Birth

Author: Tina Cassidy

Background

This refreshing exploration of childbirth – what the book describes as ‘perhaps the most natural physiological process’ – is set on the background of the author’s own experience of labour and delivery which involved having a Caesarean section, and suffering thereafter with post-operative pain and infection. The driver for the book appears to be the author’s quest to discover the ideal birth, one which she defined as being ‘safe, minimally painful, joyful, and close to nature’s design’. And the outcome is nothing short of a detailed anthropological exploration of the diverse cultural traditions of birth, and a well-researched account of the orthodox developments in obstetric care. The narrative is marked by its critical assessment of the actors who have defined the history of childbirth, and of the practices which were introduced to make labour safe, but which have often caused more harm than good. With an outsiders eye, the author was able to see through the imbalance which she thinks has skewed obstetric care, from the disproportionate influence of doctors over midwives, to the obsession with sterility which has turned hospital birth into a ‘rigid and methodical‘ affair. The book also graphically highlighted lesser-appreciated consequences of childbirth such as when it narrated the story of Andrea Yates, the mother who, under the influence of post-partum depression, drowned five of her children in a bathtub (pages 4-8, 50, 57, 65, 80 and 246-248).

Synopsis

The history of childbirth the book narrates is exhaustive and incisive, and it portrays the major developments in obstetrics in terms of their impact, both positive and negative. One the most influential breakthroughs the author chronicled in this regard is the introduction of obstetric analgesia with reference to the initial use of ether, and later of chloroform, to relieve labour pain. The author particularly noted the role of James Young Simpson who, in the early 1800’s, defended his innovation in opposition to the Scottish Church which viewed birth pain as ordained by God. The hostility to relieving the pain of labour however persisted until the taboo was broken when John Snow administered chloroform to Queen Victoria during the birth of Prince Leopold. Other seminal obstetric advances the author narrated included the introduction, in 16th century, of the Chamberlain forceps – ‘the grandaddy of obstetric tools’; the introduction of the vacuum extractor, initially as a rubber ventouse before it was modified by Tage Malmstrom into a more efficient stainless steel cup device; the introduction of ultrasound by Ian Donald who had adapted a sonar device which was developed to help ships detect icebergs; the introduction of synthetic oxytocin to facilitate labour contractions; and the introduction of incubators by Étienne Stéphane Tarnier who was inspired by the egg incubators used in a Paris zoo (pages 168-182 and 252-253).

At the heart of the book’s narrative is the transformation of childbirth, traditionally carried out at home and guided by female midwives, in to a hospital-based process supervised by male doctors. The author pointed out that home births attended by midwives was the norm until ‘the atmosphere began to change’ in the late 19th century. The author attributed this to what she said were ‘the vicious attacks from formalised medicine…when freshly minted male doctors, desperate for customers, began attending births’. She specifically noted the influence of doctors such as William Smellie, who she depicted as Britain’s most famous man midwife who, amongst other things, ‘brought male students to the deliveries of poor pregnant women’, and of Ambroise Pare, ‘the father of modern surgery’ whose ‘greatest legacy’, was ‘having women deliver lying down‘ for his own convenience. In supporting her critical assessment, the author pointed out that when midwives attended to most births, there were ‘lower Caesarean rates, fewer interventions such as labour induction and episiotomies, and lower infant mortality‘, adding that ‘having a baby at home with a midwife regularly produces a better outcome than delivering in a hospital’ (pages 30-31, 49-54 and 134-139). 

The inherently difficult nature of childbirth was reflected throughout the book, and the author attributed this primarily to how the shape of the pelvis evolved when humans starting walking upright. She argued that  most of the difficulties experienced in labour – and why ‘birth doesn’t go smoothly’ – is the way the ‘physical frame’ of the pelvis has transformed to be widest side-to-side on top, but front-to-back at the bottom. The consequence, the author noted, is that ‘the baby’s head must rotate as it descends in a grinding pirouette‘. The author also pointed out how the difficulty of labour is further compounded by such complications as large babies, breech deliveries, and female genital mutilation – all of which increase the risks of foetal distress and perinatal death. In this context, the book not only reviewed the increasing role that Caesarean section is playing in mitigating the hazards of natural delivery, but it also highlighted how the operation has become commonplace – being performed more frequently than such operations as appendectomy and tonsillectomy. The author was however more concerned about the increasing number of Caesarean operations being carried out, not for justifiable medical indications, but for ‘vanity‘ and ‘convenience‘; she argued that this situation is being driven by wealthy women who ‘are used to being in charge of every aspect of their lives’, and therefore ‘just can’t give in to the natural process that is birth’. The author complemented her discussion of Caesarean section with historical anecdotes, for example how, about 500 years ago, a Swiss pig gelder named Jacob Nufer successfully carried out the operation on his wife, and how, in 2002, a Mexican woman performed the first ever self-administered Caesarean section on herself (pages 10, 15, 25, 105-110 and 121-131).

Apart from the laudable practices that have enhanced childbirth, the author also pointed out many less honourable aspects of the history of childbirth, noting several discredited practices and personalities. For example, the author referred to how the use of X rays to determine the size of the birth canal inadvertently led to an increase in the risk of childhood leukaemia, and how Joseph DeLee introduced prophylactic forceps deliveries in a misguided and counterproductive attempt to reduce the ‘trauma and pain’ of childbirth. The book was further critical of DeLee who viewed childbirth as a disease and called ‘for the abolition of midwives’. The author also expressed her an antipathy to the trend whereby fathers now attend the birth of their children, a practice she attributed to Robert Bradley who had argued that mothers relaxed better when their spouses were present in the delivery room; on the contrary, the author asserted that nature did not intend fathers to attend the births of their children, and their presence only impeded the emotional support that mothers traditionally received from midwives and doulas (pages 20-21, 57-61, 143-146, 160-182 and 79-90). 

As much as the author was critical of the involvement of doctors in the practical aspects of childbirth, she was generous in appreciating the advances made by physicians in the specialty. In dong this, she provided detailed biographical accounts of such doctors, for example J. Marion Sims who she noted for his innovative treatment of vesico-vaginal fistulas, a breakthrough that was made possible by the ‘curved speculum‘ he innovated and which now bears his name. Acknowledging that ‘Sims practiced his gruelling technique on slave women for years’, she nevertheless said the knowledge of curing fistulas was thanks to him and the endurance of the slaves. The author also highlighted the contributions of physicians in resolving the conundrum of puerperal sepsis, a hazard that was variously attributed to such myths as women’s use of tight petticoats, and their loose morals. The author noted the roles played by such physicians as Alexander Gordon, Oliver Wendell Holmes, and Ignaz Semmelweiss in determining that puerperal sepsis was caused by the dirty hands of ‘unhygienic doctors‘. A rare female physician who featured prominently in the book was Virginia Apgar , the paediatrician who the author acclaimed for introducing the universally-adopted scoring system for assessing the health of babies at birth.

Opinion

This is a comprehensive and accessible review of the history of obstetrics which highlights the technical and cultural developments which have come to define the way childbirth is managed today. The narrative critically appraised the influence, both beneficial and detrimental, of the innovations and practices which have moulded obstetric care over the centuries. Writing from the perspective of a mother who had experienced many of these innovations, often painfully, it is perhaps expected that the author, a journalist, questioned many practices which are today accepted uncritically. The exploration of most topics, such as Caesarean section, was detailed and enlightening, but a sympathetic attitude to some unorthodox birth practices such as the Lamaze and water births occasionally limited the author’s objectivity. The author raises, but does not adequately resolve, some dilemmas such as the rising tide of Caesarean operations carried out for non-medical indications, and the unethical experiments of Marion Sims on slaves. Her arguments supporting home births over hospital births were also rather narrowly focused. These apart, the contents of the book are well-researched and the narration was compelling.

Overall assessment

This insightful account of the history and practice of childbirth is lucid and detailed, and it is supplemented with enlightening and interesting anecdotes. Most importantly, its arguments for a reassessment of accepted but questionable birth practices benefits from the vantage point of the author being a non-specialist and a mother. It is a thorough review which highlights significant medical and ethical concerns, and I recommend it to all doctors.

Book details

Publisher, Place, Year:  Chatto and Windus, London, 2007
Number of chapters: 9
Number of pages: 312
ISBN: 978-0-701-18119-2
Star rating: 5
Price: £15.02