A Brief History of Hospital-based Maternity Services
as Relates to the Routine Nursery Care of Normal Newborns

by faith gibson, LM, CPM

Historically, the care of childbearing women and their babies was provided by midwives in the mother's home. Hospitalization for childbirth was confined to indigent (homeless) women in the big charitable institutions of Europe during the 17th, 18th and 19th centuries. Due to crowded and unsanitary conditions and ignorance the principles of contagion, as many as 7 out of every 10 women hospitalized for childbirth died during outbreaks of childbed fever (puerperal sepsis), caused by the streptococcus bacteria. Classically-speaking, hospitals were avoided by the well-off who engaged physicians to care for them in the safety of their own homes. It was not until an Austrian physician and medical reformer proved that childbed fever was contagious that hospitals became a relatively safe place to give birth. In the 1840s Dr. Ignaz Philipp Semmelweis established that medical students accidently spread this fatal infection by failing to wash their hands between performing autopsies and doing pelvic exams in the labor wards. In 1879 Louis Pasteur scientifically established the modern "germ theory" and the principles of asepsis and sterilization which paved the way for our contemporary and casual use of hospitalization.

As in Europe, the first maternity hospitals in the United States cared for indigent patients and were affiliated with medical schools. Patients were considered valuable "teaching material" for medical students and free medical services were provided in exchange for the contribution they made to medical education. In the 1890s a well-organized champaign was launched by physicians to eliminate midwives, as they served this same low-income or immigrant population. Doctors felt that every midwife-attended birth was a "waste" of "valuable teaching material", and thus interfered with the education of their medical students. Between 1900 and 1930, the percentage of births attended by midwives dropped from 50 percent to 12 percent as a result of this effort.

As medical & surgical abilities improved, non-indigent women were hospitalized to treat a serious illness or a medically complicated pregnancy. Because these medically-complex situations necessitated interventions such as drugs, surgery or anesthesia and a prolonged recover period for the new mother, the baby was admitted after the delivery as a second patient to be cared by the hospital staff. Starting in the 1920s, hospitalization for normal childbirth became more popular and the use of interventions requiring anesthesia became the norm, thus all babies born in hospitals needed to be legally admitted to those institutions as their drugged mothers were unable to care for them. In some instances, the infant itself was sick or premature and needed special care. Whatever its origins, routine admission of the neonate as a second patient soon became an unquestioned and unexamined policy.

Routine hospitalization for normal childbirth was brought about by the physician shortages of the Second World War and perpetuated by Hollywood's portrayal of it as a more glamorous and scientific way to have a baby. As the war in Europe required more and more battle surgeons, the shrinking number of doctors left behind to serve the civilian population found it to be more efficient to send laboring mothers to the hospital to be cared for by nurses. This central location allowed a single physician to serve half a dozen laboring mothers at one time, as the doctor's presence was only required when the birth was imminent. Prior to 1937, less than 50% of births occurred in the hospital. By the end of WWII the rate of hospitalization was close to 80%, except in the deep south and rural farming communities, where many births were still attended by midwives. Of course routine hospitalization also necessitated centralized nurseries to care for a large number of babies born to anesthetized mothers. However, the immature nature of a newborn's immune system resulted in epidemics of dysentery and other potentially-fatal infections. Thus the problems of caring hygienically for large numbers of babies in a central nursery required expensive and complicated isolation of the babies from each other and from other patients and visitors. This resulted in elaborate infection-control procedures and an almost military regime, with limitations on visitors and a host of precautions that made hospital maternity wards user-unfriendly and increasingly costly.

It was not until the 1950s, when private health insurance companies began to routinely pay for normal maternity care, that hospitalization become the standard for childbirth. By this time physicians were accustomed to the status, personal convenience and "efficiency" of hospital-based obstetrics and greatly preferred it to the pre-war era. The American College of Obstetricians and Gynecologists was founded during this period (1951) and the general post-war baby boom was encouraging everyone to think big. Home-based birth services were still considered a "necessary evil" for poor families who could not pay the greater expense of hospitalization. In many rural areas of the country, only midwives were available to serve this uninsured & low-income population. Then in the 1960s, Medicaid and other "Great Society" programs for indigent medical care expanded their coverage to match that of the private sector. Within a very short time, federal money from Medicaid resulted in virtually a 100% hospitalization rate for normal childbirth, with care now only provided by physicians (eliminating the less costly care of midwives) and routine admission of 100% of newly born babies to expensive hospital nurseries.

In the 1970s, many mothers began to question the routine use anesthesia for normal childbearing. Not only did they prefer to be awake when their babies were born but they objected to the drugged state that left them unable to care for their babies after the birth. As "natural" childbirth became increasingly popular, these "awake & aware" mothers wanted to have their babies with them in their hospital rooms. In response to this "consumer" pressure, hospitals developed a policy known as "24 hour rooming-in", meaning that the baby stayed in the mother's room in a lucite bassinet that could be wheeled back and forth to the nursery. However, the routine "admission" of the baby to the nursery was continued, with the hospital functioning as "in loco parentis" by taking control of the baby immediately after the birth and then taking it away to the hospital nursery to be weighed, measured, bathed, "observed" and returned to the mother only after being "blessed" (diagnosed) by the nursing staff or pediatrician as "normal". By this cursory admission of the baby to the nursery, the hospital maintained the legal right to continue to charge for nursery care. The right to charge for these services also meant that the hospital incurred legal culpability in event of a problem even though the baby remained with its mother most or even all of the time. Since admission to newborn nurseries, even if only "on paper" makes the hospital vulnerable to malpractice litigation, it perpetuates military-like regimes in maternity units in which babies are "allowed" to stay with their mothers only if the nurse or pediatrician "approves". In many ways, the focus on malpractice litigation of the 1990s has replaced the focus on pathogens that marked the pre-antibiotic era of hospital care.

Conclusions

The "standard" admission of newborns to hospital nurseries, begun 75 years ago when mothers were drugged and unable to care for their babies, now routinely creates a second "paying customer" out of every childbirth occurring within its boundaries -- almost 4 million babies annually. Not only is this a needless expense, but the legal entanglements unnecessarily perpetuate the vulnerability of the institution to litigation. This gives rise to policies and procedures that interfere with breastfeeding and maternal-infant bonding, making this unfortunate artifact of the 1920s a very unsatisfactory circumstance for mothers, babies and taxpayers alike. The practice of having Medicaid pay for this unhelpful expense should be abandoned. Only sick or premature newborns needing medical care should be admitted to hospital nurseries. All healthy newborns belong to and belong with their mothers. The money saved should go for necessary and helpful health services or improved preventive care.

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