World War II and the WHO

Friday, November 13, 2009

We temporarily leave the dark ages to comment on a study I saw this week about the WHO’s C-section rate recommendations.

First, some background.

The natural childbirth movement in America began in the late 1960s and early 1970s. The origins are mucky and unclear.

It is often touted as a feminist response to the increasingly meddlesome intervention of MEN in the obstetrics business, and the increasingly medicinal, sterile, instrumental approach to obstetrics in general.

(BUT, let us not forget, that that increasingly medicinal, sterile, and instrumental approach had finally managed to put a dent in maternal mortality rates for the FIRST TIME IN HISTORY, in the 1950s.)

HOWEVER, there were lots of other things going on in the world at the time. And women up to this point had been clamoring for knock-em-out and serve-em-up obstetrics. Hospitals were advertising their painless delivery methods and their great, here’s-your-kid, isn’t-he-cute services.

Dr. O. Moscucci, a prolific researcher on the history of obstetrics in the UK, doesn’t think it was all feminism. She thinks it had a lot to do with chauvinism. Misogyny, even.

In 1942, a guy named Grantly Dick-Read (yes, that’s his name. No, I didn’t make it up. Yes, it’s unfortunate) became the Father of Natural Childbirth. He wrote a treatise that explained that primitive women, women who followed normal, biological gender roles, did not have pain in childbirth. He tried to convince women that they, too, would not have pain in childbirth if they properly prepared themselves. By, say, evincing normal gender roles.

His motives are somewhat suspect–at the time Britain was dealing with the post-World War I baby non-boom, and the new impending loss of another generation of young men in WWII. Birth rates had dropped, especially among the upper and middle classes, many of whom were educated women who pursued careers (GASP!) instead of filling Britain’s coffers with strapping young men who could strap on a helmet and go to war.

If we just convinced them that there was no pain, then there would be more kids, right? RIGHT??

[Do not underestimate the state of panic in the UK at the time. They fought WWII, virtually on their own, for years. When I said they lost an entire generation of young men, they really did. This is NOT an exaggeration.]

While the wars changed forever the way the upper and lower classes were defined in Britain (WWI was a “gentleman’s war.” WWII was a slugfest), they also changed women’s roles, permanently. Not everyone in Britain thought this was a grand idea. In fact, Dick-Read was one of those types who truly did not think this was a very grand idea.

As Moscucci puts it:

One obvious way to reverse the falling birth was to entice women of “superior stock” back into the home, where they would fulfill their functions as wives and mothers. Health reformers took up the challenge by developing an ideology of childbirth that emphasised the “naturalness” of pregnancy and birth. This ideology functioned at a number of levels. It was prescriptive, in that it rooted woman’s social role in her biological capacity for reproduction… Motherhood was not only a woman’s supreme fulfilment and reward, but also her civic duty…

TA-DAH! The “feminist” pursuit of natural childbirth was born.

What does this have to do with the WHO and Caesarian Section Rates?

As the natural childbirth movement took hold, the increasing number of C-sections was panned, world wide, but especially in western societies. If childbirth is normal and natural, then what could possibly go wrong? Why would we need operative intervention?

The World Health Organization got into the act. They decided that the upper limit of normal for C-sections should be 15%. The lower limit should be 5%. No one questioned the WHO’s judgment. After all, they’re the WHO, right?

First, let me explain that medicine traditionally does try to get a handle on optimal percentages for procedures. You don’t want to do too many, because that exposes patients to unnecessary risks. You don’t want to do too few, because you might be waiting too long and putting the patient in unnecessary jeopardy. The “optimal” appendectomy rates, for instance, are commonly set so that about 5% of the appendices that get pulled are histologically normal. That means we do about 5% too many, but it also means that the docs aren’t waiting for their patients to pull a Houdini and die of peritonitis.

So, the WHO’s “optimal” C-section rates should be based on perinatal, maternal, and postoperative morbidity and mortality. Right?

Sadly, no. The WHO’s recommendation was based on no empirical data, whatsoever. Just a wild hunch, pushed by the natural childbirth movement, that doctors should butt out as much as possible.

A new study, however, has shown that perinatal and maternal morbidity and mortality are lower with numbers of C-sections a little higher. Like, around 22-36%. Like, right where the reviled US and UK fit in.

To be fair, the US and the UK also have excellent prenatal and postnatal care, so we might be able to do a better job with the babies and the moms in general. And yes, our litigious society forces the hands of our obstetricians, who cannot afford to wait to see what happens when fetal monitoring shows distress. But it is entirely possible that our high C-section rates might not be so bad, after all.

And let’s not forget that the maternal mortality rate, which hovered right around 6/1000 for millennia, suddenly dropped precipitously right around the 1950s, when our C-section rates started creeping up. Today, in the US, it’s about 0.1/1000.

The WHO isn’t always right. Sometimes, perhaps, the docs who are taking care of the patients might actually know what they’re doing.

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Tags: caesarian, childbirth, history, humor, maternity, morbidity, mortality, natural, obstetrics, Parenting, section, WHO

17 Comments

heidi

Friday, 13th November 2009 at 4:07 pm

I have to say I'm a huge fan of C-sections and I don't care who disagrees. I do believe if you can do it naturally, go for it. My oldest and I would both be dead if not for the C-section. And, I wouldn't have been able to go on and have 3 more c-sections. Unfortunately, sometimes biology makes the only "natural" way to give birth also end in death.

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