Midwives

A better solution

I seldom read fiction, but I accepted my spouse's advice and read Frozen River by Ariel Lawhon. This fictional account of Martha Ballard, a real-life midwife who delivered thousands of babies in late 1700s New England without losing a single mother, proved to be a certified page-turner. The story involves murder, greed, avarice, mayhem, and rape—basically everything you'd expect from colonial America, plus babies.

It offers insight into the lives of Americans soon after the revolution. I highly recommend it. What struck me most was how dramatically childbirth has evolved from an all-women affair to a sterile medical procedure with worse outcomes and costs that could finance a small country's defense budget. This prompted me to reflect on my own obstetric education in the 1960s. This was when fathers were not forced to watch their offspring coming into the world or having to cut the umbilical cord.

Today's American medical students have virtually no hands-on obstetric experience, which is deferred to residency if they're brave enough to choose Ob-Gyn as their life's work. We, on the other hand, were thrown into the deep end: over 50 normal deliveries, some breech cases, which is one of nature's ways of keeping things interesting, 10 forceps or vacuum extractions (medieval torture devices disguised as medical instruments), and assisting at numerous C-sections.

In South Africa, the overwhelming majority of deliveries were performed by midwives, a secret society whose second mission, after assisting women through the challenges of childbirth, was to humiliate medical students. They excelled at both. These women could deliver a baby with one hand and crush a medical student's ego with the other—multitasking at its finest. Unlike the USA, where general hospitals are expected to cover all aspects of medical care, from hangnails to heart surgery, South Africa, following the UK's model, has numerous specialty hospitals. These included Fever Hospital for infectious communicable diseases, an eye hospital, a children’s hospital, and, naturally, a maternity hospital. If women didn’t deliver at home, this was where babies entered the world.

The Queen Victoria Maternity Hospital was just over the hill from the medical school and Johannesburg General Hospital. It was opposite The Fort, a structure dating back to before the Boer War, which had been used as a jail and is now a museum. The complex of buildings is now called Constitution Hill, which is perhaps more of a hope than a reality.

The “Vic” was where white “European” women delivered their babies and where we were sent for our first tour of obstetrics. During the apartheid era, there was no designated maternity hospital for the black population in central Johannesburg, so prospective mothers had to travel to outlying hospitals.

It was also one of the first living-in experiences for us as students. Simple bedrooms arranged along a single corridor were dedicated to us while we waited to be summoned for a delivery or to recover from being semi-conscious and exhausted. The most prominent structure in the room, aside from a single narrow bed, was a large bell on the wall — the signal to immediately go to the delivery area.

As students, we were under the strict supervision of the midwives and were required to follow their rules to the letter. They did have many letters. A delivery was a carefully choreographed event where ritual and tradition played significant roles. A mother was required to lie on her back, and the attendant — whether a student or midwife — was always on the patient’s right side. Too bad if one was left-handed. Many African women preferred to squat during delivery, which is a more effective method of giving birth. It promotes a better anatomical position, with gravity offering an additional benefit. This method suited everyone except the midwives. White women were allowed to walk around before delivery, but once in labor, they were forced back to the horizontal.

The birth of a human infant is clear evidence against “Intelligent Design.” No sentient force would create such an awkward and risky process. The problems that evolution caused are twofold. Since we are bipedal and spend most of our time upright, the pelvis, through which the baby must pass, has changed shape. Making matters worse, our heads are too large because of a big brain. For the head to pass through the birth canal, we are born before we are fully ripe for the outside world. It's like trying to thread a basketball through a keyhole.

Most other mammals give birth to offspring that are ready to survive outside — they can see, walk, hear, and even run within a day or two. A giraffe calf drops six feet to the ground and is standing within an hour. Human babies can't even hold their heads up for months. Talk about quality control issues.

Here's where the story takes a tragic turn from the ridiculous to the genuinely tragic. In the early 1900s, America decided that midwives who had been safely delivering babies for millennia were obsolete. This wasn't based on safety data (midwives had better outcomes) or cost-effectiveness (they were vastly cheaper). No, this was about money, status, and good old-fashioned sexism and racism, as many were black or immigrants.

The newly minted medical establishment, led by ambitious male physicians, launched a systematic campaign to eliminate midwives. They portrayed them as dirty, ignorant, and dangerous, despite the fact that these women had lower maternal mortality rates than the doctors trying to replace them.

Medical associations used legislation, licensing requirements, and social pressure to drive midwives out of business. They convinced the public that "scientific" hospital births were superior to "primitive" home deliveries. What they delivered instead was a medicalized system that treated normal birth like a disease requiring aggressive intervention.

By the 1950s, midwifery in America was nearly extinct—a remarkable achievement considering these women had been successfully catching babies since before recorded history. Other civilized countries, not bowing to medical machismo, kept their midwives. The results speak for themselves. The consequences of America's anti-midwife crusade are written in blood and bankruptcy statements:

Death Toll: The U.S. maternal mortality rate hovers around 22-32 deaths per 100,000 live births, depending on race and region. Europe, with its old-fashioned midwife-centered systems? Often below 10 per 100,000, with Scandinavia and the Netherlands typically seeing 3-5 per 100,000. America is the only high-income country where maternal mortality has been rising in recent decades. That's not a typo—we're actually getting worse.

The Cost of "Excellence": American childbirth is the most expensive in the world, often costing $10,000-$30,000 per birth. You could fly to Europe, have your baby delivered by a midwife, take a month-long vacation, and still spend less money. Meanwhile, countries that retained midwifery enjoy both lower costs and better outcomes. Over 35% of American deliveries are by cesarean section, compared to South Africa's rate of below 5% in my day. We've created a system so intervention-happy that normal birth has become an endangered species.

But I digress from my own educational experience. At the Vic, we were assigned to pregnant women from admission until several hours post-delivery. This meant sitting bedside for hours, sometimes days, timing contractions and trying not to fall asleep standing up. Massaging backs. We always hoped for "multips" (women who'd given birth before) because their labors were usually shorter. But the head nurse, wielding the power of case assignment like an overlord, usually gave the multips to nursing students and stuck us with "primips"—first-time mothers whose labors could last longer than a Wagner opera.

We were never assigned to "elderly primips" (any woman over 35 having her first baby, as they were regarded as high risk.) I still remember my wife's indignation when she saw this charming designation on her chart, despite not yet reaching the official ancient age of 35.

Birth, by the way, is not for the faint-hearted. St. Augustine allegedly put it best: Inter faeces et urinam nascimur (we are born between shit and piss). To which I’d add blood, mucus, and amniotic fluid with its own special eau de parfum. Midwives handled this chaos with calm expertise, using squatting positions, massage, and patience. In contrast, the modern American system often reaches for the scalpel at the first whiff of difficulty. After delivery came the placenta inspection (checking for missing pieces like a jigsaw puzzle made of flesh), followed by the newborn cleanup routine. Eighteen hours of labor and delivery left us wanting nothing more than unconsciousness, but first we had to bathe the baby until it was "bright and shiny"—apparently, hospital policy required newborns to gleam like freshly waxed cars. Once the infant's temperature had stabilized, we were permitted to deliver the package to the mother with a smile.

A colleague devised a clever plan to avoid these post-delivery responsibilities. After his second delivery, he waited until the head nurse—the matron—was patrolling the nursery. He entered, filled the tub with boiling water, and asked which bassinet baby Smith was in. He grabbed the infant by the feet and casually went over to the tub as if he was going to dunk the newborn headfirst into the steaming cauldron. Horror spread through the nursery. The Matron shrieked, “Mr. X, you are not permitted to ever set foot in this nursery again.”

Problem solved.

The irony is that we've replaced a system that worked — experienced midwives providing continuous, relationship-based care — with a fragmented, expensive, and intervention-heavy approach that produces worse outcomes. It's like replacing a reliable bicycle with a Ferrari that breaks down every mile and costs a fortune to maintain.

Countries that kept their midwives laugh at our "advanced" system while enjoying better maternal mortality rates, lower costs, and happier mothers. Meanwhile, American women, especially Black and Indigenous women who face 2-3 times higher mortality rates, pay the price for our medical hubris.

Perhaps Martha Ballard, with her perfect record and her sensible approach to birth, had it right all along. Progress isn't always about adding complexity. Sometimes it's about not breaking what already works.