to is I know both the personal and the professional side of these issues.

As an L&D nurse I saw doctors save mothers and babies from horrible suffering and I saw them do (or fail to do) things that directly resulted in the death of at least two mothers in circumstances in that today would have resulted in the loss of their license to practice medicine and possibly criminal charges as well.

Nonetheless, I am not “anti-obstetrician”. No midwife who ever worked with the SF Bay area obstetrician Don Crevey could or would ever insult the obstetrical profession per se.

Also I am personally indebted to Dr. Polhman, who also was ob-gyn. As a young married woman, he correctly diagnosed me to have an ovarian condition now called “Stein-Leventhal Ovaries” (now called “polycystic ovaries”) which caused to be  infertile.  Dr Polhman performed an “ovarian wedge resection”, which required abdominal surgery under general anesthesia. Thankfully, it was successful and I went on to have three children, so I have had personal and professional experience with both sides of the obstetrical profession.

I am not now nor have I ever been “anti-obstetrician”.

However, there has been a disturbing and often vicious tension between the practitioners of midwifery and the new discipline of obstetrics. For the last 125 years, a small, but verbally vicious number of politically-agressive obstetricians  who have insisted that the “only good midwife is a dead midwife”.

However, I actually am a good midwife, and I an personally familiar with both sides of the political issue that midwifery represents for the American obstetrical profession. At the urging of the obstetrical profession in California, I was arrested in my home in 1991 by agents of the Medical Board of California and jailed for practicing midwifery.

This was during a time when there were state laws prohibiting he practice of lay midwifery and no licening programs for professionally-qualified midwives. It was just the resul of very outspoken obstetricians in our state to prevent access to midifery services which they righly saw a economically competive.

Unfortuntely for the obsterical profession in the state of California, the ultimate outcome was not what they wanted and expected.  As a result of my arrest and the following 20-month criminal prosecution, State Senator Lucy Killea introduced the “Licenes Midwifery Practic Act of 1993 in June of that year. It was passed and signed on October 11 (also my dad and my sister’s birthday!) of 1993.

After that, I was appointed by the the very same Medical Board of California to sereve on the Board’s “Midwifery Advisory Council” from2007 until i resigned in 2013 due to the termeril illness of my husband.

  Link to Chapter Two

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Link to Chapter 2

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