Monday, March 12, 2007
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 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 (email@example.com]
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.