The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Effects of Technology on Perinatal Mortality

In the late 60's our C/S rate was 3% and we allowed all breeches to labor. Our PNM rate was 32/1000 LB. We had no Monitors and no Perinatologists. Take your pick as to what is cause and effect &/or association.

The above statement strikes me as a belief system rather than a scientifically-predicated one and disappoints me -- i should like to think that we are making a fairly graceful transition from the "authority" model to a truly evidence-based, scientific one. A great deal of creditable and non-controversial research has identified the fall in PNM in the US over the last 3 decades as due primarily to factors other than increased use of Cesarean surgery (especially for breech positions) and the utilization of continuous EFM. In fact evidence suggests that we would have enjoyed a greater improvement in maternal-infant health without the unmerited dominance of those procedures. I was an L&D nurse during the 1960s and early 70s, at a time & place with a 3-4% Cs rate, routine vaginal delivery of breeches, racial segregation and a similarly high PNM rate as quoted above. I can easily identify from personal experience and familiarity with the scientific literature what the major contributors to the reduction of PNM have been (as could anyone whose professional experience spanned that era).

Statistically speaking the largest impact was a reduction in premature births associated with a generally improved standard of living and improved access to medical care which was particularly crucial to poor Southern populations (Appalachia) and blacks (esp. in the segregated South and urban ghettos). This improved health standard was due in part to federal civil rights legislation and desegregation of schools and hospitals. The second most important factor was elimination of high and frequently repeated doses of barbiturates, narcotics and potentiator drugs administered during labor which routinely triggered respiratory depression in neonates, abandonment of routine use of general anesthesia and forceps during childbirth, and the development of RhoGAM to prevent Rh sensitization and perinatal death from erythroblastosis fetalis. Additional factors were improved imaging (ultrasound, etc.) and ability to detect anomalies during the antepartum (through AFP, amnio, CVS, etc.) with subsequent elective abortion of defective fetuses; improvements in antepartal Dx for maternal disease (HHELP, etc.); improved understanding of neonatal resuscitation (PPV with 100% O2); improved treatment of RDS (surfactants), abilities to keep preemies under a 1300 grams alive (new drugs and devices such as O2 monitors, IV pumps, NICU, etc.). Obviously the discipline of perinatology plays an important and much appreciated part, especially for tiny preemies but the greatest improvements have come from preventing pregnancy and birth related problems (which includes the abortion of defective fetuses), and reducing the overall number of preemies. Considering the magnitude of the above list, i'm only surprised that we don't have the best maternal-infant outcomes in the world.

As a student nurse in the early 1960s I remember the feeling of shock upon learning that death from anesthesia was the third leading cause of maternal mortality, outstripped only by toxemia and hemorrhage. Thank God that era has ended. Improved outcomes for mothers and babies are a complex topic which includes many social, economic and political factors as well as the hard work of obstetrical science but one cannot leave out the influence of childbirth education and the push for "awake and aware" childbirth by (dare i say it?) the lay public and the re-introduction of the principles of midwifery. This was pivotal in changing childbearing from a risky operative delivery under general anesthesia, unwitnessed by even the mother and conducted behind closed doors marked with "No Entrance - Authorized Personnel Only" -- to a family centered event which includes the active participation of the mother and family members and which is generally a far safer event. I don't know about most of the obstetricians in the United States or even on this list but i for one do not long for the "good ole' days" and i do welcome the coming evidence-based practice parameters as having the potential to create a truly superior "single-standard" of maternity care which combines the classical principles of midwifery with the best of modern medical acumen. Need i state obvious -- that respect for midwifery principles has nothing to do with whether or not one is a doctor or midwife as knowledge belongs equally to us all. Wisdom lies in the appropriate application of knowledge.

I apologize in advance for stepping on anyone's toes -- i only call attention to the factual basis of our mutual good fortune (as patients and caregivers) in enjoying a 9:1000 national PNM rate. I am reminded of a classical Quaker joke which goes like this: Late one evening a Quaker (pacifist) farm family was awakened by the sound of a burglar in the house. The farmer got up, grabbed a hunting rife and tipped-toed quietly to the head of the stairs where he could see a man attempting to empty the family silverware drawer into a sack. After clearing his throat he said "Excuse me friend, i mean thee no harm but thou standest where i am about to shoot." Suffice it to say, "i mean thee no harm".