I would call it a “pet peeve,” but the stakes are higher: I can’t stand policy arguments based on inaccurate or misrepresented historical facts. My latest peeve-trigger? Claire Howorth’s cover essay in Time magazine, critiquing “The Goddess Myth: How a Vision of Perfect Motherhood Hurts Moms.”
Now, I agree with much of Howorth’s criticism of the unrealistic standards of contemporary motherhood. It’s a main theme of my forthcoming book, Miscarriage and the Quest for the Perfect Pregnancy. But she and I part ways over the role of medicine and public health in our current conundrum. To Howorth, the problem is the out-of-control all-natural mommy bloggers, with their hippie doulas and lactation consultants, and the solution is to listen to the sensible voices of obstetricians who explain why we need hospital births for mothers, hospital nurseries for babies, and postpartum nurses who present breastfeeding and formula-feeding as equally valid alternatives.
In contrast, as I see it, the pressure on mothers comes from all directions, including the obstetricians. Pushing back against the overbearing medical approach to motherhood is as important as resisting the edenic fantasies of natural mothering advocates.
The reason Howorth is inadequately critical of obstetricians and hospitals is that she swallowed whole the cherry-picked historical facts obstetricians use to justify a highly medicalized, high-intervention approach to birth and lactation. Careful how you consume those cherry-picked facts, or you’ll choke on a pit!
First, and most egregious, Howorth relies on Yale School of Medicine obstetrics professor Mary Jane Minkin, who is quoted exclaiming, “In the 1900s, we didn’t have a lot of interventions… Guess what? People died. The average female life expectancy was 48. That was as ‘natural’ as it got.” From Minkin’s statement, you’d think that men lived to old age, but women dropped like flies from all that childbearing. In fact, in 1900, women had a slightly higher life expectancy than men.
And the average was so low because infant mortality was high. A girl or boy who made it to adulthood had an average life expectancy in the mid-60s. (In other words, don’t believe anyone who misreads statistics to argue that menopause didn’t exist before the twentieth century.) This is not to dismiss death in childbirth as a problem. But it needs to be understood in context: in 1900, women and men alike had more to fear from childhood illness and epidemic disease than from childbearing.
Second — subtler but even more important — doctors did have interventions in 1900. And far too much of the time, that was exactly the problem. Forceps could rescue a baby stuck in the birth canal, and save a mother from dying in childbirth. But they also damaged the pelvic floor, sometimes injured internal organs, and could introduce deadly infection. Used injudiciously, doctors’ interventions harmed more people than they helped.
Evidence suggests that on balance, it was safer for a birthing mother to stay away from doctors and their “help” in 1900. A study from England and Wales in the early 1930s demonstrated that the wealthiest women, who were most likely to hire doctors rather than relying on midwives or neighbors, had significantly higher rates of death in childbirth than poorer women. This is the opposite of what we would expect, since poorer people were sicker and died earlier in general. It’s pretty clear that it was the medical attendance itself that increased wealthy women’s chance of dying.1 Far too many women who would have given birth safely without intervention were subject to risky unnecessary procedures.
In another example from the United States, the Kentucky Frontier Nursing Service delivered nurse-midwifery care to poor Appalachian women in their homes in the 1920s and 1930s. The women attended by these midwives had an eight times lower chance of dying in birth than the American average, and more than ten times lower than the women attended by doctors at the local city hospital.2 Trained birth attendants could do wonders, but in the early twentieth century, it was nurse-midwifery training that provided the miracles, not medical training.
Physicians did not begin tipping the balance toward helping rather than harming their patients until the late 1930s. At that point, sulfanomides, quickly followed by antibiotics, began to effectively treat the infections doctors’ hands and instruments often introduced. Blood banking made transfusions more available to treat hemorrhage for women who gave birth in hospitals. Ergometrine, used to stimulate uterine contractions after birth and prevent dangerous hemorrhage, came into common use. Doctors finally had the tools to justify some of the faith birthing women had placed in them for a century and more.
In recent decades, critics of hospital birth have asked whether the current crop of obstetric interventions, from continuous fetal monitoring to cesarean section, are being drastically and dangerously overused, just like forceps were in 1900. In 1965, fewer than 5% of women gave birth by cesarean section. Today, nearly a third of births are cesareans. Howorth notes that the cesarean rate for first births has dropped slightly over the past three years, but she fails to put that in the larger context: a huge proportion of women continue to have unnecessary c-sections, and as Harvard medical researcher Neel Shah points out, cesareans come with an increased risk of hemorrhage, infection, and complications in future births.
The medicalized model of birth may be an alternative to the “goddess myth” Howorth critiques, but it is just as guilty of misleadingly promising women perfection if they try hard enough. It’s just a different list of demands. Submit to whatever the doctor asks — prenatal non-stress tests, birth induction, continuous fetal monitoring, cesarean section, vitamin D-fortified formula in the nursery — and you and your baby will be fine. At the very least, if you do everything, you will know that you have done everything you could.3
In fact, no one can promise perfection, and no one should make unrealistic promises even if they are temporarily reassuring. Childbearing just doesn’t work that way. When we demand perfection, our health care providers of various stripes, from obstetricians to home birth doulas, are tempted to make promises they can’t keep just to get us to calm down and focus on the task at hand. They promise too much, and do too much, in a desperate grasp at the perfection we so dearly wish they could give us. When they try too hard to do the impossible, they run the risk of hurting more than helping.
The excesses of the Goddess Myth are, in many ways, a response to the excesses of the Medicalization Myth. It won’t work to critique one and not the other, or simply atomize everything into a “celebrat[ion of] our individual experience,” as Howorth proposes. We need to see the larger pattern for what it is: an unfounded and ultimately vain hope and promise that childbearing can be made perfectible, if only we follow the right experts and put in enough effort.
- I. Loudon, “Maternal Mortality in the Past and Its Relevance to Developing Countries Today,” American Journal of Clinical Nutrition 72 supplement (2000): 241S–246S. Return to text.
- Ibid. Return to text.
- See my post on nurse-midwifery for a description of a promising evidence-based middle ground. Return to text.