Cradle or grave

Tina Cassidy
BIRTH
A history
320pp. Chatto and Windus. Paperback, £12.99.
978 0 7011 8119 2

Marsden Wagner
BORN IN THE USA
How a broken maternity system must be fixed to put women and children first
305pp. University of California Press. $24.95;  distributed in the UK by Wiley. £15.95.
978 0 520 24596 9

Mary Briody Mahowald
BIOETHICS AND WOMEN
Across the life span
286pp. Oxford University Press. £23.99  (US $39.95).
978 0 19 517617 9
 

Much of birthing women’s misery can be traced to “cephalo-pelvic disproportion”. Bipedalism severely constrains our hip size – and big brains mean that even though babies are born too early in their development for anyone’s comfort, they are still likely to get stuck in the birth canal. Rather aptly known as Eve’s curse, the brain–pelvis stand-off is an evolutionary compromise that leaves little margin for error. This stand-off accounts for the fact that most women experience far more pain during childbirth than their primate cousins; for an African proverb stating that pregnant women have one foot in the grave; and for the fact that the skill of an attendant can easily make the difference between life and death. Up to the 1930s or so, it is estimated that about 1 per cent of birthing women died (and far more of their babies).

Historically, women with cramped pelvises were likely to expire into the oblivion of that 1 per cent. But one case stands out for creating a notable swerve in British royal history. In 1817, the popular and vivacious Princess Charlotte, King George IV’s twenty-one-year-old daughter, suffered from a now textbook case of cephalopelvic disproportion; two weeks overdue and weighing 9 lbs, her baby was far too big for her pelvis, and after fifty hours of active labour, he was delivered stillborn. Charlotte herself expired five hours later from internal bleeding. Since she was King George’s only legitimate child, his throne passed to his brother, and then to his niece, who became Queen Victoria. This is an oft-told tale in obstetrics – and one in which history on a grand scale was altered by the too-narrow straits of one woman’s pelvis.

The story doesn’t just end there. By the time of Charlotte’s delivery, midwives had, among the moneyed class, given way to “barber-surgeons” – an initially disastrous shift insofar as many book-learned young men were unleashed on the female birthing population with no prior hands-on training. Charlotte’s attending physician, Sir Richard Croft, did, however, have plenty of experience and had even written a textbook on the subject. Nonetheless, he was publicly vilified for what was perceived as poor decision-making: for, in effect, failing to use the instrument of his trade, forceps, on his royal patient. The fact was that forceps could be alarmingly destructive and so had momentarily fallen out of favour. Forceps, however, could also save lives if wielded by a competent hand – and this was a case in which they very well might have saved three lives. Unable to bear the public’s opprobrium, Sir Richard committed suicide.

The journalist Tina Cassidy’s book on birth describes the diverse ways in which humans have addressed, rationalized and assigned blame for the perils of birth. She motivates her excavation by using her own twenty-first-century experience with cephalopelvic disproportion as a point of departure; what was to be her “planned” “natural” “birth experience” (each word semantically loaded in her telling) ended up being quite the opposite, thanks to her small pelvis, induction, an epidural and ultimately an emergency Caesarean section.

Cassidy unpacks various notions of the “natural” and shows the extent to which birth is in fact not just some timeless event, but culture- and class-mediated – whether it occurs among the !Kung San of the Kalahari (women give birth alone) or in Marco Polo’s China (where fathers were put to bed for forty days with their newborns) or seventeenth-century Europe, when “barber surgeons” wrested the practice from persecuted but far more competent midwives, or early twenty-first-century Brazil, where up to 90 per cent of wealthy women opt for an elective C-section. Involving the highest of stakes, birth practices are in many ways one of the most telling barometers of cultural mores.

Religious beliefs, too, have obviously had a significant role in birth – in persecuting midwives as witches, in adjudicating who was most worth saving (mother or baby), and in interpretations of pain. In 1853, Queen Victoria notably defied clerical wisdom by inhaling chloroform during her eighth accouchement. The Lancet had firmly deplored such unnatural tinkering with “natural” labour but, as Cassidy explains, it was not the fact that it was a tremendously inexact science that bothered the public. Rather, the problem was that taking away pain appeared to tamper with divine decree (ie, Eve’s curse). It followed that, when Queen Victoria, the revered temporal head of the Anglican Church, inhaled chloroform, this seemingly inconsequential private act unleashed a paradigm shift in assumptions and practices on both sides of the Atlantic; the wealthy forthwith embraced chloroform à la reine. Soon enough, in another telling paradigm shift, “refined” women were seen as being too delicate to do anything but be knocked senseless during birth.

Much of the territory Cassidy traverses is well known, especially sections on iatrogenic disease – that is, disease caused by medical treatment itself: for instance, in the twentieth century, the tragedies of foetal X-rays, and of DES (Diethylstilbestrol) and Thalidomide prescriptions – and the more recently discovered infelicities of episiotomies. Birth: A history also includes chapters on the practices that so obviously mirrored iconic cultural moments: “twilight sleep” and stirrups of the 1950s; the Lamaze movement and conscious birth of the post-60s; epidurals, birth plans and elective C sections of the 90s and the twenty-first century. As Cassidy quite rightly reminds us, birth is a ripe terrain for fads.

Her romp through modern history bears repeating because it also reminds us that “science”, or at least medical obstetrics, is often a vigilante affair. For instance, after the move from midwives to doctors, mortality rates initially shot up, as did rates of postpartum debility. Hospital births starting in the eighteenth century were a huge liability; impatient obstetricians zealously used their instruments to wrest babies from only partially opened wombs; and doctors often did not wash their hands and so transmitted the deadly puerperal fever from woman to woman – or, indeed, from corpse to woman. Even in the early twentieth century, after germ theory was known about, hospitals were still the worst places to give birth and yet, paradoxically, they became the birthing place of choice for an ever-increasing number of women; infant mortality jumped 50 per cent between 1915 and 1929 in the United States in lockstep with the widespread across-class shift from home to hospital.

This is where Marsden Wagner’s book on birth in the US comes in. Where Cassidy is a wide-eyed outsider with a lively style, Wagner is an émigré de l’intérieur. A paediatrician, perinatologist, policy wonk, expert witness at countless trials, and World Health Organization (WHO) adviser, he is a whistleblower with a clear agenda: namely, to convince his public that, in the US, obstetrics is still a vigilante practice and that the public is being duped in much the same way as it was in previous eras. In a nutshell, the birthing industry is in the midst of yet another dangerous fad: too much medical intervention in the names of two cultural values: “convenience” and “control”. Wagner believes these values are dangerous in the obstetrical context. Proof that things are amiss in the US: it has the second worst newborn mortality figures in the industrialized world, despite having the most expensive maternity system. Women are 70 per cent more likely to die in childbirth in the US than in Europe.

Wagner has three main bugbears. C sections – which have done a wonderful job of bypassing too-small pelvises – are now being overused, to the point of radically increasing medical risk, he argues; in the US, rates are 30 per cent and rising, in the UK, 22 per cent and rising, while in the Netherlands (a paragon of sound practice, according to Wagner), rates are stable at about 10 per cent – partly because of a birth culture based in low-tech home births. Wagner laments that all too many American women, including some female obstetricians, imagine C sections are safer for newborns because surgery avoids the hazards of the birth canal; this is not at all true for low-risk pregnancies. Obstetricians themselves are likely to prefer C sections because they can be scheduled and rendered routine, which obviously could never be the case for vaginal birth.

Wagner’s second bugbear is induction, which, by triggering unduly forceful contractions, can fatally rupture the uterus. In the 1990s, a drug called Cytotec was quite commonly administered (in a vigilante manner) to induce labour, even though its risks were entirely unknown; this was an off-label use, since Cytotec was approved by the FDA solely for stomach ulcers. Claiming pregnancies were postdate after forty weeks (which they are not – there is no increase in neonatal mortality through to forty-two weeks), doctors induced women for what was clearly their own convenience. Wagner, who is fond of colourful metaphors, likens induction to taking a baseball bat to a mosquito – and believes patience would be a far safer strategy for all parties.

His third bugbear is the tribal nature of the obstetrics profession, which prevents doctors from informing on each other. He boldly asserts that litigation, malpractice suits and investigative reporting are a good thing in the US, and perhaps the only thing separating many obstetricians from wholesale vigilantism. He also believes malpractice suits hasten the day when obstetricians will cede at least some power to midwives.

Why are women letting themselves be duped? Because of this tribalism and its age-old shamanistic qualities. Obstreticians are still too much “like priests in white robes”, writes Wagner, practising in insular “cathedrals”; continuing the metaphor, pregnant women are then faithful parishioners when they should be sceptics. Wagner enjoins pregnant women to shun any birth book that advises “trusting your doctor” or “listening to your doctor”. Such phrases are red flags. Instead, they should trust the scientific evidence and “trust their bodies”. I am not sure what trusting one’s body means, given that interpreting bodily signs is itself a culturally mediated, indeed often faddish, affair – as Cassidy’s book makes abundantly clear. But, certainly, basing decisions on scientific evidence is sound advice – that is, assuming the evidence is robust. And Wagner does marshal plenty of evidence that midwives are the safest attendants for low-risk births – because they are trained to wait patiently for and facilitate birth, rather than to intervene in and/or hasten it. Evidence also suggests that when the C-section rate goes over 15 per cent, the maternal mortality rate increases. And evidence also shows that planned home births for low-risk patients are as safe as hospital births. But Wagner’s trump card when it comes to policy is probably the bottom line: acting on this evidence in the US would not only lower death rates but save vast sums of money.

A call to action, Born in the USA includes a list of sensible recommendations: for a national health care system that would provide care to all pregnant women, for more home deliveries, for increased use of midwives, and, of course, for increased scrutiny, transparency and accountability of the health care system. It’s hard to argue with any of this. What makes these recommendations compelling is the vast quantity of studies and court cases Wagner cites, his copious and careful footnotes, his fascinating use of cross-country comparisons, and the sheer volume of supporting information. What weakens his book somewhat is a lack of nuance. Rising mortality rates are not just due to excessively zealous unmonitored obstetricians and their uninformed patients, but also linked to women giving birth at older ages – something he fails to mention. He cloyingly informs the reader that he is a feminist and that he will refer to obstetricians as “he” – which seems problematic given that women are gradually colonizing the obstetrics profession. He also extrapolates from cases that went to trial to speak of men’s totalitarian control of a woman’s reproductive life – which seems like a statement that needs some qualification. Invoking feminism is a risky move in itself, since feminists are all over the map when it comes to medical intervention – and in fact it is hard to show that new medical technologies have led to the greater subordination of women. What is true is that, by electing for C sections or induction, women may well be exercising their choices in a context of incomplete and false knowledge.

Mary Briody Mahowald’s Bioethics and Women takes a similar moral stance to that of Wagner and also promulgates the adjudicating power of evidentiary medicine. A bioethicist and professor emerita at the University of Chicago, Mahowald offers no clear recipes or conclusions. Where Wagner’s tone is often inflammatory, hers is earnest, at once less entertaining and more nuanced. That said, she shares Wagner’s drive for an ethics of egalitarianism (between midwives and obstetricians and between medical personnel and patients) and for an informed sceptical patient capable in most cases of choosing between treatment plans. In many ways, Bioethics and Women provides the theory behind Wagner’s attempt to foster greater “justice” for pregnant women.

Mahowald applies “standpoint theory” (a kind of postmodern counter-hegemonic ethics par excellence that privileges the standpoints of multiple and especially non-politically dominant perspectives) to the clinical setting – but with the caveat that, in the case of birth, the pregnant woman’s perspective must be prioritized because she has the greatest stake in the matter. The problem here is that a shifting tapestry of interests, stakes, knowledge claims and power relations means that medical decisions must be made on a case-by-case basis. This makes medical decision-making an art, and messy. Mary Briody Mahowald offers no recipes for balancing competing claims – of groups and individuals, for instance – or for adjudicating pesky moral dilemmas like sex selection. She is more hopeful than Marsden Wagner about the clinician, believing that the obstetrician, with the right incentives and information, can be transformed into a consistently virtuous practitioner. I am not sure this would have helped Sir Richard Croft. Still, her ethics stands as a postmodern ideal.
 
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Michele Pridmore-Brown is a research scholar at the University of California, Berkeley. She is working on a study of the biopolitics of late fertility.