Childbirth and Reproduction
CHILDBIRTH AND REPRODUCTION
CHILDBIRTH AND REPRODUCTION. During the colonial period childbirth was a predominantly female experience. Biologically and socially, reproduction was thought to represent a particularly clear example of the division of labor. While men were traditionally excluded from the childbirth experience, a network of female neighbors and relatives regularly attended home births and offered comfort, support, and advice to supplement the role of midwives, who were considered experts in birthing knowledge. Women dominated the profession of midwifery until the mid-eighteenth century. They were well equipped to handle difficulties such as excessive pain, slow progress, and a poorly positioned fetus. As birth was considered a natural process, the midwife customarily played a noninterventionist and supportive role, relying on practical experience and an appeal to female traditions designed to ease the expectant mother through the stages of labor and delivery. Labor was commonly described as a period of travail, as the pain of childbirth carried both a heavy theological burden and a very real possibility of death and debility.
The Growth of Obstetrics
Physicians entering the birthing arena in the second half of the eighteenth century challenged the predominance of midwives. Men like William Shippen, the first American physician to establish a steady practice of midwifery in 1763, offered affluent women in urban areas the promise of an expanded armamentarium of drugs and instruments combined with the expertise and prestige of a medical education. By the early years of the nineteenth century, the term obstetrics was used to refer to the new medical field in America that offered bleeding, opium, ergot, and forceps to allay painful and lengthy labors. The practical application of obstetrical knowledge suffered from the restrictions of etiquette and prudery. Instruction was primarily conducted with manikins, pelvic examinations took place under sheets without visual inspection, and students graduating from obstetrics courses rarely witnessed actual births.
The expansion of obstetrics by the mid-nineteenth century reflected a combined shift in the biomedical discourse of reproduction and the parallel professionalization and specialization of medicine. As the essence of femininity was increasingly attributed to the reproductive capacity of women, and was isolated in the ovaries, the female body became an object of medical study and intervention. Physician intervention often followed cultural assumptions rather than scientific evidence. Theories of reproduction were vigorously defended long before cell theory and advances in microscopy had allowed Oskar Kertwig, in 1876, to demonstrate that the joining of the egg and sperm nuclei resulted in fertilization. Industrial metaphors were also increasingly used to describe childbirth in terms of "production," and the specialized knowledge of obstetrics was promoted as essential to "managing" the childbirth experience.
While a lack of a systematic approach to the practice of obstetrics and the need to negotiate interventions with the birthing woman and her attendants limited the pace of change, the physicians' interventionist model provided women with something midwives could not. Ether and chloroform were first employed in 1847 to dull or erase childbirth pain; drug use and procedures for suturing perineal tears became routinized in the second half of the nineteenth century; and new types of forceps were standardized and birthing chairs were gradually modified to allow for semirecumbent or fully horizontal postures. The results were mixed. While the use of drugs, episiotomy (surgical enlargement of the vagina), and the horizontal position made childbirth easier from the doctor's perspective, they had the potential to significantly increase the difficulty, length, and pain of labor and delivery. Furthermore, when measured by mortality statistics, the physicians' safety record only matched or was sometimes worse than the record of midwives. It is also probable that physicians' techniques created new problems resulting from inappropriate forceps use, careless administration of anesthesia, and the spread of puerperal fever.
The goals of scientifically managing childbirth and maintaining antiseptic conditions based on bacteriological knowledge encouraged physicians to move deliveries from patients' homes to hospitals by the early part of the twentieth century. Only 5 percent of American women delivered in hospitals in 1900. By 1920, the figures ranged from 30 to 65 percent in major cities; by 1940, 55 percent of Americas births took place within hospitals; and by 1955, hospital births had increased to 95 percent of the total. Physicians promoted hospitals for the sterile techniques and technology they employed, including newly developed antiseptic and anesthetic procedures, the use of X rays, and a safer "low" cesarean section that was an improvement over techniques widely used since the 1870s. The move to hospitals also supported the pathological view of childbirth and the increased specialization of physicians.
There was a dramatic parallel shift from midwife to physician attendant in the first three decades of the twentieth century. As late as 1900, half of all the children born in the United States were delivered with the help of a midwife. By 1930, midwife-attended births had dropped to less than 15 percent of all births, and most of these were in the South. Physician-critics of midwifery identified the "midwife problem" as the source of all ills for childbearing women, and published a wave of articles in medical journals and popular periodicals. While public health advocates frequently spoke in their defense, midwives were ultimately in no position, economically or organizationally, to effectively respond to the charges of their critics. Despite the suggestion in national reports issued in the early 1930s that midwives had a consistently better record with maternal mortality, women continued to prefer the hospital to the home because they believed that it offered them a safer and less painful birthing experience.
The use of anesthetics dramatically changed the experience of childbirth and also facilitated widespread efforts in the 1910s to upgrade obstetrical practice and eliminate midwives. Physicians began experimenting with new forms of anesthesia like scopolamine, a drug with amnesiac properties that suppressed a patient's memory of painful contractions and created a state known as "twilight sleep," as well as various forms of spinal anesthetic. Following the publication of an article on scopolamine in McClure's Magazine in 1914, a national movement of women who advocated the adoption of twilight sleep methods by American obstetricians saw the use of scopolamine as an opportunity to control their birthing experience. Their strategy ultimately backfired as scopolamine was found to be extremely dangerous to both mother and child. After widespread use until the 1960s, the demand for painless childbirth was ultimately met by physicians, but at the price of many women losing control of the birthing experience by being put to sleep with a variety of drugs that could only be administered under the expertise of hospital attendants.
Scholars have debated the potential consequences of the medicalization of childbirth that followed these developments. Women may have benefited from the technological advances in hospitals. However, they have sacrificed both the ability to make choices for themselves and the supportive environment of home birth in the pursuit of a safer and less painful birthing experience. Improvements in hospital regulations and practices have been credited for the improved safety of birth. Likewise, the prenatal care movement, adoption of sulfonamides, blood transfusions, and X rays, and the use of antibiotics after World War II were also crucial in lowering maternal and infant death rates by the 1940s.
Natural Childbirth and Later Developments
The emergence of the natural childbirth movement of the late 1940s and early 1950s challenged the basis of medicalized childbirth. Grantly Dick-Read's Childbirth Without Fear: The Principles and Practices of Natural Childbirth, first published in 1944, opposed the routine use of anesthesia and called for less medical intervention. Marjorie Karmel's Thank You, Dr. Lamaze: A Mother's Experiences in Painless Childbirth, which appeared in 1959, also appealed to a growing minority of women who found the scientific approach to childbirth adopted by most hospitals to be lacking in personal satisfaction. In the 1960s and 1970s, feminist health advocates extended this argument by advocating the right of women to control their bodies. The publication of Our Bodies, Ourselves by the Boston Women's Health Collective in 1971 provided a political statement urging women to assume greater control over all aspects of their bodies in society, including pregnancy and childbirth. The women's health movement helped to establish collectives across the nation that launched an exhaustive critique of American childbirth practices. During the 1970s, a variety of alternative birthing methods were introduced, including homelike birthing rooms in hospitals, the establishment of freestanding birthing centers, the restoration of birth at home, and renewed interest in midwifery.
The isolation and synthesis of female sex hormones, which led to the development of the birth control pill in the 1950s, also set the stage for modern reproductive technologies like in vitro fertilization by the late 1970s. The implications of new reproductive technologies developed in the 1980s, such as cloning, surrogacy, embryo transfer, and genetic engineering, continue to provide fertile ground for debate. Furthermore, reproductive rights, which include the right to choose procreation, contraception, abortion, and sterilization, also became one of the most politically divisive issues in the late twentieth and early twenty-first centuries. Feminist scholars have shown that these debates have the potential to challenge conventional histories and reshape the culturally constructed meanings of childbirth and reproduction.
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