The Never-Ending Battle Between Doctors and Midwives. Which Are More Dangerous?

Why we live so long.
Sept. 10 2013 5:15 AM

The Disturbing, Shameful History of Childbirth Deaths

If you are pregnant, do not read this story.

(Continued from Page 1)

The best source of historic information on this subject is a book called Death in Childbirth: An International Study of Maternal Care and Maternal Mortality 1800-1950, by Irvine Loudon. (If you are pregnant, whatever you do, do not read this book.) It’s a very serious work, rich in data and graphs and analysis, but you can tell he’s furious about all the unnecessary deaths at the beginning of the 20th century. Here’s how he described puerperal fever: “A woman could be delivered on Monday, happy and well with her newborn baby on Tuesday, feverish and ill by Wednesday evening, delirious and in agony with peritonitis on Thursday, and dead on Friday or Saturday.” During the 1920s in the United States, half of maternal deaths were caused by puerperal fever. For a disease that was “preventable by ordinary intelligence and careful training,” he wrote, “these figures were a reproach to civilized nations.”

One piece of evidence Loudon uses to attribute blame for unnecessary early 20th century deaths to doctors is that rich women were more likely to die in childbirth than poor women. (Mary Wollstonecraft was one victim of an incompetent doctor; she died of puerperal fever after delivering a daughter who would grow up to write Frankenstein.) For almost any other cause of death, the poor were more likely to die than the rich. But for childbirth, poor women could afford only midwives. Rich women could afford doctors. Doctors in turn had to justify their fees and distinguish themselves from lowly midwives by providing new tools and techniques.

130906_TL_MaternalMortalityChart

Things got worse as obstetricians started professionalizing and coming up with new ways to treat—and often inadvertently kill—their patients. Forceps, episiotomies, anesthesia, and deep sedation were overused. Cesarean sections became more common and did occasionally save women who would have died of obstructed labor, but often the mother died of blood loss or infection. (Fun fact: Julius Caesar wasn’t born of a C-section. As Hutter Epstein points out in Get Me Out, until recently the technique was used to extract a baby from a dying woman. “Cesarean sections were death rituals, not lifesaving procedures. If a doctor suggested a cesarean, you knew you were on the way to the morgue.”) Women giving birth in hospitals were at greater risk than those delivering at home. Disease and infections spread more readily in hospitals, and doctors were all too eager to use surgical equipment.

Doctors perform a caesarean section, circa 1650. Woodcut from the works of 17th Century surgeon Johann Schultes.
Doctors perform a C-section circa 1650. Woodcut from the works of 17th-century surgeon Johann Schultes.

Photo by Hulton Archive/Getty Images

Too many doctors and midwives were chasing after a limited number of pregnant women, and they gained market share by touting dazzling new techniques and bad-mouthing their competitors. Exacerbating the problem, there was little government oversight of medical care or education in the early part of the 20th century. As Loudon explains, “Medical care in the United States was dominated by the belief in the virtues of competitive free enterprise combined with an intense distrust of government interference.”

“If I was forced to identify one factor above all others as the determinant of high maternal mortality in the USA,” Loudon wrote in Death in Childbirth, “I would unhesitatingly choose the standard of obstetric training in the medical schools.” They instilled an attitude of carelessness, impatience, and unnecessary interference. These deaths were “a blot for which the leaders of the medical profession are wholly to blame.”

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Death rates in childbirth finally began to drop in the 1930s with the introduction of sulfa antibiotics that were highly effective against the streptococcal bacteria responsible for most cases of puerperal fever.

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

As nutrition improved, there were fewer women with rickets, which causes bone deformations; many obstructed births in the late 19th and early 20th centuries were caused by abnormal pelvic bones in the mother. Prenatal care became a standard part of medical practice.

Reliable, safe, and legal birth control allowed women to limit and time their pregnancies, and it led to a decrease in illegal abortions, a leading cause of death in pregnant women historically.

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

* * *

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

Midwife wrapping her kit to go on a call in Greene County, Georgia, Oct 1941.
A midwife wraps her kit to go on a call in Greene County, Ga., in October 1941.

Courtesy of U.S. Farm Security Administration/Office of War Information/Library of Congress

The main battlefield today is over home births. About 1 percent of women in the United States choose to give birth at home. Counterintuitive as it may sound at first, they often cite safety concerns—they’re worried about unnecessary procedures if they give birth in a hospital. And they “trust their bodies’ inherent ability to give birth without interference.” Melissa Cheyney is an anthropologist at Oregon State University as well as a home-birth advocate and midwife. She reports that women who choose home birth “value alternative and more embodied or intuitive ways of knowing.” Home-birth advocates say women are better off giving birth in a comfortable environment, letting nature take its course.

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

A meta-analysis of outcomes from home births and hospital births shows that women who give birth at home do have fewer procedures and complications—but their newborns are three times more likely to die. The American College of Obstetricians and Gynecologists advises that hospitals and birthing centers are the safest places to give birth, and they have published guidelines for how to talk pregnant women out of a home birth. Many states are considering or tightening restrictions on midwives and home births, including Idaho, North Carolina, South Carolina, and Indiana, often in response to heartbreaking and infuriating cases of women or infants dying due to incompetent treatment.

But it turns out home birth isn’t as clearly dangerous as I expected. The Cochrane Collaboration, a highly respected organization that carefully judges medical treatments, analyzed the available evidence—which is admittedly a bit of a mess. (Among other problems, if a home birth delivery goes wrong, the woman has to be rushed to the hospital, where the complicated case may be recorded as a hospital birth rather than a home birth.) But the Cochrane Collaboration concluded that planned home births with low-risk mothers are as safe as hospital births. Once more for emphasis, though: This is only for women who have an extremely low chance of complications and who have access to emergency medical treatment if anything goes wrong. It’s tricky to compare outcomes across countries—especially because licensing and training regulations differ—but a Canadian study showed that home births were safe. (In the United States there are two main types of midwives: registered nurses who specialize in midwifery and are highly medically trained, and certified professional midwives, whose training may be, ah, less medically rigorous.)

The conflict between doctors and midwives puts pregnant women in the middle and can be uncomfortable and dangerous in itself. And it turns both sides into caricatures of themselves. Doctors focus on risks and complications; midwives focus on a pregnant woman’s comfort. Midwives talk about intuition and say pregnancy is the most natural thing in the world. They accuse doctors of lacking empathy—which isn’t surprising since medical students get a lot of empathy squeezed out of them during their training. 

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

Read the rest of Laura Helmuth's series on longevity.

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