By Anita Manning
For generations, women experienced pregnancy and childbirth at home, under the watchful eyes of midwives, neighbors, relatives, or friends. But in the early years of the 20th century, that began to change as doctors became more involved in labor and delivery and hospitals began attracting mothers from their homes to maternity wards.
United Health Foundation’s America’s Health Rankings® Public Health Legacy campaign takes a look at how pregnancy has changed over the past century.
“In the 1920s and ’30s, hospitals started marketing to women,” says historian Shannon Withycombe. The pitch was: “It’s a kind of break. Come rest for a week, have your baby, and you don’t have to take care of the family for a few days.”
Just a few years earlier, in 1915, only half of women giving birth were attended to by a physician, and most babies were born at home, says Withycombe, who specializes in the history of women’s health at the University of New Mexico, Albuquerque. “A lot of women were still having birthing experiences similar to what their mothers and grandmothers had,” she says.
In that pre-antibiotic era, hospitals often were thought of as places full of disease, and studies suggest they were no safer than homes for giving birth, Withycombe says. They may have been worse, in fact, because at home there was one patient, while at hospitals there were many, she says. While most hospitals had antiseptic policies in place by 1915, doctors went from patient to patient, increasing the chances of infection. “One of the big threats is they’ll do an autopsy and then come back and deliver your baby,” she says. To make hospitals more appealing, doctors touted their new tools and techniques, such as forceps and episiotomies, which were presented as advancements, but “training could be spotty,” Withycombe adds.
Hospitals could also seem impersonal and foreign to women who were more comfortable having babies in more familiar surroundings, Withycombe says, citing her own great-grandmother as an example. She had 14 children, the first 12 delivered at home by her mother, who died before babies 13 and 14 came along. They were born at a hospital. “She hated the hospital,” Withycombe says of her great-grandmother. “She hated having strangers deliver her babies.”
The risks of labor were significant. In 1915 in the U.S., 70 women died per 10,000 births, compared to about 1 in 10,000 today, says Dr. Thomas F. Baskett, professor of obstetrics and gynecology at Dalhousie University, in Halifax, Nova Scotia, and a 2008 History Fellow of the American Congress of Obstetricians and Gynecologists. The major causes of mothers’ death 100 years ago were what he calls HIT — hemorrhage, or massive bleeding; infection, also called “childbed fever”; and toxemia, now known as preeclampsia, a condition of high blood pressure that often went undetected and untreated because of a lack of prenatal care. “Mostly women just showed up at a hospital when they were in labor,” never having seen a doctor during the pregnancy, he says.
That’s when public health advocates within the U.S. government began to take steps to reduce infant and maternal mortality rates, establishing the Children’s Bureau in 1912, and offering maternal and child health services in larger cities by 1920. But for most women, prenatal care consisted of folksy advice to eat well, get fresh air, exercise, and stop wearing corsets, Withycombe says.
A pamphlet, “Prenatal Care by Mrs. Max West,” published in 1913 by the Children’s Bureau, offers advice on diet, debunking the adage that pregnant women should “eat for two.” No extra nourishment is needed, it said, except during the last two months of pregnancy, when the baby is gaining weight. During those weeks, it suggested adding a glass of milk or cocoa or a biscuit between meals and at bedtime. It also advised “at least two hours of each day in the open air,” and the wearing of maternity dresses: “Nowadays it is possible to have maternity clothing which is not only perfectly healthful, but both comfortable and pleasing without being conspicuous, so that the prospective mother need not deny herself the pleasure of going out among her friends.”
The revolution that brought more women into hospitals to have their babies was the promise of pain-free childbirth. In the 19th century and early in the 20th, pain relief during childbirth was in the form of chloroform and ether, which were dangerous and could only be administered by a doctor to women who could afford it. But in 1914, Americans learned that German doctors had developed “Twilight Sleep,” a drug combination of morphine and an amnesiac called scopolamine. It didn’t eliminate the pain of labor and birth, but made women forget it. Doctors were concerned because the drug increased the risk of hemorrhage, could slow down contractions, and depress the baby’s breathing.
But women wanted it and rallied to get it, forming their own Twilight Sleep clinics. One early advocate, Frances X. Carmody, went to Germany for her first Twilight Sleep delivery and four months later told a group of women gathered at a rally at Gimbel’s in New York, “I experienced absolutely no pain.” She said she ate a big breakfast an hour after the baby was born, and neither mother nor child had any ill effects. Ironically, Carmody, who founded a twilight sleep facility in Brooklyn, bled to death there after her second baby’s birth in August, 1915.i But that didn’t slow down women’s embrace of Twilight Sleep, which was used until the 1960s.ii
Women were well aware of the dangers of childbirth. “In the 19th and first half of the 20th century, everybody knew about death in childbirth, particularly those women who were about to go through the process,” writes medical historian Geoffrey Chamberlain. “Although death rates from many other conditions were high, they at least were among people who had been ill beforehand. Death in relation to childbirth was mostly in fit young women who had been quite well before becoming pregnant. They died, often leaving the baby, and other children in the family from previous births, with a widowed husband.”iii
Today, maternal mortality rates have plummeted, thanks to dramatic improvements in prenatal care and leaps in medical knowledge, along with societal supports for maternal and child health programs. From 1900 through 1997, the maternal death rate dropped nearly 99 percent, to 7.7 deaths per 100,000 live births.iv
But since 1987, maternal deaths increased from 7.2 deaths per 100,000 live births to 17.8 per 100,000 in 2009 and 2011.v
Reasons for that are unclear. Some women are having their first child later in life than their mothers did, Baskett notes, and obesity rates in the U.S. and elsewhere are high. “Both those factors increase the risk of maternal death,” he says.
But the trends toward older motherhood and obesity aren’t budging. In many wealthy countries, women are waiting to have babies — in the U.S. in 1970, one in 100 births was to a first-time mother age 35 or older; by 2006, that had risen to one in 12. And the risk of fetal death in women 35 and older is twice that of younger mothers.
Obesity during pregnancy increases risks for both mother and baby, says a committee of the American Congress of Obstetricians and Gynecologists, and in the U.S., more than half of pregnant women are obese or overweight. That raises the chances that the mother will have high blood pressure, gestational diabetes and other problems, the committee says, and places the baby at risk for premature birth, stillbirth, congenital abnormalities and obesity later in life.
Some conditions that have an impact on women’s health, and the racial disparities of concern, are reflected in United Health Foundation’s America’s Health Rankings®, which provides state-by-state data on several health indicators.
i Birth: The surprising history of how we are born, Tina Cassidy, Atlantic Monthly Press, 2006. Pp 93-94
ii Caton, Donald. Labor Dispute, Yale University Press.
iii British maternal mortality in the 19th and early 20th centuries
iv MMWR, Oct. 1, 1999/48(38); 849-85
v CDC Pregnancy Mortality Surveillance System.