Reaction to rumors of a home birth was markedly different in the United States. The news that Meghan had planned for a home birth was mocked at the annual meeting of the American College of Obstetricians and Gynecologists. “Let’s see how that goes,” Timothy Draycott, a doctor, commented at the event. “She’s 37, first birth. I don’t know. We’ll have to see.” Draycott’s comments brought both laughter and skepticism, especially in the United States, where home birth continues to be associated with danger and irresponsibility.
Not so long ago, both countries shared a respect for midwifery and home births. But over the centuries, they went in opposite directions. In the United States, technology and the dominance of obstetrics have served to diminish the status of midwifery and home birth.
It was not preordained that the United States would develop different birth practices than Britain. In colonial America, childbirth practices resembled those of England, where it was entirely a female affair. Beginning in the 1760s, however, American physicians developed an interest in normal obstetrics and gradually replaced female midwives. William Shippen, for example, provided lectures on midwifery to male physicians after returning from medical training in England in 1762. He opened a practice of midwifery in Philadelphia and “became a favorite of Philadelphia’s established families,” according to the book “Brought to Bed: Childbearing in America, 1750-1950,” by historian Judith Walzer Leavitt.
Others followed suit, expanding their practices to include laboring women. Women who opted for this new “man midwife” — and who could afford him — believed him to possess a skill lacking in the female midwife. Men had far greater access to medical education than did women and were more likely to use obstetric tools, such as forceps or anesthesia.
This frustrated midwives, and, according to Leavitt, physicians’ techniques probably “created new problems for birthing women and actually increased the dangers of childbirth.” Nonetheless, the professionalization and greater technology available to physicians gradually won the day.
By the early 20th century, physician-attended birth had become the norm. In 1900, midwives participated in approximately half of all births; by 1930, that number was down to 15 percent. “Midwifery was left to become a curious historical artifact with a sometimes dubious reputation,” explains one historian of childbirth. Within the decade, hospitals replaced homes as the primary location of childbirth, ushering in a new era of medicalized birth.
Not everyone viewed the shift as a sign of progress. Patricia Cloyd Carter, who delivered six of her nine children at home without any assistance, ranted against the practice of hospital births. She resented “being held tied down, slapped, shaken by the shoulders, ordered ‘Stop bearing down’ in tones you wouldn’t use to a dog.”
Carter was one of a growing number dismayed by the emotional and physical toll of medicalized childbirth. “What should have been the most exalting and exulting of experiences was riddled with horrors at a big inner-city hospital where I felt like I was going to the Bastille, not to be seen again,” reflected one woman to a reporter. “The delivery room was an immensely bloody spectacle in what seemed at the time like a butcher shop where everyone was wearing rubber gloves and I was in the middle like a trussed-up turkey.”
Meanwhile, in Britain, the status of the midwife did not suffer the same sort of challenge from professionalized medicine as it did in the United States. Modern statistics tell the story of this divergence. Currently in the United States, we have 33,600 obstetricians and 15,000 midwives. In Britain, there are 36,000 midwives and 1,835 obstetricians.
These clashing notions of childbirth led the two countries to respond quite differently to a recent study on which birth setting results in the best outcomes. The British birthplace study reviewed 64,000 low-risk births to determine the relative safety of giving birth in one of four settings: a hospital obstetric unit led by physicians, an “alongside” midwifery-led birth center (on the same site as a hospital obstetric unit), a free-standing midwifery-led birth center or at home.
Those who started out getting their care in a hospital were four to eight times as likely to get a C-section. Rather than being driven by patient risk or preference, this tendency toward C-sections appeared to be driven by proximity to the operating room. The study’s authors concluded that the risks of over-intervention in the hospital may outweigh the risks of under-intervention at a birth center or at home for the majority of expecting mothers.
In Britain, the National Institute for Health and Care Excellence took these findings seriously and changed its recommendations in December 2014. Americans, however, did not respond positively to the findings. Most did not believe that the solution lay in alternatives to hospital birth or in obstetric management of birth.
This may be unwise: Harvard obstetrician Neel Shah notes that “for more than a half-century, we have believed that spending many hours, if not days, in a hospital bed with a smattering of ultrasound gel, clips, wires, heart tones, random beeps and routine alarms is the safest way to have a baby.” But the 500 percent increase in the number of C-sections since 1970 has not led to better birth outcomes. “Obstetricians like me may be hardwired to operate, and too many operations are harmful to patients.” Perhaps patients should avoid obstetricians and hospitals — at least until it’s clear that they are needed, he concludes.
This reality hasn’t changed the American perception that birth without an obstetrician or outside a hospital is dangerous and irresponsible. But it distorts our understanding of the past. In fact, many Americans in recent years have fought to reclaim birth as a meaningful procedure and insisted that we honor the role that midwives have historically played in birth practices.
Midwifery organizations in the United States have done an outstanding job — through birth practices, lobbying, social media and legislation — of educating pregnant mothers and changing attitudes about home birth as well as the use of midwives. And historians of childbirth continue to provide evidence that current practices are not necessarily wedded to best practices.