For most of human history, childbirth has presented grave potential danger to mother and child. That's because—the theory goes—evolution, normally so pragmatic, has presented us with a dual challenge. Our pelvises must be narrow enough to allow us to walk upright without waddling yet large enough to deliver a baby with a head containing a human brain. All things considered, walking has been an asset to the species, but don't tell that to a woman screaming for an epidural. They don't call it labor for nothing.
The quest to make the ordeal safer—and more comfortable—goes back a long way. Over the centuries, women have been pried open, stitched, unstitched, cut apart, herded into hospitals, herded out of hospitals, told to exercise, told not to exercise, told to take drugs, told not to take drugs, etc., by authorities motivated by good intentions, ideology, and/or profit. Advances have been made, and so have mistakes. Yet despite the horrors and false starts, childbirth in the First World has become infinitely safer—so safe that women struggling with infertility now sometimes opt for IVF, and more involved measures such as donor eggs, in part because they want to go through pregnancy and labor. A process once feared has become a sought-after experience.
In her lively history Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank, Randi Hutter Epstein injects new energy into the now-familiar story of how male doctors gradually usurped a procedure that was once the provenance of midwives and how they sometimes victimized women in the process. Her book takes a kind of great-man—and not so great-man—approach to childbirth's history, focusing on some of the personalities who transformed it for better and for worse. Among other things, Epstein (herself an M.D.) shows how ignorance of the birth process, even of female anatomy, has never been a bar to men's attempt to wrest control from the practiced hand of midwives: Some of the early treatises on women's health were written by, of all people, monks.
The campaign really took off, though, when the new "experts" began to offer devices, "something concrete that they had and that midwives lacked." Among the ranks of "men with tools" were the Chamberlen family, who for two centuries, beginning in the late 1500s, aggressively guarded the design of their famous forceps. In ensuing eras, the tools were wielded in hospital maternity wards, sometimes by doctors who went from laboring mother to laboring mother (or, worse, from autopsied body to laboring mother) without washing up between visits. Epstein shows how these doctors, confident in the purity of their motives and of their hands, were slow to accept that they were the reason women were dying from childbed fever. "For centuries," Epstein writes, "anything that went wrong was blamed on some kind of inherent female weakness. "
She also shows how affluent women were especially susceptible to the doctors' double-whammy—shiny tools wielded in facilities that weren't always hygienic. Well before the days of the voluntary C-section, the notion was often put about that middle- and upper-class women were too posh to push. Or rather, too pale and peaked to push. This view of fragile womanhood opened up the market for doctors proffering techniques that might make the hard female lot easier.
Poor women, by contrast, were regarded as marvelously well-equipped to withstand the duress of labor. They could not afford the tools, so no need to create a demand where no market existed. And given that they were believed to have such wonderful fortitude and such a high pain threshold, it was seen as ethically permissible to practice on them. In the American North, Epstein says, Irish immigrants were the medical subjects of choice. In the antebellum South, an ambitious doctor named J. Marion Sims acquired a group of slave women in his quest to develop a cure for fistula, a terrible condition that results when the vaginal wall tears during labor.
Sims operated repeatedly on at least three slaves, whose interior regions he would pry open using a speculum of his invention, made from "two large spoons he picked up at the local hardware store." The speculum enabled him to plumb the vagina—seeing "everything, as no man had ever seen before," as he put it—and to stitch them repeatedly. Without anesthesia. "He sewed Anarcha upward of 30 times," Epstein writes of one of his subjects, a sentence that physically affected me every time I read it. Sims did advance obstetric medicine, but he later rightly became regarded as a "poster child for patient abuse."
Affluent women, too, could be victimized, particularly when the men with tools were joined by men with drugs. In the early 20th century, German doctors started a vogue for "twilight sleep," a treatment during which the laboring mother was given drugs that did not entirely alleviate the pain—women were restrained to contain their thrashing—but enabled her to forget about it afterward. Ironically, Epstein points out, twilight sleep was embraced by early-20th-century feminists who saw it as a way to allow women to rise above their physical role as child bearers. Thing was, twilight sleep treatment also reduced the mother's ability to push and sometimes impaired infant breathing. The vogue began to abate when a woman died.
The feminists' support suggested that women were perfectly capable of joining the ranks of meddlers and pain-inflictors, something proven for sure in ensuing decades. Epstein recounts the sorry history of DES, the synthetic estrogen confidently promoted by a husband-and-wife team from Harvard, the Smiths, who at the height of the nation's mid-century belief in "better living through chemistry" advocated DES as a preventative for miscarriage. Other researchers soon raised valid concerns about its efficacy and safety, but the prestige and self-certainty of the Harvard pair, enabled by a zealous pharmaceutical industry, ensured that the stuff was peddled for years after studies challenged it. The victims were not the pregnant mothers but their daughters, exposed to DES as developing embryos. Some died young of vaginal cancer; others were rendered infertile. The upshot was a much greater skepticism about the holy authority of doctors, which changed "the nature of the patient-gynecologist relationship."
Understandably, men with drugs and tools were opposed by men—and women—who urged women to forgo drugs and tools entirely. Among these was Elisabeth Bing, who popularized the Lamaze method of natural childbirth in America, despite the fact that Lamaze ignored her the one time she had lunch with him, talking only with a male doctor present. Her energy fed into a movement that persists—and divides—today. Bing later acknowledged that she got "the works"—epidural, laughing gas—during her own delivery, the difficulty of which apparently surprised her.
Against the odds, it sometimes seems, labor over the centuries did become safer. Epstein's history, though vivid and readable, does not spell out why, so I asked Jeff Ecker, a high-risk obstetrician at Massachusetts General and associate professor at Harvard Medical School. He cited the ability safely to do caesarian delivery with regional anesthesia such as spinals and epidurals—and, just as important, the availability of antibiotics, safe blood banks, and transfusions. In other words, the tools really were useful, or many were.
Epstein also might have pointed out the more recent attempts by women, and a different branch of the medical establishment, to reinject risk into the process. Her final chapters—on sperm banking and the fertility industry—touch more on conception than on childbearing and, as such, might seem out of place. In fact, they aren't, though she doesn't emphasize the reason why: One result of several decades of fertility treatment has been skyrocketing rates of twins, triplets, and higher-order multiple births. These have turned pregnancy into an endurance contest and childbirth into an extreme sport, transforming delivery rooms and leading to the widespread construction of neonatal intensive care units.
Multiple births—so familiar in this age of Jon and Kate, the octomom, and endless cable-channel high-risk deliveries—are far more dangerous than most people realize. For the mother, they raise the risk of almost every serious complication of pregnancy you can think of, including gestational diabetes, anemia, hemorrhage, hyperemesis (extreme vomiting), pre-eclampsia and, yes, death. But these pregnancies are riskier still for the child. Children born as multiples are far more likely to be born preterm. According to a 2009 report released by the National Center for Health Statistics, the preterm birth rate rose 36 percent between the early 1980s and 2006. The report also points out that the twin birth rate climbed 70 percent from 1980 to 2004, while the triplet-or-more rate soared 400 percent during the 1980s and 1990s. There has been a slight downtick in higher-order multiple rates lately—and the twins rate seems to have stabilized—but they remain much higher than in the pre-fertility-treatment era. Referring to the "high risk of adverse outcomes for multiple births," the report points out that "one out of every 8 twins, and one of every 3 triplets are born very preterm," compared with fewer than two of every 100 singletons, and that "death during infancy is much more common" among twins and triplets than among singletons. Prematurity is also associated with lifelong handicaps such as cerebral palsy, lung damage, and learning disabilities.
Just when we were on solid ground, with reliable science, good prenatal care, and better-informed mothers, we had to ratchet it up a notch. It's possible that we were lulled into complacency by the fact that a safe delivery—of a singleton, that is—has become routine. After all, we think, women have been delivering babies forever. How hard could it be? This time it's babies, even more than mothers, who are paying the price. Perhaps Epstein's book will help recall us to our senses by reviving the ancient memory of risk.