Nothing to do but wait

The historical account submitted by Dr. Ian Cameron in the June 2009 issue of Canadian Family Physician detailed a remarkable story of a home birth performed by Dr. Charles Webster in 1892. Beautifully written and containing excerpts from the original account by Dr. Webster in 1939, the story contains vivid imagery and highlights the physical as well as medical obstacles present in the late 19th century. The story concludes with the delivery of a stillborn child, along with some practical and medical lessons for the physician.

The epilogue of the article, however, presents cause for concern. A brief reference is made between a declining maternal mortality rate and an increased rate of women giving birth in hospital, suggesting that the shift from women giving birth at home to hospital resulted in reduced risk to the mother. While over many years this has in fact been the case (the maternal mortality rate in Canada did in fact decrease from the late 19th century to the 1920’s to the mid 20th century to present), to link this to an increase in hospital births as opposed to home births is misleading. In fact, when women initially began giving birth in hospital the maternal mortality rate increased and it wasn’t until great changes were made to the practice of obstetrics in hospital occurred that the rate declined and the remarkably low rates of maternal mortality we have today were achieved.

It is undeniably true that from the late 19th century until the middle of the 20th century there was a dramatic change in the obstetrical care of women. In the late 19th century, although more physicians (which at that time also meant more males) were becoming involved in obstetrical care and were replacing midwives, who were overwhelmingly female , , . In addition, women began to give birth in hospitals and the proportion of women doing so steadily increased throughout this period1,2, . Lastly, the maternal mortality as well as infant mortality rate declined sharply in Canada during this time. However, the transition was not entirely smooth or without consequences.

The New York Maternal Mortality Study was funded by the Commonwealth Fund and conducted by the New York Academy of Medicine from 1930-32 . The study found that home births attended to by midwives during this time actually had the lowest maternal death rate and that approximately 2/3 of the maternal deaths that occurred in hospital were preventable. This result was evident despite the fact that maternal death was attributed a midwife if she had attended to the patient at all, including in the event that the patient was later brought to a hospital, and a physician became involved. The causes of maternal death, in order of prevalence, were found to be puerperal sepsis, eclampsia, hemorrhage, and accidents. While this study is American, maternal mortality in association with hospital birth was also seen as a concern in Canada3. In addition, just as American physicians attempted to pass responsibility for maternal mortality onto midwives, so too did physicians in Canada3.

The publication of this study resulted in much debate. Physicians, and in particular obstetricians were understandably upset by the results and many argued against the validity of the study. Subsequent studies were performed and ultimately the conclusion, that in hospital obstetrical care of women contained unnecessary risk, was accepted. Over time, acknowledgement of this risk resulted in changes in the practice of obstetrics and, along with scientific advancement such as the discovery of antibiotics in 1929, the maternal mortality rate declined to where it is today.

Overall, we as physicians have much to be proud of. Medicine has changed dramatically since the late 19th century, a short time by historical standards. Nevertheless, it is important for us to remember that the improvements in care and reductions in mortality that have occurred have not always been straightforward and without consequence. It is important for us to remain humble and to respect our past and understand that just as we appreciate the challenges and at times the errors of our predecessors, so too will physicians of the future look back on see the limitations of our knowledge and practice in the years to come.

Ehrenreich, B. and D. English. For Her Own Good: 150 Years of Experts' Advice to Women (Garden City: Anchor Books, 1989)

Leavitt, J. W. Brought to Bed: Birthing Women and their Physicians in America, 1750 to 1950 (New York: Oxford University Press, 1986)

Mitchinson,W. Birth in Canada 1900 to 1950, University of Toronto Press, 2002

Wertz, D. C. and R. W. Wertz. Lying In; a History of Childbirth in America (expanded edition published 1989 by Richard W. Wertz and Dorothy C. Wertz) (New York: Free Press; London: Macmillan, 1977

King C. R., The New York maternal mortality study: a conflict of professionalization, Bulletin of the History of Medicine. 65(4):476-502, 1991.