Thursday, May 18, 2006

Were ancient midwives the obstetricians of their time?

There is ongoing research about the evolution of human childbirth. One of the remarkable things that researchers have noted is that human beings are the only animals that have assistants at deliveries. All other animals can deliver their own babies, deliver the placenta, and care for their newborns by themselves. Research has concentrated on determining what factors about human labor and delivery might have made human delivery more difficult than animal delivery and there are a variety of candidates including the large size of the infant skull, the need to keep the female pelvis relatively narrow in order to support walking and the complete helplessness of human babies.

Regardless of the ultimate reasons, these investigations raise an important question. Did midwifery arise because ancient midwives developed techniques to "manage" delivery and thereby decrease maternal and neonatal death? They must have been doing something extremely important, because midwives or specialized birth assistants spread to every culture.

Were ancient midwives the obstetricians of their time? Were they women with "advanced training" (in the form of apprenticeships and oral transmission of previously accumulated knowledge) who took childbirth from being "natural" to being midwife managed and therefore safer? If they were able to talk to us today, would they be shocked at the nature of homebirth midwifery with its focus on shunning technology? Would they instead be rushing off to hospitals to marvel over the latest equipment and techniques, and expressing regret that the technology they had at their disposal was so primative?

Homebirth midwives often assume that they are the heirs of ancient midwives. Isn't it equally possible that obstetricians are actually the true heirs of ancient midwives, women who applied whatever technology they could learn or devise to prevent maternal and neonatal death?

Labels:

45 Old Comments:

not true about all animals- animals have assistance elephants in particular

the human animal does deliver her baby and can deliver her placenta. but I imagine you have never and will never see that.

By Anonymous Anonymous, at 9:53 AM  

Anonymous:

"the human animal does deliver her baby and can deliver her placenta.

I know that it is possible, but all cultures encourage the use of assistants and have specialized assistants that are trained for the purpose. This suggests that ancient midwifery reduced death rates and was therefore adopted everywhere.

By Blogger Amy Tuteur, MD, at 10:00 AM  

and yet there is a separate profession called doctor in those places as well-- when the going got rough time to get a different type of expert--

By Anonymous Anonymous, at 10:14 AM  

This comment has been removed by a blog administrator.

By Blogger Mama Liberty, at 10:37 AM  

Human beings are social creatures. All of our major life events involve ritual, family and community. Birth is the first major life event.

By Blogger Mama Liberty, at 10:39 AM  

"Isn't it equally possible that obstetricians are actually the true heirs of ancient midwives"

Absolutely not. Obstetricians didn't inherit anything. They engaged in a systematic campaign to wipe out midwifery.

By Blogger Mama Liberty, at 11:05 AM  

Mama Liberty:

"Absolutely not. Obstetricians didn't inherit anything."

I think you are missing my point.

I am asking if ancient midwives were the technological innovators of their time. There is an assumption by contemporary midwives that they ran around looking for "natural" ways to do things when actually they may have been swearing under their collective breaths and wishing they could figure out how to make forceps that would work.

Think about it. Ancient people did not look at the ocean and say, well since we don't have fins, it would be unnatural for us to get in the water. No, they looked at the ocean and built boats.

While contemporary midwives may venerate midwifery of the age before medicine, those midwives might have been frustrated with what they had and been willing to happily exchange it for more advanced technology.

By Blogger Amy Tuteur, MD, at 11:59 AM  

so midwives did the first cesarean ? I am pretty sure not. But I do agree that ob should be a sub-speciality of midwifery--

By Anonymous Anonymous, at 12:43 PM  

Thanks for that little twist on things Amy, gave me quite a chuckle.

I think the first 'midwives' would be pretty shocked at the lack of knowledge of any modern caregiver.

By Anonymous Anonymous, at 12:48 PM  

I think the elephant info is telling -- Elephants also have reasonably rich language and live long enough to pass on information across generations.

I very much doubt the USA unassisted childbirth infant survival rate is lower than wolf puppy survival rates, or (pick any animal you wish). If so, your statement "One of the remarkable things that researchers have noted is that human beings are the only animals that have assistants at deliveries. All other animals can deliver their own babies, deliver the placenta, and care for their newborns by themselves" implies that humans can do the same thing (since our outcomes are at least as good).

"I know that it is possible, but all cultures encourage the use of assistants and have specialized assistants that are trained for the purpose." Amy, can you cite something here? I'm not sure having Grandma (or Auntie or Mom), who's had 12 kids and been to 40 other births, come around when you are birthing counts as a specialized assistant, and I'm under the impression that that was more the situation in most cultures until pretty recently.

Having an experienced woman on hand is definitely handy if you have a real shoulder distocia or massive bleed, for sure.

MM, Georgia

By Anonymous Anonymous, at 1:24 PM  

Elephants were the first thing that came to my mind when I read the original post. :-) Elephants know things...pay attention...

Anyway...

I think the average, healthy human woman at any point in history or pre-history has always been physically capable of birthing her own babies, placenta and all, and cleaning up and beginning to feed them, and so on. I agree that our nature and our humanity make us want to comfort one another in times of pain and stress, and that we feel less vulnerable when we're not alone during times of great pain and stress.

I think the first 'midwives' would be pretty shocked at the lack of knowledge of any modern caregiver.

But how far back are we going? Our ancestors of merely a century or two ago, or our earliest ancestors who would have been quite primitive indeed. If anyone is well-versed in anthropological study or can reference studies done on primitive peoples discovered only during the past century or so, that would be pretty interesting to see.

'Ancient' midwives may have been little more than female witch-doctors, and probably would no doubt think many of our modern advances are amazing magic or juju or whatever. A modern obstetrician landing amidst a primitive culture located on some unmapped island somewhere would probably find himself or herself the center of a cargo cult...;-) Good fun!! Until you run out of the magic juju. Then you're dinner.

By Anonymous Anonymous, at 2:24 PM  

no I think that you are missing the point- your profession- in America deliberately got rid of the competition(midwives) even though they were more competent - and had lower death rates- who knows what has been lost as far as skills -if the black granny midwives had been allowed to continue and were supported and they had some freedom to "pick and choose" or even design their own solutions to problems - who knows if black neonatal and infant mortality stats would be as poor as they are now.

By Anonymous Anonymous, at 3:24 PM  

Anonymous:

"so midwives did the first cesarean?"

No, but as they watched women die in agony before their eyes, I bet they wished they could.

Do you know how long it takes to die if you cannot deliver a baby because of CPD or malposition? Historically, it took about three days of obstructed labor before a women lapsed into a coma and died. The baby had usually died a day or so before.

Certainly not something to be cavalier about, is it?

By Blogger Amy Tuteur, MD, at 3:32 PM  

an interesting read for you might be -
Of Wolves and Men.

imperialism and cultural arrogance has limited ability to learn or even find out how others know things
things like anatomy- because of cultural taboos dead bodies had to be robbed from graves in order for a physician to learn anything but take time back further and before the burning of Alexandria there were all sorts of information including anatomy- do you think that the Egyptians were as culturally naive about anatomy as more modern "civilized" people?
If the Romans and any number of ancient people knew to not drink where they dumped waste- why did it take so long to figure it out again in modern times?

By Anonymous Anonymous, at 3:34 PM  

Yes, three days is how long it took Princess Charlotte, daughter (or daughter in law?) to Queen Victoria..in a hot London summer, with the baby stuck halfway out. [Shudder]

By Anonymous Joanna, at 4:37 PM  

Actually, I can't find a reference for it so please disregard my last post.

By Anonymous JOanna, at 5:03 PM  

Joanna:

You apologized too soon. Your story was basically correct.

From Medscape (you need a subscription to access it):

Perhaps one of the most famous accounts of obstructed labor is the case of Princess Charlotte of England. In 1817, Princess Charlotte, daughter of George IV, was the only eligible heir to the British throne in her generation. Her grandfather, George III, had 7 sons and 5 daughters, but Charlotte was the only legitimate grandchild. Thus, when the newspapers announced her pregnancy in early July 1817, the entire country was closely following this most important event in British history. On November 3, 1817, 42 weeks after her last menstrual period, Princess Charlotte went into labor. Fifty hours later -- after 24 hours of being in the second stage of labor and 6 hours of perineal pressure -- Charlotte delivered a 9-pound stillborn. Five and one half hours after delivery, the Princess died, presumably from hypovolemic shock after a postpartum hemorrhage from uterine atony, likely a direct result of her obstructed labor. Three months later, Sir Richard Crofts, Princess Charlotte's obstetrician, committed suicide, unable to bear the burden of responsibility for the death of the heir.

By Blogger Amy Tuteur, MD, at 5:20 PM  

Nine pounds, probably huge for the time and women were smaller then (or were royalty as large as we are today from good living conditions?). Continuing to stray from topic, does anyone know what average birth weights were in the day?

MM

By Anonymous Anonymous, at 5:49 PM  

Well, I had the name and certain facts right, but not the relationship, or the season...My memory of English history (obviously somewhat rusty) is that forceps were in fairly widespread use at this time. I wonder why they weren't used, or not used successfully?

By Anonymous Joanna, at 6:46 PM  

Okay, Joanna here, reference in hand. Don't have statistics for birth weight, but a few interesting tidbits from the wonderful "Inside the Victorian Home: a Portrait of Domestic Life in Victorian England," by the historian Judith Flanders.

From 1847 to 1876, 5 women per 1,000 births died, approx 1/3 - 1/2 from puerperal fever (which the drs could not cure: opium, champagne and brandy were given to ease the passing)

It was in the 1860s that bottlefeeding began to be recommended and a public distaste expressed by arbiters of medicine, style, etc. for breastfeeding was commonplace

By Anonymous Joanna, at 7:02 PM  

Okay, one more Princess Charlotte post, and I am done. I read an article published in the 1950s by an E Holland, who obtained some papers of Dr. Croft, the princess's obstetrician. Included were notes regarding the labor. The first stage was 26 hours; the second, 24 hours. 15 hours into the second stage, the baby passed meconium. At no point were "instruments," though present, used. As we know, the baby was stillborn and the princess died, probably of postpartum hemorrhage (she had 4 in the third stage.)

Dr. Holland's analysis was interesting. He felt that Croft was practicing under the principles of midwifery at the time. Holland characterizes this time as "forceps began to be used too freely, often
by unskilful men, and much damage
resulted. This period of abuse reached
into the time of William Hunter (who died
in 1783), Osborne and Denman, all of
London, with the result that they reactedindeed
over-reacted-strongly, and an
ultraconservative phase of midwifery
practice began.
This retrograde phase in the evolution of
obstetrics will be found discussed in the
Transactions of the Obstetrical Society of
London for 1879, when Robert Barnes
opened a discussion which spread over
three meetings. As Barnes well said:
These illustrious men thought it right to
exert all their authority in discouraging the
use of instruments, and in inculcating
blind faith in nature as the better way.
So earnest was their zeal, so commanding
their authority, that men were driven
into the opposite extreme of supine
inaction . . . Rules were laid down, and
widely obeyed, which too often allowed
parturient women to drift into danger,
injury and death.”

Hmm. Sounds like an argument that has been going on here. I am not saying that Princess Charlotte and her baby's deaths so long ago prove anything one way or another; jsut interesting that this argument has been going on for a long time, and that at least at one point obstetricians really believed in a hands off sort of philosophy.

All right, no more princess, I promise.

If anyone is interested in this article, I saved a copy and if you let me know I can email it to you. I can be reached at soulfulcville at adelphia dot net.

I found this interesting as it seems obstetricians

By Anonymous Joanna, at 10:08 PM  

"From 1847 to 1876, 5 women per 1,000 births died, approx 1/3 - 1/2 from puerperal fever (which the drs could not cure: opium, champagne and brandy were given to ease the passing)"
these were great stats for the time period

in the US the doctors (the midwives had better stats) did not have this low of maternal mortality even in 1932-- did the OBs try to get rid of midwives completely at any time?

By Anonymous Anonymous, at 1:14 AM  

Anonymous:

"in the US the doctors (the midwives had better stats) did not have this low of maternal mortality even in 1932-- did the OBs try to get rid of midwives completely at any time?"

First of all, this figure comes from a history book, not a medical text book. Second it is simply a guess. As you might imagine, no one was keeping detailed statistics at the time.

There is no doubt that doctors of the time considered midwives direct competition. For as long as the doctors insisted on relying on their intuitions as opposed to relying on research, the competition was pretty even. At the time Princess Charlotte died, doctors were still bleeding patients, to "balance their humors".

Once the doctors adopted the scientific method, the competition was over and the doctors won. That's because the neonatal and maternal death rates dropped so dramatically that it was obvious to everyone that doctors were more likely to save your life and the life of your baby than midwives were.

The victory of doctors has been so complete, that the very terms of the debate have been changed. Even homebirth midwives tout the fact that they copy doctors in the majority of medical details.

By Blogger Amy Tuteur, MD, at 7:02 AM  

"Once the doctors adopted the scientific method, the competition was over and the doctors won. That's because the neonatal and maternal death rates dropped so dramatically that it was obvious to everyone that doctors were more likely to save your life and the life of your baby than midwives were."

When exactly DID doctors adopt scientific method, Amy? I know from my grandmothers that quite barbaric things were still being done to women in the '50s. I know from my mother that barbaric things were still being done in the '70s.

Since when is a medical textbook a better source of history than a history textbook??? The reason women started having babies in large numbers in hospitals is twofold. #1 Doctors were able to eliminate large numbers of midwives through an effective "marketing" campaign. #2 Women wanted to do what they perceived was the "modern" thing. They started having babies in hospitals for the same reason they started feeding their babies formula.

Don't ask my for references. You can do some searches yourself. Go onto Google Scholar and put in "midwife elimination", "midwife history", "obstetrics history" or other such phrases. You will have to consult the work of scholars in other disciplines... history, sociology, anthropology. You might also want to take a trip to a university library.

By Blogger Mama Liberty, at 8:29 AM  

One more thing... because I can hear your retort now. Yes, a medical textbook of the time would be a source, but it wouldn't give you the complete picture. You wouldn't know anything about the practice of midwives from an obstetrical medical text.

By Blogger Mama Liberty, at 8:57 AM  

Mama Liberty:

"Yes, a medical textbook of the time would be a source, but it wouldn't give you the complete picture."

You missed the main point. The historical numbers are only a guess. No one collected accurate statistics at the time.

"The reason women started having babies in large numbers in hospitals is twofold. #1 Doctors were able to eliminate large numbers of midwives through an effective "marketing" campaign. #2 Women wanted to do what they perceived was the "modern" thing."

Let me see if I understand you. American women were not smart enough to understand that hospital obstetrics dramatically improved infant and maternal survival? They had to be bamboozled by doctors in order to get them into the hospital?

I think you underestimate their intelligence. Even if that were the case, though, it would be a fortunate coincidence since from that day to this, hospital birth has always been safer.

By Blogger Amy Tuteur, MD, at 9:25 AM  

Well, except for all those unfortunate mothers who died (5 women per 1,000 births) from that pesky puerperal fever. It took doctors a LOooooong time to come around to the evidence there. In fact, it seems to take doctors a LOoooong time to come around to most evidence when it interferes with thier beloved traditions.

By Anonymous Anonymous, at 10:22 AM  

I think you underestimate their intelligence. Even if that were the case, though, it would be a fortunate coincidence since from that day to this, hospital birth has always been safer.

In my family it has less to do with intelligence than it does status. My dad, a double master degree recipient, was the first of his family to be born in a hospital (in the '40s) and when he learned that I would give birth at home he declared his own father to be rolling in the grave at the suggestion I was pulling the family back into the steel town ghettos he worked so hard to leave. I have heard the story dozens of times from my extended family and never once have I heard how dear grandpap believed in hospital safety, but as soon as he could afford it he wanted to buy his wife a room at the hospital rather than have her giving birth at home among the riff raff of their lower class society.

I suspect this story can be repeated many times over across the United States during the same period.

By Anonymous Anonymous, at 10:31 AM  

"Let me see if I understand you. American women were not smart enough to understand that hospital obstetrics dramatically improved infant and maternal survival? They had to be bamboozled by doctors in order to get them into the hospital?"

I don't know why they were bamboozled in the United States but they were-
hospitals and doctors were killing women- and their babies you look at the statistics - directly from the health departments of the day- physicians had terrible stats- and even if that number was a estimate was it off how far off do you think it was? In the US maternal mortality ( the stats for 1915 was from just 10 states by 1929 46 states were reporting)
1915-6.1/1000; 1916-6.2/1,000; 1917-6.6/1000; 1918 - 9.2/1000 (year of the flu);
1919-7.4/1000 ; 1920-8/1000; 1921-6.8/1000;1922-6.6/1000; 1923-6.7/1000; 1924-6.5/1000;
1925-6.5/1000; 1926- 6.6/1000; 1927-6.5/1000;
1928-6.9/1000; 1929-7/1000--
I sent previously the bit on the difference in black maternal mortality and midwife-vs-physician being the physician/hospital births having 2x the maternal mortality-
here is the info from a report in Pennsylvania health department- they had started a program of midwife supervision, carried out in 3 sections of the state for varying periods of time, Philadelphia, Pittsburgh and a group of counties in the coal region.
"Statistics on the cases attended by the midwives have been kept. From 1914 to September 1930, they attended 90,926 confinements. Of this number, 1,780 were delivered by physicians and in 1,281 cases physicians were called in after delivery, leaving a total of 87,865 women attended only by a midwife. All deaths occurring in the entire group, however, are considered here as deaths occurring in the midwives' practice. There were 91,074 live births (including plural births) in the group of cases, and 77 maternal deaths, or a rate of 8.5 per 10,000 live births. There were 18 deaths from sepsis, or a rate of 2 per 10,000. The lowest maternal mortality rate ever attained in Pennsylvania is 61 per 10,000 live births and the death rate from puerperal sepsis has varied from 24 to 27 per 10,000 live births during the last 6 years. In general, from one-fourth to one-third of the deaths from puerperal sepsis followed abortions, and in order to eliminate this factor from the comparison we may reduce the stated rate for sepsis by one-third, making it from 16 to 18 per 10,000 live births during the last six years as compared with 2 per 10,000 live births for the group of cases attended by midwives. The place of delivery is of interest, only 34 deliveries taking place in a hospital. One hundred and twenty-four women were sent to the hospital after delivery, but in a number of these cases this was due to the fact that the baby needed hospitalization rather than the mother."
the other reports are similar but very long to publish here- through experience, skill and some science midwives were by far safer - that fact that men had more power and prestige is the only thing I can think of when I read info like this - science and physicians did not improve women's lot absolutely did not. After abx were introduced is when you are going to see better stats-- and on the front of legal abortion in the 1960s is when you see the next jump in reducing maternal mortality.

By Anonymous Anonymous, at 12:41 PM  

the report I just sent was for Philadelphia - the 3 coal counties and Pittsburgh were not included in that report-

as I have said before if it were today hospitals would have been outlawed!!!!!!

By Anonymous Anonymous, at 12:51 PM  

Anonymous:

What publications are you quoting from? I want to read them myself.

By Blogger Amy Tuteur, MD, at 1:25 PM  

The Victorian statistic was quoted in the history book and was based on an actuarial table of the time. I will give you the reference exactly when I am at home.
Also, it was 5 per 1000 live births.
The Victorian statisticians actually have, I understand, a pretty good reputation. I was a Victorianist by study in a highly regarded research university. For what that's worth, which is really nothing, if you could know what my salary is these days.

By Anonymous Joanna, at 1:34 PM  

same one I have been quoting from all along- THE WHITE HOUSE CONFERENCE ON CHILD HEALTH AND PROTECTION, Subcommittee report Fred Lyman Adair, MD. , Chairman section I b- published 1932 the Century Company.

By Anonymous Anonymous, at 2:03 PM  

at this point Amy I don't know where you will find a copy of the book I looked for it on line- and found a bunch of other interesting reads at Harvard and some of the other volumes in this series but not this book-- I guess I should have my copy photocopied and entered into the online book archives.

By Anonymous Anonymous, at 2:08 PM  

On page 50 same book

"Figures furnished by the Census for 1925 to 1929, inclusive, show a mortality in the first day of infant life of 15.0 in 1925 as compared with 15.3 in 1929; in the first week of infant life of 28.0 in 1925 as compared with 28.1 in 1929, and in the first month of infant life of 37.8 in 1925 as compared with 36.9 in 1929. The rates are for the expanding Birth Registration Area and are made on a basis of 1,000 live births. We observe that not only is the early infant mortality excessive but that there has been no improvements in the years 1925-1929. The record of stillbirths, from the same source for the years 1925-1928, inclusive, per 1,00o live births, shows an incidence of 36 stillbirths in 1924 as compared with 35 in 1928 in the white population , and of 76 in 1924 as compared with 81 in 1928 in the colored population."

By Anonymous Anonymous, at 2:19 PM  

Anonymous, what volume is it? Found vol 13 on Bibliofind.

By Anonymous Joanna, at 3:27 PM  

Fetal, newborn, and maternal morbidity and morality
White House Conference on Child Health and Protection. Sect. I: Medical Service. Committee on Prenatal and Maternal Care.

Publisher: D. Appleton-Century company, incorporated
Pub date: [c1933]
Pages: xxi, 486 p.

Anon, is this it?

By Anonymous Joanna, at 3:29 PM  

Publisher: D. Appleton-Century company, incorporated
Pub date: [c1933]
Pages: xxi, 486 p.

Anon, is this it?

-----------------
I don't know it is published a year later and a different publisher.
Pub date: 1932
302 pages
The Century Co. ( publishers of the New Century
Dictionary ) 353 Forth Avenue, New York City
--------
it may be similar in content or from a different
sub- committee ,

By Anonymous Anonymous, at 3:40 PM  

There were some decent declines in the overall mortality rates having to do with science -- water treatment started , and filtration, garbage... milk pasteurized, isolation if possible of communicable diseases---
TB was a big time killer
and all these have to do with birth to a degree but as has been stated those deaths were not part of the neonatal or maternal mortality stats.

By Anonymous Anonymous, at 3:46 PM  

Can I have exact title (including subtitle) from title page and any and all authors listed, anon?
Getting obsessed again!

By Anonymous Joanna, at 3:49 PM  

here you go

http://hearth.library.cornell.edu/cgi/t/text/pageviewer-idx?c=hearth;cc=hearth;sid=a52c0c73141f38493b1159f596748972;rgn=full%20text;idno=4305359;view=image;seq=0019

By Anonymous Anonymous, at 5:07 PM  

shorter address--
http://hearth.library.cornell.edu/cgi/t/text/text-idx?c=hearth;idno=4305359

By Anonymous Anonymous, at 5:09 PM  

Anonymous:

I still can't figure out what your point is. Dr. Adair's report ascribes the high neonatal mortality rate to the fact that practitioners are not skilled enough. Remember, the high neonatal mortality rate includes midwife births, and for the years you are talking about, the proportion of midwife births were relatively high.

If I understand Dr. Adair correctly, he is blaming midwives and substandard doctors for the high mortality rate and insisting that only properly trained doctors can decrease the mortality rate. So why are you citing this report?

By Blogger Amy Tuteur, MD, at 6:12 PM  

I cannot be responsible for the conclusions of the day what we can look at is the reports of very well studied midwives with a bit of additional training from scientific info who had statistics that far outstripped the doctors of the day- by far outstripped them read the rest of the info-
and the other point is you CANNOT claim that physicians and hospitals were delivering a superior product- and that is why they won out-
the majority of getting rid of midwives-before women could vote... I have read a great deal of autobiographies of physicians that practiced before and during that time period and I am sure it was a very sexist type of thinking as well as racism that drove much of their conclusions not science- more dismissive about the conclusions --well those are just poor ignorant immigrant women or those were just blacks -
I think that if there were some actually training programs implemented like the one in Penn- all over the country including and especially in the south- there may have been a much bigger drop in maternal and infant mortality before the advent of antibiotics a huge drop-- not physician training programs that took so long to grind out the help and changes in care- look at Dr. Freidman who was still fighting the docs starting in the late 40's early -
50's . it also represents an untapped resource of women who had experience and handed down information that was undoubtedly useful---

By Anonymous Anonymous, at 11:06 PM  

Amy there is some discussion starting on page 227-231
to show the state of mind--
" John Bennett Morrison, MD ( Secretary, Medical Society of New Jersey) Newark, New Jersey: I do not believe that in a gathering of this character, made up of physicians, nurses, health officers and social workers, the statement that the maternal mortality in the hands of midwives' is lower than the maternal mortality in the hands of physicians should remain unchallenged, I have heard that statement made in our state by the leading obstetricians with reference to the statistics in New Jersey, and it is as unfounded there as it is in the states referred to here. "..... it goes on from there for another paragraph and then there are pages of rebuttal

By Anonymous Anonymous, at 12:23 AM