By G. J. Kloosterman, M.D.
Originally published by Birth Gazette, Vol. 2, No. 2, 0000-00-00
From time immemorial, giving assistance to a woman in labor has been as female a task as parturition itself. This statement holds good for all cultures on this planet, and up till the 17th century, it was also universally accepted in our western culture. Smellie, the founding father of British obstetrics, wrote in the preface of his famous treatise on the theory and practice of midwifery in 1752, in a somewhat condescending way, “It is natural to suppose that while the simplicity of the early ages remained, women would have recourse to none but persons of their own sex, in diseases peculiar to it; men were only employed but in the utmost extremity.”
But in the 16th and 17th centuries, the centuries of the great discoveries, of the discovery of our planet, of our solar system, of anatomy of the human body, of the circulation of our blood, the secret realm of women had to be explored as well, and the acceptance of the male surgeon-accoucheur as superior to the midwife, was the result. This happened first in France, the country where Ambroise Paré (1510-1590) had acquired immortal merit, as the founder of obstetric science. A century later, Louis Quatorze, the Sun-King, took a male accoucheur, first for his two mistresses and finally, in 1682, also for his legal wife. From this moment on, it was more fashionable, at least in France, to be helped by a doctor-accoucheur than by a midwife. In the next century, this example was followed in the other countries of Europe. Although at first, this tendency was attributed to French immorality and deprivation, at the end of the 18th century, the superiority of the male surgeon-accoucheur was accepted everywhere in Europe. After that period, it became common practice to picture the midwife of past and present as careless, meddlesome, dirty and stupid. The important contributions to midwifery made by experienced and learned midwives like Louise Bourgeois and Justine Dittrichs, called Sigemund, are not mentioned at all in the elaborate historical introduction of seventy-two pages in Smellie’s book on midwifery.
A very important and perhaps unique document containing information on the obstetric results of a midwife around 1700 is the diary of Catherina Schrader, a Dutch midwife who lived from 1656 till 1746 and who practiced in the province of Frisia, in the north of The Netherlands. She made notes after every delivery, and these notes form a manuscript of 544 pages–her diary or “Memorieboeck” of the women, She assisted 3060 women; there were 70 twin pregnancies and 2 sets of triplets. There were 6 cases of placenta praevia totalis, whereby she performed a manual removal of the placenta followed by version and extraction of the child, that in all these cases presented in transverse position. She performed 88 breech extractions and/or version and extractions for transverse positions or head presentations with prolapse of the umbilical cord (2.9%). Her overall maternal mortality was 7%, but in 43 cases, her help was called in by other midwives or doctors and, in these cases, the patient was sometimes already dead or dying as she entered the house. In these 43 cases, 7 women died. This means that she herself delivered 3017 women with a maternal mortality of 5%, that is, less than the figure reached in the USA in 1936. [When a cesarean section was a possibility.–Ed.]
If we look at the period of three centuries (from 1550 till 1850) in which the first great achievements of obstetric art took place, then we must admit that the male invasion into the delivery room has been followed by many scientific achievements. But these proud achievements were partly reached by and gave rise to many internal examinations of women, and at the end of the 18th and especially in the beginning of the 19th century, this evoked unsuspected and, at first, completely neglected catastrophic consequences. In the University Clinic in Vienna, maternal mortality rose from 12.5% around 1800 to 49% in the period 1841-1847. The great killer was childbirth fever.
As early as 1795, Alexander Gordon in Aberdeen drew attention to the contagiousness of the puerperal fever. He wrote: “In short, I had evident proofs of its infectious nature and that the infection was as readily communicated as that of smallpox or measles. It is a disagreeable declaration for me to mention that I myself was the means of carrying the infection to a great number of women.”
In Boston in 1843, Oliver Wendell Holmes read his paper entitled “The contagiousness of puerperal fever.” In a brilliant review of the experience with childbed fever in several European centers, he stated, “it would seem incredible that any should be found too prejudiced or indolent to accept the solemn truth knelled into their ears by the funeral bells both sides of the ocean, the plain conclusion that the physician and the disease entered hand in hand into the chamber of the unsuspecting patient.” And in conclusion he wrote, “the time is come when the existence of a private pestilence in the sphere of a single physician should be looked upon not as a misfortune but as crime.”
In 1847 in Vienna, Ignaz Philipp Semmelweis proved more convincingly than ever before the contagiousness of puerperal fever. He also showed (and that is his immortal merit), that the disease was caused by performing an internal examination with unclean hands and that infection could be avoided by washing hands in chlorinated lime water.
How did the members of the obstetric profession react to these accusations and discoveries? With few exceptions, very negatively. In the USA, Meigs called the paper of Holmes: “the jejune and fizzless vaporings of sophomore writers.” And in 1848, Meigs wrote in his book On Females and their Diseases: “Having practiced midwifery a great many years and having been concerned in the visitation of the sick labouring under puerperal fever . . . visiting the same cases with those who have been so cruelly abused, as performing the part of a walking pestilence, scattering death and desolation where they desired only to do good–and seeing that I could never convict myself of being the means of spreading the contagion, I remain incredulous as to the contagiousness of the malady.”
Another famous American obstetrician, Hodge, rejected the message of Holmes, because it was too terrible to believe. In Europe, where Semmelweis had given overwhelming statistical evidence that by his method many thousands of mothers could be saved, the reaction of the obstetrical establishment was the same, and it took the discovery of Pasteur and Lister to convince every obstetrician at last. All this is strong proof that discussions on childbirth give rise to strong emotions and that male obstetricians have been very sensitive to criticism and sometimes react with emotional outbursts and the expression of hurt feelings to overwhelming statistical and scientific evidence.
But, many will say, what has this to do with present day obstetrics? We got the message: the dangers, provoked by internal manipulations have been recognized and are now almost non-existent, thanks to prevention and powerful medication. Never before in the history of mankind has childbirth been so safe for mother and child. In the last 40 years, maternal mortality dropped more than 98%, perinatal mortality by more than 75%.
But how is this reached? By prevention, by augmenting the general health of the population and by powerful methods to treat the still existing pathologies such as placenta praevia, abruptio placentae, toxemia, malpresentations and contracted pelvis.
By no means have we been able to improve spontaneous labor in healthy women.
Spontaneous and normal labor is a process, marked by a series of events so perfectly attuned to one another that any interference only deflects them from their optimum course. For healthy, normal women able to set their children into this world under their own power, all proud achievements of modern obstetrics are only a reassuring thought–but that is all the profit they have from it.
That the majority of all women always have been able to bring a healthy child into the world without any assistance is a fact recognized from time immemorial.
In 1701, the famous Dutch obstetrician, Hendrik van Deventer, defined a natural or easy birth as a birth accomplished by nature alone, without any interference of assistance; a birth not in need of any help of midwife or doctor. He even compared one of his clients with a waffle-iron from which the children rolled out as easily as waffles from an iron. In 1753, William Smellie wrote, “I call that a natural labour in which the head presents and the woman is delivered by her pains and the assistance commonly given.” Smellie also gave statistical data. He estimated that 92% of all births could be called natural.
Statistical data can also be derived from the diary of Catharina Schrader, the Dutch midwife I mentioned before, who practiced from 1693 till 1745. Natural spontaneous childbirth occurred in her practice in 94%. This figure is the more striking since her practice contained more pathology than in a random sample of the population could be expected (multiple pregnancy occurred in 2.4%; placenta praevia totalis in 2%, etc.).
If, 250 years ago, more than 90% of all women with full term pregnancies were able to bring their children into the world spontaneously without any other assistance than sympathy and encouragement, it seems utterly improbable that this power nowadays should be lost in women, who, without any doubt, are in a better state of general health.
In many textbooks on obstetrics, this fact is recognized by stating that, in principle, pregnancy and labor are normal, physiological periods in a woman’s life that only exceptionally can give rise to pathological and dangerous situations. But at the same time, obstetricians seem to agree that all children should be born in hospitals where doctors can cope with almost all sorts of emergencies and in the last 20 years, hospitalization and highly specialized supervision by obstetricians is strived at and often achieved in almost all countries of the industrialized world on both sides of the iron curtain.
But once again, our profession is accused by strong pressure groups of women supported by representatives of several scientific and learned societies, that we are looking too much at one aspect of childbirth and neglecting others. The accusation is that doctors look at pregnancy and childbirth as mild diseases that have to be handled in huge hospitals; that modern obstetrics is crisis-oriented and that all attention is focused on disasters that can happen. By doing so, we teach women to trust in medical science but we diminish the belief in self-reliance and in the possibility to perform the act of parturition under ones own power. These opponents of the obstetrical establishment stress the importance of childbirth as a creative act, performed by the young mother herself in a self chosen setting and without unnecessary medical interference.
Once again there is strong scientific and statistical evidence that modern western obstetrics is perverting the physiology of human parturition.
And once again, many obstetricians are defending themselves with emotional outbursts without trying to oppose the accusations with scientific arguments, as happened in the 19th century against the accusations made by Holmes and Semmelweis.
Whereas many obstetricians attribute the undeniable and great progress in obstetric results to the disappearance of the independent midwife and the disappearance of home confinements, a growing protest is heard among the public, among the consumers, against the restricted sterile conditions of the labor, and the very rooms in hospitals, the immense gadgetry and the ever-increasing cesarean section rate.
Some women go so far that they turn their backs to the obstetric profession, stay at home and accept the attendance of unqualified and sometimes undertrained women to escape the strict rules of hospitals. In doing so, they accept a risk for themselves and their children. The bad results of these non-institutionalized home confinements are (mis)used by the profession to justify their stark type of obstetric organization, whereas it would be much better to accept that many healthy and self-confident women wish to experience childbirth as a natural, creative act without unnecessary interference.
Whereas it is self-evident that nowhere can pathology of pregnancy and labor be handled better than in a large, well-equipped hospital by a highly specialized staff, there is no proof that normal women who are willing to bring their child into the world under their own power have any advantage of such a surrounding. It is even probably that for them such a surrounding will be unfavorable, since it enhances the chance of unnecessary surgical and pharmacological interventions.
The most important objection against this, in itself very logical and convincing idea (the sick in the sickhouse or hospital under the care of doctors and nurses, the healthy ones at home, under the care of midwives or general practitioners), is the problem that pregnancy and labor are only normal in retrospect and that there always is a possibility that something will happen “out of the blue.”
In the industrialized world on both sides of the iron curtain, only The Netherlands still sticks to the idea that pregnant women have to be considered healthy and normal until the opposite is proven. As long as everything stays normal, they can be cared for and assisted by midwives and have a free choice to stay at home or go to hospital for delivery under the care of the same midwife who was caregiver during the pregnancy.
From 1958 until 1975, the number of home confinements decreased from 70% to 35%, but since 1978, this percentage has not gone down further, and in 1982, it was the same as in 1978. The number of confinements under the care of a registered midwife only (at home or in hospital) is 40%, and this percentage is the same as 20 years ago.
The data of 1982 are given in tables 1-3 and show that a well-selected group of apparently normal women can deliver in a simple surrounding without electronic monitoring and without sophisticated means, with very good results. A perinatal mortality of 2 per thousand (including, of course, all transfers to hospital during labor), 7 times lower than the perinatal mortality in hospital and 5 times lower than the average for the whole country, is in striking contrast to the results reached in countries where home confinements went down to less than 1 or 2%. But showing that home confinements are much more acceptable than many obstetricians think is not enough. The same holds true for sharing obstetric care with midwives. Where are the advantages?
The advantages are: a far greater amount of completely spontaneous births without any form of anesthesia or instrumental or pharmacological interference. Whereas cesarean section rates in almost all countries with total hospitalization are above 10% and in some countries even 16 to 18%, this percentage was 4.7 in 1980 in The Netherlands and forceps and vacuum extractions were 5.9% in 1982. And these data of The Netherlands are already influenced by international pressure. In The Netherlands, too, there are hospitals with a cesarean section rate of 15%, influencing our national figures.
Therefore we decided in 1970 to make a very precise regional study to investigate the value of our system of selections and midwifery care. The leader of this study was my colleague, van Alten. This investigation took place in Wormerveer, a rural district north of Amsterdam.
In all, we studied from 1969 till 1977 a group of 4804 women who wanted to deliver at home or in a small home-like maternity unit and who were under supervision of a midwife or a general practitioner at or before an amenorrhea of 28 weeks. The overall perinatal mortality was 44 in 4835 = 0.9%. The highest mortality was found in the group that was selected during pregnancy by prenatal care and got advice to deliver in hospital. Perinatal mortality: 32 in 778 = 4.4%. The lowest mortality was found in the group born at home or in the maternity under the guidance of midwife or general practitioner: 6 in 3741 children = 0.16%.
In 316 cases, labor was planned and started at home, whereas during labor referral took place to the hospital. In this group perinatal mortality has been 6 = 1.9%. If we take together all women who were allowed to stay at home and started to deliver at home (or in the maternity), including the 316 cases who were referred to hospital during labor, then the perinatal mortality is 12 in 4057 + 0.3%. Three of these 12 cases were caused by congenital malformation, not compatible with life. There were 2 cases of abruptio placenta. In one case it concerned the second child of a twin, a stillbirth of 1100 grams. In 6 cases the possible avoidability could be discussed; 4 in the sphere of the maternity unit; 2 in the hospital. An improvement of the selection procedure is still possible and in the mean time realized. During the years 1978-1981 perinatal mortality in the group that delivered at home decreased to 0.18%.
The results in the country as a whole and in the Wormerveer study show that the results of deliveries under responsibility of a midwife are very good. In fact, the countries that showed the lowest perinatal mortality of the world during the last ten years, the Scandinavian countries and Holland, have one thing in common, which is not the home confinement, but the fact that in these countries an important part of prenatal care and the physiology of labor is left to midwives.
Another very important feature of the Dutch system is the amazing low number of artificial deliveries, amazing at least, if we compare them with other western countries.
In figure 9, the rates of the artificial deliveries in the total group are given; the cesarean section rate was 1%, for vacuum extraction and forceps delivery: 3.9%.
In the group selected for home delivery (including of course the referrals to hospital during labor), the cesarean section rate was 0.4%; the rate of vacuum extraction and forceps delivery together was 2.8%.
The most remarkable group is formed by the 1575 women who were pregnant for the second time. In this group the cesarean section rate was zero; there were 5 instrumental deliveries (0.3%). The perinatal mortality in this group was 1 case (less than 1%), certainly non-preventible.
All this, in my opinion, is evidence that a system based on selection during pregnancy by good prenatal care, based on the idea that the majority of all pregnant women (70-80%) belong to a low risk group, based on the idea that a well-educated midwife can bear the responsibility for both procedures (the selection and the care for the healthy ones), based on the idea that midwives and obstetricians have to be complementary, can combine very good obstetric results with a very high amount of spontaneous deliveries, that is: with active participation of the mother and the father during labor, with an absolute minimum of anesthetic drugs, with optimal possibilities for early interaction and effective bonding between parents and newborn child.
All over the world there exists in every society a small group of women who feel themselves strongly attracted to give care to other women during pregnancy and childbirth. These women like to accept responsibility. Their goal is not an easy life and a large income. Failure to make use of this rather small group of highly motivated people (mostly women) is regrettable.
The modern midwife has to be somebody who has had a training of at least three years in obstetrics. During her training she has worked and studied in a large obstetric hospital and has had a much more intense and thorough education and experience in obstetrics than a medical student. She has seen hundreds of deliveries and has delivered personally at least 50 women during her training.
Whereas she is familiar with all kinds of pathology, her aim is not to handle pathology but to recognize it as early as possible and to hand it over to obstetricians. Her pride is to advise and coach a woman during pregnancy in such a way that a normal spontaneous labor follows and a healthy child is taken in the arms by a mother who did the job herself.
Such a midwife makes it possible for the obstetrician to devote him (or her)self to the real task, that is: the study of human parturition and handling of pathology..
There is a rather great difference in the field of activity and the personality of a highly motivated nurse and a born midwife; the nurse works among the sick, preferably in a hospital, works together with doctors and follows their instructions; the midwife likes to bear responsibility, must be convinced by good arguments before she is willing to follow instructions and feels herself complementary to the obstetrician. She recognizes the superiority of the obstetrician in handling clearcut pathology, but is willing to argue with him about the limits of physiology and pathology. Very often she feels that under her guidance, pathology could have been prevented or some kind of interference could have been avoided. This is the reason why many doctors prefer to work with nurses.
In my opinion, there has to be a difference between the education of a hospital nurse and a midwife. It is unnecessary and indeed a waste of time and talent to train exclusively nurse-midwives. At the end they will have to choose: to become a maternity nurse, working in a hospital together with obstetricians and working under their responsibility, looking after pathology and using all the equipment of modern technological science, or: to become a midwife, a person who is happier if she has been able to avoid an artificial delivery than to assist at it and who sees herself more as an assistant of nature than an assistant of the doctor. Of course, if she is a good midwife, then she will be happy that doctors exist and she will do everything to send her patient in time to him, but her most important question is not always: How? But Why? The kind of nurse most akin to midwives are the district nurses. [A public health nurse who makes house calls–Ed.]
There is another argument that midwives must not be involved too much in nursing. They must get and keep a great experience in prenatal, natal and postnatal care and therefore, we think it necessary that they take care of one hundred pregnant women or more per year. This would not be possible if they were involved in maternity nursing as well.
In my country, a nurse who wants to become a midwife has to follow the midwifery training for three years, that is, as long as a woman who finished her secondary school and began midwifery training. The same holds true for a midwife who wants to become a nurse. Therefore, a nurse-midwife in my country has a training period of 6 1/2 years, almost as long as a medical student to become a doctor. They form a minority; the majority of our midwives did not take nurses’ training.
A doctor who wants to settle down as a midwife has to follow a course of one year at lest in a training school for midwives before she or he can do so.
At last, I should like to give this answer to the question: Why midwifery?
Midwifery is indispensable and an essential part of good obstetrical organization, since midwifery means: protection of health and normality, whereas obstetrics, as part of medicine, belongs to the “department of knowledge and practice dealing with disease and its treatment.”
To start a pregnancy, you need a woman and a man; their functions are different, but everybody will hope that they will love one another, respect and admire one another. To care for pregnancy and childbirth, you need a midwife and a doctor. I hope that they will love one another, respect and admire one another and will know that they are both needed and complementary.
