Obstetricians for the win!


Laura Helmuth has a fascinating series on longevity of at Slate Magazine. Yesterday’s installment was about maternal mortality. The title, The Never-Ending Battle Between Doctors and Midwives. Which Are More Dangerous?, is somewhat awkward, but the piece itself is fascinating.

She recounts the history of obstetrics, including the early 20th Century when doctors’ desperate desire to do something about maternal and perinatal mortality outstripped their understanding of their own tools.

Things got worse as obstetricians started professionalizing and coming up with new ways to treat—and often inadvertently kill—their patients. Forceps, episiotomies, anesthesia, and deep sedation were overused. Cesarean sections became more common and did occasionally save women who would have died of obstructed labor, but often the mother died of blood loss or infection… Women giving birth in hospitals were at greater risk than those delivering at home. Disease and infections spread more readily in hospitals, and doctors were all too eager to use surgical equipment.

She includes a graph of maternal mortality similar to those I have posted in the past.


Doctors began to use their technology more judiciously and new discoveries led to a massive and sustained drop in maternal mortality (and a comparable drop in perinatal mortality).

Doctors cleaned up their acts, too. A series of reports in the 1940s linked high death rates to improper medical procedures. Training improved, and doctors abandoned the most dangerous techniques. Complications from C-sections declined steadily. Medical researchers now rigorously evaluate success rates and risks of new techniques and drugs…

Improved maternal survival eventually did turn into one of the great public health and medical achievements of the 20th century—it just took an unconscionably long time. The good news today is that, globally, maternal mortality is continuing to decrease. More women are surviving childbirth, and that’s a big reason—and one of the most joyful reasons—why lifespan is continuing to climb in the 21st century.

Not surprisingly, as technology drove down rates of maternal and perinatal mortality, women flocked to hospitals to give birth. Midwifery has never really recovered.

But midwives have fought back, mainly by pretending that the massive decreases in maternal and perinatal mortality didn’t actually occur, and that childbirth was always as safe as it is today.

Helmuth notes:

The midwives and doctors, though—they’re still tangling. Midwives accuse doctors of endangering women by continuing to perform too many unnecessary procedures. Doctors accuse midwives of allowing pregnant women and newborns to die of preventable deaths.

She uses homebirth as a case in point:

The main battlefield today is over home births. About 1 percent of women in the United States choose to give birth at home. Counterintuitive as it may sound at first, they often cite safety concerns—they’re worried about unnecessary procedures if they give birth in a hospital.

Helmuth has an awesome takedown of homebirth midwives in general and Melissa Cheyney in particular:

Melissa Cheyney is an anthropologist at Oregon State University as well as a home-birth advocate and midwife. She reports that women who choose home birth “value alternative and more embodied or intuitive ways of knowing.” Home-birth advocates say women are better off giving birth in a comfortable environment, letting nature take its course.

I’m personally opposed to letting nature take its course—nature will kill you. And “intuitive ways of knowing” is just a flowery term for “ignorance.”

Helmuth appears to unaware of the confirmatory data from Oregon that shows that planned homebirth with a licensed midwife has a perinatal mortality rate 9 times higher than comparable risk hospital birth.

In the end, it’s obstetricians for the win!

But when you take a world-historical look at childbirth, it’s not midwives and cozy home births that get credit for making maternal death such an unthinkable outcome today. One of the great victories of modern times is that childbirth doesn’t need to be natural, and neither does the maternal death rate. It’s modern medicine for the win. Doctors may have killed a lot of women in the first part of the 20th century, but they can save your life today.