A Short History of How Obstetricians Replaced Midwives

A midwife measures the height of the mother's fundus at about 26 weeks to determine the probable gestational age of the fetus Author:eyeliam (licensed under the Creative Commons At tribution 2.0 Generic license)

Why do women give birth lying on their back?

Sounds like some sort of a stupid riddle, right? We all know that (at least in movies and most hospitals) women always give birth on their back (while screaming their lungs out and cursing the guy whose sperm led to the unfortunate event). The actual answer might surprise some of you. In most medical institutions women give birth on their back because it’s the position which is most comfortable for the attending doctor! A women lying on her back with her legs in stirrups gives the doctor an easy access to where the action is. Significantly, the majority of doctors examining the birthing woman will have gained all their knowledge about birth from books and hospitals and may have absolutely no idea that this position can be the most painful and inappropriate for birth (gravity, anyone?).

Currently, the average American obstetrician is male (in 2001 only 38% of obstetricians were female), has only seen medicated childbirth, and firmly believes that birth is a life-threatening condition and not a natural process. Ahem …they’re wrong! For comparison’s sake: according to The National Geographic, the lifetime risk of dying of heart disease is 1 in 5, cancer is 1 in 7, in a motor vehicle it’s 1 in 84 and due to a fall is 1 in 214! Pregnancy is far behind all these. The lifetime risk of a woman dying from childbirth  is 1 in 3,750 in North America! (That calculation includes dying of complications during pregnancy, birth, or abortion, not just birth itself.) You don’t need to be a math whiz to see that’s pretty slim. What’s more, it’s even lower in Europe, e.g. in Sweden (1 in 11,400 according to the UN) and the Netherlands (1 in 7,100 according to the UN).

You might say, though, that the risk is so low because we have doctors on hand to deal with all the possible complications (and there are oh so many complications – I mean there must be if 1 in 3 births is currently through cesarean section, right?).  Wrong. Wrong. Wrong.  The World Health Organization recommends that the caesarean section rate should not be higher than 10% to 15%. Obstetricians don’t necessarily minimize the risk of complications during birth (and they may in fact raise it) and the current C-section rate has more to do with politics, misogyny, and money than women’s bodies. Which is really, really sad if you think about it – women and their (growing) families are no longer at the centre of the birthing process. And one of the main reasons for this is that the people who now manage births are doctors.

Doctors mostly deal with pathology – you go to a doctor when something is wrong and they treat it. That’s what they’re taught to do. What they aren’t taught is dealing with the healthy normal – which the vast majority of pregnancies and births are. Back in the day, midwives did that. Midwives who were nearly all women and simply helped other women give birth and learn how to best care for their child in its earliest days. Now we have (mostly male) obstetricians who make tons of money by convincing 30% of women their bodies are somehow inadequate and they need a C-section. (Disclaimer: I’m not saying all obstetricians are nasty, greedy people. They aren’t. I’m describing the problems of a system and not pointing fingers at any one group of medical professionals.)  Your “feminist issue” bells should be ringing loud and clear.

Personally, I find the story of midwifery losing ground and male obstetricians hogging birthing women ‘to themselves’ scary, sad, and ultimately a call to action. Here’s what happened (in the US at least – it’s a bit different in other places around the northern hemisphere).

Up until around the 18th century, midwives were the norm. Women gave birth in their homes accompanied by other women. Most girl-children had witnessed their mother or a female relative give birth and breastfeed, before they themselves were married. Birth (and breastfeeding) was normal! In fact, it was so normal that if Facebook existed back in those days, it sure wouldn’t be banning breastfeeding and placenta pictures as it does today. And yes, women died in childbirth –all too often. However, comparisons with today’s unassisted births in developing countries can suggest that the majority of deaths was infection and/or hemorrhage-related, and nothing that a well-trained and appropriately-equipped midwife couldn’t usually deal with today in a home birth setting. Hint: even if the birth is not without complications that doesn’t mean there’s need for an obstetrician! Obstetricians are essential, but the majority of birth complications can be dealt with by midwives.

In the half-century between 1770 and 1820, upper-class women in American cities started to favor “male midwives,” or physicians. According to Catherine Scholten in her book Childbearing in American Society: 1650-1850, “… the presence of male physicians in the lying-in room signalled a general change in attitudes toward childbirth. With changing conditions of urban life, new perceptions of women, and advancements in medical science, birth became increasingly viewed as a medical problem to be managed by physicians. At the same time, because medical training was restricted to men, women lost their positions as assistants at childbirth, and an event traditionally managed by a community of women became an experience shared primarily by a woman and her doctor.”

In the early days of obstetric care in the US, male obstetricians only assisted middle and upper-class women (they were somewhat of a luxury service). However, as medical sciences became increasingly legitimate, obstetrics started to be considered as more than just the pastime of a few doctors who dabble in birthing women’s vaginas.  At the start of the 20th century midwives attended nearly half of all births. However, a generation later only every tenth birth was conducted in the presence of a midwife.

The (all-male) medical establishment actively lobbied and campaigned against the (all-female) midwives. They were portrayed as dirty, illiterate, and ignorant, and women were made to think that by birthing in their presence they were endangering their own, as well as their child’s, lives. I’m sure you’ll be pleased to learn that scare tactics, fear-mongering, and guilt-tripping women into doing ‘the right thing for their child’ is no new invention. And so eventually, it came to pass (with a lot of help from the medical establishment) that after having assisted women for centuries, professional midwives nearly completely disappeared in the US. But the medical community wasn’t satisfied with leaving midwives without a job. Obstetricians actually managed to get midwifery de-legalized in most jurisdictions!

What came after wasn’t all nice and dandy. By the 1960s, medicalization of birth (including a number of largely unneeded and sometimes dangerous procedures such as induction, episiotomy, C-sections, and forceps deliveries) led to a situation in which women were made to believe they could never manage to give birth ‘on their own.’ In fact women no longer gave birth – now doctors delivered their babies. Women were forced to labor without the presence of or support from partners or family (who were only seen as a source of infections and nuisances for the doctor), infants were taken from the mother at delivery and cared for in newborn nurseries (because what could a lady who ‘just pushed out a watermelon out of her vajayjay’ do with a screaming infant), bottle-feeding became the norm (easier, and ‘healthier’), and babies born outside the sterile environment of the operating room were labelled contaminated and kept separately. The real kicker: there was no scientific evidence base for any of this! Moreover, it still continues to this day in many hospitals, although there now is scientific evidence to show all of these procedures are in fact harmful!

Things are looking up now – changes are happening in maternity wards around the US and midwives are on the rise (and legal) again. The profession of nurse-midwife is one that can officially be trained for and nurse-midwives have their own organization, the American College of Nurse-Midwives. And of course there’s Ina May Gaskin – hailed the most famous midwife in the world and the only women who has an obstetrical procedure named after her (go figure). Gaskin is a veritable legend, and a woman with an incredible life-story and amazing achievements. She’s even the author of a bestseller on birth and is well-worth reading up on in her own right, even if you’re not really interested in birth – this woman is an inspiration in achieving goals against all odds!

The story of midwifery in the US comes to a bit of a circle with Ina May – it started out pretty good, went through a pretty awful period (or century), and now Ms. Gaskin and her followers are leading it into a new and better era.

 

About Maria:
A recovering scientist, healthcare analyst and junkie of all things gender and women's health

Comments

  1. Thank you for this article! It’s a great kick off to Women’s History Month. Your article reminded me of the film The Business of Being Born (which we reviewed a while back: http://feministsforchoice.com/watch-list-the-business-of-being-born.htm). This is on Netflix, and it will definitely get you geared up to have a home birth.

    And speaking of Ina May Gaskin, folks might want to read the bio that Janice wrote about her a while back:
    http://feministsforchoice.com/feminist-for-choice-ina-may-gaskin.htm

    This is such an interesting topic, in my opinion!

  2. Amazing post, Marie! Love the humor you sprinkle in–sometimes I think that’s the only way to deal with such absurdity. (I’m a word person; I can’t believe I didn’t pick up on the “giving birth” to “delivery” shift.)

    Good to know that things are changing, however slowly. I like to believe that more docs are at least open to a more holistic view of health; and for goddess’ sake, I hope more women are becoming obstetricians! Just fascinating stuff.

    • Michelle says:

      In our obstetric department (I’m an RN and Lactation Consultant in a big urban teaching hospital) we only have 1 man in the program excluding Attendings. But let me tell you, it doesn’t really help. The female OBs are just as ignorant about natural birth and breastfeeding.

  3. Thanks for the positive feedback! I’m keeping my fingers crossed for midwives and considerate obstetricians (of both sexes) – we definitely need more of those (and not just in the US…).

  4. Great article Maria! You’ve summed up everything I get so passionate about, and what motivates me as a doula and birth advocate. Birth and motherhood are the forgotten areas of a woman’s life – a time that feminists have ignored along with the patriarchy. As a feminist, I’m so very happy to see this subject matter gaining ground amongst feminist thinkers.

    I’m very proud to have been a small part of your journey!

  5. Marlena says:

    How interesting that the 2 countries with the lowest mortality rate have the majority of their births attended to by midwives.

    • Mirline says:

      I was thinking the same thing!! The countries that have the lowest mortality rate do use more midwives for births. I thought Maria would make note of that… but alas! This was still pretty informative

  6. Sharon Dietrich says:

    Excellent article and a good historic review. Quite accurate, as I have done a lot of historic research on this and several aspects of health and medicine. However, I would say that I, as a a Family Physician, was not just trained to see folks when something was wrong and treat it. I was also trained to assist folks to be and remain healthy, and was trained that birth was largely a natural process which at times required intervention. YOu may find other Family Physicians who have had the same experiences.

  7. Hi, I’ve read your article with great interest. I just came across Francis Glisson, a male, English physician who wrote in 1650 ‘The treatise of the rickets being a disease common to the children’ (english version edited by Nicolas Culpeper) and how the cause of rickets may be related to an increase in obstetricians and forceps.
    Glisson stated that he had been studying rickets for five years and that it was an “…absolutely new disease, and never described by any ancient or modern writers in their practical books which are extant at this day of the diseases of children. But this disease became first known about 30 years since in the counties of Dorset and Somerset … since which time the observation of it hath been derived unto other places, as London ….”
    Interesting, if that was a ‘new disease’ then to put that in context of the U.K. now.
    Link to review of Glisson’s work: http://fn.bmj.com/content/78/2/F154.full
    Where rickets is blamed upon feeding habits in infants (excessive feeding – he notes that it is more common in children from rich families), as well as high alcohol consumption in mothers (I haven’t looked further into this). The quote at the end of the above article is interesting too:
    “The discovery of this new disease, rickets, in the middle of the 17th century was probably due to the increasing urbanisation taking place at the time, as well as to misguided practices in infant feeding. Within a very short time early obstetricians like Willughby in England and van Deventer in Holland were describing the problems of delivering infants through women’s rickety pelvises. Perhaps it was no coincidence that the Chamberlen family also introduced the forceps into their practice at this time and that in the 17th century man midwives increasingly invaded the previously jealously guarded female province of childbirth.”
    I haven’t even started to mention the amount of mercury that was given to females at this time as a ‘cure all’…..

  8. Thank you for the article. A subject dear to our hearts at The Florida School of Traditional Midwifery, Gainesville, FL . I would like to also mention that along with Certified Nurse Midwives we also have direct entry Certified Professional Midwives ( CPM) in the US. The national organization for direct entry midwives is The Midwives Alliance of North America / http://www.mana.org. Direct entry midwives specializes in low risk, normal healthy birth in the home or birth center setting. ( Ina May Gaskin is a CPM) Our school is one of 10 direct entry nationally accredited schools in the US. We have worked long and hard to develop our program and provide midwifery education to those seeking the direct entry route. Believe it or not but we still have several states in the US that consider the practice of direct entry midwifery illegal. So we continue with these issues but also celebrate the achievements we have made in the last 20 years. Anyone wanting more information on our program please visit our web site and/or give us a call.
    All the Best,
    Glenn Cameron
    Administrative Coordinator
    The Florida School of Traditional Midwifery
    http://www.midwiferyschool.org
    “Delivering the Future-One Midwife at a Time”

    • Thank you for your comments. My mistake for overlooking the direct entry Certified Professional Midwives ( CPM) – I apologize and thank you very much for adding that! I wish you the best of luck with your very important work!

  9. Though I can sympathize with the frustration in the article at the modern birthing process, which is really a part of the bigger hospital-insurance process in the US (which most young people only encounter with pregnancy), I am sad to see it so completely targeting doctors. I am an OB. I am female. It is no longer 2001 and we are no longer only 38% of the work force. I trained at one of the busiest hospitals in California and we had a 60% epidural rate for vaginal deliveries and a a10% primary cesarean rate. It is not fair to say that the average OB has never seen a non-medicated delivery or that we see pregnancy as a disease. The 1950s are over (though I am not arguing about the historic involvement of the “medical establishment” as described in it’s war on midwifery) and it is 2012, and most of us are trained to help women have healthy pregnancies and deliveries. And every hospital I have ever worked/trained at has heavily emphasized the importance of support in labor and infant bonding and breastfeeding in the immediate moments after birth.

    In private practice I have a 3% primary cesarean rate, I am not financially incentivized to talk 30% of women into subjecting their bodies to cesareans, and I think these kinds of one-sided tirades are unfair. I am not alone, I work with a lot of OBs that take the time and thought to ensure healthy vaginal deliveries for their patients whenever possible.

    I think there is a problem with our high cesarean rate. It is very much a result of the climate of malpractice suits and insurance reimbursements. This is a discussion that should be had.

    But I also think there is a problem when women are told that “men” have made deliveries medical, that women don’t need pain relief or at a hospital, and that the “real” way to have a baby is their way. It is a fact that most people do not see home births and it is a fact that most women in the US do not WANT to have their babies at home. The reasons for those desires are vast and have a lot to do with the modern lifestyle. I do not tell my patients they should have epidurals, they are educated about it’s effects and it’s safety and they are free to chose. I do resent people who tell them they should NOT have an epidural.

    Each woman has the right to her own, informed decisions. We as women and as feminists should be pushing for increased education of women and increased malpractice and health-insurance reform that fosters women’s rights to make the best choices for themselves.

    • Mirline says:

      I think if more doctors like you spoke out, there probably would not be such a one-sided view on obstetrics and the medicalization of birth. I am an aspiring midwife, but have heard of doctors, who like you, support the natural bonding process and breasfeeding. I also understand your resentment on the people who tell mothers not to use an epidural. As a potential midwife and feminist, I do firmly believe that women should be able to make educated decisions concerning their own birth experiences.

    • A giant THANK YOU, to you and your practice peers, for being a change-maker in the US medical care culture. We need more OBs like you who practice evidence-based care.

      I think the male versus female statements in regard to maternal care arise from the historically masculine influence upon women’s experiences with childbirth. When the majority of women are birthing under the influence of a paternalistic, anecdotal, and mythical care culture, it’s difficult for the individual woman not to lump all care providers into that culture category.

      As we move into a more complete realization of the physiology of birth, I believe that the gender overtones of women’s experiences are changing. Look at how the activism of the 60′s and 70′s brought fathers back to the birth room. In the 90′s when cesarean birth was on the rise, a movement of doulas and other birth activists brought it back down again. And in the present day there are also OBs (like you) who are doing what it takes to change their birth culture, even if it means leaving the out-moded aspects of the medical model in their communities (like Dr. Biter in CA and Dr. Calvin in MN) to start birth centers which support women in evidence-based, physiologic ways.

      Times: they is a-changin’.

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