The story I hate to tell: Dark History of Obstetrics (part 3)

by faithgibson on March 6, 2016

in Contemporary Childbirth Politics, Historical Childbirth Politics 1820-1980

Link back to part 2  

Link to an “Aside” ~ Background material on standard obstetrical practices used on healthy low-risk women and consumer activism from 1950 to 1990.

The material in the “Aside” is not included in other segments of this series.

In the context of this lengthy essay, I want to point out that I’m not attempting to hold the medical profession responsible for beliefs and events that occurred during the many centuries of the pre-scientific era

This would be blatantly unfair, as no one, including physicians, realized that certain medical practices were directly responsible for iatrogenic and/or nosocomial harm. This included many archaic medical practices — bleeding people until they fainted, often repeating it until they died, the use of purging, cupping, leeches, and the so-called ‘therapeutic’ use of heavy metals like mercury, which in fact were lethal poisons.

This judgment-free zone even includes the multi-generational story of the Chamberlain family and their century-long forceps scandal and scam.

Google the words ‘Chamberlain’ and ”forceps’ if you don’t already know the story, but briefly, several generations of the Chamberlain family kept the design of their ‘magic’ forceps a secret for approximately 150 years. They did this by covering the mother up with one end of a sheet and using the other end to cover the doctor while he was using the forceps, so no one saw what he was doing.

One of the Chamberlain grandsons sold a single forcep for a ton of money, even though the functional reality of forceps requires that they be used as a matched pair.

Judgment-Free Zone for everything before the 1840s

Physicians who provided obstetrical care deserve a free pass for everything that happened before the in the 1840s. That is when Dr. Semmelweis established, via credible scientific methods, that the fatal infection known as childbed fever in newly delivered hospital maternity patients was the result of physicians and medical students not washing and disinfecting their hands (before the invention of latex exam gloves) between the autopsy room and the labor ward and carrying deadly germ on the fingers as they did vaginal exams of healthy laboring women.

Under my relaxed (and I think fair) standard, an expectation of ethical responsibility (defined as ‘the ability to respond’) only applies AFTER a substantial body of evidence was amassed by other physicianswho provided a scientific basis to correct the problems and the profession, as an organized group, still refused to take corrective action.

Three strikes and you’re out

Since 1830, there have been three well-defined, decades-long episodes in which the obstetrical profession systematically used and then propagated the teaching and continuation of poor obstetrical practices directly responsible for a substantial increase in maternal mortality.

Each of these episodes lasted a minimum of 40 years: we are currently 27 years into the most recent examples of irrational exuberance in combination with a near total lack of accountability in a culture that remarkable for its uncritical acceptance of an unscientific form of care.

The ‘industrialization’ of childbirth began by eliminating physiologically-based principles and replacing spontaneous labor and normal birth by conducting labor as a potential medical emergency and birth as a surgical procedure ‘performed’ by an obstetrically-trained surgeon on a laboring woman rendered unconscious by general anesthesia.

After the the 1960s, standard obstetrical practices included the scheduling of inductions, routine use of continuous electronic monitoring, epidurals and the ‘prophylactic’ use of Cesarean is part of an ipso facto (or sub-rosa) policy promoting the idea that obstetrical interventions and surgical delivery are safer and better (thus supposedly more ‘cost-effective’) than what the obstetrical profession considers the biology of normal labor and birth, as brought to us by bad old Mother Nature, to be pathological.

In the three long periods in question, ample scientific or at least corrective information was available, accompanied by forcefully worded requests by physicians to physicians, to end these harmful practices or stimulate the profession to adopt safer practices. There is no dearth of data in the form of vital statistics or published research.

Equally compelling is the fact that the majority of obstetrical interventions instituted in the early 1900s quickly became the ‘standard of care’ without ever having been exposed to any prior scientific evaluation.

The scientific method begins with a standard supposition: that the individual or group who want to change a traditional practice must first establish by appropriately conducted research that the ‘old’ practice is somehow defective or at least ‘sub-optimal’ and the new practice that seeks to replace it is:

  • as safe or safer
  • therapeutically effective
  • has a positive cost-benefit ratio
  • is realistically available to the public

What should have happened in 1910 when the obstetrical profession first introduced the idea of medically-managing normal labor and conducting normal childbirth as a surgical procedure was clinical research.

Such studies would include a control group of healthy childbearing women who received the traditional model of physiologically-based care as compared to a group of equally healthy women who had their labors routinely medicalized. Medical standard of care for the first stage of labor included the use of narcotics and other drugs. Conducting vaginal childbirth as a surgical procedure using general anesthesia, episiotomy, forceps, manual removal of the placenta and suturing of the perineal incision.

This never happened and yet, today’s obstetrical lobby is demanding that consumers of maternity care and supporters — birth activists, educators, midwives and family practice physician – meet an obstetrically-defined burden of “proof”, as if they were sitting on mountains for scientific research that definitively proved their practices to be optimal, while the normal supportive care (i.e. non-interventive, non-invasive) was the ‘new kid’ on the block.

In addition, the obstetrical profession has consistently ignored or rejected nearly a 100 studies that have already identified physiologically-based care to be a science-based model that is as safe (in certain aspects safer) than standard hospital-based obstetrics.

Nonetheless, spokesmen for the obstetrical profession (generally ACOG) reject these finding and insist that new research on this topic be approved by hospital obstetrical departments and conducted under obstetrical supervision.  This is a bit like having tobacco companies approved all research into the effects of cigarette smoking.

The facts of this situation – systemized, intergenerational iatrogenesis and nosocomial morbidity and mortality — have been amply communicated to the obstetrical community many times and in many ways, all to no avail. In addition to the story of Dr. Semmelweis (1830-1860), a most compelling historical example of the intractable nature of these problem comes from Oliver Wendell Holmes in 1843.

He is the famously articulate American physician who was also the author of the poem “Old Ironside” at the age of twenty-one and eventually became the father of a future Supreme Court Justice. By the time he was thirty, Dr. Holmes had become a skilled medical practitioner who also taught anatomy and physiology at Harvard Medical School.

As a doctor, Holmes had direct knowledge about the incidence, circumstance and deadly consequence of puerperal sepsis that had become epidemic in hospitalized maternity patients. He carefully applied his scientific education and investigative skills to the topic and concluded after much careful research that it was a preventable disease, what we now call iatrogenic (related to medical treatment) and nosocomial (hospital-acquired).

In time, his theories were scientifically established to be correct. He was outraged by the needless loss of life and was doubly outraged that his medical colleagues were ignoring what were, to him, the obvious facts.

After tracking down the necessary facts, Dr Holmes published a critique which was called “Contagiousness of Puerperal Fever”. It contained a list of commonsense precautions to lower the incidence of childbed fever which included improved hand-washing, especially after attending an autopsy or having an infected case.

He recommended that physicians avoid new patients for a few weeks after attending a single case of childbed fever and that an obstetrical practice completely shut down for a month if the physician was linked to two cases in a short period of time.

His final conclusion was that:

The time has come when the existence of a private pestilence in the sphere of a single physician should be looked upon not as a misfortune, but as a crime.”

An even more contemporary source – the editor of a well-respected obstetrical textbook (Davis) published in1966 –  sums it up by saying:

There can be no alibi for not knowing what is known.”

Doctors are formally educated in the biological sciences and in how to think logically. They are highly paid to know the scientific literature and be aware of the full spectrum of consequences associated with medical and surgical interventions. It is not unreasonable to expect their advice, both to the public and to individuals, to be objective and based on sound scientific sources.

An Institutionalized Inability to Learn from Past Mistakes

What these three examples of system-wide obstetrical iatrogenesis demonstrate is an institutionalized inability to learn. The habit of turning a blind eye and a deaf ear to every attempt by other colleagues and the public to end the objectionable practices or policies is a centuries-long characteristic of the obstetrical profession.

It habitually goes on for many decades (in some cases for a century) until a more interesting challenge or more lucrative idea comes along OR circumstances beyond their control force the obstetrical profession — kicking and screaming — into changing their way. This reminds me of the issue of pedophilia by Catholic priests and the bishops and other Church authorities officials who looked the other way.

Unlike the Catholic Church, who have acknowledged and accepted responsibility for bad behavior, the obstetrical profession as a group continues to deny the entire topic altogether, while they attempt to maintain total innocence by NEVER publicly admitting that their previous practices were harmful and ill-advised. They have never offered to make amends in any way for any of these tragic practices.

Alone among all the medical specialties, obstetrics has the most disturbing, discouraging and frankly inexplicable history. Instead of scientific evidence and common sense, the personal opinions of influential leaders and personal preferences of well-placed physicians has configured the obstetrical profession like a private club – which is to say, for the benefit of its members. This most miserable story is marked by two consistent but regrettable themes.

The first is the drastic nature of its many indiscretions that cost the lives of hundreds of thousands of mothers and babies — a tragedy accompanied by a stubborn hubris and steadfast denial of evidence whenever anyone questioned the obviously harmful poor obstetrical practices.

The overall numbers for maternal mortality are staggering — a physician-author of that era stated that the maternal mortality rate rose by 15% a year starting in 1916 for a decade, while birth injuries rose by 40% during the same 10 years, as obstetrics systematically  replaced physiologic care with heavily medicalized, hospital-based interventive obstetrics in which to use of forceps was the standard of care.  Such ignorance is not simply a matter of not knowing something.

The word ‘ignore’ denotes access to the crucial information coupled with a conscious choice to ignore (i.e., to not know what is knowable) and a decision to instead blunder onward, in spite of all evidence to the contrary.

Arrogance speaks for itself, but in my experience, it has been a strong element of the obstetrical mind-set down through the ages – an unreasonable assumption that the obstetrical profession as a class (thankfully there are many, many exceptional obstetricians!), among all humanity, are the only people able to understand the biology of normal childbirth.

This permits them to dismiss what we ‘little women’ want (either as pregnant or laboring women or as midwives) as irrelevant and perpetuate this ‘father knows best’ system.

The following statement is from the February 23, 1911, Boston Medical and Surgical Journal and perfectly sums up this unflattering obstetrical mindset:

“We believe it to be the duty and privilege of the obstetricians of our country to safeguard the mother and child in the dangers of childbirth. The obstetricians are the final authority to set the standard and lead the way to safety. They alone can properly educate the medical profession, the legislators and the public.” [p. 261]

The second consistent theme in the story that I hate to have to tell is a total inability by the obstetrical profession to EVER admit that their policies, or the untested hypothesis underlying decades of ‘standard’ practices, were wrong or harmful. They never say they are sorry, never pledged to learn from their mistakes or guard against repeating this habitually insular behavior in the future.

In fact, it is just the opposite – they bury, hide, ignore or deny that they ever under any circumstance made a mistake in policy or acted in an imprudent wayWhen provided with corrective information, the obstetrical profession consistently fails to take corrective action.

In this political group, obstetrics is about what is good for obstetricians.

Continue to Part  4 — Autopsies, Anesthesia, and Obstetrical Audacity –> starting with ‘Strike One’

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