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Thursday, May 22, 2014

Birth History: Death in Childbirth

In the days of our great-grandmothers and beyond, childbirth was often a dreaded, formidable time. Hospitals were usually avoided as places where only sick people went, usually never to return. The possibility of death while giving birth loomed over a woman as she came closer to her due date, overshadowing any joy of her upcoming arrival.

Among the greatest risks to a woman in childbirth were childbed fever, toxemia and postpartum hemorrhage; the last two of which are still a major cause of maternal deaths worldwide today.

Childbed fever, or puerperal fever, is an infection of the female reproductive organs and was one of the most common causes of death in childbirth prior to the early 20th century. It frequently took the mother's life within days of giving birth and was extremely painful. And it was almost entirely caused by the hygiene practices of the birth attendant - which included midwives and physicians.

It's important to make this distinction, because many times people tend to think of midwives of that time period as uneducated, inept, or practicing witchcraft in an unsanitary, ramshackle house. While there were some that did, there were many who were very capable, some even experiencing fewer deaths than their physician counterparts.

A Lysol ad from 1937, referencing
infection control both in hospital births
and those that take place at home. 
It is also worthy of noting that, unlike with neonatal mortality rates, maternal deaths were more likely to happen among women in higher socioeconomic classes: likely because they were more apt to go to hospitals to give birth or have the finances to pay for a private physician.

Dr. Ignaz Semmelweis is often credited with understanding how childbed fever was transmitted: he theorized, correctly, that midwives and physicians were spreading the streptococcus pyogenes bacteria through improper hand washing from patient to patient. He proposed that physicians wash their hands in a chlorine solution prior to delivering a child, an idea that offended fellow doctors. Despite his repeated attempts to educate healthcare workers on proper hygiene, they often ignored his requests and refused to believe they were, in fact, contributing to the problem - even as maternal deaths were decreasing among those who practiced Semmelweis' hand washing guidelines.

When he first introduced the protocols in a Vienna obstetrical clinic in 1847, the rate of childbed fever deaths in the doctors' wards was three times higher than that of the midwives' wards.

Decades before Semmelweis' work, physician Alexander Gordon made similar observations as early as 1790. His ideas were not well-received and he was essentially run out of practice. Later, physician Oliver Wendell Holmes came to the same conclusions, only to be equally rebuffed and ignored.

It literally took decades - roughly half a century - before physicians started admitting that perhaps they were indeed the cause of infection and deaths in so many women. And even then, it wasn't until around the 1930s when cases finally started to become scarce, due in part to better hygiene practices, more sanitary birthing conditions and the introduction of antibiotics and sulfa drugs. During Semmelweis' work in Austrian maternity wards, handwashing alone led to a dramatic lowering of maternal deaths.

It was 1925 when my great-grandmother delivered her last babies, a set of twins, at home. The doctor was called in - who I later discovered had questionable hygiene practices. Even then, after much was known about controlling the spread of infection, obviously some continued to disregard it. In my opinion, it's not enough to say "Women died in childbirth before modern obstetrics. You should be thankful your physician does X, Y, Z to make sure you and your baby is safe." Most of us know that maternal deaths were far more common, but do we understand why? One birth blogger who spent an unusual amount of time criticizing the natural birth movement wrote about 'those headstones in a graveyard of all those mothers and infants who had died because of natural childbirth.' (Paraphrasing a bit here, as it's been a few years ago since I read that. But still, that was the gist of the message.) One thing I have noticed: when discussing maternal deaths, many sources will completely gloss over the cause, as if it was just an unfortunate problem that happened for no reason.

Puerperal fever is still a risk of childbirth today, but in many cases we have different names for it. Although rare, it does still claim the lives of women. No longer known as 'childbed fever,' it is not unusual for women to develop fevers during labor, which are usually treated with imminent delivery, cesarean section (which alone can increase risk of infection) and antibiotics at the first sign of a problem. Chorioamnionitis, an inflammation of the fetal membranes, is caused by a bacterial infection that tends to occur in longer labors. Among the risk factors are repeated vaginal exams and internal fetal monitoring.

It is true that in many ways, modern obstetrics has saved countless lives of both mothers and babies. But you have to have some perspective on the reasons why many women died -  reasons that were primarily iatrogenic in nature - death brought about by the very people who were supposed to save them.

Childbirth in Early America - Digital History
British maternal mortality in the 19th and 20th centuries - National Center for Biotechnology Information
The Attempt to Understand Puerperal Fever in the Eighteenth and Early Nineteenth Centuries: The Influence of Inflammation Theory: National Center for Biotechnology Information

Saturday, May 17, 2014

Birth History: A Dysfunctional Culture

May is Pregnancy Awareness Month, and while I've covered some of these topics before, I've been planning to put them together in more of a series for quite some time now. There is so much to learn while pregnant, and it can get quite overwhelming when you're faced with decisions that range from the mundane to the life-changing. So much of how our medical community views pregnancy, however, is still deeply rooted in old traditions and practices, some of which were, and continue to be, groundbreaking in the field of obstetrics. Some, on the other hand, not so much.

I once heard someone say how hard can it be? You go to the hospital and push out a baby. If only it were that easy. And if you go behind the scenes much, it's probably never been that easy, for reasons that are often not clear to us until we experience childbirth ourselves. Even then, without some historical perspective, we may not realize just how dysfunctional maternity care in this country still remains, probably a century later.

Many maternity care practices were nothing short of barbaric and humiliating, yet were seen as standard practice and therefore somehow acceptable. Whether it's having your hands tied down in labor, being given pain medication that you feel you don't want or need (as we see in Peggy Vincent's Baby Catcher) or given prophylactic episiotomies and forceps births (we'll get to that later), it's all been considered status quo in "modern" obstetrics. And yet, as we see with new guidelines on episiotomy, VBAC and other protocols, it can be painfully slow to implement these changes.

You can't begin to understand the 'typical' mindset towards birth today unless you understand its history. It is a bright spot in some places, in others very dark and tarnished.

You might want to read:

Birth: The Surprising History of How We Are Born