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Common Sense Care
for Childbearing

Bringing Back the 
Hippocratic Oath to 
21st Century Obstetrics

Childbirth Declaration 


Independence from the Unscientific Forms
 of Maternity Care 
as Provided to Healthy Childbearing Women

 ‘First, Do No Harm’

‘First, Do No Harm’

Common Sense Care
for Childbearing
Bringing Back the Hippocratic Oath to 21st Century Obstetrics

The Childbirth Declaration of the Independence
from the Unscientific and Harmful Forms of Maternity Care as Provided to Healthy Childbearing Women in the U.S:

We hold these truths to be self-evident -- that every normal healthy woman has the right to preserve the biological and psychological integrity of her person and her unborn baby from all forms of maternity care that fail the test of common sense.

Common Sense Maternity Care is science-based. Common sense maternity care is organized around preserving the health of the already healthy mothers. Common sense maternity care is based on the principle of physiological management, which is in accord with and supportive of the normal biology. Common sense maternity care is careful not to disturb the normal biological process. Common sense maternity care is fundamentally “efficacious” – that is, safe, cost-effective, accessible, affordable, acceptable and mother-baby, father, and family-friendly.

The Universal Standard of Care:

Physiological management is the evidence-based model of maternity care. Unfortunately, our the dominate 20th century model of interventionist obstetrics for healthy women is not scientifically-based. This is a problem that needs to be remedied. 

A true scientific standard of care would integrate the classic principles of physiological management with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women be used in all birth settings and by all maternity care providers -- family practice physicians, obstetricians, and professional midwives.

Healthy Childbearing Women have a right to:

v   Preserve the Integrity of Normal Birth

v   Unfettered Access to Scientifically-based Maternity Care

v   Control the Manner and Circumstances of Normal Childbirth

Problem: The uncritical acceptance in the US of an unscientific premise for normal maternity care – an untested experimental system of surgical obstetrics for healthy women with normal pregnancies -- is a serious problem. The obstetrical system defines normal childbirth as a surgical procedure to be performed by an obstetrical surgeon. However, interventionist obstetrics for healthy women is a risky and expensive model that fails to account for or address the ecology of normal birth. It routinely introduces unnecessary and unnatural risks and results in iatrogenic or nosocomial harm in a significant proportion of cases. About 20% of our health care budget is spent on maternity care, so a problem of this nature dramatically increase the cost of that care without improving outcomes and in many instances, creating additional costs in both in economic and in humanitarian terms.

Solution: A science-based maternity care system that uses physiological management is safe, cost-effective and mother-baby-father friendly. The physiological model of care reserves medical and surgical interventions for the treatment of complications and at the request of the childbearing woman.

The Science: The scientific basis for physiological management of pregnancy and normal childbirth is supported by a consensus of the scientific literature both in contemporary times and historically. Physiological management is actually protective for both mothers and babies, reducing the episiotomy & operative delivery rate (and associated complications), from approximately 72% to approximately 5% [Listening to Mothers, Oct 2002] with an identical, or even slightly improved perinatal mortality rate. It is efficacious -- that is, both safe and cost effective.

How come we don’t already have science-based maternity care?

Americans are accustomed to believing that we have the very best of everything, especially the best health care system. However obstetrics, as currently provided to healthy women with normal pregnancies, does not live up to this expectation. The reason is that childbearing in a healthy population does not routinely benefit from surgical skills or routine medicalization. Worse yet, spontaneous labor and birth does suffer when the normal physiology of childbirth is disturbed. Serious problems can occur (a category known as iatrogenic and nosocomial complications) as a result of unnecessary medical interventions.

The "modern" obstetrical system fails to live up to its potential because it rejected the physiological model of childbirth early in the 20th century, believing that the routine use of medical and surgical interventions made birth safer for healthy women. To understand why obstetricians came to that unusual conclusion, we have to examine the history of obstetrical medicine. Obstetrical medicine as we know it today got its start in the medical schools of Europe during the 17th, 18th and 19th centuries. This is where the teaching and practice of obstetrics was first institutionalized. It was this institutionalized model of maternity care that was adopted as the form of obstetrics still used in the US in modern times. 

Nineteenth Century hospitals as places for obstetrical education

BACKGROUND: In Europe during the Middle Ages there was a large population of pregnant women who were both indigent and homeless. Usually they were unmarried, widowed, immigrants, friendless or otherwise without resources -- the equivalent of what we now call “street people”. During the last weeks of their pregnancies they sought shelter in charity hospitals run by Catholic nuns. The ‘hospitality’ extended by these nuns is the origin of the modern word ‘hospital’ and idea of hospitals as places of caring.

Eventually these early centers of hospitality became linked to medical schools and evolved into places to conduct clinical research and teach clinical medicine. The most efficient way for medical students to learn about normal birth and to diagnosis and treat complications was to use the large number of hospitalized patients as teaching cases. This in-patient population provided medical students with opportunities to learn and practice their clinical skills.

Unfortunately, being a patient in these early hospitals also exposed childbearing women to extreme crowding and unhygienic circumstances – no running water, no sanitary toilets or even a bed with clean linens. No one understood the bio-hazards associated with hospitalization. Many times the crowding was so bad (and the understanding of contagion so poor) that women were made to share a bed with other patients. When they went into labor, they become teaching cases for the students of the medical school. As 'clinical material', they were repeatedly exposed to invasive procedures and to surgical deliveries (such as the use of forceps). 

All of this occurred long before the development of the germ theory of disease, exam gloves, techniques of asepsis and sterilization, laundry service, anesthesia or antibiotics. Never in the history of the human species had large numbers of unrelated women ever been aggregated in one place for childbirth. These early hospitals did for contagion in childbirth what gay bath houses did for hepatitis and HIV-AIDS, which is to say, to function as a vector which spread a lethal infection to healthy and otherwise unrelated people. 

Unfortunately, the extreme biological hazards of this situation were accompanied by an equally extreme level of preventable mortality. In some of the larger hospitals of 19th century Europe , two (or more) newly delivered women and their babies died each and every day, for months at a time. Medical professionals and the lay public were both acutely aware that the maternal-infant mortality rate was much higher in hospitalized patients than when doctors and midwives attended to the mother in her own home. Obviously the invasive procedures so central to the teaching and practice of obstetrics somehow violated the ‘ecology’ of normal birth (to the detriment of both mothers and babies), although the medical profession could not explanation how or why.

The ‘ecology’ of natural systems is modern term describing a complex set of ideas that did not exist in the 19th century. None the less, the concept of 'ecology' is an excellent way to understand the integrity and finely-tuned process crucial to normal child birth. Biological, hormonal, psychological and sociological factors must all work together to preserve, protect and promote normal childbearing. Like the global climate, the ecology of childbearing is a highly-orchestrated natural system with its own feedback loops and self-correcting mechanisms. Its adaptive capacity is amazingly broad and effective – a fact attested to by the survival of our species. For healthy women in surroundings which preserve that ecology, pregnancy and birth was normally successful. We know this statement is true because the human species has survived (and in fact, thrived) into the 21st century. 

However, the adaptability of any ecological system is never indefinite. The delicate balance necessary to safe childbirth was seriously harmed when laboring women became clinical material in the medical education process. Clinical instruction in obstetrics was a double edged sword. On the positive side, it greatly improved the understanding and technical skills of the medical profession. This advanced the knowledge-base of obstetrics and eventually led to many of the amazing and life-saving abilities associated with modern medicine. Unfortunately for childbearing women in the 18th and 19th centuries, this happened long before the discovery of microscopic pathogens and the development of the germ theory. Bodily intrusions (such as vaginal exams and the use of forceps) and other medical and surgical interventions caused iatrogenic complications to become the norm. Epidemics of a fatal infection – hemolytic streptococcus which caused septicemia or ‘puerperal sepsis’ -- gave the earliest hospitals a terrible reputation and caused them to be thought of as places where people died. As one can imagine, the obstetrical profession was very anxious to fix this problem. 

However, it was not until 1881 that the knowledge necessary to correct these problems began to emerge. Dr Louis Pasteur, a French physician now known as the ‘father of pasteurization’, was also the first person to formulate and teach the germ theory of infectious disease. By understanding the role of bacteria in making women sick and how to prevent cross-contamination through hand washing, use of antiseptics and sterilization, the obstetrical profession was finally able to stop the horrible epidemics of hospital-based fatalities. Improved housekeeping standards, liberal use of antiseptics, access to aseptic and sterile supplies, isolating the maternity wards from other parts of the hospital that housed infected patients -- al combined to end the mass causalities from childbirth septicemia in Europe (although individual cases continued to occur). This ushered in what we now refer to as “modern medicine”.

The Development of 20th Century Obstetrical Care in the US  

In the early part of the 20th century, hospitals in the US proudly adopted these ‘new’ ideas and epidemics of childbirth septicemia in American hospitals also become rare. But in spite of everyone’s best efforts, an unusual number of septic fatalities still occurred. As had been noted for centuries, doctors continued to observe a much higher maternal mortality rate in hospitalized women when compared to births attended by doctors and midwives in the mother’s own home.

However, the teaching and practice of all forms of medicine in an institutional setting was, from the medical profession’s standpoint, ever so much more satisfactory in every way. It was a godsend to have a nursing staff available 24-7 and to have them keep meticulous notes on each patient that doctors could refer to at a later time. Immediate access to x-ray and lab services and fully staffed operating rooms really bumped the practice of medicine up to a whole new level of efficiency. Doctors were particularly impressed by the convenience that came with having patients stay put in hospital beds, so that medical professors, med students, interns and residents could make the rounds of all their patients without leaving the building.

By comparison, home-based maternity care was seen as the bad old way of 19th century. Making house calls was considered to be an inefficient use of the doctor’s time. Also it often forced doctors to provide care in grim circumstances, such as tenements and rural farms, which deprived them of electricity and running water.

Surely these ‘domiciliary services’, as home-based care was referred to by the medical profession, were not appropriate for the new era of ‘scientific medicine’ and ‘modern medical miracles’. It was an exciting time of bright promises and obstetricians were committed to leaving behind the old-fashioned ways with all deliberate speed. The principles of physiological management and the caregivers that depended on physiologic process – mainly midwives and GPs --were right at the top of the list of ‘bad old ways’ to be replaced by the new ‘science’ of interventionist obstetrics.

How Obstetrical Intervention Became the “Norm” in the US

In 1910, two influential East Coast professors of obstetrics – Drs. Joseph DeLee and J. Whitridge Williams – had a theory. They had observed that ‘aseptic’ techniques (a - not & septic - infected = free from infection) were able to end the epidemics of fatal infections, but not able to prevent all individual cases of infection. This was particularly true for situations in which medical and operative interventions were used (induction of labor, repeated vaginal exams, episiotomy, forceps, manual removal of placenta). So they advanced a simple hypothesis – were doctors to conduct all births as a surgical procedure, all deaths from infection would be eliminated. They were describing a two part process. First ‘birth’ should be distinguished from ‘labor’ and secondly, birth should treated with the same kind of special sterile processes, special staff and sterile operating room that was already being used for major abdominal surgery.

This new configuration identified the physician’s role as focused primarily on the birth as a surgical procedure, to be performed in sterile garb and a ‘surgically sterile’ operating room. As a surgical procedure performed by a physician, it came to be referred to as “the delivery”.

Under these conditions, labor was referred to by the medical profession as ‘the waiting period until the doctor was called’. During the long and often tedious hours of labor, patient care was to be provided by hospital nurses. They were instructed not to call the doctor until it was time for the mother to be taken to the OR-type delivery room and prepared for the ‘delivery’. Then the doctor, in his official capacity as a surgical specialist, performed the highly technical ‘procedure’ of vaginal or operative delivery.  This was indeed worthy of the professional fee commonly charged for the services of an obstetrician.

To help guarantee the highest level of sterility and thus a safer birth, doctors believed that it was necessary to use general anesthesia to put the mother to sleep. Under chloroform or ether, the unconscious mother would lie perfectly still, and thus not accidentally contaminate any of the sterile sheets or instruments by moving around or touching things. However, when birth is conducted under anesthesia, the mother cannot make right use of gravity or push as effectively, so the use of episiotomy and forceps seemed to make a lot of sense to obstetricians. 

Doctors genuinely believed that routine use of episiotomy would protect the mother’s pelvic floor. They likewise reasoned that episiotomy, together with forceps, would protect the baby’s head from being battered on “the mother’s iron perineum”. In addition, the medical world believed that obstetricians would never be able to use forceps properly in difficult or emergency situations unless they maintained their skills by using forceps routinely in every normal case. It was agreed that the routine use of forceps was the only responsible thing for obstetricians to do.

Unfortunately, the abandonment of physiological management and its replacement by the routine use of obstetrical interventions, resulted in a marked increase in maternal-infant mortality and morbidity. Between 1910 and 1920, maternal deaths increase by 15% per year. Birth injuries to babies – usually the result of maternal anesthesia and the use of forceps -- increased by 44% during the same decade.

In addition to infection, there were other mortal dangers faced by childbearing women. These were usually the result of poverty, malnutrition, disease, overwork and forced childbearing.  As the educational level and standard of living rose, these situations gradually improved. The great advancements in maternal-child health that have occurred in the 20th century are primarily the result of improved public health measures and economic conditions. This was brought about by public sanitation projects, better access to education, a better diet, adequate housing, improved working conditions, appropriate access to medical care when needed, the safety net of social programs and access to effective contraception.

Only a tiny portion of the gains made in women’s health and the overall improvement in maternal and infant mortality rates associated with the 20th century can be attributed solely to obstetrical interventions. However, the obstetrical profession has always taken the lion’s share of credit for the dropping mortality rate. They remains convinced that only interventionist obstetrics stands between women and childbirth-related death and disability. 

Obstetrical interventions, such as drugs, anesthesia, forceps and Cesarean, can and are lifesaving for women or babies with serious complications. Unfortunately, the obstetrical profession believed that all normal labor and birth should be medicalized, using these same intervention routinely on every childbearing women. And so the same interventions used for complications became the standard of care for normal birth. At the same time, the normal ways of providing care to healthy women – physiological management -- was purposefully dismantled. This was accompanied by comments from the obstetrical profession that there should be only one standard for maternity care and that standard should be an obstetrical one.

How19th Century Ideas Contaminated 21st century Maternity Care

It is a convoluted path that led from Dr Semmelweis’s time in the 1840s to 21st century obstetrics in the US. However,  it is just a fluke of history that the epidemic nature of puerperal sepsis in hospital settings of the 18th and 19th centuries influenced and defined the development of maternity care for healthy women in the US in the 20th and now the 21st century

As consequence of the fatal epidemics of child birth septicemia in 19th century hospitals, childbirth as a surgical procedure to be performed by a physician became the ‘gold’ standard for the entire 20th century. During the last two decades of the 20th century, forms of medical and surgical intervention were ratcheted up to include routine induction of labor, nearly universal use of epidural anesthesia and frequent use of episiotomy and vacuum extraction. For many women, ‘elective’ or medically unnecessary Cesarean has become the crowing glory to the medicalized model of birth. 

This is particularly odd conclusion to a story and a strategy that started out to prevent iatrogenically- generated epidemics of childbirth septicemia as it occurred in teaching hospitals of Europe and the Northeast coast of the US in the late 1800s and early 1900s. However, its not too late to reassess the situation and correct the problem by adopting a science-based maternity care system that uses the principle of physiological management when providing care to healthy women with normal pregnancies.

“Primum non nocere”
In the first place, do no harm..."
bringing the Hippocratic Oath into the 21st Century

Physiological: …"..in accord with, or characteristic of, the normal functioning of a living organism (Stedman’s Medical Dictionary definition of “physiological” – 1995)

Physiological management is the evidenced-based model of maternity care. It is associated with the lowest rate of maternal and perinatal mortality, is protective of the mother's pelvic floor, has the best psychological outcomes and the highest rate of breastfed babies. Dependence on physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, Cesarean surgery, post-operative complications and delayed or downstream complications in future pregnancies. Physiological management is both safe and cost-effective.

Conventional obstetrics as applied to healthy women is the opposite of evidence-based, physiological management. Its associated with a high level of medical interventions, obstetrical complications, anesthetic use, instrumental deliveries, Cesarean surgery and post-operative complications including emergency hysterectomy, delayed complications such as stress incontinence and pelvic organ prolapse, downstream complications in future pregnancies, long-term psychological problems such as postpartum depression, lower rates of breastfeeding and increased asthma in babies born by cesarean section. Conventional obstetrics for healthy women is neither safe nor cost-effective.  [see "What Every Pregnant Woman Needs to Know about Cesarean Section", a systemic review of the scientific literature by the Maternity Care Association of NYC available at  www.maternitywise.org

A long over-due and much needed reform of our national health care policy would integrate physiological principles with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women. Physiological management should be the foremost standard for all healthy women with normal pregnancies, used by all practitioners (physicians and midwives) and for all birth settings (home, hospital, birth center). This “social model” of normal childbirth includes the appropriate use of obstetrical intervention for complications or at the mother’s request.

Physiologically-sound practices, science-based principles of care include:

Continuity of care,
Patience with nature,
Social and emotional support,
Mother-controlled environment (place) 
Provision for appropriate psychological privacy,
Mother-directed activities, positions & postures for labor & birth
Full-time presence of the primary caregiver during active labor
Recognition of the non-erotic but none the less sexual nature of spontaneous labor 
Upright and mobile mother during active labor 
Non-pharmaceutical pain management such as showers & deep water tubs 
Judicious use of drugs and anesthesia when needed (hospitalized mothers)
Absence of arbitrary time limits as long some progress, mother & baby OK
Vertical postures, pelvic mobility and the right use of gravity for pushing
Birth position by maternal choice unless other factors require otherwise
Mother-Directed Pushing -- NO prolonged breath-holding (Valsalva maneuver)
Physiological clamping/cutting of umbilical cord-- after circulation has stopped (3-5 mins)
Immediate possession and control of newborn by mother and father
On-going & unified care and support of the mother-baby for postpartum

Physiological management can be used by physicians and midwives
of all educational backgrounds and in all birth setting  

History of Midwifery ~ Ancient to Present 

Common Sense & Semmelweis  ~ History of Birth as a Surgical Procedure

Index for Evidence-based Maternity care by Topic  
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