The Washington PostDemocracy Dies in Darkness

The key to lowering America’s high rates of maternal mortality

Health-care providers have forgotten the central lesson of two millennia of gynecology.

Mali Givens, 33, of the District, is examined by Ebony Marcelle, director of Midwifery, Family Health & Birth Center at Community of Hope. (Sarah L. Voisin/The Washington Post)

The Centers for Disease Control and Prevention reports that rates of maternal mortality in the United States — already the highest in the developed world — are on the rise.

In 2019, American women are more than twice as likely to die of pregnancy-related causes than they were in 1987. The effects of this crisis are disproportionately felt by black women, who die at three to four times the rate of white women. Politicians have begun to take action: Democratic Sens. Elizabeth Warren (Mass.) and Kamala D. Harris (Calif.) have each introduced new plans to combat rising maternal mortality with federal incentives for hospitals and implicit bias training for medical students.

These are important steps in the right direction. Yet it is striking that, although the solutions offered by Harris and Warren are new, the underlying causes of maternal death are anything but. The CDC cites hemorrhage and infection as two of the leading causes of pregnancy-related death, the same conditions described as “excessive bleeding after birth” and “childbed fever” in centuries-old medical texts.

Today those conditions are entirely treatable, but they persist because medical attention focuses overwhelmingly on the child, not the mother. Prenatal appointments revolve around heartbeat monitors and ultrasound scans. A majority of doctors still prescribe bed rest, even though it does not reduce preterm labor but does put women at considerable medical risk. Finally, several states with the strictest antiabortion laws have maternal mortality rates over twice the national average.

These legislative and medical efforts are symptoms of a culture that values fetal health and development over the health and safety of mothers.

But it was not always this way. In fact, before modern medicine, gynecology centered on the woman’s body. Of course, women in pre-modern societies hoped to give birth to healthy children, just as we do today, but before medical technology made fetal development comprehensible — even visible — physicians and midwives valued a mother’s health in ways that are notably missing in American culture today.

The origins of “western” gynecology can be traced to the ancient Greeks, who imagined a woman’s body ruled by her reproductive system. Because the womb was thought to affect all aspects of a woman’s health, ancient gynecology was holistic, focused not solely on reproduction but on a host of diseases supposedly unique to women.

In practice, this meant that ancient physicians were encouraged to listen to their female patients and to take complications from pregnancy and childbirth as serious manifestations of the power of the womb. The ancient Greek medical text “On Diseases of Womendevotes 11 chapters to the “Diseases of Pregnant Women” and another 22 to postpartum complications. And it admonishes doctors who “make mistakes” by failing to ask “accurate questions” of their female patients, and instead “proceed to heal as though they were dealing with men’s diseases.” Ancient Greece was no feminist utopia, but even in that harshly patriarchal society, physicians recognized the danger of ignoring women.

Fifteen-hundred years later in medieval Europe, Christianity offered new models for pregnancy and childbirth. Women were encouraged to meditate on childbirth as penance for Eve’s original sin and to liken their suffering to that of the Virgin Mary. But even within a deeply religious culture focused on suffering as a means to redemption, medieval medical treatises still emphasized treatment for the pain and dangers of labor and delivery.

The 12th-century Latin medical treatise “On Conditions of Women” provided a regimen for pregnant women that included long baths and foot rubs, as well as a lengthy section on “Difficulty of Birth,” with attention to various life-threatening complications in delivery. Though the treatments advised were nowhere near effective (suggestions included having the laboring woman ingest a charm written on cheese or wrap a snake skin around her belly), they illustrate that preserving the health of the laboring woman by whatever means possible — magical or medical — was the primary concern.

Concern for women’s health did not mean complete disregard for the fetus. Fetal deaths were all too common before modern medicine, and pre-modern Europeans worried about these deaths. In response, the church granted authority to laypeople, even women, to perform baptism in cases of fetal emergency. Nonetheless, concern for the spiritual health of the fetus did not trump concern for the mother’s physical health. One recipe for stillbirth delivery in a 15th-century English manuscript calls for a plaster of mugwort (artemisia vulgaris) to be laid across the mother’s belly so that she can “have deliverance without peril.” Even in these most tragic circumstances, medical texts remained focused on the mother’s health.

Thanks to rising literacy rates and the invention of the printing press, by Shakespeare’s day women could read about reproductive medicine, much of it still borrowed from the ancients, in printed manuals. The most popular of these, and the first published in England, was “The Birth of Mankind: Otherwise Named The Woman’s Book,” a translation and adaptation of a German bestseller.

Again, this manual on childbirth, pregnancy and newborn care prioritized maternal health. Its translator, Richard Jonas, explained that he published the work in English instead of the usual Latin common to medical books out of “love of all womanhood,” so that women could “read and understand” it and find relief from the “manifold daily and imminent dangers and perils” suffered in childbirth. No wonder, then, that Elizabethan ladies snapped up so many copies.

What can medicine from the past teach us about women’s health care today? Should 21st-century women long for a return to ancient, medieval or Renaissance gynecology? Of course not. The “imminent dangers and perils” of childbirth are prominent in pre-modern medicine precisely because women died so often from infection, hemorrhage or preeclampsia. Thanks to modern medicine, doctors can treat each of these conditions. This is unequivocally a good thing for women and their babies.

Yet sometimes they don’t treat those conditions, and not because they lack knowledge or because their remedies are as futile as charms on cheese. Somehow, our culture has forgotten that women are central to the experience of pregnancy and childbirth. Their bodies, symptoms, pains and illnesses warrant careful medical attention today, just as they did for the past two millennia. For as much as medicine has come a long way since the ancient Greeks, even they knew that a doctor may be “correctly taught by the sick woman why she is sick.” And so it is even today.