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.
For those of you interested in the history of cesarean section, the “breakthrough” operations conducted in the 1890s by Murdoch Cameron in Scotland are open access and make fascinating reading. They were done in three women with a pelvis too small for delivery due to rickets and dwarfism, for which the survival rate was particularly grim. You have to have respect for these early surgeons who had limited equipment and facilities, and managed to develop the technique to the life-saving and safe one it is today.
http://www.ncbi.nlm.nih.gov/pubmed/20752567
and
http://www.ncbi.nlm.nih.gov/pubmed/20752975
Obstetricians burst moments when the baby is born.
But but …the US has one of the highest maternal mortality rates!!!…Right? (says almost every clueless NCBer)
OT – another Dahlen quote from Sydney Morning Herald:
“There is no intent to deny a woman an epidural if she wants one; we need to ensure they’re not used unnecessarily.”
There is such a thing as an ”unnecssarepidural”? Does she mean that women with pain-free labor are being given epidurals?
Oh yes, all the women who don’t want epidurals who are being forced to have them, and get pain relief against their wishes.
All the consent forms that are presumably being signed under duress, the women being forced to hug a pillow and stay still for instertion against their will…possibly at gunpoint…
Ms Dahlen if you want an epidural you should get one, if you don’t want one, you don’t ask for one and can decline one if offered- I’m not sure an epidural is “unnecessary”, it is either desired by the woman or not, and that’s entirely up to her.
That’s rubbish. As I have commented before, the midwives in my corner of Australia openly declared that they will not offer pain relief, and will try to talk women out of an epidural or delay them at least.
I think it depends on the midwives, to be honest. The ones I saw were based in the hospital and used the L&D birth suites, whereas the ones that my best friend saw were in a birth centre attached to a hospital (If you wanted anything more than gas, you were transferred to the hospital L&D. It’s just down the corridor). I was offered pain relief, and with the first, a sleeping tablet because I’d been awake for ages and they wanted to help me rest. She asked to be transferred for an epidural because when the midwife had TOLD her to push, the pain ramped up to being unbearable. The midwife kept saying “Just 45 minutes more…” Eventually, she was transferred. She got her epidural and it was discovered that she had an anterior lip, which was then followed by shoulder dystocia. From the reactions of the medical staff that cared for her as well as seeing her soon afterwards, I am so glad that she trusted her instincts and insisted on being transferred to L&D, because we might have lost one or both of them.
No, I think she means that in her “professional” opinion, women are asking for epidurals when she feels that they could “get through it” with a shower, reassurance and a back rub.
Sure, they COULD, but why should they?
because Dahlan believes in the paternalistic model of care.
“You don’t worry your pretty little heads about that pain. Just bear through it and everything will be fine.”
Imagine a guy saying that.
And that’s what it really is about, isn’t it.
I don’t see why midwives need to be paid. I think I could find a little cave for them, drop some food off, maybe help them cart some water from the creek. After all it’s how midwives have lived for hundreds of thousands of years. It’s what their bodies are designed to do.
It doesn’t have to be “either-or”. One of the nicest aspects of my year in Cambridge [UK] was the COLLABORATIVE relationship the midwives had with OBs. Each worked within his/her sphere of competence. I had autonomy within certain clearly defined parameters — so when I called the OB he knew he was really needed. Not the “2 a.m. can I give the patient a sleeping pill? syndrome”. I never felt that I was a “subordinate”.
Antigonos- do you feel that sort of collaborative relationship between obs and nurse-midwives here in Israel as well? It seems that way from a patient’s perspective, but I’d like to know if things really work that smoothly from the care providers’ perspective.
No. I had to get doctor’s approval for a considerable number of actions that I could perform without even notifying an MD in the UK. On a personal basis, working with a doctor I knew well, he might say to me to do what I thought best and he’d countersign, but legally it remained that he did have to sign off.
Example: as a UK midwife I am licensed to give up to 100 mg of pethidine [Demerol] in divided doses, IM, to a patient WITHOUT any permission from an MD, the assumption being that if the patient required more, then possibly the labor was not proceeding without complications and therefore an MD was needed. Here, ALL medication orders must be countersigned by an MD, and not infrequently I’ve found that the MD wants a different dosage than I think appropriate.
This is probably sensible, especially when I first came to Israel [1976] and many midwives were granted licenses by reciprocity as there was a great shortage of both nurses and midwives. Some came from excellent backgrounds, some were distinctly inferior [the large Russian immigration caused changes in licensing procedure since some were discovered not only to be uneducated, but using counterfeit or borrowed certificates. Now all applicants for nursing/midwifery licenses must pass an exam]
Agreed, Antigonos. In Australia, HB is really a fringe practice, despite the ideology expressed by Dahlen and others. Almost all midwives work in hospitals, and medications and monitors are amongst the tools of their trade. Australian midwives (specialised RNs) were amongst the first to have an extended role – including prescribing (within scope of practice) and suturing.
Coronary Care nurses don’t believe in a different paradigm for heart function than Cardiologists, nor do NICU nurses. Why would MWs?
Agreed, I feel so sorry for America in that these two fields seem to be butting heads and bad mouthing each other. Wouldn’t want to bring a child into that culture full stop.
In the hospital, as a patient, you don’t see this turf war stuff play out. I’ve had babies in three different hospitals, and from the patient’s point of view, there’s seamless coordination between OBs and labor and delivery nurses (and labor and delivery nurses are the smartest, most energetic, most compassionate nurses I have met so far as a patient). That OB + labor and delivery nurse combo is the standard in the US (and you spend 90-95% of your time interacting with nurses, rather than doctors–the doctors pop in very occasionally if things are going well).
Another possible combination in the US for a hospital delivery is to have nurse midwives (CNMs–nurses with specialized graduate training) working with OBs. (I don’t know how that works out in real life. Could others chime in?) In any case, that is definitely the minority approach–usually it’s OB plus labor and delivery nurse, rather than OB plus nurse midwife.
The thing is that in real life, you don’t see this stuff in the hospital, which is a professional environment, and you might not even lay eyes on a midwife.
I agree that I’m not going to be familiar with giving birth in a US setting, I don’t have that experience.
However I know that I will be laying my eyes on a midwife as I’m a resident of the UK. I know you didn’t know that and I’m not trying to nitpick, I realise I should have made that clear in my earlier post.
Personally I feel ob+midwife combo is best. From my research it seems as though America needs to come up with some comprehensive training for midwives and make the law regarding the necessity for this training transparent. The training should also be modeled on other country’s, such as Canada, who have excellent birth statistics and a similar culture. Those that are unhappy with such legislation possibly shouldn’t be in this career.
The states have a plethora of highly qualified HCPs, although for logistical reasons, the OB and L&D RN is the usual combination.
I like the idea that there is no reason for a turf war between an RN and OB, while I can see logical reasons for turf wars between MWs and OBs.
Well, it all sounds great, but in reality, it functions very differently. I’m a canadian trained ob, working in Canada, with registered midwives. It is the biggest source of frustration for me in my career. The problem isn’t even necessarily their training. It’s their philosophy and their optimism bias. It’s the lack of understanding of the mounting risks as they push on past the point of safety in hopes of achieving a vaginal birth, only to consult well past when they should have. They have strange ideas about pain relief and really messed up ideas about what constitutes informed consent. Ad then, when you try to improve communication and patient care, they get defensive and passive aggressive. It sucks in a lot of places, I’m afraid, even in Canada. And I am an obstetrician who values patient choice And autonomy. Te difference is, I value it for women who don’t choose natural birth as well. C section by choice, ok. Epidural, ok. Pain free, ok. This doesn’t work with ost midwives I’ve met.
Wrote that too fast so ignore typos. I meant drug free, ok…
With the level of woo obvious inherent in the midwives in my corner of Ontario, I’m inclined to agree. Three of my friends were under the care of the same midwifery collective and all three ended up with epidurals, one was delayed three hours before the request was honoured, one laboured in hospital for 24 hours before it was suggested (baby was delivered after 40 hours of labour), and I don’t know how long it was before the third was “allowed” to have hers. I know that one of these people was told that an epidural would delay her labour by several hours, that there were many risks, and that it was best just to push through the pain.
While I think that midwifery is wonderful in theory, in practice it leaves much to be desired.
I second everything you say. I’ve had many interactions where Canadian midwives have interfered with a woman’s request to get an epidural, where they have allowed their “optimism” bias, as you put it, to delay OB consultation well past the point of safety and I’ve seen two intrapartum deaths because of it.
Having delivered three times with an army of nurses and three different OBs in three different hospitals, I don’t understand why a midwife is so special or necessary. US labor and delivery nurses are amazing people. (Actually, make that four times–I also had to have an induction for a late miscarriage and everybody in labor in delivery was amazing and compassionate. I really appreciated it.)
By the way, I know we all look and sound the same to you, but Canada is really quite distinct from the US. Canadians are (as a rule) quieter and more docile than Americans.
Sorry about the generalisation, realise now that it was pretty bad! I guess so long as women aren’t caught in the fray and are informed adequately then whatever care they receive is the right kind
Don’t mistake politeness for being docile 😉
Hee hee!
I’m an American married to a Canadian. From what I’ve heard, Canadians are really, really into differentiating themselves from Americans.
Canada does not have a “similar” culture to the US. Not when it comes to health care. Not when it comes to autonomy. Not when it comes to the role of government…I could go on.
The training for midwives exists. It leads to the CNM or CM credential. The problem is that it requires years of education that the women who become CPMs can’t get admitted to, can’t afford, or don’t think they need.
Between CNMs and OBs this exists. My sister just had her first with a CNM, at a hospital. Throughout her pregnancy she coordinated with an OB at the hospital and things went great. The conflict is between CPMs, which are probably even worse than laypeople and OBs, who are highly trained professionals. CNMs go through extensive training, are licensed, certified by the state, undergo rigorous testing, and constant review, just like OBs do. CPMs watch some videos and read some books and maybe observe a birth or two. Sort of like someone claiming to be qualified to fly a plane because they’ve watched Top Gun and read a book about planes.
True to an extent, but there are also a very large number of loony CNMs out there. Moreover, even among the non-loony CNMs, there is inexplicably a very accepting attitude toward CPMs.
Things would be a lot better without CPMs, but that alone won’t solve the problem.
As I mentioned elsewhere, i come from a “dinasty” of midwifes. The dinasty stopped actually with my grandma, but I know a lot of storie on how midwiferi in the first half of 1900s was in Italy.
Lets remember, please. 1900. Italy. Rural country in what now would be developing World. Fascism.
There are a series of misconceptions that the modern midwifes seem to have. I call them the Underfed Myth , the Dirty Myth and the Evil Interfering OB Myth
The Underfed Myth: Women used to eat bad! This is why they and their babies died so much!
Actually they didn’t. Eat badly, that is. Sure, there were bad years, but in the country at least people eat very well indeed. Everybody had chickens. Everybody had cows. Everybody had a vegetable garden. There was the pig to be slaughered every year. And everything was organic and fresh and in season.
They eat well. They died nonetheless.
The Dirty Myth; Lack of Sanitation! This is what killed all those women and their babies!
Actually by 1910s in Italy people knew germ theory. Even people in the villages. They probably didn’t sterilize every single thing, but they knew enough to wash their hand and keep a labouring woman and then the baby clean.
They knew enough to keep reasonably clean. They died nonetheless.
The Evil Interfering Ob Myth: Patriarchal Men have stolen birth from women!
Actually, men were being patriarchal before, when they didn’t give a damn if women lived or died. As Antigonos says very well, men supposed some women would die. Doctors didn’t go to birth. It wasn’t their business (save if you were very rich. Because, money). They weren’t interested.
I actually have some interesting anecdotes about the aforementioned myths, passed down the generations. The lack of historical awareness of those people is astounding.
Oh, do share them!!
I second kumquatwriter. Write a blog and post a link.
I have no time for a Blog, sadly! But I can write some and post in the comment section if you wish!
Guest post, perhaps??
That would be great! Maybe e-mail them to Dr. Amy as a guest post too.
Clearly those Italian villagers were too ignorant to just trust birth. Garibaldi probably told them not to, so it’s his fault.
You’re right about the Evil Interfering OB Myth, T. My mother grew up poor in New York City and she recalled that almost all of the women in her old neighborhood labored with midwives that were paid for by the city and local charities. This was during the Great Depression. The only time a woman went to the hospital was if she had complications.
One of the things I really liked about that Slate article is that it successfully acheived the sort of balanced reporting that is too often replaced by false equivalence these days (ie “most people think that planet Earth is round, but it is still controversial. Members of the Flat Earth Society say…”).
OT: Reminds me of genetic counseling. Women who are carriers for major birth defects usually choose to do the IVF route with genetic testing of the embryos.
Why would anyone with Factor X (carrier for Autism gene) want to do the natural route is beyond me.
Oops! Fragile X syndrome:
http://www.fragilex.org/fragile-x-associated-disorders/fragile-x-syndrome/
For the record (and I’m sure you already know this), even though people with Fragile X syndrome do often display autistic behaviors, it is an over-simplification to call it the “Autism gene”. The vast majority of people who display autistic behavior have a normal Fragile X gene (FMR1).
Anecdotely correct. My ASD daughter tested negative for fragile X, although it was suspected, so there is obviously some correlation between the two.
IMO, the ability to eliminate genetic illness through IVF, is one of the greatest medical achievements of recent years.
I also think that those who are looking for an autism gene can look until their dying day. I think it is just a category of retardation, and not a specific illness. Similar in a way to cerebral palsy, which is often caused by damage at pregnancy and birth. My daughter was oxygen deprived at birth, (through a rare complication and nobody’s fault), and we knew to look out for repercussions. It started off as developmental delay; by five she had her autism diagnosis. A lot of badly abused toddlers end up being diagnosed as autistic. There is nothing genetic about these cases.
I nearly went the route of IVF with preimplantation genetic diagnosis for baby number 2. It is a tough decision to make, especially if you have a syndrome yourself and feel like you’ve had a pretty good life in spite of it (oddly enough it felt like I was trying to deny myself somehow..). Anyway it didn’t end up happening that way, but now with one child without a genetic defect and one child with I would be much more inclined to do the genetic testing if I were to have a third (not likely).
If there is no genetic involvement in ASD’s, then why do they run in families?
There are multiple possible causes of autism and it is likely that quite a few genes can contribute to autism, individually or collectively. In some cases (such as Fragile-X), abnormality in a single gene can result in autistic behavior. In other cases, it may be small effects of multiple genes that act together to result in a person being on the autism spectrum. In other cases, physical damage to the brain (such as oxygen deprivation as described by MichelleJo) can result in behavior that is diagnosed as autistic. The fact that ASDs can run in families doesn’t mean that every autistic person inherited a gene or genes for autism, and the fact that some people develop autism due to physical damage to the brain doesn’t mean that it doesn’t have a genetic component in other people.
There is definitely a genetic component to ASD because identical twin studies showed that if one twin had ASD the likelihood of the other twin having it was 95%. That is high, but it also shows that something else is going on because the other 5% is pretty high. Although whatever is going on has to happen in the womb unless we are talking about misdiagnosis or cases where an injury led to autism like symptoms because the actual pathology of autism is in brain development that happens early in embryonic development.
Autism can be caused by de novo mutations in single genes, so one possiblity for the 5% discordance is that the mutation occurred in the earliest days of embryonic development, either immediately after the twins split or slightly before, and the cells with the mutation were disproportionately represented in one of the embryos.
Also, in the case of the abused toddlers, it’s really hard to figure out cause and effect here. Autism in families is linked with some mood disorders, and some parents with an untreated mood disorder are more likely to be abusive towards their kids, autistic or not. or a parent who is having emotional issues already may lash out much more severely and punitively at an autistic child, whose unusual behavior she can’t understand or handle, than at a neurotypical child who has the social and communication tools to escape even a little of the mistreatment by placating or complying with the abuser.
It is the one gene with the highest positive correlation.
So while it is not THE autism gene, the syndrome definitely provides data that autism can have a genetic cause.
Agreed.
This isn’t directly related to obstetrics, but it is a hilarious critique of “natural” and “alternative” medicine:
http://www.slate.com/articles/health_and_science/science_of_longevity/2013/09/tim_minchin_s_storm_critique_of_alternative_medicine_and_defense_of_reason.html
Great rap song. Thanks for the post.
Minchin rules. Odd the cartoon doesn’t look much like him, but the cartoon of his wife looks a lot like her.
Be warned if you ever see him live, he performs without shoes. We sat at the front and I got rather distracted by the toes…I do not like feet.
Slate seems to have learned a lot from their Robert F. Kennedy anti-vaccine fail. Or was was that Salon? I can never keep those two apart.
The thing I like about OB’s compared to midwives (note I think there are some excellent midwives out there, who are qualified and provide excellent care to their patients) – is that they care for women throughout the lifespan not just pregnancy and childbirth. Further, I don’t believe they are invested in either “normal birth” or “cesarean birth” as they certainly can do either (a midwife can’t) – but are heavily invested in good outcomes that go beyond whether or not their patient lived or died. I wish I would have been able to have the OB I had for my second pregnancy for my first (note: where I live low risk women can choose midwife or GP for prenatal care) – the care I got was exceptional and very mindful of my needs as a patient.
OT: Holy crap, I just learned there is a woman’s studies professor in my university — just down the hall actually — who actively teaches undergraduates that they should birth at home because feminism.
http://www.ourbodiesourblog.org/blog/2010/05/giving-her-students-a-gift-of-independence-jill-wood
I am really irritated about this.
I laugh to think how much those girls paid for their useless ‘Women’s Studies’ degrees. It’s probably evil, but I can just imagine how many people would have thrown their resumes in the trash pile. Then again, they are probably CPMs now.
I think it is probably like many “studies” degrees. If you are really committed to making a profession of the field — say, as an activist or a counselor to women in crisis — that degree will not hurt you and may even help you. It is when you try to find a job in another discipline that you will struggle more than someone with a more general degree.
Ugh. I have a degree in Animal Science, but I had to take a certain number of liberal arts classes to graduate. I ended up with two women’s studies classes, and was told that if I took a third, I could have graduated with a minor in it. I declined.
I tried ‘studying women’ one night when I was in college. I got slapped.
Ha! At my old university, the women’s studies department was called “The Center for the Study of Women.” Which makes it sound like they keep them in cages.
My degree is in psych, with a minor in Gender Studies. Emphasis on human development. I’d intended to go into counseling adolescent girls.
Once I realized how much I loathe and despise teenage girls, the degree became mainly useful as a punch line.
Oh G-d teenage girls.
Who only every come to see me if they are pregnant, trying to avoid getting pregnant, anorexic, bulimic or self harming. Sometimes several of the above at once.
Once, memorably, just to complain that her parents hadn’t bought her an iPhone, and it was, like, bad for her self esteem, and could I tell her mum that it was, like, medically needed and stuff!
Give me teenage boys and their shin splints, acne, torn ACLs, ingrown toenails and excessive sweating any day of the week!
Naw, give me the girls. The boys where I am do things like shoot each other dead with guns.
They start that later here, thankfully.
Paramilitaries don’t recruit under 16s, it’s a rule or something.
any treatment for that excessive sweating? Please, I need help with two teen boys at home!
If it’s armpit sweating, start with Dry Idea unscented roll on. If that doesn’t do the trick or if it’s for hand or feet sweating, talk to your doctor. Full body sweating can’t be helped much.
Teen girls (especially 13-14) aren’t actually human. They’re vicious raptors, attacking anyone who comes close, mostly peers. There’s really nothing anyone can do, except try to keep them from doing permanent damage to themselves or anyone else.
Then I’m lucky. My 13 y.o. girl is a pleasure 95% of the time.
My grandmother (who had 8 kids – 5 of them girls) always said if she had had the money, she would have sent them all to boarding school from age 12 to 16. She may have been on to something 😉
So, at risk of ruining your funny comment with a pedagogical question, did the Gender Studies degree help? Did it provide you with something you wouldn’t have gotten from regular psych classes?
My eldest niece turns 11 next month, and she’s already mastered the teenage eye-rolling, attitude, and sense of entitlement. I really pity my sister-in-law and her husband, who will eventually have to deal with 3 teenage girls under the same roof. With one bathroom.
I am also already dreading my daughter’s teenage years, and she’s six months old. At least my sister-in-law will be able to give me advice, assuming she isn’t insane with rage and frustration by that time.
Don’t worry too much. I have two girls. The oldest one was a horrible teenager complete with rebellion. It was hard, but now she is the sweetest 23-year-old women I have ever known. She makes me proud every day. My youngest who is almost 17 never had any of the typical teenage girl problems. She said she saw her sister go through it and never wanted to be that person and she’s not.
I couldn’t work out what the degree was about either, that couldn’t be covered by something else like a Literature degree or history degree. As far as I was concerned, women that were studying medicine, science, engineering and business degrees were practising feminism in action.
Agree, Karen. An older male ex-president of my specialist College once suggested we (women members) start a ”women’s group.” (I think he was honestly trying to be feminist).I had to explain that we were ordinary emergency physicians, not female emergency physicians.
That’s not feminism that’s biological essentialism.
It was fun taking part in the scrum of the comments section yesterday. The people from the Woo who showed up were pummeled.
Life’s tough outside the echo chambers, isn’t it? No one is deleting those MEAN comments!
The suggestion that OBs made childbirth “more dangerous” is really, really misleading, if not complete crap. Look at the plot of maternal mortality. After 1920, it continually decreases, which indicates that childbirth is overall safer, not more dangerous.
Yes, there were certainly instances where women died who would not have died under the old approach. However, if you lose one to save 4, which would reflect the change from 1920 to 1945, you are making it safer, not more dangerous. Moreover, that result creates an opportunity to build, because you can focus on preventing that additional loss.
But I will say, the data don’t really indicate any dramatic changes anywhere. Basically, it shows a steady (exponential) improvement in maternal mortality from 1930 to 1980, with mortality cut in half every 7 years. The only deviation from that trend occurs from about 1960 – 1965. There is no indication that there was any dramatic change in behavior of doctors originating in the 40s due to their newfound studies. Outside of that stagnate period in the early 60s, doctors have steadily been increasing the safety of childbirth for mothers.
Also, and this may be discussed on earlier comments, but other surgeries in that time frame (before germ theory) must have been fraught with infections for the same reason.
It’s not a bad article, but I take issue with her at several points. The whole point of doctors becoming involved in obstetrics was due to the appalling maternal and infant mortality when birth was exclusively the province of women who called themselves “midwives” but who had no formal scientific training. Doctors have a long history of being involved in difficult births — it wasn’t midwives who developed the first forceps, after all, and the first forceps were developed in the 18th century. When a C/S inevitably meant the death of the mother, forceps — even the very traumatic mid- and high forceps never done nowadays, were a huge advance.
A big problem was that, while cardiac conditions, or cancer, were recognized as pathology even in ancient times, birth was “normal” for the human female, and no good statistics were kept prior to the 20th century [really only from the 1920s]. Why bother studying the physiology of birth when it was what women “were designed to do”? So when Helmuth says that doctors actually made the situation worse, she’s not really correct. For one thing, they were the first to decide that there had to be better obstetric solutions — until then, it was thought perfectly normal that a substantial percentage of women and babies would die. And in the absence of data, it’s quite true that some mistaken assumptions led to practices we would decry today, so that even by the 60s doctors were working from fairly limited data. And, the technology was primitive. I began my career before fetal monitoring or ultrasound. We are light years away from that, now. The lowest gestational age, when I first graduated, for a premie to be thought to be viable was between 30 and 32 weeks. So yes, doctors did make a lot of mistakes 100 years ago that they don’t make now. That’s not a reason to claim they are inferior to midwives now [especially the untrained, non-professional kind]
This is what was unartfully trying to say on Jezebel yesterday. There was a post about how women still die in childbirth and it contained an excerpt from an article about how they field of obstetrics was born of misogyny and greed and women giving birth were basically tortured and infected whilst midwives were much more skilled and better at their jobs. I obviously don’t know as much about it as you do, but I like to think I can smell an agenda and apply logic. Midwifery was informal relative to the burgeoning field of obstetrics, so what data is being used to determine outcomes 100 years ago or more? Such data is obfuscated here in 2013, and largely uncollected in under-developed countries. I guess Im saying I want to know more about those hospital v. Home birth mortality rates of so long ago.
I watched a special on lobotomies a long time ago, it was very illuminating about the culture of medicine in the usa long ago. It was a self-protective league of doctors who operated with basically no ethical review. The documentary centered around a physician who prescribed lobotomies for basically anyone, and killed an inordinate amount of patients. He especially liked doing them on black people for some reason. They could do whatever they wanted. Its a lot like midwifery today.
isn’t the practising on black people still what happens today in medicine in general?
Actually, no. The standards for human research are much more stringent than they were in the past. Furthermore, because of historical abuses it’s very difficult to convince blacks to sign up for clinical trials. As a result, they are underrepresented which is hindering research on diseases that impact them more severely like high blood pressure and prostate cancer.
the abuses of black people still go on, didn’t some members of the medical profession try to publish Henrietta lacks’ dna and by extension, her current family’s dna last year without their permission? they had to be stopped. i’m glad black people resist efforts to use them in clinical trials for anything.
There must be a distinction made between the use of a doctor [“accoucheur”] and a midwife prior to this century — it wasn’t “home vs. hospital” birth. Women delivered at home unless they literally didn’t have a roof over their heads. [Even surgery, with the early ether/chloroform anesthesia in the 2nd half of the 19th century was often done in the home]. Doctors had incredibly poor education in medicine generally because the science was so primitive — Pasteur was also practicing in the 2nd half of the 19th century, btw. Procedures we think of nowadays as almost laughable, such as bleeding, purging, leeches, cupping, and so forth were still seriously being used by “medical practitioners” not all that long ago.
Midwives were women who attended women in labor, full stop. They had NO formal education at all that distinguished them from the average literate woman of the period and not always that. In some cases, it was a dynastic business, and one has to suppose that a certain amount of empiric knowledge was passed on: a woman whose belly was in a certain shape might be expected to have a long labor [whether the midwife understood that the baby was OP is debatable]; at a certain stage, it was common for a woman to want to turn on her left side and/or vomit [“7 cm sign”]. Most had probably learned how to ascertain the fetal lie manually [what are now called Leopold’s maneuvers] But these midwives could not tell you the diameters of the inlet of a normal pelvis [although they had a rough way to measure if it was adequate using their fingers to determine the “diagonal conjugate”]. In other words, their expertise came from observation and experience, not from scientific data, and their conclusions were frequently inaccurate or downright wrong. Some were better than others, but all, by today’s standards for CNMs, were ignorant.
I don’t know why it is a point of pride for today’s homebirth midwives to want to turn the clock back to the way it was, because the way it was, was pretty awful.
There are records, though of course not as thorough or as many, of birth outcomes from 100yrs ago or even further back. Family bibles, journals, letters, medical journals by the doctors of the time, birth certificates, death certificates, gravestones that are legible and probably some books have this information. True, it is not as complete as we might like, but it seems to give a pretty good picture of what was going on.
I didn’t get the impression that they were claiming OB’s were inferior to midwives now, but I may just be reading the article from the POV I want to use.
I also think it’s not technically “unfair” to talk about how Physicians had to sort of invent the wheel when it comes to new medical fields, and that lots of mistakes get made along that path. To switch to another field, which I’ve voraciously been reading about the history of for the past year, heart surgery has left a lot of horrific sounding experimentation in it’s wake to get to where we are today (Using another person as a heart/lung bypass machine? Why the hell not! Cutting open your own leg and feeding a tube through to your heart in the kitchen? Sure, I’m a crazy person. Convincing new parents to let you open up their newborn and do a “real” repair that has a much higher chance of killing their baby, vs a palliation that MIGHT fail 15 years from now? Just glad I didn’t have to be one of those parents) – but my god, the benefits reaped from those bold risks.
If Dr Norwood had been afraid to convince parents to let him experiment on their hypoplasts 35 years ago, think of all the kids that are home and thriving today that would have otherwise been just snuggled by their moms while they suffocated over the course of a few days? And now, building on that, Dr Emani is finding ways to help some of those kids actually regrow a functioning left ventricle. Because you can’t get amazing results, without taking really bold risks.
I don’t know as much abotu the specifics of early obstetrics, but it seems that if those early obstetricians had been afraid to forge those paths, and worried about what people might think of those risks today, how many mothers and babies would be dead as a result? People are going to color their feelings when reading about it with their own prejudices, but my color is “grateful”.
Tim, that’s the “you can’t make an Omelette” school of Evidence Based Medicine.
You learn as much from the failures as the successes, you don’t WANT the failures, but they are inevitable.
100 years ago if you had a stomach ulcer you got milk through an NG tube while confined to a hospital bed for weeks, but you might well have bled to death from your ulcer somewhere along the way.
Then there was vagotomy and gastrectomy…which was an improvement, but major surgery, and you still might have bled to death from a perforated ulcer.
Now we have Omeprazole available over the counter and antibiotic eradication therapy for H.pylori…and the death rate from perforated ulcers is orders of magnitude lower.
Unfortunately you can’t skip straight from “milk” to “Losec”, and mostly people do the best they can at the time with what they have and using what they know.
I’m just grateful that there are people bold and brave enough to break those eggs Dr Kitty 🙂
The fact that there’s still Dr’s brave enough to risk it in this litigious day and age, when their entire career and reputation is on the line, is amazing and like I said – I am hugely grateful.
“Good Enough” is never good enough, and we are all lucky there are those brave enough to recognize that.
And then there are morons like this
http://scienceblogs.com/insolence/2013/08/26/in-clinical-research-the-road-to-hell-is-paved-with-good-intentions/
Yes, it can be good to be aggressive and creative in trying new but risky approaches, but you’d think there would be at least some preliminary evidence using animal models that it can work.
I wouldn’t pat anyone on the back without considering how the ‘eggs’ feel about it. A lot of them had no choice in the matter. Its ugly business, even if its needed (like animal experimentation).
In the past people had the excuse that informed consent and medical ethics were sort of option extras and the cultural mores were very different (in the 1950s, for example, Drs rarely told people if they were diagnosed with cancer- we do things differently now). No one should be able to say that they experimented on subjects without consent now.
Every drug trial or experimental treatment will have people it will not benefit and people it may even harm, but that is how it works.
The alternative would be paralysis- never moving forward or changing because of the risk that a change may be worse than the status quo…which it might be, but you also lose the chance of finding out if it is better too.
We’re talking about treatment given with consent here. One can argue that most patients probably can’t give a truly “informed” consent to such things, as they are beyond their comprehension, but if the best attempt is made… what more can you possibly ask for? Is it better to just let people die?
Let’s take my example of Dr Norwood, learning to perfect his now quite famous surgery – those children would have been otherwise sent home to die of hypoxia while their parents held them. There is a lot of babies who died in surgery instead of their parents arms to get to where we are now – that is a fact. But they would have died either way, and if their parents consented to a massively risky surgery for the chance of life, isn’t that ok?
Less clear then, the morality of fixes for things like TGA vs the palliative procedures that were previously used. Parents were consenting to a much higher risk of surgical death (lets say 50% vs 5%) , for the tradeoff of having a child who could live an entire lifetime, versus the all but guaranteed death as a teenager. One could argue that they were too emotional, and again, lacked full understanding to provide proper informed consent, but what system would work better?
I have friends now who are letting the surgical staff in Boston “try” things that are still not 100% proven yet, because it offers their kids a chance at a better, and easier life. Again, maybe they are not fully capable of informed consent, because they aren’t physicians. But they are parents who are willing to take some risk for the reward of a better/easier life for their kids. I’m glad they are brave enough to make those choices for their children, and I’m glad those surgeons are brave enough to try these things because it improves humanity overall.
I don’t know any researcher that doesn’t take it incredibly hard when they lose a study patient…particularly those surgeons studying new techniques, probably because they are very intimately connected with their patients bodies and very invested in the outcome.
“Health statistics represent real people with the tears washed off” right? Well, those tears get washed off us providers too – we just don’t talk about it much.
I love this comment. To assume otherwise (that it would not be taken hard) is to assume that anyone developing a new drug, a new surgical technique, etc is in it purely for selfish reasons (ego stroking, financial, etc.) – If someone wanted to just be rich, there are much easier ways of going about it.
I can’t go into specifics for confidentiality reasons, but when someone, knowing all the risks, volunteers to be the first person in the area to have a procedure, and it doesn’t end well, it is devastating for all the health providers concerned, even tangentially.
It isn’t that the surgeon can shrug, “oh well, if at first you don’t succeed, try, try again” and merrily go off to persuade the next rube to sign up to be a Guinea Pig.
Tearful phone calls, horrible conversations with grieving families, second guessing yourself, waking at drenched in sweat reliving the moment where it all went wrong….
It isn’t that the ” broken eggs” are easily forgotten, or should be, just that there will always be some.
Or desperate enough to break those eggs. It’s not nice to be in the position of ‘guinea pig’, but when there aren’t a lot of options it’s the choice that gets made.
If you want an example of the discovery of a disease followed by its solution in a period of only a couple of decades, just look at the consequences of being Rh Negative for pregnant women. Even after the major blood groups were discovered, it took a while for the Rhesus factor to be isolated. It was known that some women, for some inexplicable reason, would have one child and then each subsequent child would be sicker and sicker until the pregnancies ended in miscarriage but no one knew why. The development of Anti-D [or Rhogam] made it possible for Rh negative women to have all the children they wanted. This was a MEDICAL advance, with obstetric implications that have been huge.
And now we have women who refuse the Rhogam shot because they think it’s unnecessarily exposing themselves and their baby to “toxins”. People have entirely too short of memories.
Twenty years ago I was newly pregnant and diagnosed as being Rh Negative. I read a book about the discovery of blood types, factors and the creation of Rhogam. It was a challenging book for a lay person like myself to understand but all I have to do is look at my seven healthy children and be incredibly grateful for medical advances.
A friend was born in the 70s with biliary atresia. His parents were given the choice of a possible liver transplant on him by age 9 months- with who knows what outcome- or a new experimental procedure to make a new duct. The new procedure was given a 3% chance of working. They had no good options and were watching their baby become sicker every day. They took the 3% chance- and it worked. For 20 years. And then failed. He ended up with a transplant after all, but had a good healthy 2 decades of life before it. I can;t say if I was desperately hoping my child would stay alive, I wouldn’t take those small odds either.