Birth Story

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.

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.

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.

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.

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.

The rising rate of birth by Caesarean sections has hit Asia, with China reporting that 46 percent of its births now end in surgery, according to a global survey by the World Health Organization reported in the medical journal The Lancet.

Nine countries were targeted in the WHO study -- Cambodia, China, India, Japan, Nepal, Philippines, Sri Lanka, Thailand, and Vietnam -- with births in both small and large institutions examined for two or three months in the capital city and two other regions in each country. In all, about 108,000 births were scrutinized at 122 institutions.

China had the highest rate of Caesarean births in the survey. The country with the next-highest rate was Vietnam, with 36 percent, followed by Thailand, with 34 percent, and Sri Lanka, with 31 percent.

Cambodia had the lowest rate of Caesarean births, 15 percent, which is the rate the WHO and other health groups recommend. The C-section rate over all for the Asian countries surveyed was 27 percent.

Amniotic fluid embolism was first identified in 1926, but it still isn't fully understood today.

AFE is rare, unpredictable and unpreventable, accounting for between 5 and 10 percent of maternal mortality in the United States, and is likely triggered when amniotic fluid enters the bloodstream. However, by no means every woman who gets amniotic fluid in her bloodstream suffers an AFE.

Some estimates have AFE occurring anywhere from 1 birth in 8,000 to 1 in 30,000, with mortality running as high as 80 percent. Many women who survive AFE suffer life-altering brain damage.

A study published in the American Journal of Obstetrics & Gynecology in 2008 found AFE occuring in about 7.7 of every 100,000 births -- that's about 1 in 13,000 births, which makes it a rare event -- and still killing more than one in five mothers it strikes.

The authors of the AJOG article found associations between AFE and mothers older than 35, Caesarean births and "placental pathologies" like placenta previa, in which the placenta attaches low in the uterus, where it can cause hemorrhaging and other complications during a pregnancy.

However, the study did not find an association with artificial induction -- the use of drugs like Pitocin to start or hurry up labor.

AFE displays a cascade of symptoms that can include cardiac arrest and disseminated intravascular coagulation, or DIC for short. During a DIC, a person's clotting factor is deployed all at once, after which hemorrhage can ensue. A mother can die from these events and so can a baby who is still in the womb -- the saddest birth story of all.

Robbie and Susan Goodrich had been married three years when she died of an amniotic fluid embolism during the birth of her son Charles Moses last year.

The couple had been full of plans. Robbie would ramp up his career so that Susan could scale hers back to spend more time with the children. Now he's going back to work after a year's leave of absence, as a single father.

Moses Goodrich

During a phone interview, Goodrich said, "I'm throwing myself into my work, so I can go home and be with the kids."

Goodrich said, "I have to re-invent myself as a widower, with two kids in diapers. I'll do what has to be done to put bread on the table, but it's just me now.

"I know that the process isn't over. I have to do everything that has to be done emotionally to deal with the loss of Susan. I have to accept that it won't be the same me or the same life," he said.

On Dec. 6, Moses took his first steps.

On Dec. 10, the family celebrated Susan's birthday the way they usually had. They cut down a tree for Christmas, went snowshoeing, made Susan's favorite tapas.

"We celebrate her birthday. Her death day coincides with Moses' birthday but we celebrate Moses and the life that she gave on that day.  We celebrate who she was and how she lived and not the accident of her death," Goodrich said. "Though that's easier to say than to do."

Photo courtesy of Robbie Goodrich

Charles Moses Goodrich celebrated his first birthday on Sunday with several of his "moms," the women who joined together to breastfeed the little boy after his mother, Susan, died of an amniotic fluid embolism hours after his birth, one year ago today.

Robbie Goodrich, Moses' dad, hosted the "moms" and their husbands and children for an afternoon party at the YMCA in Marquette, Mich., for games, swimming, pizza and cake. Moses' 2 1/2-year-old sister, Julia, had chosen the theme for the party, "Candy, Candles and Candy Canes." There were two cakes, one made up of lavishly frosted cupcakes and the other in the shape of the number 1, striped with red M&Ms to look like a candy cane, Goodrich said.

The Goodriches, Moses' "moms" and their families

"It's a very severe winter here," Goodrich said of Marquette, a city of 20,000 in Michigan's Upper Peninsula. "The moms said they were glad to get the kids out of the house. Moses had a great time going from mom to mom. He was in hog heaven." (Robbie Goodrich, who provided this photo, is in a blue shirt under the painting on the wall, holding Moses, in a red shirt with blue sleeves.)

People magazine featured the Goodriches in a story last June about the remarkable "cross-nursing" collective that formed to honor Susan Goodrich's desire that her son be breastfed for the first year of his life. Seeing Goodrich struggle to buy breast milk in Moses' first days, family friend Laura Janowski offered to nurse the infant, and the collective grew from there.

Moses was weaned about a month ago, before the Goodrich family went to Virginia for the Christmas holidays, Goodrich said.

In all, 26 women nursed Moses, some coming once or twice, others coming regularly at a set time. Carrie Fiocchi came daily at 9 a.m.; Kyre Fillmore came at lunchtime from the first week until Moses was weaned, Goodrich said.

After a year's leave of absence from his job as a history professor at Northern Michigan University, Goodrich went back to work today.

He had re-arranged his life so that Moses could be breast-fed because "it seemed like the right thing to do for Moses, not only to kickstart his good health, but also for the nurturing, the being held for hours and hours. It turned out that having moms and kids come to the house was great for Julia, too, and it was good for me -- that support. I'm sad that it's over," Goodrich said.

Jane Seymour, the third wife of King Henry VIII of England, was hardly the first woman to die in childbirth. However, her status as the mother of Henry's only son made her death in 1537, probably from puerperal fever, an outsize event at the time. Although she was never crowned Queen of England -- Henry perhaps withheld that honor until after she had borne him an heir -- Jane was the only one of Henry's six wives to receive a queen's funeral.

Jane Seymour

Jane died about two weeks after the long, difficult birth at Hampton Court Palace of her son, Edward, who would briefly reign as King Edward VI. She was mourned by all of England, and by Henry to a singular degree. He wore black for a year, refrained from marrying again for more than two years, and was buried next to Jane -- and Jane alone -- in St. George's Chapel at Windsor Castle when he died in 1547 at the age of 55.

Even though her importance to the country derived wholly from her status as wife and queen of one of the world's most powerful men, Jane's death in childbirth would reverberate through history.