A famous glass of milk

Dr. Howard A. Kelly, the subject of the previous post, is incidentally the star of a true story that has been recounted so often it has taken on a highly embellished life of its own.

While a very young man, Kelly was hiking around in rural Pennsylvania when he stopped at a house to ask for a glass of water. Thinking he looked hungry, the young woman who answered the door gave him a glass of milk instead.

Fast forward many years. The woman went to a hospital in the city to seek help with a serious gynecological condition. The great Dr. Kelly, as he now was, treated her successfully.

When it came time for the bill, the woman discovered that the invoice read, "Paid in full with one glass of milk."

Like many top doctors of his day, Dr. Kelly, who lived from 1858 to 1943, charged enormous fees. However, Audrey Davis, a friend and biographer, wrote that he often treated people for free. (Remember, people didn't have health insurance in those days.) For every patient Dr. Kelly charged for his services, he treated three for free, Davis reported.

So Dr. Kelly's generosity to the woman who had shown a young man a kindness was an everyday thing for him.

Still, it's a great story.

A Caesarean section in Philadelphia

Dr. Howard A. Kelly

Dr. Howard A. Kelly

In 1888, nine years after Robert Felkin brought back his amazing story from Uganda, Dr. Howard A. Kelly of Philadelphia, a brilliant young obstetrician who would go on to help found the medical school at Johns Hopkins University in Baltimore, announced at a convention of the fledgling American Gynecological Society that he had performed the first successful Caesarean section in Philadelphia in 51 years—that is, the mother had survived the operation.

Very few members of the audience he was addressing that day had ever attempted even one Caesarean section because, at the time, the procedure virtually always ended in the mother's death.

A Caesarean section in colonial Africa

Robert Felkin, a British physician and missionary, reported witnessing a Caesarean section performed by an indigenous healer in Kahura, Uganda, in 1879 that featured antisepsis, anesthesia, cauterizing and sutures.

The woman had been given banana wine, and had been secured to a table with bark cloth at her chest and thighs. A couple of men held her waist and ankles. The practitioner cleaned his hands and the woman's belly with banana wine and water, and then he made one quick, vertical incision through the skin, and a second through the uterus.

An assistant cauterized the wound when it bled with a red-hot iron. The baby was lifted out and the placenta removed. The woman was rolled over so the fluid could drain out of her abdomen, and then the abdominal wall, but not the uterus, was sutured with bark cloth and sharp skewers. A paste made of chewed roots was slathered over the incision and covered with a banana leaf and a cloth bandage.

The skewers were removed after a week. The wound had healed by the time Dr. Felkin left 11 days later, and mother and baby, who mostly had been nursed by a friend, were doing fine, he reported.

The basics of birth safety

What do women need when birth becomes difficult? The Averting Maternal Death and Disability program has identified a handful of intervention capabilities that should be in place for emergencies wherever babies are born.

These "signal functions" include having personnel on hand who are trained to administer drugs by injection -- antibiotics, anticonvulsants and "oxytocics," which can start or speed labor -- manually remove the placenta and other "products of conception" not leaving the body spontaneously, and perform assisted vaginal delivery -- with forceps, for example.

AMDD, a major initiative of the Mailman School of Public Health at Columbia University in New York City,  has worked with UNICEF and other partners for 20 years to bring down maternal-mortality rates in the developing world.

Its directive, issued in 1997, cites two additional interventions that might be necessary to save lives -- Caesarean section and blood tranfusion. These two go beyond the basics of a birth center -- in some parts of the world they are strictly wish-list items -- but they can often make the difference between life and death, as they did in our case.

AMDD doesn't include anesthesiology in its signal functions, although surgery is difficult without it.

We in the United States might view these interventions as humdrum, or even as irksome or worse if they become part of our own birth story, but behind the development of each one of them are amazing tales.

Forceps/vacuum birth hazard: Asia survey

One big surprise of the WHO survey of Asian births was that "operative vaginal delivery" -- the use of forceps or vacuum -- had the highest death rate for mothers of any method.

Ninety-seven women died during the 108,000 surveyed births. Of those, 53 died during spontaneous vaginal births, as would be expected, given that those were the majority of births (75,000 deliveries), for a rate of less than .1 percent.

However, of 3,465 OVD births, nine mothers died, a rate of nearly .3 percent. In a commentary that accompanied the WHO report in the medical journal The Lancet, the editors called the figures "a sobering reminder of the dangers of operative deliveries," although they noted that most OVDs are "high-risk situations that cannot be easily avoided."

Twenty-three of the 16,500 mothers having Caesaean sections "with indications" during labor died (more than .1 percent), and one woman died of the 554 having elective C-sections during labor (a rate of nearly .2 percent).

The report also found that women undergoing elective Caesarean section were  far more likely to spend time after the birth in intensive care than women whose births were spontaneous.

The irony is that while many unnecessary C-sections are being performed in some areas, women in other areas who desperately need them are not able to get them, the WHO report notes.