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 18^th 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 20^th 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.