Source: Lew Rockwell | VIEW ORIGINAL POST ==>
Many traditions throughout history have come to view the prenatal period and childbirth as one of the most important moments in a human’s life as it sets the stage for all that follows. Unfortunately, much in the same way we desecrate the death process by over-medicalizing it (to the point research has found doctors are less likely to seek end of life care at a medical facility), the same issue also exists with childbirth. Many physicians I know who are familiar with the hospital birthing process chose to skip it and give birth at home (along with many more doctors featured in a 2016 documentary).
Conversely, a minority of childbirths do need advanced medical care, and for those mothers, access to a hospital greatly benefits them, particularly if actions are taken to mitigate the most dangerous aspects of hospital birth. As such, childbirth occupies a similar place as many other medical controversies; neither side of the issue is entirely correct. However, the discussion remains perpetually polarized because advocates on either side will not acknowledge the valid points raised by the other side for fear of weakening their own position. Since I feel strongly about the dangers of hospital birth, it is my hope in this article that I will be able to portray both sides of the issue fairly.
Note: I feel one of the most destructive trends in our society has been the devaluation of motherhood (e.g., when I visited China, it was striking how much more respect and consideration they gave to pregnant women) and children. Beyond new life being necessary for the viability of our society, it often ends up being the most transformative and fulfilling experience in a parent’s life. Yet, so much of our societal messaging encourages us to shun that path and put our hearts into other things. In parallel, a general disconnect has been fostered upon this entire process where it is treated as a sterile, lifeless, and mechanistic event we need to be separated from and entrust to someone else—which I believe is the ultimate problem that underlies many of the issues that will be discussed in this article.
The History of Midwifery
A lot of the dysfunctional things that have come to characterize the birthing process (e.g., unnecessary hospital interventions that create complications begetting more hospital interventions) make much more sense once you understand the history behind them and how childbirth was transformed from a natural human life-event to a medical emergency requiring those interventions.
From the start of America, midwives were highly valued in colonial communities, receiving housing, food, land, and salary for their services (particularly since they also served as nurses, herbalists, and veterinarians). Then, during the 1800s, midwives played a key role in the westward expansion, particularly in the Mormon migration to Utah, but by the early 1900s, a variety of social factors (e.g., economic pressure and societal prejudices) caused midwifery’s reputation to decline.
Much of this was due to male doctors (who had initially been averse to delivering babies) displacing midwives. This began in the late 1700s when it became fashionable in Europe to have doctors attend deliveries, after which an influential Harvard professor (and its first profession of obstetrics) convinced his American colleagues to enter, for example in 1820 stating:
Women seldom forget a practitioner who has conducted them tenderly and safely through parturition they feel a familiarity with him, a confidence and reliance upon him which is of the most essential mutual advantage. . . . 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.
Once doctors entered the field of midwifery, it quickly became necessary to justify their “expertise” and a gradual medicalization of childbirth began.
Dr. Joseph DeLee (who later became known as the father of obstetrics), in 1895, opened Chicago’s first obstetric clinic, and since it was successful, opened an obstetrics hospital which also trained doctors and nurses and developed lifesaving innovations (e.g., incubators for premature infants) which lowered the childbirth mortality rate.
Simultaneously however, because DeLee observed so many complications and deaths from childbirth, he was of the opinion that natural childbirth was extremely dangerous for both the mother and child, and hence needed to be medicalized. In turn, he spoke actively (e.g., at a 1915 professional meeting) against the use of midwives, arguing they lowered the standards of the profession, and were childbirth to be seen as a more dignified profession, higher fees could be charged, and more doctors would be willing to replace midwives.
Following this (like many zealots), in 1920, he argued that the approaches he had developed for challenging pregnancies (e.g., forceps, episiotomy, toxic anesthetics) should be used for most of them, while other doctors argued these approaches were too aggressive in many of the situations where DeLee advocated for them. However, due to his growing influence in the profession and success in making childbirth a part of the medical curriculum (in part due to how many doctors he trained) by the 1930s, his standardized invasive approaches became increasingly popular, particularly since society had become enamored with advanced technology improving things.
Finally, near the end of his career (in 1933), due to increasing maternal deaths and complications from hospital infections, he became an advocate for cleaner maternity wards, which met significant resistance from his colleagues (although not as severe as what Ignaz Semmelweis faced almost a century in Austria for pointing out that doctors not disinfection their hands was routinely killing mothers).
From one perspective, I can greatly sympathize with where DeLee came from, as significant issues needed to be addressed (e.g., in 1913, the infant mortality rate was 13.2%). However, he failed to recognize many of them were due to the abhorrent living conditions of the time (which as I show here were also the primary driver behind the incredibly high mortality from infectious diseases).
At the same time however, some of his approaches (e.g., making women partially unconscious during labor and then pulling the babies out with forceps) were abhorrent (and explicitly detailed within his classic 1920 paper), and set the stage for a variety of other harmful and unnecessary interventions to hijack the childbirth process.
Worse still, he seeded the idea within the medical profession that childbirth was inherently pathologic and required a doctor to save the mother and child—despite the fact for most of human history, we had not needed them. Likewise, the maternal death rate was actually the highest between 1900-1930 (when DeLee’s practices came into vogue), and it was only after years of deaths and mistakes that the standard of care began being improved and maternal deaths declined. Nonetheless, even now, over a century later, the United States still has a significant issue with these deaths (which is particularly noteworthy as during the period below, those deaths were declining in the other wealthy nations).
Note: another controversial doctor James Marion Sims, who in 1845 began experimental gynecological surgeries on African American slaves (without anesthesia—and operated some on individuals up to 30 times) and after roughly 4 years of work, perfected the surgeries enough to use them on white women (with anesthesia) after which, in the 1850s, he opened the first women’s hospital (which was mired in controversy due to how barbaric some of his procedures were, their high fatality rate, and some of the unnecessary brain surgeries he did on black children). Nonetheless, he became one of the most famous doctors in the country (e.g., he was the 1876 president of the AMA) and is considered to be the father of gynecology.
At the exact same time DeLee’s work occurred, a variety of federal and state initiatives recognized that the incredibly high infant and maternal mortality rates were connected, and that appropriate prenatal care could prevent them (e.g., Mother’s Day was created at this time to provide maternal support to prevent those deaths).
Simultaneously, a debate known as the “Midwife Problem” unfolded, with some (e.g., doctors) advocating for the abolition of midwifery (largely to shield themselves from competition) and others supporting it with proper training and licensing (as they felt midwives could play a critical role in preventing deaths if utilized correctly). Laws were passed in some states (e.g., those that simply did not have enough doctors to attend childbirths) to regulate midwifery, and schools were created to improve midwifery standards. However, by the 1930s, the increased use of hospitals for deliveries made it possible to close many of these schools.
Fortunately, a 1921 Federal law provided for training nurse midwives, and in 1931 (owing to the increasing recognition of the failures of American obstetric care), a successful nurse midwifery school emerged (which amongst other things, had a maternal mortality rate of one-tenth that of the country). Their graduates then created numerous schools and created the modern discipline of nurse midwifery.
Note: in parallel, the Frontier Nursing Service (founded in 1925 by a British trained midwife) trained nurses and provided extensive midwifery (and medical care) to the woefully underserved inhabitants of the Appalachians, which ultimately resulted in a far lower maternal death rate (roughly one third as much as the rest of the country). In turn, when many of its nurses returned to England at the start of World War 2, they also created a successful nurse midwifery program there as well.
Following this, in the 1940s and 1950s, due to limited existing opportunities to practice clinical midwifery, most of the graduates of these programs had to fill other obstetric related roles, and ultimately only a quarter served as midwives. In the 1960s, a variety of attempts were made to address this (e.g., having them work at hospitals where 70% of the births were taking place), and it was not until 1968 that more opportunities began to emerge (due to one school finding a way to integrate with New York’s medical system).
Shortly after, a variety of rapid shifts occurred (e.g., key professional organizations endorsed nurse-midwifery, feminism came into vogue, the media promoting midwifery, federal funding for it, an explosion of childbirths from the baby boomers coming of age that the existing system could not accommodate) which propelled midwifery into the mainstream. In turn, many doctors began partnering with midwives, programs became officially recognized by the U.S. Department of Education, and public demand for midwife supervised home births exploded.
This increased demand quickly exceeded the available supply, after which there was a rapid proliferation of non-nurse midwives (lay midwives) with highly variable degrees of training (who had their first national meeting in 1977). By the 1980s, nurse-midwives were present throughout the healthcare system, and a split developed in the medical community between obstetricians who recognized their value and worked with them versus those who viewed them as economic competition that needed to be eliminated (particularly because there was now an overabundance of obstetricians).
Since then, midwifery has faced additional obstacles from the medical system but has continued to develop. Mixed opinions exist within the obstetrics field towards midwifery, and its accessibility varies. Since the 1990s, approximately 1% of births have been at home (although recently it suddenly increased to 1.5%).
Note: this abridged history necessarily omits the immense struggles countless incredibly dedicated midwives went through to make midwifery available to the public or just how much that work approved the abysmal obstetric care that existed throughout the country and the human cost that came with it.
A Standard Hospital Birth
When women go into labor, it is frequently viewed as a medical emergency that necessitates getting to the hospital as quickly as possible (e.g., this idea has been reinforced in television and movies for decades) and then struggling and having the doctor miraculously deliver the baby.
During this whole process, the following will happen.
• The mother will be placed in an uncomfortable and stressful environment (where many unfamiliar people enter and exit the room), be subject to repeated vaginal examinations, and typically placed on her back with the legs spread out.
• The mother will be placed on fetal heart rate monitoring (typically via the abdomen, but sometimes also through an electrode applied intravaginally to the baby’s head).
• If the mother delivers too slowly, she will be given pitocin (oxytocin) to speed up the rate of contractions and may have her amniotic membrane prematurely ruptured.
• To mitigate her discomfort, she will often be given an epidural.
• Once the baby starts to come out, it may be pulled out with forceps or a vacuum extractor if the labor progresses “too slowly” or an issue arises.
• To prevent tearing and to make childbirth easier, mothers will often be given a prophylactic episiotomy, which preemptively cuts the vaginal opening to widen it.
• If any of the above goes awry, the mother will be converted to having a C-section.
• Once the baby is born, the cord will be immediately cut (and the placenta disposed of). The baby will typically be separated from the mother for a prolonged period (e.g., to go to a newborn nursery or the neonatal intensive care unit), and will receive a vitamin K shot and a hepatitis B vaccine and then have their blood drawn. Lastly, if the baby is a boy, circumcisions are often performed in the first days of life while they are still at the hospital.
• Finally, following this, if all goes well, the mother will go home with the baby in a few days, or a week if issues emerge.
However, while many of these steps can potentially save an infant’s life, many of them create significant long-term complications, and many increase the likelihood more hospital interventions will be needed.
This in turn, touches upon a criticism of the medical industry—medical interventions often thrust you onto an assembly line that requires more and more of them (e.g., many psychiatric drugs are prescribed to treat the side effects of other psychiatric drugs). Typically, it takes time to see this process play out, but in the case of labor and delivery, the changes requiring additional interventions occur quite rapidly—whereas in contrast, almost none of this is seen outside of the hospital.
Note: I believe this bias towards excessive intervention in part occurs from obstetric units being understaffed (e.g., if a doctor is attending 6-10 mothers, the deliveries need to be artificially sequenced so that they don’t occur simultaneously and accelerated so they aren’t held up in one place) and due to OBYGN’s having significant liability risk if anything goes awry with a pregnancy if the standard protocols had not been followed.
Any intervention that interferes with women’s ability to cope in labor has enormous implications: it can destroy feelings of achievement and self-esteem. Women who feel they have coped have more confidence in their mothering abilities than women who feel traumatized by the birth process. Specifically disturbing to this aspect of common labor ward practice is the data of Robson and Kumar reporting an association between procedures in labor, such as artificial rupture of the membranes, and the delayed onset of maternal affection.
We’ll now look at the issues with each of the previous approaches.
Note: as we go through these, consider that America currently spends at least 111 billion dollars on childbirth (which is twice that of most high income countries) yet ranks last amongst the high income nations in both infant and maternal mortality.
