Change And Choice In Childbirth

24.3.06

• Places of birth and choices of support.
• Medicalisation of pregnancy and childbirth.
• Maternal mortality - the silent crisis.
• Choice and rights.

Changing place of birth
• 1927 ~ 85% home births.
• 1961 ~ 32% home births.
• 1980 ~ 1.3% home births.
• Hospital birth increasingly synonymous with "safe birth."

Man-midwives
• Exploiting medical knowledge.
• AKA "accoucheurs."
• William Smellie (1733-1815).
• 3 stages of labour.
• Rise of the surgeon - apothecary - general practitioner.

18th Century
• 1730s - increased use of forceps.
• More anatomy, physiology and pathology knowledge.

But…
• Limited obstetric teaching.
• No successful caesareans before 1890s.
• Despised by physicians and surgeons.
• No Royal College of Obstetricians until 1929.

Reducing the risks of childbirth
• James Young Simpson - anaesthesia in childbirth 1849.
• Queen Victoria's "blessed chloroform" 1851.
• Management of complications.
-Placenta praevia.

Puerperal "childbed" fever
• Streptococcus pyogenes.
• Ignaz Semmelweis (1818-65).
• Vienna Maternity Hospitals.
• Proved medical students carried infection to maternity wards from mortuary.
• Introduced carbolic hand wash.
• Semmelweis ridiculed.
• Louis Pasteur (1822-95).
• Joseph Lister (1827-1912).
-Antisepsis technique.
• Single Causation theory.
• 1880s - obstetric antiseptic practice.

Medicalisation of childbirth
• Increased use of anaesthesia.
-"Twilight sleep" fiasco.
• Western women "all have difficult labours."
• GPs applied forceps under general anaesthetic in 50% of normal deliveries.
-For doctor's convenience?

The backlash?
• Grantley Dick Read (1890-1959).
• "Natural Childbirth" published 1933.
• Stressed the "psychosomatic" as opposed to "mechanistic" approach.
• "Fear-tension-pain" syndrome.
• Advocated more relaxation and less drugs.

Professionalisation of midwifery
• Pre-20th Century image: "drunken old hags."
• 1902 Midwives Act.

Maternal mortality
• 1890s ~ 13 maternal deaths a day.
• 1990s ~ <1 maternal death a week.
• 1920-1929 ~ 25,000 maternal death in UK.
-Puerperal infection, toxaemia, haemorrhage.

Statistical black spot - Rochdale
• Most dangerous place in Britain to give birth in 1930.
• 90 maternal deaths per 10,000 deliveries.
• Government inquiry.

"Magic bullets"
• Gerhard Domagk (1895-1964).
• 1935 - developed first sulphonamide.
-Prontosil.
-Led to almost 100% recovery from puerperal fever.

Reversing the trend
• Ergometrine.
• Blood transfusions.
• Penicillin (1945).
• NHS (1948).
• Improved medical education.

Liverpool's contribution
• Robert Minnitt (1889-1973).
-Developed self-administration of obstetric anaesthesia "gas and air" machine.

New issues
• Increasing rates of medical intervention.
• Episiotomy rare before 1970s.
• Caesarean rates.
-1950s ~ 2%.
-2000s ~ 20%.
• Screening and monitoring.