Marjorie Tew
Chapter 1 of Safer Childbirth? A Critical History of
Maternity Care. London: Free Association Books, 1998, p.1-39. [Buy
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In Britain, by the 1980s, society had come to accept that birth, the essential physiological event by which the human race has perpetuated itself, must now take place in a medical institution. The family home was the traditional birthing place right up to the start of the 20th century and for many years thereafter, yet by the early 1980s hardly 1% of British births took place there. For such a revolutionary concept to be accepted by a culture within such a short period of its history and with such unanimity must be a rare phenomenon. How did it come about?
Britain cannot claim to have been the pioneer of this revolution. It began rather earlier and progressed rather faster in many of the other economically developed countries, with the outstanding exception of Holland. The change was most rapid among the European immigrant populations, of the New World, the United States of America (USA) and the then Dominions of the British Commonwealth, Australia, Canada, New Zealand and South Africa, where a vigorous medical profession was seeking to establish itself. The revolution in maternity care was even more complete in countries, as in Eastern Europe, where a political revolution had ordained that social and economic betterment was to be achieved through systems of planning and control by experts, and betterment in maternal and infant welfare through a system of childbirth care planned and controlled by medical experts. By the 1980s in all these countries birth at home was as rare as in Britain. The same underlying reasons for the change, through immensely complex, can be recognized in different places.
At first, the advantages of a medical institution of any kind were recommended as an alternative to the family home, but gradually the specialist consultant obstetric hospital, equipped with increasingly sophisticated technological instruments, has become favoured at the expense of the non-specialist hospital, not so equipped and used by general practitioners with the co-operation of midwives for delivering their patients. In England and Wales in 1990 only 1.6% of births took place in geographically separate general practitioner units (GPUs) compared with 12% in 1969.
Hospital care in several countries is organized on three levels of specialization. Level 1, the least specialized, corresponds approximately to the British GPU The tertiary level 3 hospitals are the most specialized and provide care similar to that provided in the largest of the obstetric hospitals in Britain. British data are rarely published by size of unit, so it is not possible to identify separately the British equivalent of level 2 and 3 hospitals overseas.
But why should birth take place in any kind of hospital? One reason is because a hospital is the place where doctors can best deploy their technical skills and harness the instruments of developing technology to assist them. But why does birth need the technical skill of a doctor? Surely the success of human reproduction is demonstrated by the enormous expansion in the world's population and this has been achieved over the centuries without the mediation of obstetricians or hospitals for all but the tiniest proportion of people. Given favourable environments, other species reproduce successfully without medical or veterinary intervention. Given a favourable environment could not the human species do likewise?
The response to this question would seem to be that civilization has often not provided a sufficiently favourable environment and its price has been to submerge the human mother's natural instincts and deprive her reproductive system of its natural competence. Human reproduction has been numerically successful, but there have been many casualties on the way. This has brought great suffering to the individual families involved. In addition, it has created anxieties for communities and nations which see their survival as depending on constant replenishment with healthy babies ready to grow into productive citizens and sturdy warriors. Individuals and communities, therefore, share concern to find whatever assistance they believe will reduce the casualties of reproduction.
Every culture has its own medicine men to whom it looks to solve its problems of illness and death. Western cultures look to their academically trained doctors and their confidence in doing so has increased greatly over the last two centuries. Cures have no longer had to depend on mystery, magic and faith, or at least they are no longer perceived as doing so. The spirit of scientific enquiry, which became particularly lively in the 18th century, led to greater understanding of the physiology and anatomy of the human body and of its pathology. Understanding the causes of illnesses offered a first step along the path to surviving them by finding methods of prevention or cure. It was, however, still to be a long time before medical science developed effective treatments for the most frequent causes of death.
In England, as in other industrializing countries in the 19th century, populations were expanding rapidly, despite the very high death rates in all age groups which caused personal and social concern. One expression of the social concern was the introduction in 1837 of the legal obligation to register every death, with the sex and age of the deceased. Live births were also to be registered, but it was not until 1874 that it became compulsory to do so. The information collected was linked with that obtained from the decennial censuses of population, the first of which was carried out in 1841, so that patterns of mortality could be described and trends discerned. The statistics were presented, often with commentaries, in the Annual Reports of the Registrar General of England and Wales [1] until 1973 and thereafter in other official publications of the Office of Population Censuses and Surveys [2,3].
Great changes took place in the industrial and social environment in the 19th century. The expansion of industry led to increased pollution but also to increased employment and incomes. In general, the extra food and clothing people could buy compensated for the unhealthy conditions in which they had to work and live. Cheaper, more abundant and more varied food became available from the rising output of the farming industries, both at home and in the New World. Municipal authorities carried out impressive feats of sanitary engineering to supply pure water to town dwellers and safely remove domestic waste.
Death rates remained high until 1870, but thereafter they experienced a spectacular and sustained decline. The grateful public were disposed to give the medical profession the credit for this improvement and the medical profession was certainly not disposed to disclaim the honour. Instead it enjoyed the heightened prestige.
The honour was, however, misplaced as later epidemiological analysis, which evaluates the effects of the treatment of disease on patients as a whole, was to prove [4]. The great decline in mortality was brought about not by life-saving medical treatments, but by the life-saving consequences of non-medical developments. The most frequent causes of death had been infectious diseases, including cholera and tuberculosis. The chief reason for the decline in mortality was the decline in deaths from these causes. Through the discoveries of 19th century doctors and scientists, like Edward Jenner, Louis Pasteur, Robert Koch and others, much had been learned about the causes and modes of transmission of infections, but few effective medical treatments were developed for more than sixty years after the great decline in the death rate started. Certainly, vaccination against smallpox was available in the 19th century and antitoxin treatment for diphtheria from the early years of the 20th, but these diseases made up only a relatively small proportion of the killing infections. By the time that antibiotic drugs like sulphonamide, penicillin and streptomycin were available to treat specific infections and immunizations had been developed to prevent them, the diseases concerned had long since ceased to be frequent causes of death. Mortality rates from them had fallen dramatically and continuously since 1870 and would almost certainly have gone on falling without the added impetus of the new treatments, welcome bonus though these were.
The outcome in infectious illnesses depends on the balance between the prevalence and virulence of invading organisms on the one hand and the strength of the hosts' defences on the other. The work of the sanitary engineers greatly reduced the prevalence of harmful bacteria. Improvements in diet and living conditions helped strengthen the hosts' defences. The balance shifted in the hosts' favour so that gradually they won the contest. Their greater resistance to infectious diseases, including tuberculosis, was reflected in the rapidly declining mortality from these causes in all age groups. This change took place during the years before the advances in medical knowledge could make an appreciable contribution to the cure of the diseases or, except for smallpox, to their prevention. Analysis of the historic succession of events led the epidemiologist, Professor Tom McKeown [4], to conclude in 1965
We owe the advance in health mainly, not to what happens when we are ill, but to the fact that we do not so often become ill. And we remain well, not because of specific preventive measures, such as vaccination and immunisation, but because we enjoy a higher standard of living and live in a healthier environment.
Earlier analysis of experience in Australia had led to the same conclusion - that improvements in provisions for public health and in other living standards had been more effective in combating infectious diseases and reducing infant mortality than the immunization and serum treatments which became available in the 1930s [5]. It is virtually certain that the reasons for the parallel decline in mortality which took place in other industrializing countries over the same period were the same.
The most frequent causes of death have changed during the 20th century. Effective, indeed spectacular, treatments have been developed for many diseases and death rates from them have been reduced. But it is still true that the general level of health depends much more on people not contracting diseases, by adopting a life-style which enables them to build up their own natural defences, than on medical cures for diseases contracted or medical preventive immunizations (Chapter 9, pages 381-2).
That this explanation for the decline in mortality, disclosed by epidemiological analysis in the 1950s and 1960s, was greeted with general surprise and scepticism, not least among the medical profession, revealed how deeply ingrained was the popular misconception about the powers of doctors. That it has remained a misconception is due to popular misinformation, fostered on the one hand by the medical profession which has, on the whole, more to gain by treating disease than preventing it, and on the other hand by the public. For it is perhaps essential as a reassurance to human vulnerability that people want to overrate the powers of those on whom they rely for the help they need when illness has not been prevented. While such ill-informed attitudes towards health and sickness in general prevail, it is understandable that society should believe that, although reproduction is not a disease, its problems are also better solved by medical intervention than by environmental improvement and healthy life-styles. And since the prosperity of doctors concerned with maternity care is vitally dependent on this belief, it is understandable that they should- make great efforts to propagate it.
The decline in mortality after 1870 was experienced by all subgroups in the population except for two. These were mothers in childbirth and infants in the first year of life. Surprisingly, these two groups did not seem to have benefited from the improved standards of living, at least according to the statistics. But the apparently high maternal and infant death rates towards the end of the 19th century may have been due, in part, to more complete recording. There are many problems involved in the certification of death to particular causes. Changes in the climate of public opinion may have made doctors more willing to attribute the death of mothers frankly to their maternity instead of to other contributory causes with less emotive connotations [6]. For whatever reason, the maternal mortality recorded for 1896-1900 was 5.5 per 1000 five births, having fluctuated around 5.0 throughout the 19th century.
The compulsory registration of births after 1874 probably led to the reporting of both the birth and early death of some infants, events which previously the parent had not considered it necessary to record officially. The average infant mortality rate, at 153 per 1000 live births, was as high between 1891 and 1900 as between 1841 and 1850, though rather higher than in the 1880s when it averaged 142. More complete recording was likely at most to have raised these death rates only marginally and was very unlikely to have obscured a real downward trend in the mortality of mothers or infants coincident and commensurate with the general experience.
The causes of infant death are different at different stages: those which occur within the first four weeks, the neonatal period, are most strongly related to conditions experienced during fetal development and birth - the sooner after birth the death occurs, the stronger is this relationship; deaths which occur in the next eleven months, the post-neonatal period, are most strongly related to conditions in the physical environment to which the infant is exposed. Soon after the turn of the century the persistently high infant mortality rate at last began to fall and when after 1906 the statistics showed separately the deaths at different stages, it was clear that all the improvement was happening in the post-neonatal period. The benefits of the improving environment were obviously now extending to these children also. Apparently only the deaths of mothers and infants associated with maternity were not so reduced.
England was a pioneer in the collection of demographic statistics. Records in other countries are not always as reliable or as readily available, but where they do exist they show the same experience as in England: from the later 19th century downward trends in mortality were experienced by most of the population but not by mothers and their new babies. The phenomenon was common to all the more economically developed countries.
These results caused much public disquiet. What was preventing maternity-related mortality from falling? How could this disturbing experience be reversed? When death threatens, societies in search of a remedy turn to their medicine men, to their doctors. And the doctors of Western medicine were very willing to accept the challenge (Chapters 7 and 8).
There had, of course, been a long history of outstanding medical men who studied and tried to relieve the problems of childbirth. There was an even longer history of competent midwives who eased the problems of childbirth in practice and of a few midwives who were able to study the subject and write instructional books about it. But in the later 19th century many birth attendants were not competent. The great majority of them were then, as they had always been, women. They could be professional midwives, trained by apprenticeship with or without some formal, theoretical instruction- or self-trained handywomen who picked up their skills by observation and practical experience and who were cheaper to employ than the trained midwives; or the untrained, unskilled helpers, the relations, friends or neighbours, who were cheapest of all to employ for they only expected to be paid by some reciprocal service.
It is probable that some of the practices of the handywomen and untrained helpers actually added to the already considerable risks of the poor women they attended. Doctors might condemn these birth attendants, but they would not have considered replacing them for such low financial rewards. As their interest in childbirth extended, however, doctors soon recognized professional midwives as commercial rivals who undercut the market they wanted by charging lower fees. Doctors were, therefore, only too willing to attribute the high mortality in child- bearing to the incompetence of midwives. They claimed, without any supporting evidence, to provide a safer service, albeit at a higher price. Attacks on their professional skills gave increased urgency to the aspirations of midwives to regulate L their profession and improve their training, but ironically their success in doing so involved the sacrifice of their traditional supremacy as providers of maternity care.
As the 20th century progressed, the formally trained midwife ousted her informally trained colleague and the untrained handywoman, but her role became increasingly subordinate to that of the doctor. It was particularly so in hospital where she worked virtually as an obstetric nurse. She had more respect and greater independence of practice when she delivered mothers in their homes. The policy of the increasing hospitalization of birth advocated by doctors, allegedly to improve the welfare of mothers and babies, was in fact a very effective means of gaining competitive advantage by reducing the power and status of midwives and confirming the doctors' ascendancy over their professional rivals.
Professional rivalry was not limited to the contest between the male-dominated medical profession and the female midwifery profession. ,The medical profession was itself divided into generalists: those doctors who undertook maternity care as an integral part of general patient care - indeed it was the corner-stone around which general practices were built up - and specialists: those doctors whose whole time was devoted to the study and treatment of the illnesses associated with reproduction. Until the 1920s, the generalists predominated in numbers and influence. Most of their maternity patients, like their other patients, were attended m their homes, though a fashion was growing among their richer clientele for treatment in private nursing homes and small local hospitals. The trend towards delivery in such institutions continued in Britain after maternity care became free on the introduction of the National Health Service in 1948.
The territory of the specialist obstetrician was always the hospital, the workshop where cases of obstetric pathology could be assembled, their problems studied and treatments devised and monitored. But the speciality of obstetrics, or midwifery as it used to be called, did not yet have a separate status as an academic discipline. It received little esteem from the ancient faculties of medicine and surgery, to which it was related. In the 1920s, obstetricians campaigned successfully to assert their independence. The British (later Royal) College of Obstetricians and Gynaecologists was founded in 1929 and quickly became very influential in exalting the status of obstetricians and eventually ensuring their domination of maternity care.
To do this they had to discredit and constrain not only the independent midwives, but also the general practitioner obstetricians. The latter were gradually persuaded that they were competent to attend only restricted categories of women defined as being at low risk, while after 1970 in Britain administrative Health Authorities were gradually persuaded to close the small hospitals where obstetricians had little influence. Indeed, after the operation of the National Health Service had relieved general practitioners of the obligation to ensure their incomes by building up their practices by themselves, they no longer found complete maternity care to be so essential a corner-stone. A survey of practices before 1955 found that only 30% of the general practitioners interviewed were anxious to do midwifery [7]. Many, probably most, found that it suited them to be persuaded that they were not competent to provide any intranatal care, which made unpredictable and often inconvenient demands on time in exchange for the disproportionately small additional reward their terms of service provided. It turned out that the method which was adopted by the new National Health Service of remunerating general practitioners, mainly by capitation fee for patients registered on practice lists and only marginally by fee for specific service, was to have an unintended side-effect of great importance to the maternity service, that of discouraging their involvement in intranatal care (Chapter 2).
The place of birth is related to the kind of care that different categories of birth attendant are qualified to give. But more fundamentally, the relationship is with the different kind of care which different birth attendants believe that it is biologically right to give. The traditional role of midwives was, as the medieval derivation of their name denotes, to be 'with woman' throughout her labour, giving her emotional support and encouragement. The midwife's skills lay in ensuring the necessary hygiene and in knowing how to help the labouring woman to use her own reproductive powers to bring forth her child naturally and without damage. Her skills were essentially non-interventive and the philosophy which underlay her practice was of the biological rightness and sufficiency of the natural process. As the influence of obstetricians on the midwifery training programmes increased, the philosophy became compromised and midwives were permitted and taught to perform certain interventions, but mostly at a low level of technology and capable of being practised in the home without fixed equipment. They were not allowed to acquire technical skills which would have made them effective substitutes for obstetricians.
But when the woman's pathological state raised obstacles to natural delivery too great for the woman's powers and the midwife's skill to overcome, the doctor had to be called in to complete the process with the use of instruments. Until the 20th century, this was done primarily to save the life of the mother; later motivation was more often to save the life of the baby and ease the distress of the mother. Doctors, whose predecessors invented obstetric forceps in the 17th century, retained the monopoly of their use thereafter. The manipulation of forceps requires the doctor to stand by the supine woman, the position which the Latin derivation of their name, obstetrician, describes.
To their monopoly of instrumental delivery, the doctors added in the 19th century another monopoly, the administration of general anaesthesia for the relief of pain. These extra services, despite their extra cost, increased the demand for doctors as birth attendants. The services could be performed in the home ' but more conveniently for the doctor in a hospital where he encouraged his patients to come. In other respects the doctor's midwifery practices were similar in restraint to those of the midwife. Well into the 20th century, undergraduate medical schools were still preaching the doctrine of 'masterly inactivity', waiting for the birth process to complete itself naturally. When serious complications in labour called for operative delivery (and after advances in surgery had made obstetric operations less hazardous) or when they called for continuous intensive supervision, the appropriate place of delivery had to be the specialist obstetric hospital. When, after 1950, the range of interventions, surgical, pharmacological and electronic, proliferated and required the use of expensive technological equipment the only place they could be carried out was the obstetric hospital. As obstetricians became more confident to use the interventions at their disposal, they increasingly abandoned the philosophy of restraint. They redefined normality in pregnancy and labour to justify the widespread practice of antenatal, intranatal and postnatal interventions, so that the need, as they perceived it, for most births to take place in hospital became inevitable. And since obstetricians, despite their vaunted skills, could never predict with accuracy when a complication would arise, the sensible precaution was to take every step to ensure that all births should take place in their kind of hospital.
There was no possibility around this time of making birth in hospital a legal obligation, much as some obstetricians, then and later, might have wished it, for any proposal to do so would have incurred the immediate disapproval of public opinion as an assault on individual freedom. It would have aroused lively opposition from defenders of human rights. It was not until the 1980s, with near total hospitalization secured, that some obstetricians in the USA and Australia, noticing with apprehension the signs of renewed interest among women in giving birth at home, thought it necessary finally to assure their monopoly by advocating compulsory hospitalization (pages 26, 245). But before this recent panic, legal compulsion was judged to be superfluous as long as the objective could be attained by more subtle strategies designed to overcome every obstacle and close up every loop-hole by one means or another. The overriding need was to propagate the belief that birth was essentially dangerous and only under obstetric control could the danger be reduced. If parents wanted live, healthy babies, if communities wanted to replace themselves with vigorous stock, they had to be persuaded that this could only be achieved by entrusting the management of pregnancy and delivery to obstetricians working in obstetric hospitals.
And the earlier the indoctrination started, the more effective would it be. Antenatal care, a concept of the 20th century, was soon embraced as the perfect example of preventive medicine. Regular clinical examinations would detect deviations from normality in time to correct them or at least keep them from jeopardizing a safe birth. Although most diagnostic techniques and available therapies have in reality never been accurate or appropriate enough to meet the challenge, antenatal clinics have provided an excellent medium for replacing the mother's trust in the adequacy of her own physiology to achieve safe reproduction, by trust in the powers of obstetric management to achieve a superior outcome.
In most spheres of human activity, confidence is of great importance in leading to successful results. In no sphere is this more true than in childbirth where the physiological processes are so intimately dependent on psychological states. In the sphere of maternity care the obstetricians' objective was to make their profession the sole repository of confidence. To achieve this objective required an unremitting campaign of propaganda. This proved to be astoundingly successful in winning the approval, active or passive, of the vast majority of the population, through tactics which roused both positive and negative reactions. The propaganda won the approval, or certainly numbed the critical faculties, of the wider medical profession, as well as of legislators and administrators whose responsibility it is to formulate and execute policies for the organization of the maternity service. It inspired the confidence of the lay public, but most critically, it destroyed the confidence of mothers in their own reproductive efficiency and it destroyed the confidence of the alternative birth attendants, midwives and general practitioners who believed in restraint and practised accordingly (Chapters 3 and 4).
The message propagated received a positive welcome, or at least it was accepted with little hesitation, from the wider medical profession. All branches of medicine were becoming more scientific in outlook. Advances in the understanding of all aspects of human biology led to the development of effective, scientifically based treatments for illnesses, both curative and preventive. It seemed a reasonable analogy that greater understanding of the physiology of childbirth should lead to the development of effective treatments, both curative and preventive, for its pathology. It was accepted as an inevitable corollary that preventive treatments would involve interference in the natural process of apparently healthy pregnancies. There is a long history in all fields of medicine of failure to evaluate new treatments before approval of their adoption as standard practice. There seemed no reason to have a different attitude to obstetric innovations.
After 1950, academic departments of obstetrics burgeoned, but their activities in the fields of biochemical and biophysical research far outstripped their activities in psycho-social or in epidemiological research. They did not investigate and so did not come to understand the fundamental interrelationships between emotional and physical processes, underestimating the importance of the former and overestimating the independence of the latter. When the results came to be reported of evaluative research which did not support accepted doctrine, doctrine and practice have been modified reluctantly or not at all in accordance with the findings.
For many years, despite the increased input of medical resources into maternity care, the mortality rates remained stubbornly high. But now at last obstetricians were propounding a new doctrine and now at last mortality rates had fallen and were continuing to do so. It was all too easy to believe that the decline in mortality was the result of the new obstetric methods.
Separate departments within university medical faculties show great mutual tolerance. They do not criticize each other's research nor the principles which underlie what they teach to students. Thus developments in obstetrics were taken on trust as worthy of scientific respect. The logical pitfall of assuming a causal relationship between coincidental trends was ignored, without consideration, by obstetricians. It was likewise ignored by the wider medical profession, which had often been lured into the same pit by the prospect of promoting their interests, directly or indirectly, by such illogical assumptions, for example in encouraging the public's belief that its health depends chiefly on medical care. The obstetricians' position was greatly strengthened by having at least the tacit, and more often the explicit, approval of the leaders of medical thought (Chapter 9).
The logical pitfall of spurious correlation and the lack of analysis of results were more culpably ignored by official committees which were appointed in Britain, ostensibly to give sound and impartial advice to the Minister of Health on what provisions should be made for the maternity service. Naturally, the members of the committees or their advisors included medical experts and the influence of obstetricians was particularly strong. So-called 'evidence' was taken from interested parties, but their submissions amounted to no more than statements of their sectional opinions, which they seem never to have been asked to support with factual evidence, and the material they submitted was never critically scrutinized for validity. The recommendations made in the reports of these committees were not at all impartial but largely endorsed the fallacious submissions of the most eloquent witnesses, the obstetricians' representatives, and gave the sanction of official authority to the obstetricians' ambitions.
An abrupt and radical break with this traditional approach to assembling and assessing information was made by the House of Commons Health Committee under its chairman, Nicholas Winterton, when in the session 1991-2 it conducted a further inquiry into the maternity services. It took evidence from a wide range of individuals and groups, users and providers of the services, as well as impartial researchers who had evaluated relevant outcomes (the first edition of this book, Safer Childbirth?, being included). In sharp contrast to its predecessors, the committee considered the evidence with open minds and came to the conclusion that the arguments put forward by the critics of the service, with supporting evaluated data, were far more convincing than the unsupported assertions of obstetricians. Therefore in 1992 it produced its Report which recommended a fundamental change in the philosophy which underlies the service which should henceforward be organized in the interests of the users, the mothers and babies, and no longer in the interests of the providers unless there was clearly no conflict between these [8].
Such recommendations implied radical changes in practical provisions. To ensure that the Winterton Committee had properly understood the issues involved and judged impartially, the Department of Health appointed an Expert Maternity Group to carry out a further review of policy. The title, Changing Childbirth [9], of the report in 1993 of this independent committee announces that it too was convinced that reorganization was necessary and that 'women and their families should be at the centre of maternity services which should be planned and provided with their interests and those of their babies in mind'. Not surprisingly, organized obstetricians disapproved of future changes to their disadvantage and did what they could to obstruct them.
The lay administrative and executive officers should also have been impartial on clinical issues. Management control, however, is probably simpler when deliveries are concentrated in institutions, preferably large institutions, than when they are dispersed throughout the community. The officers had no professional interest in disputing the policy of their medical colleagues whose views they are accustomed to respect. They were apparently quickly persuaded of its rightness and willingly played their part in its implementation by extending facilities for delivery in obstetric hospitals and curtailing facilities for delivery anywhere else, If necessary colluding with other health personnel to do so (page 17 and Chapter 5). Their reactions to changes called for by the Winterton and Changing Childbirth Reports cannot yet be known in 1993.
The lack of validating evidence was not, however, seized upon by opponents of hospitalization and obstetric management. Most of the doctors who believed in non-intervention reluctantly came to concede that the propaganda must be true since 'everyone else believed it. They found themselves swimming against the ever-rising tide of pressure from their professional colleagues. Certainly, they increasingly conformed to the restrictive booking rules that were being imposed on them and participated less and less in intranatal care.
A few of those who were most sceptical about the new obstetric dogma and who had kept their own careful records were able to write up their results. They produced evidence of perinatal mortality rates very much lower under their care than in hospital and showed that this was not achieved by booking for or transferring to hospital all the potentially difficult cases. (Perinatal mortality comprises stillbirths and deaths in the first week of life.) In the 1950s and 1960s in areas where hospital beds were scarce or considered to be too far away, most bookings were for general practitioner care. Inevitably, they included some at high predicted risk and some which developed complications whatever their predicted risk, but the general practitioners were accustomed to managing abnormal deliveries and did so while maintaining a perinatal mortality rate below, often far below, the national average. For example, a general practitioner reported that in a rural practice in Kent, between 1946 and 1970, there was
a low rate of booking and delivery in hospital, a relatively large proportion of high risk cases under sole practitioner care, a low rate of transfer from GP to consultant care at all stages, a majority of complicated cases managed by GPs
and a perinatal mortality rate, including transfers, about two-thirds of the national average [10]. Other general practitioners in Scotland and Essex were able to estimate from their results that they could have cared safely for 95% and 80-85% of cases in their respective practices [11,12]. Yet such carefully documented analyses carried no weight with obstetricians and those responsible for policy in the maternity service:
Obstetric indications for booking ... appear to be based on the assumption that general practitioners should never be placed in the position that they should have to exercise their judgement on an obstetric matter [12].
A few of the diminishing number of general practitioners who have continued to offer intranatal care since 1970 have reported their results [13-19]. They are allowed to deal with fewer complicated cases, but the outcome for the low-risk women they do attend is very good indeed. Obstetricians are adamant, however, that these good results are only achieved by the transfer to hospital at some stage of all cases with the slightest risk of an unfavourable outcome and that they do not constitute a satisfactory reason for opposing total hospitalization. The validity of this counter-claim will be examined in Chapter 8.
This minority of 'old school' doctors found themselves increasingly at odds with the majority of their colleagues. These included an older group, who found it more convenient to hand over intranatal care to hospital obstetricians, and a younger group of post-1950 graduates.
For recently trained doctors the convenience argument could be rationalized by positive conviction of the rightness of the new practices and by negative fear, for their teachers impressed on them that they were not competent to conduct a delivery without specialist supervision (pages 17, 68).
By referring patients, and if necessary directing the less willing of them, to hospital, these converts became the most effective instrument through which the obstetricians' monopoly of childbirth was secured. in many cases, the tactics they used to persuade or direct were unethical and reprehensible. They frightened women by exaggerating the dangers of confinement at home or in a GPU, while they omitted to mention the dangers of confinement in hospital. They rebuked unwilling women for selfishness and irresponsibility in preferring their personal comfort to the safety of their babies' lives. They raised every conceivable objection, real and imagined, practical, medical and legal, to home delivery. if all else failed, they withdrew their medical service, not only to the woman for conditions connected with her pregnancy, but also to the rest of her family for any illness.
Journals and newsletters, such as the organs of the National Childbirth Trust and the Association for Improvements in the Maternity Services (pages 234-9) in which consumers can report their personal experience of maternity care, have over the years printed many testimonies of women from all parts of Britain of the deliberately unkind and unjust treatment they have received from their family doctors and obstetric consultants when they dared to ask to give birth at home. Doctors who behave in this way disregard the prejudicial effect on outcome of the stress they cause to the pregnant woman. Their behaviour flouts the founding rule of the profession, first do no harm, yet organized medical bodies have taken no action to prevent it. Apparently they accept the doctors' defence that their behaviour is necessary to protect the true interests of stubborn, unreasonable and misguided women and those of their babies or, alternatively, to protect themselves from any liability should the predicted disaster occur and be the subject of litigation.
The experience of British women has not been unique. It has been repeated many times over in countries like the USA, Canada and Australia, where medical policy is antagonistic to home birth and medical tactics serve the same purpose.
Throughout the 20th century, the thinking of leaders of the midwifery profession has been much influenced by the opinions of obstetricians and they have been steadily weaned from adherence to the philosophy of non-intervention to acceptance of the advantages claimed for intervention. Moreover, like the doctors, they have found practical compensations for the erosion of their independence and responsibility. To set against the loss of the job satisfaction of providing total, continuous midwifery care is the attraction of predictable hours of work in hospital, albeit with the impaired satisfaction of providing fragmented care. In hospital they are likely to work only in the antenatal clinic or in the labour ward or in the postnatal wards. Even in the labour ward their responsibility finishes at the end of their shift, whatever the stage of delivery the mother has reached.
For many years, the official voice of the Royal College of Midwives was in harmony with that of the Royal College of Obstetricians and Gynaecologists. Though dissent among midwives started to be organized from the mid-1970s, many midwives in senior administrative posts remained converted to the policy of hospitalization and made their contribution to frustrating the aspirations of non-conforming mothers.
To protect mothers from treatment by incompetent midwives, a system of supervision of midwives was introduced as one of the reforms following the Midwives Act, 1902 (pages 242- 3). The office of Supervisor of Midwives continues to be carried out with commendable attention to the duty of ensuring that high standards of practice are maintained. The standards set, however, tend to be those that would be acceptable to obstetricians. Practice that is more in accordance with the principles of non-interventive midwifery or with the acknowledgement that the mother's wishes, even if not conforming with current orthodoxy, should be respected is liable to provoke stem disapproval and suspension for the offending midwife, without pay and sometimes for a long period. Deregistration is the ultimate penalty. With the risk of such threats to their careers and livelihoods, midwives are effectively deterred from offering mothers a service deviating from officially accepted standards, even when in their judgement these are not in the best interest of the mother concerned.
Whatever problems there had been in converting established birth attendants to the new orthodoxy, obstetricians took effective steps to ensure that they were not repeated with their successors. Once the dogma had been proclaimed and accepted by staff in the obstetric departments of Universities, Teaching Hospitals and Schools of Midwifery, the students were soon indoctrinated and the favoured attitudes firmly implanted. They were required to believe unquestioningly what they were taught on their teachers' authority alone and without supporting evidence. Students found that, to be sure of passing examinations, it was safer to conform, whatever their original attitudes had been.
Instruction in theory and clinical practice was appropriately revised, so that new medical graduates and, to a lesser degree, certified midwives, found themselves qualified to carry out intranatal care only with reliance on interventions which they were conditioned to believe were usually necessary and certainly beneficial. They were deprived of experience of physiological childbirth, of delivery achieved by the natural process throughout. They were deprived of confidence in their ability to supervise the event without the immediate availability of technical aids of lesser or greater sophistication, which means in any place other than the obstetric hospital.
In consequence, it came to pass that local health authorities in Britain were able to argue that, although a woman had a legal right to demand a home birth and they had a legal obligation to supply a midwife, the law was unrealistic and could not be complied with, for they had no midwives in their employment with the experience, confidence and competence to conduct a home delivery and could not count on finding a general practitioner willing to provide medical cover for the birth. Hence they adopted a variety of stratagems to absolve themselves from their legal obligation: they tried to persuade the woman to withdraw her demand in the face of the concerted contrary advice of medical officers, midwives and health visitors. If that was insufficient persuasion, they could convince her to withdraw by supplying an attendant who was disposed quickly to diagnose an impending complication for which care in hospital was mandatory. Thus did local health authorities interact with educators to add their contribution to the obstacle race any mother must run if she sought to avoid a hospital confinement.
For one reason or another, it was hardly surprising that so few women finished up by giving birth at home, whatever their original preferences might have been (Chapter 2).
Obstetricians, contemplating the fait accompli, like to say that women showed their approval of the obstetric management of childbirth by opting for hospital delivery 'with their feet'. The strength of forces propelling them in that direction left women with little alternative. In addition to the advice of their doctor, they were bombarded from all sides with admonitions that to give birth anywhere else was to endanger their own and their baby's life. They heard the message on television and radio programmes; they read it in the daily press and women's magazines. The media, for all their vaunted mission to expose injustice and discuss both sides of an issue, devoted far more time and space to relaying obstetric orthodoxy than to questioning its soundness. Irrespective of political persuasion, they appeared to be curiously timid about conducting any sustained campaign opposing the medical establishment. Any temporary episodes of interest stirred up by enterprising journalists were soon extinguished. In this behaviour, the lay media reflected the attitude of their medical counterparts, who seemed equally unwilling to press criticisms of obstetric orthodoxy.
Women's self-confidence was under continuous attack and was often not improved by their experience of antenatal care, which obstetricians had come increasingly to dominate. Monitoring the health of a woman during pregnancy was a 20th century innovation (Chapter 3). At first in Britain it was mainly organized by local health authorities and carried out by their own medical officers and midwives.. When the National Health Service enabled all mothers to have free antenatal care from their family doctor, most of them did so and general practitioners then found themselves the usual provider of this part of the maternity service. But at the same time, more antenatal clinics were being set up or extended in hospital to cater for the increasing number of women booking for hospital delivery.
The objective of antenatal care had at first been to build up the mother's general health. Under the influence of obstetricians the emphasis changed to detecting, and if possible correcting, any condition in pregnancy which could endanger a safe outcome. Some of the diagnostic tests require only modest equipment and can be carried out satisfactorily in the woman's home or her doctor's surgery. Recent scientific advances have made possible more sophisticated diagnostic procedures, like ultrasound scanning, amniocentesis, cardiotocography (Chapter 3) and others, which require expensive technological equipment and specialized technical staff to operate it. These facilities can only be provided in an obstetric hospital where most women must now expect to have at least some of their antenatal care. Women whose pregnancies are found to deviate in any way from accepted normality are almost certainly referred to hospital for care. Diagnostic tests never give results which are 100% accurate, so they tend to be interpreted over-cautiously to avoid the risk of missing real danger signals. Apprehension is increased among mothers suspected, whether rightly or wrongly, of some abnormality and so, in turn, is their willingness to accept the need for specialist care.
The treatment prescribed for certain conditions in pregnancy requires antenatal inpatient care in hospital. It has been found that women of comparable health status are more likely to be admitted for such care if they have their antenatal care at hospital clinics than elsewhere [20]. The criterion of need seems to depend, not simply on the maternal condition, but also on the accessibility of hospital beds. Unless financial restrictions apply, there are medico-political incentives to fill vacant beds and patients can most easily be recruited from among women attending the hospital's outpatient antenatal clinic. Women are thus conditioned to regarding hospital as the appropriate haven for the care of the ills, real or suspected, of pregnancy and in due course labour. The increase in antenatal admissions to hospital from 15% of deliveries in 1973 to 34% in 1985 suggests a much more generous interpretation of maternal morbidity [21].
It is the inherent disadvantage of any system for the detection of prognostic signs of abnormality that it may implant in the subject some fear that the abnormal condition already exists or is likely to develop. Unless certain cure or prevention can be offered to give complete reassurance, the anxiety created may bring its own dangers which have to be set alongside the dangers of the undisturbed, although possibly false, confidence of ignorance.
It would, however, be quite wrong to imply that all women, or even a majority of them, complied against their wills with a system imposed on them. Most came to acquiesce with greater or lesser enthusiasm in the new arrangements. They certainly did want to produce live healthy babies and they were willing to-concede that 'doctor knows best' and accept the new advice he was giving. In Britain and other Western countries, but not apparently Holland where the influence of midwives has remained considerable, mothers had learned to fear labour as an ordeal at best unpleasant, at worst unbearable. The prospect of handing over responsibility for its conduct to a doctor versed in technical skills for assisting the process was not unattractive, especially with the added inducement of effective pain relief. At all events it seemed a reasonable and brief sacrifice for that promised long-term advantage, declared to be otherwise unattainable.
But in any case many women did not regard hospitalization as a sacrifice. Since the 19th century women in the upper and middle classes had been choosing doctors rather than midwives as their birth attendant and gradually some kind of hospital rather than home as the place of delivery (Chapter 2). The practical attraction of a hospital confinement increased as standards of comfort there were raised and the environment made less austere. Some mothers were glad to be relieved briefly of their domestic responsibilities and to avoid disorganization in their own homes. Problems of later readjustment could be faced if and when they arose.
In time, hospital confinement became the model to which women of the lower classes aspired. It was desired as an assertion of social equality. So the co-operative attitude of women of all social classes was another potent factor in facilitating the transition to total hospitalization.
As with the poorer classes in a relatively rich country, so with all classes in a relatively poorer country, the demand for hospital maternity care represents escape from the stigma of poverty and social inferiority, Though misguided, this may prove to be as powerful a motive as the desire to reduce the risks of childbirth in influencing the organization of maternity care in less economically developed countries. The organized medical profession will always be glad to encourage such aspirations.
When given the opportunity to choose between birth attendants, the woman's preference for doctors (once always male) may have been based on more than the promised superiority of their clinical skills. Psychologists have hypothesized that the changed attitude arose from deep psycho-sexual causes - the female fantasy of the weak woman being rescued from distress and danger by the strong male. The doctor's motives or becoming involved in maternity care may arise from similar deep causes - the male fantasy of the strong man rescuing the weak woman from distress and danger. After his essential contribution to initiating the process, the male takes no further part, biologically, in reproduction. The mystery and power of creation is vested in the female. The male is said to resent, at least subconsciously, this exclusion and the implication of inferiority.
Anthropologists detect different ways in which this resentment is manifested in different cultures. In Western medicine, the male obstetrician reasserts his superiority over the female when he finds her body unable to carry out its function of reproduction competently by itself and he can take over her prerogative by intervening to assist and complete the process. He reasserts his superiority most emphatically when he cuts open the womb and extracts the baby without any cooperation from the mother, an intervention apparently so deeply satisfying to the operator that, now that its danger to life is relatively small, is imposed on ever slighter pretexts (Chapter 4).
At a personal and superficial level, the socially approved obstetrician/patient relationship legitimates a limited and non-committal physical intimacy which gives pleasure to some men and some women. For women at the other extreme, the physical intimacy from which they can only escape by forgoing professional care is a constant source of disgust, distress and tension.
At a general and deeper level, a more cynical theory is that the male acquisition of the domination of childbirth and society's acceptance of this situation represent a fundamental counter-attack on the female's strivings and achievements along the road towards political and economic equality. Cynics see this as a salutary demonstration that inroads into man's territory have been accompanied by the surrender of her own, woman's territory - a universal acknowledgement of her essential subservience.
Many male obstetricians would resent having their choice of career attributed to any of these psycho-sexual or socio-sexual motives. A more prosaic explanation is that their. choice was unemotional and quite pragmatic. their first ambition was to be a specialist doctor and obstetrics, combined with surgical gynaecology, was the speciality with the most promising career appointment vacant when they made their choice.
Hospitalization of childbirth is the medium through which the philosophy of interventive obstetrics is carried into practice. That philosophy, now held by most obstetricians, is opposed to the philosophy of non-interventive midwifery, once held by all and still held by many midwives. One philosophy cannot take precedence over the other unless its practitioners likewise take precedence. For the realization of total hospitalization of birth, a necessary condition was the resolution of a power struggle between the rival providers of maternity care, a struggle in which career obstetricians gained victory over career midwives. However, the original reason for the struggle was, not the idealistic aim of asserting the superiority of a philosophy, but the self-centred aim of securing better career opportunities for male obstetricians in a hitherto female occupation. They won the interprofessional contest partly because of the poor fighting qualities of the midwives and the weakness of their occupational organization, inherent female characteristics (Chapter 2).
Unlike men, women in all occupations seem to have a basic disinclination to grasp the material advantages to be gained for themselves through organizing in a trade union . in order to pursue their group interests at the expense of competitors. Midwives in earlier centuries never succeeded in doing so. They were never persuaded to try to emulate the success of male trade guilds and professional colleges. When in the late 19th century their thinking changed and they got around to setting up their own professional organization, they were heavily dependent on advice and support from sympathetic doctors. In any case, the regulation of midwives was, from 1902 to 1983, in the hands of the Central Midwives Board (CMB), the body which was appointed to implement the provisions of the 1902 Midwives Act but which for most its life included only a minority of midwives among its members. The College (later Royal) of Midwives was prevented from exercising the same authority over its members as the medical Colleges did over theirs and the authority was further weakened by the considerable influence on it of obstetrician colleagues. This has been a sort of 'Trojan horse', which discouraged organized midwives from perceiving their professional interests as opposed to those of obstetricians and so from organizing effective self-defence. Obstetricians' influence at this level was greatly assisted by their influence, through the CMB, over midwives' training, which progressively undermined new midwives' faith in an old, and opposing, creed.
But in fact, many individual midwives did not see obstetricians, on whose interventions they relied in cases of complicated delivery, as opponents. Exemplifying the 'inferior sex' stereotype, midwives (weak and female like their clients) recognized the limitations of their skills and waited to be rescued by obstetricians (strong and male). Whether or not the intervention called for would also rescue the mother or the baby, the midwife had let someone with different skills take over responsibility for the outcome. She deferred to a superior profession and her defence was enshrined as a legal obligation under the regulations of the Midwives Act, 1902.
Organized midwives, from inclination and legal necessity, shared this attitude of ultimate inferiority and were disposed to bow to the superior wisdom of organized obstetricians with whom they would have preferred to co-operate than dispute. While they were agreeably co-operating, the interests of midwives as midwives with a philosophy of their own were steadily being eroded and their occupational subordination confirmed. But the significance of the struggle was wider than its direct effect on the professional groups concerned. The obstetricians' victory for their occupation implied also victory for their philosophy, victory for the medical management of procreation, which directly affects everyone.
As obstetric management came increasingly to dominate intranatal care in the 1970s, some midwives became urgently aware of the threat to their survival as a profession and as practitioners of a fundamental philosophy. A group of them organized a movement, which they called the Association of Radical Midwives [22], within the Royal College of Midwives to reassert their role as the guardians of normal childbirth, which, in the absence of obstetric interference, would be completed without complication in around 80% of cases. Their thinking, backed by impartial analyses of the results of maternity care which had been published since 1977 and investigations by the World Health Organization, influenced the Royal College of Midwives to adopt a more independent stance and introduce their own proposals for reform (Chapter 2).
In the course of the 20th century, the British midwife has undoubtedly sacrificed much of her independence of practice and public esteem for her profession as midwife, in favour of her role as obstetric nurse, increasingly competent to operate sophisticated technological instruments but less competent to empathize with the mother and facilitate the physiological process of labour and delivery. But she has not sacrificed all her independence, all her status, all her traditional skills. This is in marked contrast to experience in some other countries, notably the USA, Canada and Australia, where the midwife has been all but annihilated through the actions and propaganda of a politically powerful obstetric profession.
Since professional midwives in so many countries are weak, it is not surprising that their International Confederation, formed again in 1951 after its wartime disbandment, has been unable to give its members effective support in re-asserting the philosophy of non- interventive midwifery and winning political recognition for its practice. But if it can do little to protect the professional status of midwives, its triennial conferences generate great enthusiasm and mutual comfort among the members who participate, so that hopes are kept alive that future reforms are worth fighting for (Chapter 2).
In this regard also, obstetricians have been much more effective. In the 1930s, the young British College of Obstetricians and Gynaecologists was quick to extend its influence to the then Dominions of the British Commonwealth. The American College of Obstetricians and Gynaecologists was founded in 1951. International co-operation and consultation flourished and was soon formalized in 1954 in the International Federation of Gynaecologists and Obstetricians, an organization with considerable influence and success in propagating widely the beliefs and practices of interventive obstetrics.
Obstetricians have been joined in recent decades by powerful allies who profit from the operation of obstetric management. As new anaesthetic agents and techniques for their administration have been developed, the discipline has become too complicated to be left under the control of anyone other than a specialist anaesthetist. The service of an anaesthetist is required whenever general anaesthesia has to be administered, As when delivery is by caesarean section - an increasingly favoured procedure in many obstetric hospitals - or when the mother asks for epidural analgesia to relieve her pains while she remains conscious, a plea encouraged increasingly by her birth attendants.
Anaesthetists have acquired a vested interest in the kind of obstetric management that creates jobs for them by making them essential members of the obstetric team. A very small number of maternal deaths are caused by the tragic side-effects of anaesthesia. If these are to be prevented, specialist anaesthetists claim that they must be involved. If their availability is essential for a safe delivery, and if all mothers are to be given the option of comprehensive pain relief, as anaesthetists advocate, then birth must take place in their workplace, the hospital. Adequate, or indeed any, anaesthetic cover cannot be provided in GPUs or the family home and this makes them, in the opinion of organized anaesthetists, totally unsuitable places for birth, whatever other advantages may be claimed for them (pages 175, 212).
Many babies, born after operative or instrumental deliveries or to an anaesthetized or drugged mother, are in such a poor condition to start independent life that they have to be resuscitated and removed to a special or intensive care unit where their progress can be monitored through a battery of highly sophisticated electronic instruments. A complex science of neonatology has been built up to save the lives of sick and underdeveloped infants, and doctors have become specialists in this fascinating, often distressing, often rewarding, branch of paediatrics. It is plausible that the sooner special care starts, the sooner will the child recover. For this reason neonatologists can advocate that birth should take place close to the facilities for special or intensive baby care, which exist in the larger obstetric hospitals. This is to ignore the evidence that a much smaller proportion of the babies born outside obstetric hospitals, like the babies born in hospital who escape the invasive interventions, arrive in such poor condition that they need special care at all. The careers of neonatologists depend largely on a regular throughput of sick and immature babies, the victims or perhaps the successes of interventive obstetrics (Chapters 4, 5 and 8).
The advances in interventive obstetrics, anaesthesia and neonatology are dependent on the technological instruments and pharmaceutical products by means of which the interventions are carried out. The manufacturers of these have a strong commercial interest in promoting their use. The sale of drugs has to comply with legally imposed safety regulations, which take account of known dangers, but some dangers do not become known until after, sometimes long after, a drug has been used. Until their products are proved harmful, the drug companies have every incentive to encourage obstetric practices which will maximize their sales.
There is no corresponding restriction on the sale and use of equipment. Instruments of one kind and another have been developed with admirable ingenuity, so that hitherto inscrutable processes or states can be observed or deduced. They have certainly helped to increase knowledge. Whether they have helped to increase wisdom is very doubtful. They are sold on the merits of their fascinating appeal to technologically minded doctors. They are bought and put into routine service without having to show that they result in a net improvement, short-term or long-?
The interests of the manufacturers of medical equipment and drugs coincide exactly with the interests of those who preach and practise obstetric management and conflict directly with the interests of those who preach and want to practise natural childbirth. Only the former group of clients has access to the valuable financial support, liberally provided from commercial sources, in the dissemination of propaganda. Also sharing a commercial interest in hospitalization are the manufacturers of baby products, particularly substitutes for breast milk, for they have found the concentration of births there a most convenient environment for sales promotion, though the goods they advertise and later sell are often not in the baby's best interest.
More ironic is the obstetricians' success in winning the support of their brother professionals, the lawyers (Chapter 5). The essence of the legal system is that it should probe and sift evidence impartially before a judgement is made. Judges acknowledge their ignorance of medical matters. Their criteria are that treatment given should be in the best interest of the patient and administered by the most effective methods currently known, so that they turn to the reputed experts in the discipline concerned. The experts on childbirth to whom they refer are obstetricians, not midwives.
The experts' integrity is taken for granted. The possibility of a conflict of interest between the providers and receivers of treatment is not addressed. The obstetricians' assertions are accepted without ascertaining that they are based on an unbiased evaluation of clinical and statistical evidence. In particular, lawyers have accepted expert submissions that caesarean section offers the safest solution in cases of obstetric complication and that a record of the fetal heart rate by an electronic monitor is an indispensable indicator of the correctness of further treatment, both opinions for which there is discrediting evidence (Chapters 4 and 8).
Pursuit through litigation of grievances arising in maternity care has become more popular in recent decades. Fear of litigation is quoted as one of the chief reasons for the impressive rise in the incidence of caesarean section and the continued use of electronic monitors. Obstetricians have got themselves into the ridiculous position of having to perform an operation, or carry out a diagnostic procedure, in order to forestall successful litigation on the grounds that they did not do everything possible to secure a safe outcome, when in fact their action is much more likely to prejudice a safe outcome in most cases.
In the USA, hysteria has gone even further. Courts have been persuaded to grant orders forcing women to be detained in hospital and undergo obstetrical procedures, in particular caesarean section, against their will. A body of legal thought is growing that, once it has reached the stage of viability, the fetus has rights distinct from the mother and these rights are to be safeguarded according to the obstetrician's, not the mother's, judgement. The mother is to forfeit her right to be protected from physical assault, which is what a surgical treatment for which she withholds her consent actually is.
Obstetricians would clearly like a legal embargo on any alternative to hospital intranatal care if this were politically and practically feasible. In Britain, the Royal College of Obstetricians and Gynaecologists has suggested to successive Government Committees reviewing the maternity service that recommendations in this direction would be welcome, but the recommendations have not been made, nor have politicians acted on the suggestion. In 1987, a prominent Australian Professor of Obstetrics, who claimed to have widespread support among the medical profession, certainly among obstetricians, called for laws banning home deliveries on the unsustainable grounds that they are much less safe [23].
Despite their almost total monopoly of childbirth care, the anxiety of obstetricians the world over to prevent the slightest competition, by any means however offensive to human rights, surely betrays an uneasy lack of confidence that their style of management is indeed as superior as their propaganda proclaims.
And it was the effectiveness of their propaganda which ensured the obstetricians' ultimate success. Their universally appealing argument in favour of hospitalization was that birth would thereby be made safer for mother and child. Obstetric management would reduce, not only the dangers of complications which had occurred, but also the dangers of complications ever occurring. The natural process, the immensely complex and wonderfully co-ordinated sequence of interdependent events and relationships, the product of aeons of evolution, would be made safer by the interventions devised by 20th century obstetric scientists.
What evidence did obstetricians have to justify their ambitious claim? They constantly drew attention to the coincidental trends of rising hospitalization and falling mortality and implied, indeed asserted, a causal relationship between them (Chapters 6-8). Neither they nor anyone else thought it necessary to test statistically whether this conclusion was valid. When the simple test was eventually carried out by the present author, the claim was found to be unsustainable. The correlation between the annual proportional increases in the rate of hospitalization and the annual proportional decreases in the rate of perinatal mortality was strongly negative. This implies that, if births in obstetric hospitals had not increased, perinatal mortality would have fallen by more than it actually did (pages 344-8 and Figure 8.1).
For the statistical test to be carried out, however, the necessary data had to be available and progress towards total hospitalization was well advanced before this happened. Nevertheless, other statistics were available by the mid-1960s from which highly relevant inferences in the same sense could have been drawn by impartial analysts.
If obstetricians were to be able to show that mortality rates were lower when births took place under their management than when they took place under the supervision of midwives or of general practitioners, they needed to measure the results of care under each system. Measuring results means collecting and collating appropriate statistics and making them available for impartial analysis, so that fair and informative comparisons can be made and valid conclusions drawn.
Collecting and processing statistics is an expensive undertaking. It requires a considerable degree of skill and judgement from those who have to decide what statistics it will be appropriate to collect and how they can be most informatively collated and presented. It requires accuracy and honesty on the part of those who actually collect the original information and compile the necessary data forms. It requires even more skill, judgement and honesty on the part of those who carry out the analysis if their interpretation is to be accurate and impartial. These attributes are just as necessary in the days of computers as they were before.
Specific statistics may be collected prospectively for the research purpose of testing some hypothesis and the cost will be met by whomsoever finances the research topic. No one in any country ever set out to test the hypothesis that hospitalizing birth made it safer. So precisely appropriate statistics for this purpose were never collected. Analysts have to make the best use they can of existing statistics, whether these are derived from official or unofficial sources, provided they are reliable. Most of the official statistics come as the by-product of some administrative requirement, such as the compulsory registration of births and deaths and the management of health services at central and local levels. The collection is financed more or less generously from the public purse.
As stocks of data go, Britain is relatively well endowed, but even so routinely published official statistics before the 1960s were rarely classified by place of birth and the sparse stock of statistical results for earlier years comes mainly from specific investigations. Not many more were so classified after 1960. Nevertheless, they make a useful contribution towards evaluating outcome at each place during the period before the 1980s when hospitalization became virtually complete and effectively put an end to the possibility of making informative and valid comparisons.
Because total hospitalization came later in England than in most other comparable countries, while at the same time her collection of medical statistics was relatively advanced, she is in a unique position to supply material referring to large national populations and relevant to the evaluation of different systems of care.
Since 1952, the Ministry of Health and its successors, the Department of Health and Social Security and later the Department of Health, have commissioned a continuous review of the causes of the maternal deaths which occur each year. By 1952, the number of these had fallen low enough to make individual enquiries a feasible exercise. The results of these confidential enquiries have been published triennially, but it was only between 1964 and 1975 that they were classified by place of delivery and mortality rates shown relative to the number of births booked, though not necessarily delivered, at each place. The data given did not make it possible to control for differences 'm the predicted risk status of the mothers booking at each place, beyond their age and parity (the number of children they had previously borne), but mortality rates, in total and at specific ages and parities, were highest for births booked for hospital (page 321). After 1975, maternal deaths were too few to support meaningful analysis by place of confinement (Chapter 7).
In the field of perinatal mortality the endowment is richer. Because infants of low birthweight are at such high risk of dying and because their perinatal deaths make up such a large proportion of the total, the Ministry of Health routinely collected information about them, along with their place of birth. Between 1954 and 1964, the Chief Medical Officer published his analysis of the results in his annual reports. They showed that the rate for stillbirths plus neonatal deaths was very significantly higher if delivery was in a hospital, a category which then included GPUs. He continued to collect the data after 1964 but ceased publishing the results. The unpublished returns for the years 1967 to 1973 were later supplied to the present author in response to her private request. They confirmed the significant excess mortality in hospital (Table 8.3).
Annual records derived from registration data of births and stillbirths, which were published by the Registrar General from 1965 to 1968, also showed that stillbirth rates were much higher in hospital than at home. From 1969 to 1981, the figures were given separately for obstetric hospitals and GPUs and made it clear that it was in the former that the excess mortality occurred. In the course of the 1970s, a drastic reduction was enforced in the number of births at home. This affected principally women who would otherwise have had planned midwifery care and low mortality. Without them, the stillbirth rate for the remaining home births was left increasingly to reflect the high mortality of the small core of women who, though at high risk on account of biological or social factors, made their own choice to reject professional care of any kind. Nevertheless, by 1981 the stillbirth rate in hospital was still significantly higher than in GPUs and home combined (Table 8.7).
The meagre store of official statistics can be supplemented with data obtained from two nationwide sample surveys of births and associated deaths (Chapter 8). These were conducted in 1958 and 1970 under the auspices of the Royal College of Obstetricians and Gynaecologists and were financed by a charity, the National Birthday Trust Fund. They had in fact been preceded in 1946 by a survey of maternity in Great Britain (Chapters 3 and 4), but the statistics published in the report contribute hardly at all to the evaluation of outcome at each place of birth. In 1946 the importance of this issue was not apparently realized.
In the later surveys an immense amount of detailed information was collected about every birth, live and still, that occurred in Britain in one single week of each year, 1958 and 1970, providing representative samples of experience around these periods. The 1958 survey went on to collect information about every stillbirth and neonatal death which occurred in the following three months. The characteristics of these larger numbers of deaths could then be related proportionally to the characteristics of all births to reveal instructive associations. In 1970 information collected on deaths was limited to those occurring in the survey week and so the smaller numbers gave less scope for cross-classifications and subanalyses.
The published results of the surveys (Chapter 8), particularly the one in 1958, provided an invaluable store of information on many aspects of childbirth and quantified many significant associations between predicting risk characteristics and outcomes. The terms of reference for the Steering Committee of the 1958 survey included the gathering of information about the possible effects of the place of confinement. But the published reports, for no explained reason, presented only a few cross. classifications relevant to this issue. To the impartial observer the statistics which were published in whatever detail they were categorized and whatever the predicted risk status of the births concerned, showed consistently and unmistakably an excess of mortality among the births in hospital (Table 8.1). Yet, amazingly, they were interpreted as showing precisely the opposite - an excess of danger for births outside hospital and especially for births at home.
If cross-classifications with other risk factors for which there were survey data would have satisfactorily explained the apparent excess of mortality in hospital it is incredible that they were not published. The distortion of fact was quite out of keeping with the scholarly quality of the rest of the report, which commanded wide respect and probably served to gain credence for the distortion. The other findings did not conflict with professional interests. The finding of excess mortality in obstetric hospitals was in total contradiction of them and proved to be too great a challenge to impartiality.
The biased interpretation or deliberate misinterpretation, reiterated many times in the report, was accepted not only by those who had a professional interest in believing it, but also by a much wider public who mistakenly trusted the experts to be impartial. If anyone, disinterested statistician or other, protested at the time about this blatant misrepresentation, there seems to be no record of such protest in medical annals. On the contrary, frequent references can be found in the literature to the 'conclusive' finding of this survey that the family home is the most dangerous place for birth and this view certainly informed the thinking of those in a position to influence official policy for the maternity service. Its influence in propagating this belief was not limited to Britain. The welcome message was repeated uncritically by obstetricians around the world.
In 1970, about one-third of British births were still taking place outside the obstetric hospitals, but the number of associated perinatal deaths there in the survey week was very small, both absolutely and relatively to births. This was used as the reason for not publishing detailed comparisons with the much larger number of deaths, both absolutely and relatively, associated with births in hospital. Careful scrutiny and re-assembly of the published data, however, enabled mortality rates in specific subgroups of births to be closely estimated. Comparison between results for births in hospital and outside repeated the true findings of the 1958 survey, a consistent excess of deaths in hospital. Explicit data, which would have confirmed this unequivocally, could be derived from the collected material, but they were not published by those in charge of the survey. It was not until 1983, after a persistent campaign carried on for two and a half years by the present author., that the data were finally released. The results were devastating to obstetricians' claims, for they showed that at every level of predicted risk measured, high and moderate as well as low, perinatal mortality was highest by far for births in obstetric hospitals and lowest for births at home (Table 8.6).
But by 1983 revelation of the facts came far too late to influence the course of events. Whether or not by deliberate intention, the results of the 1970 survey, which confirmed the true findings of the 1958 survey and of every other relevant. source of data and thus should have changed policy if policy is to benefit the users and not the providers of the maternity service, were obscured and withheld until it was too late to matter. Total hospitalization had already been achieved.
Was there reason to doubt that these results, which reflected the outcome of obstetric care as a whole, were giving a less than fair picture of the promised benefits of hospitalization? If hospitalization and obstetric management were going to reduce mortality overall, this could only be achieved if mortality was lower in cases when particular interventions were practised than when they were not.
After 1950, maternal mortality from all causes was already falling quickly, related to certain medical treatments but only marginally related to obstetric interventions. Intervention was not often called for in order to save the life of the mother. Even in morbid conditions like severe toxaemia or pre-eclampsia, where the mother's life is in danger until the pregnancy is ended, there is no evidence that the downward trend in mortality was hastened, markedly or indeed at all, by the rising incidence of the induction of labour or elective caesarean section (Chapter 7). By 1991 some leading obstetricians were voicing misgivings about the benefits of interventions. In a memorandum to the Winterton Committee, one Professor wrote, 'It must be recognised that diagnostic and therapeutic interventions have their own intrinsic risk. On some occasions an intervention may cause the harm one is trying to prevent. An intervention without proven benefit cannot be justified on the basis that it will "do no harm"' [24, p. 800].
Most specific interventions are undertaken ostensibly in the interests of the infant. But in fact they were all introduced and adopted as routine practice without any trials having been conducted to confirm that they did reduce perinatal mortality in the circumstances in which they were being used. Retrospective results showed consistently that mortality was higher in the subgroups subjected to intervention. The conventional defence is that the interventions were only used to avert a greater danger, but this defence cannot be sustained. Induction, for example, was carried out in nearly as many births at low predicted risk as at high and often not as a response to medical indications (page 156). If mortality is higher after individual interventions, irrespective of the predicted risk of the birth, it must follow that overall mortality will be higher under the system of obstetric management which incorporates all the interventions and practises them liberally, even in low-risk subgroups which would otherwise have experienced low mortality rates.
Interventions which need the equipment and expert staff of a specialist hospital are very probably life-saving in certain, but infrequent obstetric emergencies and when such emergencies occur some distance from a hospital, delay in performing the intervention may well increase the danger to the point of death. Avoiding this potential risk for the few is widely held to be the conclusive argument justifying the total hospitalization of all births.
But obviously, avoiding this danger must be to court others. There is absolutely no evidence that the routine use of interventions prevents the occurrence of emergencies. There is positive evidence that the routine use of interventions increases the dangers of death. In each case this increase may be small, but it affects a lot of cases. In aggregate these 'routine.' dangers, added to by the dangers of unnecessary interventions which often follow mistaken diagnoses, far outweigh the 'emergency' dangers. This is what mainly causes the mortality rate for births in specialist hospitals, where such 'routine' dangers are prevalent, to be higher than that for births at home or in non-specialist hospitals, where both 'routine' and 'emergency' dangers are rare.
But the intention of obstetric interventions, devised by experts drawing on a wealth of scientific knowledge, is to improve the ease and safety of childbirth. Are there scientific reasons why they should fail in their purpose? Great discoveries have certainly been made about the physiological processes involved in childbirth, but a great deal about the essential interactions is as yet imperfectly understood. What has been demonstrated is that any artificial interruption at any stage of the naturally ordered processes upsets the co-ordination of the subsequent elements of the integrated sequence and so reduces the safety and efficiency of the whole. In the words of an eminent Dutch Professor of Obstetrics [25]
... Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference with them will only detract from their optimal character ... the danger will arise that the physiological part of obstetrics will be threatened by doctors who all too often will change true physiological aspects of reproduction into pathology.
Indeed the purpose of many interventions has to be to compensate for and if possible put right the harmful consequences of the damage created by an earlier intervention. Thus is generated the aptly described 'cascade of intervention' [26].
Induction may initiate labour, but it initiates many other problems as well. For the mother there are, inter alia, the physical problems of increased pain, increased need for analgesia or anaesthesia, increased restriction of mobility through having to have a fetal monitor applied, increased need for instrumental or operative delivery, increased risk of postpartum haemorrhage, increased risk of postpartum infection; she is also liable to experience the emotional problems of a sense of her own incompetence and failure and of delayed bonding with her baby. For the baby there are, inter alia, the physical problems of a lesser or greater degree of immaturity, of a reduced oxygen supply and increased distress, of respiratory depression through the absorption of sedative drugs given to the mother, of injury from instrumental or operative delivery. There are no means of knowing whether the baby suffers emotional problems, and how serious they are, from losing its control of the timing of its delivery, from the greater violence of induced contractions and of instruments, physical forces it has not evolved to cope with, or from its greater risk of being separated from its mother for special or intensive neonatal care. The interventions and their consequences will be described more fully in Chapters 4 and 8.
There are, therefore, sound biological reasons why obstetric interventions, however well intentioned, should have failed to make most births safer and sound biological explanations for results which show an excess of mortality among births in hospital under the management of obstetricians.
The facts are, however, that by the 1990s for some reason both maternal and perinatal mortality rates had fallen to a small fraction of what they had been fifty years before. The decline had taken place continuously after a long period when these mortality rates, unlike others, had remained persistently high, The English experience was shared by other developed countries and everywhere it happened over the period when the influence of obstetric thinking and practice was increasing rapidly.
The hypothesis that the decrease in mortality was caused by the obstetricians' increased domination of maternity care is seductive but, sadly for its proponents, it does not stand up to impartial investigation. It is opposed on the one hand by statistical results and on the other by biological expectations, factors which are mutually consistent. There must, therefore, be some other hypothesis to explain the decline in mortality and its timing. The obvious alternative is that the declining mortality was brought about by the improving fitness of the procreating population, principally of childbearing women but also of their mates.
In all living species healthy offspring are most likely to come from healthy parents. Declining death rates and increasing expectation of life are reliable indices of a population's improving health status resulting from rising standards of living, especially from better nutrition. But a woman's fitness to reproduce depends only partly on the standard of living and of nutrition she currently enjoys. It depends also on the nutrition she has received since her conception, throughout her fetal, infant and childhood life, when the structure of her body and her reproductive organs were developing.
The trend in death rates indicates that, although the current standards of nutrition enjoyed by women of childbearing age were improving in the late 19th century, their physical development had been inherited from more deprived times. Only after 1900 did the infant environment improve. Smaller family sizes meant more food for each child. Better nutrition not only increased an infant's resistance to infectious diseases, but also to diseases of malnutrition like rickets which impair skeletal development and, in particular, cause malformation of the female pelvis. For women, malformed pelves certainly cause problems at delivery which seriously threaten the survival of both mother and child and malformed pelves were very prevalent among the childbearing women of the 19th century.
As the prevalence of infant malnutrition diminished, so did the incidence of pelvic malformation and other maldevelopment affecting the reproductive system among future mothers. But it was not until the 1930s, two generations after the first decline in the general death rate, that the effect of this improvement began to show and the first signs appeared of a decline in maternal mortality.
It so happened by chance that these first signs were immediately followed by powerful life- saving innovations in medical treatment. Popular opinion, medical and lay, was quick to give all the credit for the welcome improvements in maternal mortality to the new medical treatments and overlooked the possible contribution of improved maternal health and physique. The earliest and most striking of the medical innovations, the discovery and introduction of antibiotic drugs, was followed by a speedy and steep reduction in maternal deaths from puerperal sepsis. The less dramatic effect of increased resistance to infection by healthier hosts was overshadowed, though discerning observers did recognize that the use of antibiotics did not provide the full explanation of the reduced mortality and morbidity from what had hitherto been a most intractable, and the greatest single, cause of maternal death (Chapters 4 and 7).
The perinatal mortality rate was less quick to fall. Although from the 1940s it did so continuously, the pace of decline was not constant. It was particularly rapid in war-time Britain, but this pace was not achieved again until the 1970s. Most of the mothers in the 1940s had themselves been babies twenty or thirty years earlier when special programmes for maternal and infant welfare were adding to the benefits of generally improving standards of nutrition, or at least giving special protection to these groups from the privations imposed during the world war of 1914-18.
The effect on infants of the economic depression and widespread unemployment of the 1930s, although partially ameliorated by welfare programmes, was reflected in the sluggish decline in perinatal mortality in the 1950s. The high level of employment and the management of the economy during the war years of the 1940s, plus more intensive welfare provisions, led to higher standards of nutrition, particularly for mothers and babies. These were in due course reflected in the accelerated decline in perinatal mortality in the 1970s. Continued post-war economic prosperity and welfare programmes ensured a cohort of mothers sufficiently healthy to withstand the effects of the high level of unemployment in the 1980s and early 1990s, so that perinatal mortality continued to fall (Chapter 8).
Maternal and perinatal mortality are critically dependent on standards of maternal nutrition both during the gestation period and, no less importantly, during the mother's life since her own conception. The process is cumulative over generations. The health and physique of one generation of mothers depends on the health and physique of their mothers and, in turn, of their grandmothers and great grandmothers. The improvement in health of the general population, which manifested itself in lower death rates from 1870, took two generations to manifest itself in lower death rates for mothers and even longer for their babies. just as improved health caused death rates in general to fall in the absence of effective medical treatments, so would maternal and perinatal death rates have fallen, after the appropriate time lag, in the absence of effective obstetric treatments.
Improving maternal health over the generations has led to a declining perinatal mortality rate to which the greatest contribution has always been made by births of low weight (those under 2500 grams or 5 1/2 pounds). Low-weight births are themselves also strongly correlated with poor maternal health. It might have been expected that the proportion such births make of the total would also decrease as maternal health improved. Surprisingly this has not happened. This may be because the expected decrease has been offset, to a greater or lesser extent, by some of the most frequent obstetric interventions which are designed to forestall the diagnosed impending dangers of continued uterine life, but which inevitably cut short the baby's gestation and may in the end bring dangers more life-threatening than those they avoid.
In the course of the 20th century many treatments have been developed to cure certain types of pathology and prevent others. Where they are effective, they reduce mortality and add to the beneficial consequences of the population's good health. Particularly in the second half of this century, treatments have been developed to cure or prevent certain types of pathology associated with pregnancy and childbirth. Where they are effective, for example, in the prevention of rubella, with its consequent congenital malformations, and of neonatal haemolytic disease caused by maternal rhesus iso-immunization, they reduce mortality of mothers and infants and add to the beneficial consequences of the mother's good health and physique. But they are not always effective and can do more harm than good. This is highly likely if treatments, which may be appropriate for specific pathological conditions which occur in the small minority of cases, are used in healthy pregnancies and labours, which make up the large majority.
The coincidence of the improving health status of mothers (and fathers) and of the increasing practice of obstetric interventions in maternity care has had the disastrous consequence of perverting the scientific understanding of what essentially makes birth safe. The professional bias of obstetricians and their medical colleagues, not surprisingly, is to attribute the decline in associated mortality which has already taken place mainly to the results of their treatments. This has suppressed any lingering doubts about the rightness of their philosophy, that nature unassisted is a poor midwife, that the natural process is always fraught with dangers which obstetric interventions can in most cases reduce and in no case increase. It has inspired in them a misplaced confidence that their research should be directed towards creating ever more sophisticated clinical procedures. In fact it has produced a vast amount of information of value in the study of fetal development and its pathology but of little relevance to the long-term objective of making human reproduction safer.
Research to unlock nature's secrets has been directed down channels at the end of which the Holy Grail does not lie. For obstetricians' interventions concentrate on the physical and biochemical processes of birth and neglect the no less essential emotional processes, the function and effect of which they undervalue. Obstetricians are motivated to undervalue them because emotional processes fall outside their sphere of expertise and acknowledgement of them would impede rather than facilitate implementation of their theories.
From their unsound reading of history they go on to recommend that future improvement can be achieved only by the continuation and intensification of their efforts. Conviction that their diagnosis and prescription are correct blinds them to the overwhelming evidence that supports the alternative philosophy so eloquently summarized by Professor Kloosterman [27]:
... giving birth is mostly a normal physiological event which does not require any form of medical intervention ... a natural phenomenon that only requires medical interference in pathological and rather exceptional situations.
... we cannot improve labour in a healthy woman. We can change the process, we can shorten it, we can speed it up, we can try to take away pain, but at best we will do this without doing any harm. This leads to the conclusion, that the ideal obstetrical organization brings aid to women and children who need help (the pathological group) and protects the healthy ones against unnecessary interference and human meddlesomeness.
The later stages of the process which culminated in the obstetricians gaining pre-eminence as providers of maternity care have been completed quickly in the last twenty years. But the foundations for change had been well laid in the development of the contributory and interacting factors over earlier decades and even centuries. Understanding the present situation requires more detailed knowledge of the changing earlier states which led up to it: of the changing roles and changing training of the rival birth attendants; of the changing practices in maternity care, antenatal as well as intranatal and postnatal; of the changing attitudes and expectations of childbearing women; of the changing involvement of society; of the results of maternity care at different periods and how they were misinterpreted, misrepresented and ignored in the determination of policy. This unsatisfactory state should be brought to an end if the reforming recommendations of the recent reports of the Winterton Committee and the Expert Maternity Group are implemented.
The following chapters will outline the historical sequence and interaction of the events which led up to the revolution in maternity care and make it clear that the chief beneficiaries of the revolution are not, as we are led to believe, mothers and babies, but the dominant providers of care and the supporting professions who share the same interest. The diverse strands of the complicated tapestry will be brought together and the implications for the future will be indicated in the epilogue.
Marjorie Tew was until her recent retirement a Research Statistician at Nottingham University Medical School, Nottingham, UK.
ISBN 1-85343-426-4
Free Association Books