More than any other endeavor, save death, the history of childbirth is quite literally everyone’s history. The stories recounted in this volume remind us of the broad themes that have dominated the history of childbirth in the United States for the last century and continue to resonate today. These include debates over the place of birth, the benefits and limitations of medical intervention and technology in birth, the status of women as providers of care and decision makers concerning their own maternity care. How are these themes manifested in contemporary US maternity care? After a steady rise from 1996-2009 that resulted in the highest cesarean rate in US history (32.9%), the cesarean rate has been decreasing at a glacial pace to a 2016 rate of 31.9%.1 The current rate is still far beyond what evidence suggests it should be, if this abdominal surgery was only about improving health outcomes,2 but what was seen as an inevitable increase in cesareans has not occurred.3 Rates of other interventions, such as medical induction of labor, electronic fetal monitoring and epidural anesthesia are also at all-time highs, though these too have largely plateaued.4 Nonetheless, the ongoing tension between medical intervention and a desire for a more humanized approach to birth continues to resonate in contemporary practice. There has also been a resurgence of public interest in the health of mothers in childbirth, ranging from questioning their pre-pregnancy health, particularly related to obesity,5 to a concern with postpartum depression,6 to outrage that maternal mortality in the United States is apparently rising, while most countries in the world report significant declines.7 Perhaps in response to the increasing rates of intervention without improved outcomes, there has been a notable growth in the relatively small numbers of out-of-hospital births in the United States, either at home (0.97% of all births) or in freestanding birth centers (0.47%) for a total of more than 57,000 births in 2015 – a figure larger than the total number of births in twenty-six states.8 Between the polar opposites of high levels of cesareans (Hialeah Hospital in Florida reported a 65% cesarean rate for low risk mothers)9 and the large proportions of women professing an interest in out-of-hospital births (64% in one national survey),10 there has also been an array of efforts to make childbirth less interventionist. This has been manifested in clinical recommendations,11 film documentaries, and myriad advocacy efforts.12 One of the pleasures of reading the essays in this issue is the familiar reminder of how the themes of medical intervention, women’s empowerment, and inter-professional battles over the control of childbirth recur over time. For example, in the context of home birth, Wendy Kline’s essay superbly documents the work of the legendary Dr. Joseph B. DeLee in establishing the Maxwell Street Dispensary in Chicago in 1895 as a base from which doctors in training could learn about childbirth not only from lectures, but by attending mothers in labor.13 It’s a notable corrective to the history of home birth at a time when home births are again on the rise. Contemporary studies of home birth typically focus on the battle between the obstetrical establishment based in hospitals and the midwives and mothers challenging that establishment.14 Such a conflict isn’t inevitable as seen in Kline’s essay as well as in contemporary England and the Netherlands where part of the process of planning for a home birth involves registering with the health system, thereby insuring smoother transfers between home and hospital if necessary.15 As Kline relates, DeLee’s commitment wasn’t to home birth per se, but to advancement of the then nascent field of obstetrics through hands-on involvement in home births to upgrade the empirical training of residents. DeLee’s commitment to elevating the status of obstetricians extended to a vigorous campaign against midwifery and helped shape the battle over professional control of childbirth from the 1880s to the 1920s, by which time midwifery as an independent profession was largely eliminated in the U.S.16 Midwifery has been re-established in the United States, but largely in the form of nurse-midwifery; and while midwives attended almost one in ten births in the U.S. in 2015,17 that number pales in comparison to most European countries where midwives attend a majority of all births.18 The preeminent role of medical technology in not only shaping the practice but also the culture of maternity care is the subject of Jacqueline Wolf’s insightful essay on electronic fetal monitoring.19 The emphasis on childbirth as a potential medical disaster that could only be prevented by treating every laboring mother as a high risk patient shaped twentieth-century maternity care practice. This medicalization of childbirth elevated the profession of obstetrics, enhanced the reputations of hospitals as centers of science, and served to drive out competition from “other practitioners” like midwives and family doctors.20 A key element in this process was the redefining of birth as dangerous not only among clinicians, but also in the public’s mind.21 Even now, a 2011-12 national survey of US women who had recently given birth found only 58% agreeing with the statement, “Giving birth is a process that should not be interfered with unless medically necessary,” though that represented a notable increase from the 45% of mothers who agreed with the same statement a decade earlier.22 The dominance of the medical model also led, perhaps inevitably, to a counter movement such as the Czech experience with an implementation of the “Leboyer” method to hospital maternity care as described in Ema Hrešanová’s essay.23 Hrešanová’s study of the introduction of “humanized childbirth” at the Ostrov Hospital is a valuable reminder of the critical role some clinicians have played in efforts to reduce medical intervention in childbirth. The story of Hana Marková and colleagues’ campaign to use the principles of the Leboyer method at Ostrov documents the fortuitous intersection of clinicians willing to explore new ideas and an institutional setting and time period where such innovation was possible. As with most changes in institutions and behavior, the challenge is the sustaining of these reforms and Hrešanová documents the inevitable push back from the broader profession and the institutions that were threatened by their new ideas. The Czech and Slovak Republics apparently continue to face these challenges. As one recent study noted, while cesarean rates in industrialized countries have plateaued, they were the only two of twenty-two such countries studied that have recently continued to experience rapid increases in their cesarean rates.24 As noted, there is an ongoing US challenge, though largely consumer led, to the medical model in the contemporary out-of-hospital birth movement, which has seen a 66% increase in births in homes and freestanding birth centers between 2004 and 2015.25 It is perhaps a result of the institutional barriers to change that has led about one in seventy (1.4%) US mothers, particularly non-Hispanic white mothers (2.2%), to forego even trying to birth within the current hospital system. To give birth outside of a hospital in the United States, women face considerable institutional (e.g. no insurance coverage) and cultural (e.g. being told by friends you’re risking your baby’s life) challenges,26 yet more mothers continue to pursue this option. It is far less messy to study childbirth from the perspective of institutions and professions, but what of the mother’s sense of her experience in childbirth? Too often, mothers are caught between the conflicting demands of consumer groups advocating for less intervention in childbirth and a maternity care system relying on medical intervention at every stage of pregnancy to prepare for even the rare possibility of a poor outcome. A combination of professional, institutional, economic, gender, and social factors led to the dominance of the medical model, but this control came at a cost as well. Maternity care practice under the medical model has the potential to lead mothers to experience childbirth as a disempowering, emotionally painful, and dehumanizing experience,27 akin to post traumatic distress disorder as Paula Michaels’s essay explains.28 Her thoughtful history of trauma in childbirth captures the evolution of thinking about how society views the experience of childbirth and women’s responses to it. It’s only recently that the dimensions of the problem have been understood with one study finding 9% of US mothers meeting the screening criteria for birth trauma,29 a state instituting universal screening for postpartum depression,30 and suicide being identified as one of the leading causes of maternal death,31 suggesting Dr. Michaels has provided historical context for a much larger problem than is generally understood. I have been fortunate to have the opportunity to focus on the subject of childbirth for the past four decades because it involves a richness and diversity I hadn’t found in my prior research on political processes. My training in political science has, however, provided a valuable foundation for understanding how childbirth has fit (uncomfortably) into the larger health care system. The elevating of midwifery at the turn of the twentieth century in England for example, was less a recognition of their value as providers than an effort to reduce infant mortality and improve the health of potential soldiers because so many were found unfit for the Boer War.32 Likewise the contemporary concern over striking racial disparities and the high US maternal mortality rate is as much about politics and how we as a society choose to distribute health care resources as it is about women’s health.33 The universality of childbirth will inevitably result in its intersection with all sectors of society as these essays illustrate. What makes childbirth research so exciting is the recognition that an event experienced everywhere for all human existence varies so widely in practice depending on place, time, and culture. As a result, the study of childbirth provides insight not only into how women and children are valued, but also how a society views, culturally and economically, its professions, institutions, and families. It’s a bonus for historians that studying childbirth also enables them to get immersed in rich storytelling from the distant past,34 the last century,35 or last decade36 and understand better the forces that shape health care practice as a whole. Childbirth research is fascinating not simply because it provides insights into medical practice, but because it is a reflection of society as a whole. The recent growth in interest in childbirth as a matter of historical inquiry is reflected in formal studies of the practices related to birth37 and the women’s professions related to it,38 as well as recent books by clinicians39 and journalists40 documenting aspects of the history of childbirth. The intensely personal emotions childbirth can provoke have clearly moved some to explore the origins and evolution of practices related to birth. The dedication of a volume of this journal to a forum for papers on the history of childbirth will hopefully encourage further exploration of this ceaselessly fascinating subject. Footnotes 1 B. Hamilton, J. Martin J, M. Osterman, A. Driscoll, and L. Rossen, Births: Provisional Data for 2016 (Hyattsville, MD: National Center for Health Statistics, 2017). 2 G. Molina, T.G. Weiser, S. Lipsitz, et al., “Relationship between Cesarean Delivery Rate and Maternal and Neonatal Mortality,” JAMA 314 (2015): 2263-70. 3 E. Declercq, H. Cabral, and J. Ecker, “The Plateauing of Cesarean Rates in Industrialized Countries,” American Journal of Obstetrics & Gynecology 216 (2017): 322-23. 4 J. Zhang, J. Troendle, U. Reddy, et al., “Contemporary Cesarean Delivery Practice in the United States,” American Journal of Obstetrics and Gynecology 203 (2010): 326.e1-.e10. 5 J. Snowden, J. Mission, N. Marshall, et al., “The Impact of Maternal Obesity and Race/Ethnicity on Perinatal. Outcomes: Independent and Joint Effects,” Obesity 24 (2016): 1590-8. 6 K. Venkatesh, H. Nadel, D. Blewett, M. Freeman, A. Kaimal, and L. Riley, “Implementation of Universal Screening for Depression during Pregnancy: Feasibility and Impact on Obstetric Care” American Journal of Obstetrics and Gynecology 215 (2016): 517.e1-.e8. 7 Krugman P. “States of Cruelty,” New York Times 2016 August 29, 2016; Amnesty International, Deadly Delivery: The Maternal Health Crisis in the USA. (New York: 2010). 8 J. Martin, B. Hamilton, M. Osterman, A. Driscoll, and T. Mathews, Births: Final Data for 2015. (Hyattsville, MD: National Center for Health Statistics, 2017). 9 T. Haelle, “Your Biggest C-Section Risk May Be Your Hospital, Consumer Reports 2017 May 16. 10 E. Declercq, C. Sakala, M. Corry, S. Applebaum, and A. Herrlich, Listening to Mothers III: Pregnancy and Birth. (New York: Childbirth Connection, 2013). 11 American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine, Safe Prevention of the Primary Cesarean Delivery. Obstet. Gynecol. 123 (2014): 693-711. 12 E. Armstrong, and E. Declercq, “Is it Time to Push Yet?” in B. Hoffman, N. Tomes, M. Schlesinger, R. Grob, eds. Patients as Policy Actors (New Jersey: Rutgers University Press, 2011), 60-82. 13 W. Kline, “Back to Bed: From Hospital to Home Obstetrics in the City of Chicago,” Journal of the History of Medicine and Allied Sciences 72 no. 4 (2017). 14 R. DeVries, Making Midwives Legal: Childbirth, Medicine, and the Law. (Columbus, Ohio: Ohio State University Press, 1996). 15 R. Devries, C. Benoit, E. van Teijlingen, and S. Wrede, eds. Birth by design: Pregnancy, maternity care, and midwifery in North America and Europe (New York: Routledge, 2001). 16 J. Litoff, American Midwives: 1860 to the Present (Westport: Greenwood Press, 1978). 17 J. Martin, B. Hamilton, M. Osterman, A. Driscoll, and T. Mathews, Births: Final Data for 2015. 18 J. Zeitlin, A. Mohangoo, and M. Delnord, eds. European Perinatal Health Report: Health and Care of Pregnant Women and Babies in Europe in 2010 (Paris: Euro-Peristat Project, 2014). 19 J. Wolf, “Risk and Reputation: Obstetricians, Cesareans, and Consent in the Nineteenth, Twentieth, and Twenty-first Centuries,” Journal of the History of Medicine and Allied Sciences 72 no. 4 (2017). 20 E. Declercq, “The Trials of Hanna Porn: The Campaign to Abolish Midwifery in Massachusetts,” American Journal of Public Health 84 (1994): 1022-8. 21 R. Wertz, and D. Wertz, Lying-In: A History of Childbirth in America (New York: Free Press, 1977). 22 E. Declercq, C. Sakala, M. Corry, S. Applebaum, and A. Herrlich, Listening to Mothers III: Pregnancy and Birth. 23 E. Hrešanová, “The Island of Alternatives: Power and ‘Gentle Birthing’ in Socialist Czechoslovakia, the 1980s,” Journal of the History of Medicine and Allied Sciences 72 no. 4 (2017). 24 E. Declercq, H. Cabral, and J. Ecker, “The Plateauing of Cesarean Rates in Industrialized Countries,” 322-23. 25 J. Martin, B. Hamilton, M. Osterman, A. Driscoll, and T. Mathews, Births: Final Data for 2015. 26 M. Cheyney, Born at Home: The Biological, Cultural and Political Dimensions of Maternity Care in the United States (Belmont, California: Wadsworth Publishing, 2010). 27 S. Ayers, “Thoughts and Emotions During Traumatic Birth: A Qualitative Study. Birth 34 (2007): 253-63; C. Beck, R. Gable, C. Sakala, and E. Declercq, “Post-traumatic Stress Disorder in New Mothers: Results from a Two-Stage U.S. National Survey,” Birth 38 (2011): 216-27. 28 P. Michaels, “Trauma and Childbirth,” Journal of the History of Medicine and Allied Sciences 72 no. 4 (2017). 29 C. Beck, R. Gable, C. Sakala, and E. Declercq, “Post-traumatic Stress Disorder in New Mothers: Results from a Two-Stage U.S. National Survey,” Birth 38 (2011): 216-27. 30 K. Clark, J. Gessner, and M. Bombaugh, “Massachusetts Postpartum Depression Program a Model for a National Plan,” in Stat. Boston, 2017. https://www.statnews.com/2017/01/09/postpartum-depression-massachusetts/ (Cited 9/12/2017). 31 C. Palladino, V. Singh, J. Campbell, H. Flynn, and K. Gold, “Homicide and Suicide during the Perinatal Period: Findings From the National Violent Death Reporting System,” Obstet. Gynecol. 118 (2011): 1056-63. 32 J. Kingdom, “The United Kingdom,” in A. Wall, ed. Health Care Systems in Liberal Democracies. (New York: Routledge, 1996), 127-62. 33 E. Declercq, “Understanding the US Maternal Mortality Problem,” in Public Health Post (Boston: Boston University School of Public Health, 2016). 34 N. Gelbart, The King's Midwife: A History and Mystery of Madame du Coudray (Berkeley: University of California Press, 1998). 35 M. Breckinridge, Wide Neighborhoods: A Story of the Frontier Nursing Service (Lexington: University Press of Kentucky, 1981). 36 J. Wolf, “Risk and Reputation: Obstetricians, Cesareans, and Consent in the Nineteenth, Twentieth, and Twenty-first Centuries.” 37 R. Wertz, and D. Wertz, Lying-In: A History of Childbirth in America; J. Leavitt, Brought to Bed: Childbearing in America, 1750-1950. (Oxford: Oxford University Press, 1986), 295. 38 J. Litoff, American Midwives: 1860 to the Present; D. McGregor, From Midwives to Medicine (New Brunswick: Rutgers University Press, 1998). 39 M. Sloan, Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth (Bodega Bay, California: Bodega Bay Books, 2014); R. Epstein, Get Me Out: A History of Childbirth from the Garden of Eden to the Sperm Bank (New York: W. W. Norton, 2011). 40 T. Cassidy, Birth: The Surprising History of How We Are Born (Boston: Atlantic Monthly Press, 2006). © The Author 2017. Published by Oxford University Press. All rights reserved. For Permissions, please email: email@example.com
Journal of the History of Medicine and Allied Sciences – Oxford University Press
Published: Jan 1, 2018
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