CHILDBIRTH IN OLDEN TIMES

It’s around Halloween, so I figured I’d tell you a horror story. A tale that you might confront personally if you found yourself as the caregiver in a post-disaster scenario.

In centuries past, women married in their mid-teens and often had 8 to 10 children, no, that’s not the horror story. The horror story was whether a woman survived childbirth. Childbirth was so dangerous back then that a woman would sometimes make out her last will and testament as soon as she found out she was pregnant.

Let’s look at the Mayflower: Three women were pregnant when they boarded the Mayflower on its journey to America. One child, Oceanus Hopkins, was born during the voyage and died during the first winter in Massachusetts. Another infant, Peregrine White, was born just off Cape Cod and lived to an old age. A third was stillborn after arrival at Plymouth; the mother died as a result of childbirth.

In addition to the fear of maternal death or of the child dying, there was no pain relief during labor, except maybe for whisky. In Puritan communities, pain during childbirth was considered to be deserved. According to Genesis 3:16, it was thought to be God’s punishment for Eve and all women who came afterward.

In the year 1800, a woman’s chances of dying during childbirth was about two percent per birth. If a woman gave birth to eight or more children, her chances of eventually dying in childbirth were pretty high, and your chances were even worse if you were the baby. The chances of a child dying before the fifth birthday were around twenty percent.

Rich women commonly employed wet nurses to breastfeed their babies for them. You might think this increased their chances of surviving, but hormones produced during breastfeeding are nature’s way of spacing out children. As a result, rich women often ended up with more pregnancies than poor women. At two percent mortality per birth, the rich might have had even worse outcomes than the poor. If you were a slave in the Southern States, things were much, much worse for both the mother and baby.

For good or bad, Medical doctors began to take part in childbirth. They had the latest medical knowledge at their fingertips, but the latest 18th or 19th century knowledge wasn’t always such a good thing. Midwives were and are often still preferred, at least having personal experience on their side; physicians came with the access and authority that comes with the title and the ability to use hospitals.

The advent of hospitals, however, wasn’t such a great thing. As a matter of fact, the first hospitals in the U.S. were meant for poor folk that couldn’t get doctors to come to their home. Before we understood bacteria and how infection spread, many were death traps. In fact, the doctors themselves were often sources of infection for women in labor, going from patient to patient with unwashed hands and instruments. As a result, hospitals were places of last resort as post-childbirth infections ran rampant.

In the 1840s, physicians began to wash their hands or use chlorine solution between obstetric patients. The more strict the hand washing routine, the lower the rate of infection in the hospital ward. Despite this, the idea didn’t receive acceptance by the medical industry at large.

Childbirth changed dramatically, also in the 1840s, with the development of anesthetics. A Dentist named William Morton developed the use of ether for surgery in 1846 and obstetrician James  Simpson introduced chloroform in 1847. Queen Victoria of England herself used chloroform during her delivery in 1853. It was her eighth child.

In 1914, a method called Twilight Sleep was developed, which caused the mother to sleep through delivery. The drugs, however, sometimes caused respiratory depression in the baby (in other words, stopped it from breathing at birth) and even overdosed some mothers.

In the early-mid-20th century, advances in medicine finally outpaced the access of the lower classes to medical care. A doctor appointed city health inspector for the Hell’s Kitchen area in 1901 found that 1,500 newborn babies died in the district every week.

This doctor, named Sara Josephine Baker, was someone special. Her efforts to improve care included inventing infant formula, opening prenatal clinics, training babysitters, and opening milk stations in the city. Her efforts resulted in a huge decrease in infant and child deaths. By the time Baker retired in 1923, New York City had the lowest infant mortality rate of any major American city. I sure hope that, somewhere, there’s a statue dedicated to her.

The main dangers for women in childbirth in the 19th century were the same you’ll see in a long-term survival event today: prolonged labors, excessive bleeding, and infection. Fetuses in abnormal positions, narrow pelvises, and large sized infants were (and are) difficult to deliver. At one point or another, it became clear (often after two or more days in labor) that no progress was being made. This required a doctor to use instruments like forceps to pull the child free or to crush the child’s skull and remove it.

You heard me. There were entire chapters in every obstetric textbook on destructive procedures to kill and remove a baby that was “stuck”. Often the baby was already dead at this stage and there was a strong chance that the mother would also die, so these were decisions made in desperate situations; desperate situations you, medic, might experience one day if something really happens that takes away modern medicine.

Excessive bleeding was another common problem; it is still a risk in childbirth today. Modern obstetrics has recourse to drugs, however, which help to control it. In olden times there was almost nothing a midwife or doctor could do to stop a post-birth hemorrhage and many women literally bled to death.

Infection was the other great scourge of childbirth. Women are very susceptible to infection during and immediately after the process of childbirth. Fevers were both common and deadly, usually starting one or two days after delivery and spreading to the blood within a week. Even an apparently normal birth was no guarantee of a safe recovery for the mother. The strain of a long labor, a stuck placenta, or any number of complications increased the risk significantly.

The greatest improvement in the reduction of bad outcomes was the decrease in the number of births per woman. As smaller families became the desired norm and family planning became popular, the emancipation of women helped save many lives. There were still many families that were large by modern standards, but by 1900 the average woman could expect to bear four children– about half the number her mother had. Today, it’s even less.

The practice of putting women to sleep during labor wasn’t commonly done at home, changing the face of childbirth in modern society. In 1900, over 90 percent of all births occurred in the mother’s home. In 1940, over half took place in hospitals and by 1950, the figure had reached 90 percent. The substitution of doctors for midwives and hospitals for home delivery, however, did little to save lives.

Then, in the late 1930s, antibiotics were introduced. By the end of World War II, the widespread use of antibiotics cut childbirth deaths to its present low level.

Because of the importance of antibiotics in saving lives from infections, We wrote a book known as Alton’s Antibiotics and Infectious Disease, which hopes to give you options in preventing avoidable deaths in disasters or remote settings.

Childbirth is still a challenge; have a baby and, as far as I’m concerned, you’ll never have to prove your courage in any other way.

Joe Alton MD

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