the risks of childbirth -- 1/08/20

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Today's selection -- from The Body by Bill Bryson. The risks of childbirth:

"The business of pregnancy and birth has never been easy. However tedious and painful childbirth is now, it was much worse in the past. Until the modern era, levels of care and expertise were often pretty appalling. Just determining whether a woman was pregnant was a long-standing challenge for medical men. 'We have known a practitioner of thirty years' standing blister the abdomen in the ninth month under the idea that he was treating a morbid growth,' wrote one authority as late as 1873. The only truly reliable test, one doctor noted drily, was to wait nine months and see if a baby emerged. Medi­cal students in England weren't required to study any part of obstetrics until 1886.

"Women who suffered from morning sickness and were rash enough to declare it were likely to be bled, given enemas, or dosed with opiates. Women were sometimes bled even if they had no symp­toms at all, as a precaution. They were also encouraged to loosen their corsets and to abjure 'conjugal enjoyments.'

"Almost anything to do with reproduction was considered suspect­ -- pleasure above all. In a popular book of 1899, What a Young Woman Ought to Know, Mary Wood-Allen, an American doctor and social reformer, told women that they could engage in conjugal relations within marriage so long as it was done 'without a particle of sexual desire.' In the same period, surgeons developed a new procedure called an oophorectomy -- the surgical removal of the ovaries. For a decade or so, it was the operation of choice for well-off women with menstrual cramps, back pain, vomiting, headaches, even chronic coughing. In 1906, an estimated 150,000 American women underwent oophorectomies. It more or less goes without saying that it was an entirely pointless procedure.

"Even with the best care, the long process of creating life and giving birth was agonizing and dangerous. Pain was considered a more or less necessary correlate of the process because of the biblical injunc­tion 'in sorrow thou shalt bring forth children,' Death for mother or baby or both was not uncommon. 'Maternity is another word for eternity' was a common saying.

"For 250 years, the great fear was puerperal fever, or childbed fever as it was more commonly known. Like so many other diseases, it seemed to leap into ugly existence from out of nowhere. It was first recorded in Leipzig, Germany, in 1652 and then swept through Europe. It came on suddenly, often after a successful delivery when the new mother was feeling quite well, and left the victims fevered and delirious, and all too often dead. In some outbreaks, 90 percent of those infected died. Women often begged not to be taken to the hospital to give birth.

"In 1847, a medical instructor in Vienna named Ignaz Semmelweis realized that if doctors washed their hands before conducting intimate examinations, the disease all but vanished. 'God knows the number of women whom I have consigned prematurely to the grave, 'he wrote despairingly when he realized it was all a matter of hygiene. Unfortunately, no one at all listened to him. Semmelweis, who was not the most stable of persons at the best of times, lost his job and then his mind and ended up stalking through the streets of Vienna, ranting at thin air. Eventually, he was confined to an asylum where he was beaten to death by his guards. Streets and hospitals should be named for him, poor man.

"A commitment to hygiene did gradually catch on, though it was an uphill battle. In Britain, the surgeon Joseph Lister (1827-1912) famously introduced the use of carbolic acid, an extract of coal tar, into operating theaters. He also believed that it was necessary to sterilize the air around patients, so he built a device that put out a mist of carbolic acid all around the operating table, which must have been pretty awful, particularly for anyone wearing spectacles. Carbolic acid was actually a terrible antiseptic. It could be absorbed through the skin of patients and medical practitioners alike and could cause kidney damage. In any case, Lister's practices didn't spread much beyond operating theaters.

"In consequence, puerperal fever went on for far longer than it need have. Into the 1930s, it was responsible for four out of every ten maternal hospital deaths in Europe and America. As late as 1932, one mother in every 238 died in (or from) childbirth. (For purposes of comparison, today in Britain it is one in every 12,200; in the United States, it is one in every 6,000.)

"Partly for these reasons, women continued to shun hospitals well into the modern era. Into the 1930s, fewer than half of American women gave birth in hospitals. In Britain, it was closer to one in five. Today the proportion in both countries is 99 percent. It was the rise of penicillin, not improved hygiene, that finally conquered puerperal fever.

"Even now, however, there is huge variability in maternal mortality rates among countries of the developed world. In Italy, the number of women who die in childbirth is 3.9 per 100,000. Sweden is 4.6, Australia 5.1, Ireland 5.7, Canada 6.6. Britain comes only twenty-third on the list with 8.2 deaths per 100,000 live births, putting it below Hungary, Poland, and Albania. But also doing surprisingly poorly are Denmark (9.4 per 100,000) and France (10.0). Among developed nations, the United States is in a league of its own, with a maternal death rate of 16.7 per 100,000, putting it thirty-ninth among nations.

"The good news is that for most women in the world childbirth has become vastly safer. In the first decade of the twenty-first century, only eight countries in the world saw their rates of childbirth deaths increase. The bad news is that the United States was one of those eight.

" 'Despite its lavish spending, the United States has one of the highest rates of both infant and maternal death among industrialized nations,' according to The New York Times. The average cost of childbirth in the United States is about $30,000 for a conventional birth and $50,000 for a Cesarean, about three times the cost for either in the Netherlands. Yet American women are 70 percent more likely to die in childbirth than women in Europe and about three times more likely to suffer a pregnancy-related fatality than women in Britain, Germany, Japan, or the Czech Republic. Their infants are no less at risk. One of every 233 newborn babies dies in the United States, compared with just one in 450 in France and one in 909 in Japan. Even countries like Cuba (one in 345) and Lithuania (one in 385) do much better.

"The causes in America include higher rates of maternal obesity, greater use of fertility treatments (which produce more failed outcomes), and increased incidence of the rather mysterious disease known as preeclampsia."

author:	Bill Bryson
title:	The Body
publisher:	Doubleday
date:	Copyright 2019 by Bill Bryson
pages:	294-297