The Rise of Childbirth Interventions
Prior to 1750, childbirth was viewed as a natural life event and was attended by midwives, who let birth take its course and intervened when necessary. However, that image of birth changed, for five main reasons, and interventions during childbirth began to rise.
The first reason childbirth became viewed less as a natural process was the role of the doctor was viewed. As doctors received more and more training, many felt that a doctor was there to “do something” and not simply be a spectator. Having a doctor’s care was seen by much of society as having “the best” care. Doctors also shared the idea that they must perform. Doctors often used interventions to hurry a labor, impress the family, or win approval or status for his work. Simultaneously, as doctors received more training, the amount they could do also increased. This was furthered by patients agreeing to the use of interventions. Therapies used were often not forced upon patients because patients were willing to endure sometimes horrific procedures in order to feel better.
Second, the attitude about birth also began to change. Instead of a normal life event, birth was perceived as a process that could go wrong, in other words, a potential disaster. Much of the system treated women as if they were diseased or had a pathology. Many at the time felt the primary purpose of doctors was to look for trouble in birth, and women often acceded to doctors’ control because they thought it would make birth safer for them and their babies.
The third reason that interventions began to rise was due to class issues. Middle- or upper-class women were thought to suffer more because of their tight clothing, rich diet, lack of exercise, and greater susceptibility to nervous strain. They were thought to have more difficult deliveries and some even believed that evolution made them have smaller pelves to begin with. Upper-class women also experienced perhaps excess interventions simply because they could afford them. In 1935, the National Health Survey found that cesareans occurred at 1.3% in relief families versus 3.7% among women with a family income of $2000 or more.a The percentage of hospitalized women undergoing episiotomy ranged from 25% among relief families to nearly 50% among women with family income over $2000.a
Poor women also saw an increase in interventions but for much different reasons. Instruments were used needlessly on poor patients, who were thought healthy enough to endure almost anything. In fact, poor women were often used for training purposes or experimentation. Other evidence supports interventions were sometimes used unjustly. As early as the 1890s, case reports in a Boston maternity hospital revealed that interventions were used and justified by moral judgments about the patients as too lazy or stupid to delivery by themselves
Various interventions began steadily rise in the United States after 1900, with a steep incline up leading up to the 1920s. For example, from 1910 to 1921, interventions in labors in one Boston maternity hospital increased from 29% to 45% of all deliveries. b By 1920, doctors believed that “normal” deliveries were so rare as to be virtually nonexistent. b In 1923, a Boston obstetrician said that birth is “subject to variations from the normal, which may be disastrous to the mother or baby, or both.”
One such procedure that took rise was the cesarean section. In 1794, the first successful cesarean in the US was performed on Elizabeth Bennett in West Virginia by her husband at their cabin. The procedure was crude and performed by Mr. Bennett because the doctor attending refused to do it on moral grounds. Nearly a hundred years later, in 1882, the cesarean section was revived by a German named Max Sanger and developed into a largely successful method to deliver women with deformed pelves. b Sanger had success in 80% of his operations. In 1894, the first cesarean section in Boston was performed upon a small women with a tiny pelvis who had previously lost two babies. Not far away, in 1913, the Director of Sloane Hospital in New York began to gain expertise in performing the cesarean section as well. b He even came up with the dicta “Once a cesarean, always a cesarean.” b
A popular intervention at the time was the use of ether and sometimes chloroform. Ether was gaining much buzz after being used for a tumor surgery during a public demonstration at Mass General Hospital in 1846. In 1848, Dr. Walter Channing first used ether for childbirth and encouraged other physicians to try it. By the 1850s, ether and chloroform begin regular use during labor and delivery.
Part of the stimulus for these uses was because not experiencing the pains of labor had great appeal among women, which led to another intervention known as Twilight Sleep in 1914.
Important documents of the time supported the rise of interventions as well. In 1920, Dr. Joseph DeLee of Chicago wrote The Prophylactic Forceps Operation, which became a benchmark for obstetrical practice. b He urged that outlet forceps and episiotomy be made routine in normal delivery. b DeLee believed that tearing the perineum would cause “permanent invalidism,” such as prolapsed uteri, vesico-vaginal fistulas, and sagging perineums. b He said episiotomy would restore “virginal conditions,” b and that forceps would prevent damage to the baby’s brain caused by contractions pushing the head against the perineum. b
He presented a lengthy list of possible injuries caused by “natural, spontaneous labor” and claimed that 4-5% of babies died from such damage. b Long, hard labors were often responsible, he said, for epilepsy, idiocy, imbecility, and cerebral palsy. b He even believed such procedures could save a child from a life of crime. By 1923, American obstetrical textbooks began to recommend that second stage labor be allowed to last no longer than two hours, and during the 1930s, DeLee’s procedures became normative in many hospitals, though this did vary by setting. Forceps were found to be used two to three times more frequently in hospital deliveries when compared to non-hospital deliveries.a
The media also reinforced the rise of interventions. In 1929, Harper’s called for more maternity beds and more respect for obstetricians because “childbearing is not a purely physiological process.” In 1930, Ladies Home Journal says that “motherhood is easier and safer due…to the modern hospital and great strides in obstetrics.”a
During this time, there was a growing movement for preventative care, as well. Around 1910, prenatal care became more meaningful, b and doctors realized women showing signs of eclampsia could be treated to prevent its development. b Blood pressure and urine screenings became more standard. b The Wassermann test was also developed and used to detect maternal syphilis. b In 1918, Maternity Center Association of New York was founded to provide more complete maternity care.b
All in all, the rise of interventions brought some progress and some setbacks, particularly when interventions were used needlessly or differentially for unethical reasons. At this critical time in the turn of the century, for better or for worse, women’s health was gaining growing attention.
a. Thomasson MA, Treber J. From Home to Hospital: The Evolution of Childbirth in the United States, 1927-1940 [Internet]. National Bureau of Economic Research; 2004 Nov [cited 2016 Mar 15]. Report No.: 10873. Available from: http://www.nber.org/papers/w10873
b. Wertz RW, Wertz DC. Lying-In: A History of Childbirth in America, Expanded Edition. New Haven: Yale University Press; 1989. 302 p.
c. 09 JMGSN, 2014. Tragedies to transplants, the history of Longwood – The Boston Globe [Internet]. BostonGlobe.com. [cited 2016 Mar 15]. Available from: https://www.bostonglobe.com/lifestyle/health-wellness/2014/11/09/tragedies-transplants-history-longwood/5I7WEMXXIcxUx2BbvaoVAN/story.html
d. Brigham and Women’s Hospital: Integrated Residency Program in Obstetrics and Gynecology [Internet]. [cited 2016 Mar 15]. Available from: http://www.partnersobgynres.org/aff-bwh.asp
e. Long T. Jan. 14, 1794: First Successful Cesarean in U.S. [Internet]. WIRED. 2011 [cited 2016 Mar 16]. Available from: http://www.wired.com/2011/01/0114caesarean-first-us/