The Wisdom of Industrializing Biological Systems

Read the New Yorker article first :

“THE SCORE - How childbirth went industrial” 

Click here for a web link to the original New Yorker article . Published October 09, 2006

Part Two -- What happens when you attempt to industialize our normal biology?

The last section of this 3-part essay focused on the industrialization of biological systems. A substantial list of unintended consequences is associated with mass production techniques of any kind, whether for farming, ranching, egg production or systemizing care for normal childbirth.

However, we can’t overlook the historical dangers associated with childbirth. Obviously the absence of professional care does not, by itself, make normal childbearing better or any safer. This distrubing realization resulted in the development of a traditional system for providing maternity care that has existed since the dawn of humankind. As recorded by 5,000 year-old Egyptian Hieroglyphics, the principles of physiolgoical care for normal childbirth were acknowledged and utilized by trained midwives as a formal discipline as long ago as 3,000 BCE. This means that midwifery truly is the world's oldest profession. But we wouldn't be debating the pros and cons of industrializing the care for normal birth if midwifery care were 'perfect'.

At the cusp of the 21st century the big question is whether industrialized childbirth results in the greatest level of safety, patient satisfaction and cost-effectiveness? Dr Gawande refers to these practices as the “obstetrical package”, a term that describes the medicalization of normal maternity care as purposefully developed by the medical profession over the course of the 20th century.

The question so far unaddress is the fundamental nature of childbirth in a healthy population. What is the optimal management for this healthy cohort? Is childbirth a normal and reasonably dependable aspect of our reproductive biology or it it, as the author of older obstetrical text books insisted, a "nine-month disease that requires a surgical cure"? Is it really a ‘disaster waiting to happen’? The obstetrical profession asserts that it is only ‘normal’ in retrospect. Is that a useful way to relate to the care of childbearing women?

Today's essay (part 2) focuses on the biological nature of childbirth and its relationship with the right (or wrong!) use of gravity and the most frequent historial complication of normal birth. The classical or more frequent complication of childbirth as always been an inability by the mother to push the baby out under her own powers, a problem that gave rise to the first use of obstetrical instruments (forceps) that could make up for Mother Nature's failures without having to sacrific the life of either mother or baby.

From there we will look at how the industrialization of childbirth fits in the modern day picture of maternity care, starting with that first tool of obstetrical industrialization - obstetrical forceps. Our modern romance with obstetrical technology starts with the propriety development of forceps by the Chamberlain family in the late 1600s. Unfortunately, use of forceps eventually became a routine accompaniment of obstetrical practice for all childbirth, even when the mother was healthy and there was no 'dystocia' or disproportion between the size of the baby and her pelvis.

Identifying the basic nature of childbirth

When it comes to industrialized childbirth, it is obvious that the current system for providing care to healthy women has a variety of problems. No matter what the obstetrical profession or Dr. Gawande may believe, the majority of childbearing women are healthy and at the end of nine months, they are enjoying a normal pregnancy. Practically and statistically-speaking, normal childbirth in healthy women does not benefit from the routine use of medical procedures or surgery.

But for all the faults of a systematized approach to childbirth, a disturbing reality must constantly be acknowledged: Pregnancy and childbirth complications can and do occur, even for women with no obvious problems or risk factors. The industrialized childbirth of the early 1900s was fueled by this disturbing reality. Its worthy goals were the complete elimination of all preventable complications and ‘bad outcomes’ in pregnancy and childbirth.

In THE SCORE, Dr Gawande stated flatly that: "For thousands of years, childbirth was the most common cause of death for young women and infants". This was presented as an undisputed ‘common sense’ fact. And yet, for all the certainty of Dr G’s assertion, we do not actually know if it is true: Was childbirth was the most common cause of death for our ancestors? It certainly seems plausible. Without credible evidence to the contrary, the American public has always assumed that the obstetrical definition of childbirth as serial killer of young women and newborn babies was a sad fact of a woman’s life before the 20th century. In the minds of most Americans, only the development and wide-spread deployment of modern obstetrics has been able to stop the carnage of Mother Nature gone mad.

Childbirth – Normal Biology or Gender-specific Curse?

It is the belief that childbirth is a dangerous and dysfunctional aspect of female biology that underlies the philosophy of industrial obstetrics. Fear-based beliefs that medical and surgical interventions are necessary in every normal childbirth is what generated the policies and practice of 20th century obstetrics. As for those mothers who somehow delivered without having such interventions, well, the official explaination is that they were "just lucky this time", aluding to the idea that the narrowly missed catastrophy would fall next time uless they took the appropriate evasive action. The obstetrical profession has always believed that nosocomial (hospital-based) or iatrogenic (practitioner-based) harm that resulted was far outweighed by the ‘obvious’ benefits and therefore, neither the theory nor the practice of routine obstetrical intervention required any further study.

The obstetrical profession’s fear of childbirth gave rise to the second central belief -- that childbearing women can only be saved thru the universal application of the “obstetrical package”. The confluence of these concepts decides what the ‘rules of the factory floor’ are in 2007. Regrettably, one can predict that factor-floor childbirth will inch forward, year by year, towards what is believed to be the ultimate mechanism of obstetrical reliability – the progressive elimination of vaginal birth.

The active verb ‘to give birth’ will eventually be replaced by a purely obstetrical vocabulary, in which the obstetrician is the means of production, the baby is the product and the parental- consumers are compliant, complacent, well-insured and grateful.

Looking at Historical Documents for Clues

Just for the sake of argument, let’s assume that the process of childbirth, with its propensity for unexpected problems, was a bad mistake by Mother Nature. If this is the case, analysis of vital records and birth certificate data over the last century should be able to easily document the superiority of industrialized obstetrics. Statistics comparing the maternal-infant outcomes of medical versus physiological management would demonistrate that the higher the rate of intervention (i.e., use of the obstetrical package) lowered the morbidity and mortality and conversely, failure to employ the “pre-emptive strike” would be accompanied by very high rates of complications and fatalities.

Were that the case, industrialized obstetrics would clearly be associated with dramatically improved outcomes.

However, this hypothesis is not substantiated by world-wide scientific literature or the obstetrical history included in Dr. Gawande’s account. As readers will recall, Dr G. described how the level of mortaility of mothers and babies was just as high in 1940 as it was in 1910, when obstetrics first imposed a medical and surgical model on normal childbirth. Here is an excerpt of that section of THE SCORE in Dr G's own words:

"By the early twentieth century, the problems of human birth seemed to have been largely solved. Doctors could avail themselves of a range of measures to insure a safe delivery: antiseptics, the forceps, blood transfusions, a drug (ergot) that could induce labor and contract the uterus after delivery to stop bleeding, and even, in desperate situations, Cesarean section. By the nineteen-thirties, most urban mothers had switched from midwife deliveries at home to physician deliveries in the hospital.

But in 1933 the New York Academy of Medicine published a shocking study of 2,041 maternal deaths in childbirth. At least two-thirds, the investigators found, were preventable. There had been no improvement in death rates for mothers in the preceding two decades; newborn deaths from birth injuries had actually increased. Hospital care brought no advantages; mothers were better off delivering at home.

The investigators were appalled to find that many physicians simply didn’t know what they were doing: they missed clear signs of hemorrhagic shock and other treatable conditions, violated basic antiseptic standards, tore and infected women with misapplied forceps. The White House followed with a similar national report. Doctors may have had the right tools, but midwives without them did better. " [end excerpt]

This is hardly a affirmation for the 'tools' of industrialized childbirth.

Instead, physiologically-managed labors and births using classical non-medical methods and often occurring in non-medical settings, have maternal-infant outcomes equivalent to those of the obstetrical package, but with a rate of maternal and infant interventions two to ten times lower. If childbearing biology was indeed just a bad mistake of Mother Nature, this would be impossible. [Click here for ObGynNews report the BMJ study - June 2005].

Historical records and contemporary experience both give good reason to question the cultural belief that all childbirth is a disaster waiting to happen. However, attitudes and behaviors of physicians and midwives in many other industrialized countries do not reflect that belief, nor do they depend on policies such as the pre-emptive strike to manage normal childbirth. And yet, the cost of maternity care in these countries is far less than in our own and the maternal-infant outcomes in these countries are far better than the US. The experience of community midwives in the US and abroad is also the very opposite of these ideas. [see CNM studies by Patricia Anderson, CNM on the cost effectiveness of planned home birth attended nurse-midwives - AJNM]

As for the historical record, anthropology researchers report strong evidence that many aboriginal societies, living lives undisturbed by civilization, have remarkably good health, with little or no discernable heart disease, cancer, diabetes, dental decay, etc. In those cultures, childbirth is neither greatly feared nor frequently complicated. Obviously, we can never know for certain what childbirth for early humans was like. But there are intriguing historical clues that call into question the 20th century obstetrical conclusions that our childbearing biology is normally abnormal.

Historical Support for Alternative Theories

An example of ‘simpler times’ can be found in the historical records of the early settlers of Colonial American. A detailed bibliography of John Adams provides an interesting record of the dozens of large families of the founder of our country and their wives during the American Revolution and early years of the new American government. In these accounts, which span the 50 years before, during and after the Revolution, more children and women of childbearing age died from virulent forms of influenza and TB and from epidemics of small pox, cholera and typhoid fever than childbirth-related complications.

Martha Ballard, a midwife who practiced for 30 years in rural parts of the New England colonies, delivered 3,000 women during this same period. The detailed diary of her midwifery practice became the subject of academic study in the 1990s. The author searched the birth and death records of the day in order to determine the accuracy of Martha Ballad’s information. According her personal diary and cross-referenced official records, there was not a single maternal death recorded among the births she attended.

Nonetheless, childbirth in centuries past is of little help to us today, in our own very different and highly developed civilization. So I will stipulate the obvious. In the distant history of the human species, in a world with NO emergency medical or surgical services, in which entire populations were subjected to floods, forest fires, pursuit by wild animals and periodic starvation, childbirth was an additional serious danger to a significant number of childbearing women and infants.

Optimal management of Childbirth in the 21st Century

Does the industrialization of obstetrics provide optimal management of Childbirth in the 21st Century? Is the standardization of childbirth helpful to the majority of the contemporary childbearing population – that very important 70% who are healthy and have normal pregnancies?

What happened when the traditional social and professional structures that supported physiological management of normal birth for five thousand years were purposefully dismantled and eliminated during a 10-year period of time (1910-1920) and replaced by an expensive and capital-intensive childbirth ‘industry’? What is the nature of this new idea – the unopposed, unexamined ‘industrialization’ of American childbirth? Has childbirth been industrialized in other developed countries and if not, what is their experience with normal birth?

A comment by a contemporary obstetrician is instructive:

“... The hallmark of obstetrical quality is the prevention of the rare disaster rather than the optimal conduct of the many normal cases” [Dr. Brody 1981]

By its very nature, industrialized birth must be influenced by economic factors above everything else. In order to maintain economy of scale, industrialized childbirth must try to fit individuals into predetermined norms. This applies to hospital patients and hospital staff alike. In an effort to predictably provide good outcomes or defend itself against unpredictable bad outcomes, it generates a medially aggressive process that revolves around the mentality of the ‘pre-emptive strike’. Its methods require the routine use of medical procedures – intensive care hospitalization, aggressive obstetrical management of labor, immobilization in bed, liberal use of drugs, anesthetics, episiotomy, operative delivery, etc.

Seventy percent of the time, these medical and surgical procedures are not done because the laboring woman actually has a present-tense complication or even a high likelihood of developing one, but ‘just in case’. The rare future possibility trumps the actuality of the moment. Since there is a rather lengthy list of rare but possible complications in the index of every obstetrical textbook, the list of ‘just in case’ maneuvers is likewise lengthy. Whether one is being medically treated for a heart attack or ‘treated’ for normal labor, the medical ministrations are remarkably similar, at least as defined by the serious looking hospital personal coming and going from the room, the number of medical devices attached to the patient and the many different charges appearing on the patient’s hospital bill.

The unexamined issue for the 21st century is what does it mean to eliminate physiological childbearing and then standardize ‘normal’ childbirth care predicated on these ‘worst case’ scenarios? What impact do these policies have on healthy childbearing women? One of the characteristics of industrialization - automobile manufacturing for example - is that the actual product itself doesn’t have a role in the industrialized process -- it is simply a passive part of the system, acted upon by others, like a toy doll being assembled.

In the industrialized model of modern childbirth, there is no active role for the childbearing woman. Her duties are restricted to being a good patient – passive and compliant. Surgical delivery by Cesarean Section renders the mother totally inert and virtually irrelevant, as the entire process can go on without her even being conscious.

What is the impact of this learned helplessness on society? What public policies and individual actions are appropriate? What should we do personally?

Above all, where exactly is the delicate line in which a society balances the benefit of new technologies and new ideas, while protecting the integrity and quality of our personal lives?

So far, the quality of the public debate on these important topics has been very poor. One of the reasons is that the near universal lack understanding of normal biology and normal physiological care for normal birth among the public. And despite anyone’s understanding, the question still remains as to whether or not childbirth had always been and remains fundamentally dangerous.

Earlier in this series, I addressed many of the issues of labor, especially the psychological and social aspects and normal or non-medical methods to help women cope with the stress and pain of labor. But the basic mechanics of getting a baby thru the cervix, into the birth canal and out into the world is still the best kept secret of the 20th century.

Biology 101 – Bones and Body Parts of Normal Birth

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 letter ‘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 her 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 idea is not anatomically correct. Imagine instead that you are looking at an upright pregnant woman from the side and that she will labor and give birth in this same 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 ‘j’ 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!). If instead it were to go straight down towards the floor (the “I” theory of the childbearing pelvis), it would be extremely hard for the mother to reach it and the baby might be injured as it fell to the ground. Not doubt this “frontal delivery” is an important survival characteristic, as 99.99% of human history predates hospital obstetrics, which meant it was the mother herself who was responsible for ‘catching’ her baby.

Childbirth has been designed by biological selection to be successful all by itself, independent of any other person or medical interventions.

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 -- encroaches 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 slightly bent in on the fourth side, making it impossible for anything that is the same size and shape as its circumference to pass through unimpeded.

However, in the second or pushing 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 movable and able to be pressed back out of the way by the baby’s head, as it descends deeper into the birth canal and gets closer and closer to being born. Think of those little pet doors that open and move out of the way as the dog or cat passes throught. The human sacrum also is jointed or hinged where it join to the lower end of the spine and it to move slightly to provide more room for the baby to pass.

In addition, the hormones of pregnancy soften the cartilage that hold the two sides of the pubic bone together, so these pelvic joints become unusually elastic. This permits the pelvis to also 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.

This is graphic of a mother giving birth without the added benefit of gravity, while lying on her back.The baby must first negotiate its way under the pubic bone by rotating its head from sideways to an up / down orientation.

Then the crown of the baby's head spins under the public arch and will be born pointing up, towards the ceiling.

Gravity – What a concept!

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. The right use of gravity naturally stimulates effective uterine contractions, helps dilate the cervix and assists the baby to descend through the bony pelvis. To help the birth process move along, women are encouraged to walk around during labor. Being upright and mobile during contractions also diminishes the mother’s perception of pain, perhaps by stimulating endorphins. On the rare occasions that require the mother to lie down, midwives also noted that 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, is lying down can reduce the pelvic size by almost a third, while simultaneously requiring the mother to push her baby up hill, and around a 60-degree bend. Not only does this requires that she defy gravity, but she must do this with the doorway partially blocked, reducing the aperture of the pelvis. When the mother is bearing her own weight on her back and lower spine, such as lying with her legs held up in stirrups, the sacrum cannot move back out of the baby's way.

If the baby is small or the mother’s pelvis is big, the normal forces of labor and extra effort by the mother can overcome this impediment. However, when the mother is on her back, the baby must still emerge at an angle heading upwards, towards the ceiling. Obviously this is a lot harder and takes a lot longer than it would if gravity were used to benefit mother and baby.
Regardless of the answer to that, how did our ancestors manage this central aspect of human reproduction – labor, birth and the new baby? So let’s take a little excursion into the biology and sociology of birth. In order to do that we also have to acknowledge the role what really is the world’s oldest profession – midwives as helpers and guardians of mothers and babies.

Giving Birth with Grace and Gravity

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 them and their babies. 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.

Eve 2.0 ~ Nature's program for normal birth

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 the get-go of the human species, older experienced women always helped younger, inexperienced women during the hours of labor and during the moments of birth. This also included caring for the new mother afterwards, as she learned to breastfeed and take care of her new baby. Experienced assistance of this kind (Eve 2.0!) eventually became 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 the old world language of England, the word ‘mid’ meant “with” and the word ‘wife’ referred to “woman”. Thus a ‘midwife’ was someone who was ‘with woman’ during the events of childbearing.

“The practice of midwifery dates back to the beginning of human life in this world. At this supreme moment of motherhood it is probable that some assistance has always been required and given. Its history runs parallel with the history of the people, and its functions antedate any record we have of medicine as an applied process. To deny its right to exist as a calling is to take issue with the eternal verities of life.” Dr. Josephine Baker, M.D. 1911-G, page# 232

The first record of midwifery as an established discipline can be found in the hieroglyphics of ancient Egypt in 3,000 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 his midwives to kill all the first-born sons of the enslaved Hebrew population. The Egyptian midwives, at great risk to their own lives, declined to carry out such orders. When these midwives were called before the Pharaoh to explain why they did not do as directed, they answered that the Hebrew women, unlike the Egyptian women, were “lively upon the birth stool” and delivered before the midwives arrived.

“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.” Dr. Hardin, M.D.1925-A; p. 347

During the first 5,000 years of recorded history, the discipline of midwifery was empirically-based and organized around meeting the practical needs of laboring women. These universal needs are primarily psychological, emotional, and social. The care of midwives included ‘patience with nature’, the right use of gravity 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, no surgical instrument or procedure ever developed by medical science has been able to make birth better or safer in healthy women with normal pregnancies than spontaneous labor and normal birth attended by an experienced birth attendant.
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”.

The classic principles of physiological management include a basic trust in biology and support for the normal process of labor and birth. It is 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), patience, and the right use of gravity.

“...that trained midwives surpass 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.” [1931 Testimony on midwifery care, White House Conference on Child Health and Protection by the Committee on Prenatal and Maternal Care]

The Birth of Industrialized obstetrics: FORCEPS – Microcosm of Difficulties to Come
The first act of the industrial childbirth revolution was the invention of obstetrical forceps in 1650. According to historians, the first functional pair of forceps was due to the ingenuity of an English family of doctors – patriarch William Chamberlen, sons Peter I and Peter II and grandson, Peter III. It was William Chamberlen’s accurate knowledge of the bony pelvis and his understanding of the mechanics of normal childbirth that permitted him to design the first obstetrical instrument that would permit a physician to forcibly extract a living baby out without causing it permanent harm or death.

For centuries physicians had been looking for a method or instrument that would permit them to extract the baby in cases of obstructed or ineffective labor. The obvious question is why it took so long to design something like forceps and why didn’t anybody come up with alternative methods until the vacuum extraction was developed in the 1970s? What is so special about the anatomy of the childbearing pelvis? Unfortunately, the use of force to get an undamaged baby out is very much harder than it looks. In order to understand what was so remarkable about the Chamberlen intervention, readers refer back that primer in the bony anatomy of childbirth and the simple physiology of normal childbirth earlier in this essay and entries on this blog.

In general, the successful extraction of a live baby from the birth canal without hurting either mother or baby required a functional understanding of the “J” shape of the pelvic canal and the simple fact that when a mother is lying down, a physician using any form of physical and mechanical force (root of the word “forceps”) would have to be pull the baby around the 60 degree angle of the pelvis. In order to accomplish this, the angle of the pull is straight up towards the ceiling. Unless the doctor is suspended from the ceiling, this would be a very difficult maneuver. The 60-degree angle and the need to exert force going upward are just two issues that the design of obstetrical forceps had to overcome.

Using William Chamberlen’s original pair of forceps as a push-off point, successive generations of the Chamberlen family developed and refined their designs over the next century. It should be noted again that the operative word in forceps is ‘force’. Whether the use of force is a blessing or a curse depends on many factors.

While obstetrical forceps are potentially a life-saving technology, their history is a disturbing story marked by intrigue, unbridled competition, ego-centricisim, personality cults, gender politics and old-fashioned greed. William Chamberlen’s life-saving invention was kept as a family secret for more than a hundred years.

The surreptitious use of the forceps was accomplished by tying one end of a bed sheet around the neck of the doctor and covering the lower half of the mother’s body with the other end. The box containing the forceps was slipped under this visual tent and the forceps taken out and inserted into the mother vagina by “touch”. No one in the room, not even the mother, knew what they looked like or exactly how they worked.

The invention of forceps was the first time in the history of obstetrics that a manufactured instrument became the personal or ‘intellectual’ property of its doctor-developer. Unfortunately, this proprietary relationship with an obstetrical invention led to a host of abuses. Due to the unwillingness of the Chamberlens to make their discovery available to the public, it is conservatively that estimated that during the 17th and 18th century hundreds of thousands of babies who could have been successfully delivered by forceps (had the technology been in the public domain) instead died as a result of obstructed labors. After 4 to 6 days of useless labor, the baby would die and the mother was often left with severe and permanent damage to the tissue of her pelvis (fistulas) and life-long incontinence.

While forceps were designed to rescue babies that otherwise would have been permanently damaged or died, the use of instrumental delivery by the medical profession gradually become more and more indiscriminate, based on obstetrical fashion instead of medical need. In particular, forceps were used excessively on wealthy patients who didn’t need them while being withheld from maternity patients whose babies would die with help, all because the family could not pay the large professional fee.

Forceps in the 20th Century

In early 20th century American, this enthusiasm turned into an irrational exuberance, as forceps become central to the routine practice of obstetrics. Normal birth was characterized as a dangerous mistake of Mother Nature, whereas forceps were portrayed as making birth safer and better. This was the forerunner of today’s identical claim by the obstetrical profession that Cesarean section being better and safer than normal birth. As they say, ‘the more things changes, the more they stay the same’.

In the early years of the 20th century, a famous obstetrician of that era (Dr. Joseph DeLee) was infamous for defining the biology of birth as a patho-physiology -- no more ‘normal’ for the mother’s perineum than “falling on a pitchfork”. Even worse, the poor baby’s head was being used as a “battering ram on the mother’s iron perineum”. His solution was the routine use of episiotomy (incidentally giving rise to an entire century of unnecessary episiotomies!) and forceps to save the mother and baby from what he defined as the pathological effects of normal birth.

From 1910 to the 1940s, they were routinely used at all physician-attended births. As late as the 1970s, low or “outlet” forceps deliveries were still the norm in the South and more rural parts of the US. They were used routinely where I worked in the L&D as last as 1976 (Orange Memorial Hospital and Holiday Hospital in Orlando, Florida).

Ultimately, forceps changed the nature of maternity care, tipping it away from physiological management by midwives and general practice physicians and towards the male-dominated profession of obstetrics. The use of forceps became the single most important element of obstetrical practice and virtually eliminated physiologically-based maternity care, since instrumental delivery must be accompanied by the use of anesthesia and episiotomy.

Traditionally, maternity care had been a personal service between two people of the same social status who had an on-going relationship and lived in geographically proximity. But midwives were not permitted to use forceps, which was a restricted practice of medicine. Thus the idea of ‘market share’ was introduced, making obstetrics into an economic adventure shaped and dominated by market forces.

The obstetrical profession took on the mantle of being the source of all knowledge about normal reproduction and the only credible source of wisdom about proper care during childbirth. To their way of thinking, this equated to a medical version of “manifest destiny”. Newspapers and women’s magazines picked up this drum beat and soon the lay public was socialize to the idea that more intervention in birth was, well, more better. The manifest destiny of industrialized childbirth in the US had been born. Within a single generation, virtually all childbirth services were reorganized around hospitals, physicians, obstetrical interventions, with forceps at the top of the list.

Intellectual Property Versus the Normal Anatomy of Childbearing

For mothers who are too tired to push or for whom the baby is in distress, the use of obstetrical forceps to extract the baby can be life-saving. That puts the invention and use of forceps in the pantheon of modern medicine, both as a humanitarian advance and as an aspect of the ‘industrialization’ of maternity care. Unfortunately, the thing that has distinguished the use of obstetrical forceps was not any form of humanitarian concern.

I could not possibly improve on the historical account of the invention, the politics and the lasting consequences than to simply provide the original words of obstetrical historians.

Before providing the test of these historical excerpts, I must mention that ‘obstetrics’ is a 20th century word. From the time of the Ancients until the last 1900s, the word midwifery was almost synonymous with the idea of maternity care, regardless of the gender or status of the practitioner – midwife or physician.

The obstetric forceps:  a short history and descriptive catalogue 

by BRYAN M. HIBBARD,

The introduction of forceps into obstetric practice is variously described as one of the great advances in obstetric care, or alternatively as an example of the brutal use of new instruments whose only purpose was to advance the cause of man-midwifery.

The latter view was held by many eighteenth-century midwives who saw their business slipping into the hands of medical practitioners, and sometimes by modern historians reacting against what they see as the subsequent domination of childbirth by men, with their persistent tendency to intervene unnecessarily in a physiological process.

…any obstetrician worth his salt had to have a pair of forceps to his name. Witowski, whose Histoire des accouchments was published in Paris in 1887, described mid-nineteenth-century obstetricians as "possessed with an incredible ardour for inventing instruments sometimes dangerous, often useless, but always ingenious".

If you had your name attached to an instrument, you were tempted to use it whenever it was necessary and often when it was not; and your students learnt to do the same.

"Give me a pair of Kiellands and a pair of Wrigleys and I am content" was, as I remember it, the received obstetric wisdom in the 1950s,….

The past proliferation of forceps does, however, provide an important clue to past practice. The massive intervention in normal or slightly delayed labours, which was such a feature of obstetric practice from the mid-nineteenth century to the 1930s, stimulated the production of new designs. In the hands of an experienced practitioner, forceps could relieve an enormous amount of distress and save maternal and infant lives. Their misuse, which admittedly occurred on a grand scale

BRYAN M. HIBBARD, The obstetric forceps: a short history and descriptive catalogue of the forceps in the Museum of the Royal College of Obstetricians and Gynaecologists, London, Royal College of Obstetricians and Gynaecologists [27 Sussex Place, London NWl 4RG], 1988, 8vo, pp. iii, 69, £2.00.

The Dirty Secret of the Doctors Chamberlen:

The use of forceps to deliver babies has had a long twisted history. As far back as the twelfth century there were instruments described in such a way as to only be useful in removing babies that had died. The use of obstetrical forceps to effect delivery to save the child didn't come into prominence until the mid eighteenth century. Over a century later than it should have.

Power, fame, and greed all played a role in keeping this instrument a secret, so that those with the knowledge [of forceps] could claim that they alone could deliver patients when everyone else had failed. But before we condemn the foul secrecy that was used for personal gain, the secret of omission that was responsible for countless of thousands of babies' deaths for over a hundred years.

In 1813, a woman found an old hidden trunk which described and contained the invention of the Chamberlen family--the obstetrical forceps. In this trunk was evidence indicating that Peter Chamberlen, who died in 1631, was the first to use the technique. In fact, he claimed to be the one who could handle the impossible cases. 

Along with his brother, they became prominent practitioners with the secret, and used their success to control the instruction of midwifery in England. Peter's nephew, also named Peter, was the first Chamberlen to actually become a doctor. He maintained the secrecy, assuring his success and prominence, and was the attendant at births of the royal family, who alone benefitted from his solution for difficult births.
Had any of the future monarchs died at their deliveries, like the "little people," because of not using forceps, history might be vastly different

Dr. Chamberlen, armed with his secret, issued his own "Cry of Women and Children as Echoed Forth in the Compassions of Peter Chamberlen." After his death, his son, Hugh, tried to sell the family secret to a French physician, Mauriceau, claiming he could deliver even the most difficult cases in minutes. Mauriceau tested him by assigning him a woman in labor who was a dwarf, and he failed.

Hugh Chamberlen translated Mauriceau's book into English, he wrote in the preface of how, "My father, brothers, and myself (though none else in Europe as I know) have by God's blessing and our own industry attained to and long practiced a way to deliver women...without (harm) to them or their infants."

He later sold his secret in Holland, where the Medical-Pharmaceutical College of Amsterdam was given the sole privilege of licensing physicians, for a huge amount of money, to use the secret technique of the Chamberlens. Finally, someone with scruples bought the privilege and went public, but it seems he himself was sold only one part of the forceps pair, meaning that either he was defrauded by the Medical College or Chamberlen had done it to them. Meanwhile, babies suffered the consequences of this thievery.

Hugh Chamberlen's son, also named Hugh, was a friend of the Duke of Buckingham, and because of this his statue stands today in Westminster Abbey. He's the one who finally freed the obstetrical forceps for general use at the beginning of the eighteenth century, ending the countless needless infant deaths that his family's secret had caused. About the same time, a Dr. De la Motte addressed the Paris Academy of Medicine, [and] stated how he felt about anyone who might invent a successful instrument like that, and what should happen to him should he keep it secret for is own profit:

"He deserved to be tied to a barren rock and have his vitals plucked out by vultures."

conclusion of historial text
~~~~~~~~~~~~~~~~~~~
No doubt the development of forceps were as exciting to the medical profession in the 17th and 18th century as our contemporary enthusiasm for computer technology and the Internet have been to us in the 20th century. It is human nature to embrace technologies that allow us to control the here-to-fore uncontrollable, and it is particularly sweet when it gives us a personal or economic advantage over everyone else.

For the last century however, the concept of ‘balance’ between the needs of maternity patients and the obstetrical profession has been largely ignored in the US, a time when the use of obstetrically-managed childbirth care became the social norm. There are approximately 4 million births each year, more than 90% of which are obstetrically managed.

And yet, there has been little public debate, no public oversight based, no scientific monitoring of the large pantheon of obstetrical interventions and technologies. We have no objective scientific body that can provide evidence-based guidance to develop cost-effective national maternity care policies. It seems that the practical needs of childbearing mothers and the system for providing maternity care to healthy women have both fallen into a cultural blind spot.

Like many areas of modern life, maternity care for healthy women can be organized in two diametrically opposed ways. One is sustainable, socially–conscious, cost-efficient and has a small carbon footprint. The other, refereed to by Dr G. as the ‘obstetrical package’ -- is associated with a large carbon footprint and ever-increasing economic, ecological, and humanitarian burden.

Unfortuantely, the current obstetrical status quo is unsustainable -- industrialized childbirth for a healthy population fails the cost-benefit test. The status quo is also unacceptable in that it fails to meet the practical needs of the childbearing population. But the good news is that unlike war, terrorism, global warming and many other ills facing America today, we do know what to do about this problem. It’s called physiological management. The use of its prinicples can be of benefit to all categories of childbearing women, even those with high-risk pregnancies. It can be used by all categories of birth attendants – obstetricians, family practice physicians and midwives. It works wherever the mother wants or needs to be – home, hospital or independent birth center.

The missing link is YOU!

For more on “Green Maternity Care”, visit http://www.normalbirth.org/.

Part Three: 

The Next Wave of Industrialization –

 18th century Medical School and Clinical Training

What happens when you 'industrialize' social biological aspects of life - part one of 3-part essay.

If you have not read the New Yorker article “THE SCORE - How childbirth went industrial” the following critique will be of limited value.

Here is web access to this New Yorker article on the internet. It was originally published October 09, 2006



A brief excerpt from THE SCORE, by Dr Gawande:

“The question facing obstetrics was this: Is medicine a craft or an industry?
If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills —… maneuver[s] for the baby with a shoulder stuck, ...for the breech baby, the feel of forceps... You do research to find new techniques. You accept that things will not always work out in everyone’s hands.

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. …Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth.
We have reached the point that, when there’s any question of delivery risk, the Cesarean is what clinicians turn to—it’s simply the most reliable option.
These were the rules of the factory floor.

A measure of how safe Cesareans have become is that there is ferocious but genuine debate about whether a mother in the thirty-ninth week of pregnancy with no special risks should be offered a Cesarean delivery as an alternative to waiting for labor.
Yet in the next decade or so the industrial revolution in obstetrics could make Cesarean delivery consistently safer than the birth process that evolution gave us. [emphasis added]


An Alternative Thought: part one of a three-part essay ~

“Obstetrics has been rated as the least scientifically-based specialty in medicine” [Dr. Ian Chalmers 1987].

It is not my intention to impeach the well-earned prestige of physicians or to disregard the many valuable contributions of modern medicine. As an L&D nurse, I was profoundly gratefully each and every time obstetrical medicine was able to save the life or prevent permanent damage to mothers or babies suffering from the complications of childbearing.

I am personally grateful to a wonderfully sympathetic obstetrician-gynecologist. Without his astute diagnostic and surgical skills in 1962, I would not have been blessed with the ability to become pregnant with my wonderful children. That would also have deprived me of my grandchildren, which surely is one of the best parts of being a parent.

But when it comes to the ‘industrializing’ of normal birth, I am not a fan. I’m aghast at the comments of Dr. Gawande, which promote the idea of obstetrics as an ‘industry’. Instead of the individual skill of the physician, now it’s the industrial “rules of the factory floor” that decide the kind of care provided by obstetricians. Obstetrics is all about what is best for obstetricians, instead of what serves the basic biological safety of childbearing and practical needs of mothers and babies.

Dr Gawande believes that the greatest good for society is to be achieved by passively permitting the ‘obstetrical industry’ to eliminate the biology of spontaneous vaginal birth and replace normal birth with assembly-line Cesarean sections, as is already being done in Mexico City, where all birth is an elective surgical procedure scheduled at 15 minute intervals, Mon-Fri, 8am-5pm. Dr Gawande argues that the industrial revolution in obstetrics could “make Cesarean delivery consistently safer than the birth process that evolution gave us.”

This is clear vote of “no confidence” by the obstetrical profession, who publicly describe our evolutionary biology is as a defective and undependable system, while obstetrical interventions -- particularly Cesarean section -- are pictured as the better and safer route. However, that is a false and misleading claim which is overwhelmingly refuted by the scientific literature. Having major abdominal surgery is not in the best interest of childbearing women. A paper recently published paper by Department of Obstetrics and Gynecology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA, entitled “Vaginal birth after caesarean section versus elective repeat caesarean section: assessment of maternal downstream health outcomes” concluded that:

“The results of our analysis suggest that the downstream consequences of multiple caesarean sections must be incorporated into patient counseling regarding VBAC, especially in women who are considering additional children.

Specifically, for women who desire multiple children after a single caesarean, a strategy encouraging VBAC will result in fewer cumulative hysterectomies than an elective repeat caesarean section strategy.

Our results should also be taken into consideration when making policies about the mode of delivery after one prior caesarean section: they suggest that if the ‘pendulum’ continues to swing away from VBAC, the incidence of placenta praevia and placenta accreta, and their associated morbidities, will continue to rise sharply.”

Industrialized Childbirth

Industrialized childbirth is a capital-intensive system for turning the normal biology into a mass produced “product” of the obstetrical profession.

In 20th century terms, industrialization is a capital-intensive system which does a fine job of producing affordable cars, computers, cell phones and Nike athletic shoes. But the object of industrialization is to make a profit by making things cheaper and more readily available. That is not the same thing as making things better or safer.

We generally believe the quality of being ‘industrious’ is a valuable character trait – that is, focused and consistent energy, applied to achieve a socially valuable goal. But what happens when that quality of industry – in this case, large-scale assembly-line methods -- are grafted onto social and biological processes? Over the course of the 20th century, we have seen our schools, childcare, hot meals, family farms, family fishing businesses, forest management, animal husbandry and many other aspects of our lives become standardized, mass-produced, franchised, out-sourced or contracted out to the lowest bidder. Do assembly-line methods as applied to biology and sociology make our lives better, worse or just different?

One example of this conundrum can be found in the traditional practice of agriculture and animal husbandry. The heavy industrializing of these biological systems has virtually obliterated the individual farmer or family-based fishing business. Now called the agri-business, huge mechanized farms replace family farms. In doing so, society exchanged individual initiative, personal responsibility and ecological balance of the family farm – all planet friendly ‘green’ characteristics, with a small carbon foot-print -- for a high volume, assembly-line industry. By trading quality for quantity, mass production techniques injected a high level of bio-hazard. Recently, E-coli contaminated spinach was shipped all over the US from a single grower in California, resulting in the deaths of several people, including a two-year old child.

Cattle ranching, chicken and hog farms, milk and egg production have also been revamped to make for high volume methods. However, aggregating so many animals together is highly stressful and disruptive to live stock. Worse yet, industrial levels of animal waste, aggregated together in a confined space, create a biologically toxic situation of mammoth proportions. To realize the full impact of this, contrast the biological waste generated by a dozen chickens on a couple of acres of land with what happens when you use the industrialize the same few acres with a 100,000 chickens in tightly packed pens. When this natural ecological balance is ignored, the result is thousands of pounds of manure that contaminate the water and a nauseating stench that pollutes the air. Overflowing hog lagoons in North Carolina and tight-packed cattle pens in California are just two examples this industrial-strength problem.

Without the constant use of prescription drugs, factory farms animals become sick and die. Factory farming and ranching both depends on the pharmaceutical industry to stay in business. Growth hormones increase milk production, force chickens to lay more eggs and fatten cattle. Antibiotic-laced animal and chicken feed is required to overcome the potentially-fatal infections from crowded pens. The blow-back from the industrial use of antibiotics in animal husbandry is an increase in the number of virulent, drug-resistant bacteria and contamination of ground water with large quantities of antibiotics that are excreted in animal urine. Unfortunately, there are many other instances of this sort of industrial ‘blow-back’.

Does the agri-business have anything to do with the baby-business?

Few people think of industrialized childbirth as having anything in common with factory farming or hormone-enhanced egg and milk production. But it has more in common than one would think, starting with the capital-intensive structure of the hospital-industrial business (buildings, expensive equipment, sterile supplies, etc) and the need to maintain its economy of scale thru the economical use of space and staff time.

In order to have some control over the patient census, hospitals must have an orderly flow of patients that matches the number of beds and staff available at any one time. For labor and delivery units, that means control over the timing of labor, at least for some percent of the patient population. This inevitably puts pregnant women on the ‘clock’, as the hospital is reimbursed at a much higher rate for performing medical and surgical procedures than the rate for the simple use of the labor room and the nursing staff.

For example, 5 women in labor for 24 hours each (a total of 5 deliveries in that 24 hrs period) is not nearly as profitable as 15 women who, thanks to speeding up labor through the use of artificial hormones (Pitocin, etc), are able to be ‘delivered’ in just eight hours and whose care requires only one shift of nurses. The hospital reimbursement for 15 deliveries in 24 hours is much greater than the reimbursement for only 5 deliveries. Even though the hospital can recover additional fees for the prolonged use of the labor room, it ties up the very foundation of the industrialized model -- scarce real estate and employees, in this case, 3 shifts of nurses. This is a net loss compared to the billable units in the additional 10 deliveries, especially if 30% of them are Cesarean sections, which are billed at an even higher rate per minute of time.

To understand the industrial childbirth perspective better, I have included the following remarks from a well-known obstetrician who conducted a study on elective inductions. He is quoted in ObGynNews as recommending the off-label use of an ulcer drug (generic name misoprostol or “Cytotec”) and the elective induction of labor:

“Oral misoprostol is far and away the most cost effective labor induction method”, Dr. Arthur S. Maslow asserted at a meeting on ob.gyn, gynecologic oncology, and reproductive endocrinology.

“It's a great agent. It works very, very efficiently. It's very safe. We've had no complications, no uterine ruptures. And it's ungodly inexpensive: 27 cents per tablet. At the most we use two or three tablets,” Dr. Maslow said at the meeting, sponsored by the Geisinger Health System.

“The best part about it is that you can block-schedule your nurses so that you have enough on hand. With a 90% successful induction rate within 8-10 hours, if we start our inductions at 7 a.m., we know that we're going to have X number of patients in labor being admitted by 4 p.m.

That's helped our hospital tremendously,” said Dr. Maslow, director of maternal and fetal medicine at the Geisinger Health System in Danville, Pa.

…. we make them [maternity patients being induced] walk for 2 hours. They can stay in the hospital, go to the mall, I don't care. Just don't rest them during an induction. You're killing your hospital financially if you do that, just killing them. It's not fair to the hospital …” Tips on Labor Induction Using Oral Misoprostol - Study of 2,200 elective inductions; Ob.Gyn.News; April 1 2004 • Volume 39 •

Cytotec is not the only drug that is frequently employed to hasten labor in a medicalized attempt not to ‘kill your hospital financially’. Another artificial hormone known as prostaglandin gel (made from pig semen) is also used to ‘ripen’ the cervix, so that labor can be induced. Unlike Cytotec, it costs about $400 a dose.

However, induction also requires the use of yet another drug “Pitocin” -- an artificial form of the natural hormone oxytocin. According to various sources, between 50% and 80% of all labors are either induced or artificially sped up with one or more of these powerful drugs. Perhaps it is not just a co-incidence that 50% of all malpractice cases brought against obstetricians involves the use of these labor inducing or accelerating drugs

From the standpoint of hospital staffing ratio and insurance reimbursement, electively scheduled Cesarean sections are even more advantageous. One large hospital in Michigan is replacing half of its labor rooms with operating rooms, in anticipation of a 50% CS rate by the time their new unit opens in 2011. [University of Ann Harbor, 2006]

Bio-hazards – Nosocomial blow-back

Another similarity between the agri-business and the birth business is that doing business on an industrial scale inevitably results in a bio-hazardous environment in. Aggregating sick people or healthy childbearing women or healthy infants together in hospitals has always been a bio-hazardous nightmare. The very early hospitals were thought to be places to avoid at all costs, since few people left them alive. The word for hospital-acquired infections, errors or other hospital-related patient harm is “nosocomial”. [for historical perspective, read “The Cry and the Covenant” by Morton Thompson, 1949].

Not a new problem

As long ago as 1881, a professor of obstetrics at the Edinburgh Maternity Hospital in Scotland lamented the infectious dangers of aggregating pregnant women and babies in institutional settings and the virulent nature of the nosocomial disease in hospitalized women known at the times as childbed fever.

Before the widespread understanding of the germ theory, doctors couldn’t figure out what was causing maternity patients to become septic, but they did realize that it was provoked by aggregating childbearing women together in an institutional setting. It was common knowledge among doctors and the lay public that maternal deaths were several times higher when women delivered in hospitals than when they gave birth at home. This was even safer for women to deliver precipitously on the doorstep of hospital before any medical care could be given (no vaginal exams or exposure to dirty linens, etc), than to deliver after being admitted to the hospital.

In a paper presented to the Edinburgh Obstetrical Society Session in 1881 on “the systematic use of antiseptics on midwifery [i.e., maternity] patients”, the author (an obstetrical professor) provided details about the nosocomial risk of childbed fever in institutional environment [i.e., hemolytic septicemia]. A frequent topic among obstetricians was whether they should move all their healthy maternity patients back out of hospitals in order to eliminate these nosocomial deaths. Ultimately, he and other obstetricians concluded that the training medical students required that the medical profession perpetuate hospital-based maternity care, which provided unlimited access to the necessary ‘clinical material’ (teaching cases). Here is an excerpt from 1881:

“…. concerning the question of maternal deaths, it must be admitted that the diminution of maternal mortality is the main object of our art. These maternal deaths during childbed … have been shown … to be striking in their frequency. In our own hospital I … find that out of 10,043 women who have delivered in it, almost 2 percent or nearly 1 in 50 have died.

I speak of prevention rather than cure because …in its presence we are nearly powerless or at least not in a position to rely with certainty of the efficacy of any of the means employed. If we are comparatively unable to cope with puerperal fever once established, it becomes our duty to be all the more anxious to adopt any precaution which may offer a reasonable hope of preventing it.

Since the opening of the [new Edinburgh maternity] hospital, there have been 12 deaths.., 10 have taken place from this cause [puerperal sepsis]. What I believe to have been the origin of the disease, viz, is the want of a separate mortuary and the performance of post-mortem examinations in the hospital. Since that report, the fault has been remedied and the hospital thoroughly and repeatedly disinfected.

Notwithstanding all this, the deaths from puerperal fever have continued. Yet during that period there has not been recorded a single case of death from a similar cause in the extern practice [i.e. labor and birth in the mother’s home]…

This brings us back to the old question long ago worked out by Sir J. Simpson, … and others of home versus hospital practice and of the greatly increased mortality of hospital as compared with home.

….. To me it seems sufficiently established that maternity hospitals must exist, as much for the benefit of women at a time when they most need shelter and assistance, as for the clinical instruction which the medical student can receive there and there only.

It must be borne in mind that the majority of the intern cases [hospital instead of home] are single women who have been seduced, and who, apart from their mental condition, …. have previous to admission, been in straitened circumstances and badly nourished, and are consequently specially liable to be quickly and gravely affected by any septic influence under which they may be brought.

The present Maternity Hospital being a necessity and puerperal fever having been shown to exist there, and to have been the direct cause of death in 1 out of every 32 women and as all needful sanitary improvement have been made, it becomes necessary to look for the prevention of this scourge by means apart from the building itself.

What then is the nature of this disease, which has proved fatal in our new hospital to one out of every 32 women who have been delivered here? And is it feasible to suppose that it can be prevented? I do not believe that we can hope to prevent puerperal fever entirely…. but I feel certain that by strict attention to antiseptics we shall be able to reduce its occurrence to a minimum and render its presence in hospital practice, where I have just said it is most common, a rarity. [Edinburgh Obstetrical Society Session 1880-1881 “On the systematic use of antiseptics in midwifery practice”; emphasis added]

The Germ theory of Contagion

Nosocomial infections were greatly reduced after the discovery of pathogenic bacteria (germs) and the role of different kinds of microscopic organisms in causing infectious disease. In 1881, French physician Louis Pasteur drew a picture on a chalk board at a prestigious medical meeting in France of what streptococcus bacteria looked like under a microscope. Pointing to his picture of rectangular microbes that resembled a string of boxcars on a train track, he made his now famous pronouncement “This, gentlemen, is the cause of Childbed Fever”. The discovery of micro-organisms established as a scientific certainty the role of bacteria in causing infections. The dramatic pronouncement by Dr Pasteur permanently influenced the practice of medicine and surgery all across the world and actually is the foundation of medicine as a scientifically-based discipline.

For the previous 2 centuries, obstetricians had been frustrated by their inability to prevent nosocomial infections. Their considerable medical skills permitted them to use forceps or even perform a Cesarean to save the baby, only to have the mother (and perhaps the baby also) become infected with childbed fever and die a few days later from hemolytic septicemia. The discovery of pathogenic bacteria as the source of infectious disease was enormously exciting to the medical profession. Finally there was something tangible, something that could be seen under the microscope and killed by strong chemicals and exposure to heat. An understanding of the germ theory and the principles of antiseptic and aseptic techniques provided doctors with a way to prevent wholesale epidemics, thus making hospitals into a place of healing instead of a place to die.

Over the course of the next 30 years, this single event changed the practice of medicine from a hit and miss art form to a budding science with unlimited potential. Dissemination of the germ theory particularly influenced the way normal childbirth was conducted. For the first time the medical profession understood that anything which touched an infected person would be contaminated by pathogens and thus it became a source of contagion. This eventually was describes as the 'vector', a mathematical term for the place where two lines cross. In this case, it describes a remote point for the transmission of disease, in which the two infected people never personally had any contact with one another and yet the pathogen from one infected person found its way to healthy person who also became infected and thus was a second victim. This contagious chain of events could go on endlessly and result in massive epidemics.

Using the science of microbiology and employing a generous dose of Yankee ingenuity, the obstetrical profession threw itself into approximately 30 years (1880-1910) of antiseptic and aseptic-based remodeling of building and of innovative ideas about medical care. Hospitals were striped of all ‘fu-fu’ – rugs, curtains, upholstered furniture, etc. Strict house keeping standards were imposed, with frequent dousing of the walls and floors with Lysol. Stainless steel replaced wood and fabric and institutional green become the color du jour. Delivery rooms were tiled floor to ceiling; equipment was stainless steel or chrome for easy disinfecting. Rules for hospital visitors were very strict, with even more draconian restrictions for visitors to the maternity floor. Children under 16 were totally barred from the maternity ward.

Nosocomial Infections stubbornly persist

However, eliminating nosocomial infections was more difficult than anticipated. As reported by the professor from Edinburgh in 1881, simply disinfecting the building was not able to provide the hoped for rate of zero infections. The enemy was an invisible pathogen hundreds of times smaller than the period at the end of this sentence. This meant that nosocomial infections had as many sources as the employees of the hospital had fingers -- nurses, medical students and attending physicians all had multiple opportunities to spread deadly bacteria. An innocent error, a minor mistake, carelessness or wanton disregard anywhere along the institutional chain of events could result in contamination and contagion.

All it took was one incidence of unwashed hands, an improperly cleaned piece of equipment, a contaminated surgical instrument, an unsterilized bed sheet, a dirty bedpan, a broken sterilizer, an outdated antiseptic, a sneeze or a cough – anyone or anything in this great institutional smorgasbord could be the harbinger of a fatal error. Janitors, central supply clerks, nurses, housecleaning, all were equally likely to be guilty. Eliminating nosocomial infections is the archetypical Herculean effort, cleaning the stable out each and every day, for each and every patient and relative to each and every items used – linens, instruments, other equipment -- only to be back to square one the very next minute.

“...in 1921 the maternal death rate for our country was higher than that of every foreign country for which we have statistics, except that of Belgium and Chile.”[1925-A; HardinMD, p.347]

"Maternal mortality in the country when compared with certain other countries, notable England, Wales and Sweden is, according to Howard, is "appallingly high and probably unequaled in modern times in any civilized country".

“The ‘International Year Book of Care and Protection of Children’ gives emphasis to the fact that the Untied States has still a higher rate of maternal mortality than any other of the principal countries of the world …. Twenty five thousand women die in the United States every year from direct and indirect effects of pregnancy and labor. Three to 5% of all children die during delivery and thousands of them are crippled.” [1925-A p. 350]

Iatrogenic contributors to nosocomial infection

The elimination of nosocomial infections was a high priority of the obstetrical profession in the late 19th and very early 20th century. By 1910 hospital buildings had been remodeled, hospital policies forbid visitors who might themselves be ill and antiseptic principles were routinely used by the staff. In theory, this should have stopped cross-contamination dead in its tracks.

Despite these aggressive measures, hospital-acquired infections continued to be the most frequent cause of maternal-infant death. After much sole searching, leaders in the obstetrical community had to admit that doctors themselves were part of the problem. A well-known obstetrician and author (Joseph DeLee) lamented the continued high rate of nosocomial infections associated with hospital childbirth. In his 1924 obstetrical textbook, Dr DeLee identified the role of doctors in a hospital setting as a vector for these infectious diseases and recommends additional changes in hospital policies to reduce infection:

“Without doubt the physician carries the greatest danger of infection to the confinement [labor] room. The germs in the air, in the bed clothes, in the patient’s garments, even those of the vulva, may be the same … as those he [the doctor] brings with him, but the former are not virulent ….

The physician comes in daily contact with infections disease, pus, and erysipelas cases, and his person, clothes and especially his hands may carry highly virulent organisms.”

The air in the ordinary home does not contain any virulent bacteria, but this cannot be said of general hospitals admitting pus cases, pneumonia cases, and tonsillitis patients into the same wards with maternity patients. That under these circumstances puerperal infection may originate has been amply demonstrated to the author. The maternity case should be in a part of the general hospital absolutely isolated from the rest of the wards, best in a detached pavilion of its own as the older obstetricians have always taught.” [Obstetrical textbook Dr DeLee p. 294]

Patient harm is described as “iatrogenic” (instead of nosocomial or hospital-based) when it is the direct result of actions (or inactions) by a medical professional. The obstetrical profession had to admit that many maternity deaths were actually iatrogenic complications. One way that this came to light was by comparing physician-attended birth with those attended by midwives. Contrary to expectations, puerperal septicemia in mothers who had their babies delivered by midwives was rare.

“In New York City, the reported cases of death from puerperal sepsis occur more frequently in the practice of physicians than from the work of the midwives”. [Dr. Ira Wile, 1911-G, p.246]

But among themselves, doctors also admitted that it wasn’t just hospitalization that increased rates of childbirth septicemia. The more manipulations done during labor the more infections. Common obstetrical procedures and manipulation included vaginal exams, rubber bogies gradually filled with water to pry open the cervix, and other use of ‘artificial, forcible or mechanical means’ to advance the labor or bring about the birth. The included all surgical procedures – episiotomy, forceps, Cesarean section, etc – which greatly increased the rate of morbidity and mortality.

Here is how the problem was describes by Dr. DeLee [p. 292-293]:

“Let the [mother’s] natural immunities be broken down, as by severe hemorrhage, shock, eclampsia, etc or let a new virulent bacterium be introduced; let the accoucheurs [archaic word for obstetrician] in his manipulation carry too many of the vaginal bacteria up into the uterus (a procedure not entirely avoidable), or let him, by his operations, bruise and mutilate the parts too much, or let him break up the protective granulation referred to, and the germs will rapidly invade the system, producing a disease know as puerperal infection, termed by the older writers as child-bed fever.

The asepsis of the patient therefore consists mainly in the preservation of her immunities by sustaining her strength, procuring a normal course of labor, avoiding the necessity for operative interferences, and conducting these with the least possible amount of damage.”

Hospital epidemics finally halted, discovery of antibiotics has unintended consequences

It was not an easy or instantaneous transformation, but eventually the systemic use of antiseptics, aseptic technique and eventually, sterile supplies, eliminated epidemics outbreaks of puerperal sepsis in hospital maternity wards. Obstetricians ascribed their success to the hospital policy of conducting of labor and birth under conditions of surgical sterility, as a “surgical” procedure. It was the Holy Grail of obstetrical practice, but in spite of flawless sterile technique, individual cases puerperal septicemia continued to kill a small percentage of new mothers.

With the discovery of antibiotics during WWII, it was assumed that finally the danger of hospital contagion was a thing of the past. Antibiotics were administered ‘prophylacticly’ to hospital patients in the mistaken belief that these drugs would “nip it in the bud”, should an errant germ gain entrance. With this powerful new weapon against virulent bacteria, doctors felt free to intervene as much as convenient, assuming that should the mother develop signs of infection, they could just order a shot of penicillin and the problem would magically fade away.

Unfortunately, that idea was wrong. Hospital-acquired infections tend to be the most virulent and antibiotic-resistant forms of bacteria and drug therapy can no longer be counted on to cure them. Hospitals do their very best to keep contamination and contagion away from laboring women, but the need to sterilized absolutely everything that a labor patient or newborn baby comes in contact with is extraordinarily expensive and only partly effective, as human systems that require inhuman perseverance frequently break down despite everyone’s best efforts.

The longer someone is a patient in a hospital and the more procedures performed (skin punctured or instruments inserted into body cavities, etc) the higher the rate of nosocomial diseases. These antibiotic-resistant pathogens tend to become incorporated into the normal flora (the nose, throat and alimentary tract) of hospital workers. Once these infections are under way, they are not easily treated. Nosocomial infections are responsible for about 20,000 deaths in the U.S. per year. Approximately 10% of American hospital patients (about 2 million every year) acquire a clinically significant nosocomial infection. [Supplemental Lecture (98/05/09 update) by Stephen T. Abedon (abedon.1@osu.edu]

Three-part essay ~ End of part one -

Stay tuned for part two -- Identifying the basic nature of childbirth, the right (and wrong) use of gravity and the role of obstetrical forceps in the earliest attempts to industrialized childbirth by taking a short-cut. Forceps were originally intended to rescue babies whose mothers couldn't physically give birth naturally, but soon became the 18th and 19th equivilent of "elective Cesarean", that is, the idea that man-made tools and interventions could somehow make birth "better" than old-fashioned biology.