Friday, July 13, 2012

A history of hospital birth

On its website, Midwifery Today features a timeline entitle The History of Midwifery and Childbirth In America. The timeline extends from 1660 to the late 1990's. It contains interesting tidbits of information about childbirth practices, interspersed with general historical events. It seems quite comprehensive with the exception of one curious omission. It barely mentions mortality statistcs.

To my mind, the history of childbirth is a continuing effort to master its inherent dangers. Childbirth is and has always been, in every time, place and culture, one of the leading causes of death of young women and the leading cause of death of newborns. Indeed, the primary purpose of a childbirth attendant is to increase the chance that the mother will live, at least, and hopefully the baby will live too.

The secondary purpose of a childbirth attendant is to comfort the mother as she endures the excruciating pain of labor. The history of childbirth has also been a continuing effort to master the pain of childbirth. That's another curious omission from the Midwifery Timeline. It makes no mention of chloroform, general anesthesia or epidurals, arguably among the most important advances in the history of childbirth.

I suspect that the reason for these glaring omissions reflects the direct entry midwifery obsession with process. The outcome, whether or not the mother or baby lived, is virtually irrelevant.

Perhaps another reason why the timeline is silent on the issue of mortality statistics is that they illustrate the spectacular success of modern American obstetrics. For hundreds of years midwives presided over childbirth and had almost no impact on the appalling rates of maternal and neonatal mortality. It was only with the advent of modern obstetrics that the mortality rates began to fall.

I thought it might be interesting to look at the statistics that the Midwifery Today timeline left out. I took as the starting point the timeline itself. It faithfully chronicles the movement of birth from the home to the hospital starting in 1900. In every decade, it reports the ever increasing percentage of hospital births. Yet it is silent on massive declines in maternal and infant mortality that occurred simultaneously. For each point in the timeline where the percentage of hospital deliveries is mentioned, I looked up the corresponding maternal and neonatal mortality rates. The above graph is the result.

As the percentage of births in the hospital rose, the maternal and neonatal mortality plunged. The graph is a powerful way of demonstrating that the association is dramatic. During the 1900's, for the first time in history, using the tools of modern obstetrics, the terrible inherent dangers of childbirth were mastered. Could we do even better? No doubt, and the search continues to make birth even safer than it is today. As Dr. Atul Gawande wrote in his New Yorker article (The Score, How childbirth went industrial), "Nothing else in medicine has saved lives on the scale that obstetrics has." The graph makes that very clear indeed.

Infant and maternal mortality rates abstracted from CDC on Infant and Maternal Mortality in the United States: 1900-1999. Although neonatal mortality is a much better measure of obstetric practice, neonatal mortality figures were not collected in the earlier part of the century. Therefore, infant mortality statistics are used as a proxy, albeit imperfect.

This piece first appeared on The Skeptical OB in December 2009.

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