A Brief History of Birth—How PABC© (Predominant American Birth Culture) Congealed
In order to gain an appreciation of how we got to our current state of affairs, how to improve the future of birth in this country for yourself and children, and also have a better understanding of this book, it’s important that you get at least a brief overview of major events in birth history. Unless otherwise noted, all are U.S. events. See References for History of Birth Citations.
Biblical times, African and European Continents:
Midwives adhered to a strict level of cleanliness per the admonition of Moses.They also educate young women about their bodies, having children, and healthy pregnancies per that same admonition.
AD 98 Soranus, a classical Roman who attended births, wrote a textbook of obstetrics that was used until the 16th century.
Middle Ages and Renaissance (AD 500–1500), European Continent:
Barber-surgeons began trying to monopolize childbirth services. Women were forbidden to practice medicine or midwifery, and many midwives were accused of being witches and killed. Only men were allowed in the medical schools, and soon the barber-surgeon was delivering most of the babies.
1522: Dr. Wertt of Hamburg dressed up in women’s clothes to gain entry to a labor room. He was discovered and burned at the stake for his efforts.
1544: The first book of obstetrics was printed in English called the Birth of Mankynde by Thomas Raynalde.
1596: Scipione Mercurio instructioned attendants that for a Cesarean section, you need four strong assistants to hold the patient down as the incision is made; then apply a liquid concoction of varied herbs before removing the baby. He did not, however, record if this event would increase the odds that either the mother or child would survive.
Colonial Times (circa AD 1600), European and North American Continent:
The importance of midwives to the social order is shown in the fact that several New England towns provided a house or lot rent-free to a midwife on condition that she does not refuse when called. Non-English colonies often kept midwives on the colonial payroll. In New Amsterdam they were called Zieckentroosters, or comforters of the sick, and received liberal salaries and special privileges. The Dutch West India Company salaried midwives and gave others free houses in the city on the explicit condition that they attend to the poor upon request. The French colony of Louisiana paid midwives until 1756 and provided physicians regularly to examine the quality of their practice.
Bishops in the Church of England were the first to legislate control over midwifery. Richard and Dorothy Wertz in the book Lying-In state:
In the 17th century and before, English bishops were the only public authorities overseeing midwifery. The bishops had desired to prevent witchcraft associated with birth and to ensure that midwives were loyal to decrees of the church and state regarding birth, since midwives could baptize infants in emergencies. The bishops required that before beginning practice a midwife receive an Episcopal license, which prohibited her from coercing fees, giving abortifacients, practicing magic, or concealing information about birth events or parentages from civil or religious authorities. The license also prohibited her from refusing to attend poor women.
Because of this influence, civil licensing began in the colonies. Again quoting Lying-In:
In the American colonies where the Anglican influence was most strongly felt, such as New York and Virginia, civil licensing of midwives was required. In 1716 New York City required licensing for midwives in an ordinance that echoed the Episcopal licenses of England. Such licenses in effect placed the midwife in the role of servant of the state, a keeper of social and civil order.
The predominant belief was that labor pain was woman’s punishment for Eve’s sins
1650: William Chaberlen invented forceps, but they were rarely used. They were instead kept as a family secret for many years.
William Smellie offered free care to indigent women, thus providing clinical
1700s: Upper-class families began to rely on male doctors as primary caregivers
The first obstetric wards in Britain opened. Men became doctors merely by attending births and then being quizzed later.
Physicians did not associate hand washing with infection and would go from autopsies to delivering babies without washing in between.
1765: Dr. William Shippen opened the first formal training for midwives.
1772: 20 percent of delivered women contracted childbed fever, nearly all of whom died. Suggested causes: overcrowding, unwed maternity.
1799: Dr. Valentine Seaman led a course for midwives in New York City. A course in anatomy and midwifery was led by Dr. William Shippen in Philadelphia.
1816: The first stethoscope for listening to fetal heart tones externally was introduced by René T. H. Laënnec. Adapted stethoscopes, called Pinard horns and fetoscopes, became widely used.
1817: Britain mourns as Princess Charlotte dies five hours after a 50-hour labor and stillbirth. The public blamed her doctor, Dr. Croft, who later committed suicide. Opponents of man-midwifery advocated the return of female midwives. The medical establishment reacted by advocating quicker use of forceps.
1828: The word obstetrician was formed from the Latin, meaning “to stand before.”
1848: Dr. Walter Channing of Boston first used ether for childbirth.
1853: Queen Victoria of England extolled the “virtues” of receiving chloroform during birth of her seventh baby. Receiving choloroform during childbirth became a status symbol.
1860: Louis Pasteur found bacteria and lack of washing was the major cause of puerperal (childbed) fever. Students were to scrub their hands in chloride of lime before having any contact with the patient. Physicians were the perpetuators of childbed fever, as midwives had observed the association between sanitation and maternal death thousands of years previous to this time.
1894: The first clinic Cesarean section was performed in Boston.
1898: German doctor August Bier injected cocaine into his assistant’s spinal column (the forerunner of the modern day epidural). It numbed the fellow’s lower body, but the next morning he woke with horrible vomiting and headaches.
1900s: Government involvement in maternity health care began in the early 1900s. Both federal and state bureaus became involved. The state bureaus primarily dealt with the problem of birth attendants. Even though fewer white, middle-class American women were being attended by midwives, many immigrants from Europe brought their own midwives with them and settled in major cities. As late as 1920 these midwives were attending 20–40 percent of all births in mid-Atlantic cities. In some cases, this meant they were practicing illegally. Fewer than 5 percent of women gave birth in hospitals.
Scopolamine, which causes amnesia, was used during childbirth.
1910: The Flexner Report revealed that 90 percent of doctors were without a college education. The Carnegie Foundation for the Advancement of Teaching published Abraham Flexner’s critical report on medical education in North America. Flexner stated that obstetrics made “the very worst showing.”
1914: New England Twilight Sleep Association was founded to force hospitals to offer the procedure. Upper-class women formed Twilight Sleep Societies, and it became a sign of superiority to use it during childbirth. Twilight Sleep is a combination of morphine, for relief of pain, and scopolamine, an amnesiac that caused women to have no memories of giving birth. Upper-class women initially welcomed it as a symbol of medical progress, although its negative effects were later publicized.
Ankle and wrist restraints were used to keep women from injuring themselves under the influence of Twilight Sleep.
1915: A paper by Joseph DeLee in the Association for the Study and Prevention of Infant
Mortality described childbirth as a pathological process. He stated that childbirth was not a normal function and that midwives had no place in childbirth.
Infant mortality from birth injuries increased by 40–50 percent. Between 30-50% of women gave birth in hospitals by 1921.
1918: The United States stood 17th out of 20 nations in mortality rates. Maternal mortality reached a plateau, with a high of 6 to 7 deaths per 1,000 births between 1900 and 1930.
1920: The medical profession won stronger licensing laws and helped shape the medical system so that its structure supported, rather than undermined, professional dominion. Forceps were used in 30 percent of births. The most frequently used obstetric textbook, by Dr. Joseph DeLee, stated that childbirth is a pathological process from which few escape “damage.” In efforts to prevent problems, he proposed that the caregiver employ routine interventions. He suggested that the obstetrician sedate women at the beginning of labor, allow the cervix to dilate, give ether during the pushing stage, cut an episiotomy, deliver the baby with forceps, extract the placenta, give medications for the uterus to contract, and repair the episiotomy. Because of his influence with the American obstetrician, caring for labor and birthing women went from responding to problems as they arose to attempting to prevent problems through routine use of interventions as a way to control the course of labor. This led to every woman in labor being dealt with in this way. To a large extent, American obstetrics is still functioning under the medical paradigm of childbirth it inherited from Dr. DeLee.
1920s: Moving birth into the hospital removed a trained female attendant and the benefits.
1921: The Sheppard-Tower and Infancy Protection Act became law. It provided funds to train people to seek for ways to improve maternal and child health. A range of 30–50 percent of women gave birth in hospitals.
1925: Mary Breckenridge founded the Frontier Nursing Service of Hyden, Kentucky.
1929: The American Medical Association lobbied against the Sheppard-Tower Act and Congress allowed it to expire.
1930: The American Board of Obstetricians and Gynecology was established. Obstetricians sought to achieve dominance over the nonphysician specialists, such as midwives. Nurse-midwifery appears, stemming from the profession of nursing rather than midwifery. Their emphasis was on assisting doctors in their profession. Nurse-midwives provided supervision for rural immigrant midwives. Most practicing midwives were black or poor-white granny midwives working in the rural South. A scholar who conducted an intensive study concluded that the 41 percent increase in infant mortality due to birth injuries between 1915 and 1929 was due to obstetrical interference in birth.
1933: Maternal mortality was 58.1 deaths per 100,000. Maternal mortality had not declined between 1915 and 1930 in spite of women moving childbirth into hospitals, increased prenatal care, and better birthing techniques as reported by the White House Conference on Child Health.
1935: 37 percent of births occur in hospitals.
1938: Twilight Sleep used in all hospital births.
1939: 50 percent of all women (75 percent of all urban women) delivered in hospitals.
1940: 95 percent Twilight Sleep rate. This heavy dose of narcotics and amnesiacs completely incapacitated laboring women and caused women to lose control. Maternal mortality is 47 deaths per 1,000.
1944: Dr. Grantley Dick-Reed wrote Childbirth without Fear.
1950: 88 percent of births occurred in hospitals. Maternal mortality was 29.2 deaths per 100,000. Forceps were used 75 percent of the time.
1953: Dr. Fernand Lamaze published his findings about labor and delivery in Russia. His work helped bring the fathers back into the birth room.
1955: The American College of Nurse Midwives (ACNM) was formed.
1956: La Leche League was founded.
1958: Dr. Robert Bradley introduced husband-coached natural childbirth
1957: The book Thank You, Dr. Lamaze by Marjorie Karmel was published
1960: Marjorie Karmel and one of her book’s admirers, Elisabeth Bing, a clinical assistant professor at New York Medical College, formed the American Society for Psychoprophylaxis in Obstetrics (better known as ASPO/Lamaze), to teach childbirthing classes. 97 percent of births occurred in hospitals. Maternal mortality was 26 deaths per 1,000. Continuous electronic fetal monitoring was introduced.
1963: International Childbirth Education Association (ICEA) was founded.
1965: On July 30 U.S. President Lyndon B. Johnson signed into effect Medicaid and Medicare.
1968: Continuous electronic fetal monitoring was introduced, only used on 5–10 percent of women, those considered “high risk.”
1970s and onward:
Doctors made more money per hour for a hospital visit than they did for an office visit.
1970: Maternal mortality is 20 deaths per 100,000. National certification in nurse-midwifery educational programs began.
HMOs were created.
1971: The Farm, a hippie commune in Tennessee, was founded by Stephen and Ina May Gaskin, the mother of modern midwifery. The Birth Center of Santa Cruz was started.
1973: ACNM stated, “The preferred site for childbirth because of the distinct advantage to the physical welfare is the hospital.”
1975: The Birth Collective at Freemont Women’s Clinic in Seattle began. Less than 1 percent of births were attended by midwives. Maternal mortality was 16.1 deaths per 100,000. 20 percent of American women chose to have an epidural.
1976: The Division of Nursing began to fund nurse-midwifery education programs. 5 percent Cesarean rate.
1977: Informed Homebirth (IH) was founded by Rahima Baldwin Dancy in response to the need for information on how to prepare for a safe delivery at home. The original childbirth educator training program was developed in 1978.
1979: The first studies were conducted on labor anesthesia, including Demerol.
1980: 98.9 percent of births occurred in hospitals. The ACNM developed guidelines for establishing “alternative” birthing services. They changed their negative home birth statement to one that endorsed practice in all settings. Maternal mortality was 12.6 deaths per 100,000. The American Academy of Family Physicians (AAFP) opposed nurse-midwifery and issued formal statements to that effect. AAFP stated the belief that all nurse-midwives should work nonindependently and that all payments should go through the physician.
1982: The Midwives Alliance of North America (MANA) began. One-third of its members were CNMs, and the rest were other types of midwives. Insurance (liability) coverage declined rapidly for CNMs from 1982 to 1985, with some companies either totally withdrawing from coverage or making it expensive. 16 percent of all births occur on Saturdays and 16.6 percent of births occur on Sundays.
1983: The National Association of Childbearing Centers was established. The Federal Trade Commission intervened in a CNM-doctor case and negotiated an agreement that prohibited the insurance company from any form of discrimination against doctors who collaborate with CNMs.
1985: The AMA set out to create legislation and regulation for all nonphysician health-care workers that would not allow these workers to practice independently. Maternal mortality was 10.6 deaths per 100,000. 6.8 percent of babies are born with low birth weight (under 2,500 g). The World Health Organization (WHO) recommends that the Cesarean section rate should not be higher than 10–15 percent.
1988: 25 percent Cesarean rate. Patient-controlled epidurals, which allow women in labor to adjust the timing and frequency of their anesthesia with the push of a button, come on the scene.
1989: Forceps used in 5.5 percent of births. 18.9 VBAC rate; 9 percent induction rate. 47.7 percent of women received at least one ultrasound during pregnancy. 8 percent Continuous Electronic Fetal Monitoring rate. 9.4 percent of births occurred prior to 37 weeks gestation.
Hospitals introduced LDR rooms (Labor, Delivery and Recovery rooms, where you labored, gave birth in, and recovered all in the same room rather than moving to different rooms for each of those stages).
1990: 10.7 percent of births occurred prior to 37 weeks gestation. Physicians who at one time had no interest in taking care of poor, pregnant women became more willing to do so as Medicaid increased payouts for services and made acquiring these fees easier. 41 percent of births occurred between 37–40 weeks gestation. Once again, AAFP opposed nurse-midwifery and issued formal statements to that effect. AAFP stated the belief that all nurse-midwives should work nonindependently and that all payments should go through the physician. Maternal mortality is 9.2 deaths per 1,000. 11.3 percent of births occur at or beyond 42 weeks’ gestation. 75.8 percent of women received prenatal care.
1992: Forceps used 10 percent of the time. Doulas of North America (DONA) was founded to legitimize the benefits of female birth attendants. The governor of New York signed a new Professional Midwifery Practice Act into law in July. The act defined midwifery as a profession with a specific scope of practice and called for a board of midwifery to regulate the profession.
1992–1999: A handful of organizations are founded to train and certify independent childbirth educators and doulas.
1993: Again, the AAFP opposed nurse-midwifery and issued formal statements to that effect. AAFP stated the belief that all nurse-midwives should work nonindependently and that all payments should go through the physician. The first randomized, controlled trial to observe the effects of epidural anesthesia was halted after it was concluded that it would be unethical to continue the study due to bad outcomes. The ACNM obtained a stable, long-term professional liability program. The number of jurisdictions that grant prescriptive authority to CNMs increased from 14 in 1984 to 31 in 1995.
1994: 94.5 percent of births occurred in hospitals. There was a 14.7 percent induction rate and 85 percent continuous EFM rate. The North American Registry of Midwives (NARM) offered its first written examination to test the knowledge needed for safe, beginning-level, direct-entry midwifery practice to implement a process to certify direct-entry midwives. Federal law required all state Medicaid programs to pay for care provided by CNMs.
1995: 21 percent Cesarean rate. Maternal mortality is 7.6 deaths per 100,000. Some insurance companies refused to write policies for physicians who worked with midwives—or charged physicians higher premiums if they did—thus imposing restrictions and requirements that limited and burdened the practice.
1996: NARM expands the certification process to include entry-level midwives. 28.3 percent VBAC rate
1998: 19.4 percent induction rate
1998: The rate of midwife-attended births grew at a high and rising rate, showing a 45 percent increase since 1982. The rate of midwife-attended hospital births rose even more sharply, increasing by 1,000 percent since 1975.
1999: 6 percent forceps rate. VBAC rates plummet after ACOG releases new guidelines for doctors and hospitals attending VBACs, making it unrealitistic for either of them to support VABCs, both financially and in practice. Dr. Marsden Wagner (former director of Women’s and Children’s Health in the WHO) noted that ACOG “has no data to support it [the 1999 VBAC recommendations], no studies showing improvements in maternal mortality or perinatal mortality related to the characteristics of institutions or availability of physicians.”
2000: Maternal mortality is 6.9 deaths per 100,000. Much to the chagrin of ACOG and most OBs and hospitals, findings on a landmark study on using CPMs for home birth is released showing that home births with a qualified midwife are safer than OB- or CNM-assisted hospital births.
2001: 11.9 percent of births occurred before 37 weeks gestation. 16.4 VBAC rate
2002: 26.1 percent cesarean rate. 20.6 percent induction rate. 85 percent Continuous EFM rate. 91.3 percent of births occurred in hospitals. Maternal mortality is 7.1 deaths per 1,000. 7.8 percent of infants are born with low birth weight (under 2,500 g). 12.1 percent of births occurred before 37 weeks gestation. 51 percent of births occurred between 37–41 weeks gestation. 6.7 percent occur at or beyond 42 weeks gestation. 12.6 percent VBAC rate. Midwives attend 8.1 percent of all births (94.6 percent CNM attended). 83.7 percent of women received prenatal care. Of all out-of-hospital births, 65 percent occurred at home and 27 percent occurred at a free-standing birth center. 68 percent of pregnant women received at least one ultrasound during pregnancy. Births occurring by day of the week:
2003: 26.1 percent Cesarean rate. 11 percent of vaginal births are attended by certified nurse-midwives. Direct-entry, CPM, and lay midwives attend 4 of every 1,000 U.S. births. The U.S. ranks 41 out of 60 nations in infant mortality.
2004: Maternal mortality is 7 deaths per 100,000
2005: WHO and UNICEF rank the U.S. 34th in maternal mortality. AAFP reviewed all of the evidence on VBAC and the necessity of 24-hour OB and anesthesia, it recommended that “TOLAC (trial of labor after Cesarean) should not be restricted only to facilities with available surgical teams present throughout labor since there is no evidence that these additional resources result in improved outcomes.”
2006: 22 percent of women have their labors induced.
2007: 31.8 percent Cesarean rate , representing a more than 50 percent increase since 1996.
2008: 33 percent Cesarean rate. The United States has some of the worse pregnancy outcomes than almost every other industrialized country, yet provides the world’s most expensive maternity care. An average 80 percent of women elect for an epidural for vaginal delivery. ACOG releases the following statement after much press is given to the Ricki Lake documentary The Business of Being Born:
The American College of Obstetricians and Gynecologists (ACOG) reiterates its long-standing opposition to home births. . . . ACOG acknowledges a woman’s right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births. Childbirth decisions should not be dictated or influenced by what’s fashionable, trendy, or the latest cause célèbre.
2009: America ranks 45th in Infant Mortality rankings. ACOG revises its guidelines on electronic fetal monitoring, denouncing years of standard practice. According to Dr. George A. Macones, who headed the development of the ACOG document:
Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002, Although EFM is the most common obstetric procedure today, unfortunately it hasn’t reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.”
In another ACOG revision, they stated that elective inductions should not be done prior to 39 weeks gestation and that the physician capable of performing a Cesarean should be readily available any time induction is used in the event that the induction isn’t successful in producing a vaginal delivery, although they do not define what “readily available” means.
ACOG admits decades of inappropriate guidelines when they relax their position on women eating and drinking in labor. Once completely banned during labor and birth, they now support women drinking “modest amounts of clear liquids during labor if they wish,” citing that they now see the benefits of eating and drinking during labor in relation to providing energy and comfort.
As you can see, childbirth has not always been viewed as a peaceful experience and has always been subject to predominant cultural attitudes, whether those voices are from the religious, scientific, or public and social sector. It can be easy to get wrapped up in the pain, fear, and other obvious factors that can accompany childbirth. But it takes a deep understanding of ourselves, faith in the process and our bodies and babies, and a long-term perspective to walk into the birth experience with confidence and eagerness and walk out of it with the joy and serenity you are seeking. We are at a distinct advantage in our earth’s history where we have thousands of years of both successful and failed documented birth practices, the knowledge of how to prevent the majority of complications in pregnancy, birth and postpartum, the experience and wisdom of our ancestors and modern-day birth “sages.” There is all kinds of support during the birth year, and science and technology to back us up where we need it, such that there is no need to fear the birth process as our mothers before us did. We should be rejoicing and throwing off the old robes of the fear of pain or being conscious for the event, the distrust of our bodies, babies, and instincts, the patriarchal (from religion or government) control of this process, and the mind-set that it is better, clinically or otherwise, to completely hand our bodies and babies over to “the experts” to handle. For too long we have handed over our responsibility and power to those who would willingly shape our lives for us. Birth transforms you into much more than a mother. Birth is a rite of passage. It is your right of passage. Claim it!
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