Birth Story

In the early 17th century, before the scientific method began its ascendancy in the Western world, the Englishman William Harvey described how the blood circulates through the human body, solving a mystery that had stumped scientists for centuries.

Some other scientists — Galen, the ancient Greek; Ibn al-Nafis, who worked in Egypt in the 13th century; and Michael Servetus, a 16th-century Spaniard — had got a chunk of the story right.

William Harvey

Only Harvey, who assiduously tested his theories on living animals, figured out that blood circulates throughout the entire body.

He published his thesis in 1628, as On the Motion of the Heart and Blood in Animals. His discovery is considered one of the most important achievements in medical history.

Harvey introduced the "experimental and observational approach" to scientific inquiry, the British medical historian P.M. Dunn writes in an article for the Archives of Disease in Childhood.

In addition to his revolutionary work on blood, Harvey also advanced our understanding of human reproduction. His practice extended to obstetrics, and he was interested in and knowledgeable about birth.

Harvey's 1651 book On the Generation of Animals, published with the stunning essay "On Parturition," debunked the idea that embryos were fully formed at conception, and advanced the theory of epigenesis, which held correctly that a chick, for example, grew all its various parts from a single cell.

Harvey also addressed labor, advising birth attendants to let nature take its course rather than to intervene unnecessarily. Harvey's tract was the first original work on obstetrics written by an Englishman. Aside from these famous works, the rest of his prodigious writing has been lost.

What remains is "truly remarkable when judged against the ignorance of the times and the prevalent reliance on ancient authority," Dunn writes of Harvey.

I'm embarking on a series of posts about blood. I can't help it. I'm fascinated with blood.

The final classic symptom of amniotic fluid embolism is disseminated intravascular coagulation (DIC). When I suffered an AFE during the birth of my younger daughter, I was nothing but classic.

I hemorrhaged to the point where all the blood ran out of my body three times over. I didn't die from this event because I received a total of 87 units of blood and blood products — whole blood, plasma, cryoprecipitate and extra clotting factor.

I am alive to tell our birth story because thoughtful strangers had donated their blood, a large stockpile of blood was five minutes away when I needed it, and because a whole raft of people had done the work over centuries to figure out how to make someone else's blood work in my body.

And, by 1997, the blood supply had been made safe again, after a horrific tainting with the HIV/AIDS virus.

The bill for my daughter's birth, including two surgeries (a Caesarean section and separate hysterectomy performed to stop the bleeding), a stint for the baby in the high-risk nursery, a night for me in the intensive-care unit and an additional four days in the hospital, was $100,000 all those years ago.

Blood accounted for $13,000, more than 10 percent of the total.

Blood was a major factor in giving our birth story a happy ending. Fascinating!

This is my 75th post, something of a milestone for me, especially as it coincides with roughly six months of blogging — and a change of status.

I was part of a group laid off last week from the Chicago Sun-Times, where I had loved, loved, loved being a features reporter. The economics of print journalism caught up with me, as they have with so many others.

Where do I go from here? This is no idle question for me, and I'm just beginning to work out the answer.

Over the course of the past couple of years, I have enjoyed learning about new media, and now here I am, with both feet in the 21st century. I blog three times a week, I tweet, I even built my own website (with lots of help).

At the same time, I believe in the values of old media — checking facts, maintaining a certain distance from sources, and allowing both sides to have their say in a civil discourse.

Even while I find myself slipping into the conventions of the new, I hang onto my belief that the best journalism serves the reader's need to know about, and understand, the society she lives in.

I think I have picked a great topic to write about, because it seems to me that birth is on the cusp, just like me. Modern medicine knows how to make birth safe, and yet the maternal mortality rate appears to be going up.

Not only that, but I can't help but notice that while 99 percent of American women have their babies in hospitals, most of the voices making themselves heard in books and blogs belong to women who are dissatisfied with and critical of the hospital experience.

And with Caesarean-section rates rising out of all proportion to any statistical need for their use, those voices are gaining an intelligent and often passionate following.

Where do we go from here? I believe that one thing that will help us answer that question is an understanding of how far we have come.

Cartoon by Shel Silverstein

A fight worth watching is shaping up in the New York State Legislature, where a bill that would ease restrictions on the practice of midwifery has attracted opposition from the American Congress of Obstetricians and Gynecologists, the new political arm of the 59-year-old organization that represents physicians who specialize in caring for women.

The bill, dubbed the Midwifery Modernization Act by its supporters, would give midwives the right to attend pregnant women without first obtaining a written practice agreement from a medical doctor.

On June 17, ACOG held a press conference in Albany to warn that the bill could compromise the safety of mothers and babies by exposing them to the risk of delivering without medical backup in the event of an emergency.

Midwives say that they sometimes have a hard time finding a doctor, say, in rural areas, willing and able provide a written practice agreement. And, they say, the problem is not confined to the boondocks.

After St. Vincent's Hospital in New York City closed last April, seven midwives who attend home births found themselves without a practice agreement, according to a story in the New York Times. St. Vincent's, a Catholic hospital, reportedly was uncommonly sympathetic to home births.

New York has as many as 900 midwives, more than any other state, according to Laura Sheperis, president of the New York Association of Licensed Midwives, in a separate story. Fifteen states so far do not require written practice agreements, which Sheperis has characterized as a "cumbersome and unnecessary barrier to health care and provider choice."

The bill would not prohibit doctors and midwives from creating written practice agreements; it would remove the requirement for them.

ACOG came out swinging against home births (along with the American Medical Association) in 2008 in response to "The Business of Being Born," a film that featured the home birth experience of actress/former talk-show host Ricki Lake.

"...Monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies," ACOG stated in 2008.

Obstetricians deliver about 70 percent of American babies, while midwives, mostly nurse-midwives, handled roughly 8 percent of births in 2004. Family physicians attend about 20 percent of American births.

"Pregnant Graffiti" by Petteri Sulonen

There is more than one way of looking at this, I know, but I believe I cheated death when I survived an amniotic fluid embolism during my younger daughter's birth in 1997. These extra 13 years, and counting, seem like a stupendous lagniappe tacked onto the lifetime I was meant to have.

That might be why, every so often, an event comes along that reduces me to a heap of gratitude for the medical advances, the professional competence, the technology — and the luck — that saved me. My older daughter's college graduation last week was one of those events.

Nora had just turned 10 when Maeve was born. She had not enjoyed being an only child, and was thrilled about the prospect of welcoming a new baby into our family. I had spent 4 1/2 months on bedrest, punctuated by a couple of terrifying bleeding incidents, which Nora had suffered through along with her dad and me. We were all relieved when the pregnancy reached term, and I went into Prentice Women's Hospital for a scheduled induction.

That fall Friday was a holiday from school, and Nora was off picking apples with friends in a far suburb, hoping that when she came home she would meet her new sister or brother.

She came back instead to a phone call from her dad, telling her about Maeve, who by that time was swaddled up in Prentice's high-risk nursery. Nora wanted to talk with me, but her dad said I had had a rough time and couldn't come to the phone. At the time he was talking with her, he still didn't know if I would live or die.

What if I hadn't survived? Both my girls would have been motherless, but Maeve wouldn't have known anything else. Nora would have suffered a devastating loss.

That didn't happen, of course. Because I have been there these 13 years, I know the scrapes Nora has been through, the joys, the disappointments, the accomplishments. Success in school never came easily to her, but last week, she graduated cum laude from DePaul University in Chicago.

I don't want to take credit for Nora's successes, but I do believe that mothers make a difference in their children's lives. I am proud of the wonderful young woman my daughter has become, and I am grateful that I have been there to see it.

Abraham Flexner, the author of a report that re-structured American medical education, and his brother Simon, who headed up the Rockefeller Institute for Medical Research, were two of the most influential men of their day. But they owed their success to some degree to their older brother Jacob.

Jacob Flexner

Their father, Morris, lost his haberdashery business in Louisville, Ky., in the Panic of 1873. Jacob, an intelligent young man who hoped to be a doctor, was forced to go to work immediately to help support the family. He became a pharmacist, as close as he could get to his dream, and eventually owned his own store, according to an account by Ward O. Griffen MD in The Annals of Surgery.

“Upon that choice my whole subsequent career and those of others of our family have depended," Abraham Flexner wrote years later in his autobiography.

Jacob "was throughout his life a person of quick and remarkable intelligence, and he must have realized that we were all destined to humble careers unless at the first opportunity a break was made," Abraham Flexner wrote.

Jacob Flexner was a Louisville pharmacist, but he too played a role in the birth story.

After Simon Flexner dropped out of the sixth grade in Louisville, Ky., in the 1870s, his father, Morris, arranged a tour for him of the town jail, warning that if he didn't straighten out, that was where he would wind up.

But after Simon, the fourth of nine children, nearly died of typhoid fever at the age of 16, he found his passion — infectious diseases.

Simon Flexner

Flexner went to work as an apprentice in his brother Jacob's pharmacy, where he learned to use a microscope. Doctors he knew from the store gave him tissue samples for his self-directed studies in histology, the study of microscopic structures in tissues, and pathology.

At 26, he earned his medical degree from the two-year program at the University of Louisville. His younger brother Abraham, a recent graduate of  Johns Hopkins University, arranged for Simon to study pathology there under William Henry Welch, who was helping to bring the scientific method to American medicine.

Flexner became a microbe hunter extraordinaire, helping to suss out the causes of meningitis among Maryland coal miners, bubonic plague in San Francisco's Chinatown, and a common dysentery that is now known as Flexner's bacillus. He also played a critical role in the conquest of polio.

In 1902, Flexner became the head of the new Rockefeller Institute for Medical Research, and this is where the birth story intersects his own. Flexner assembled an amazing team of scientists that included Alexis Carrel, Peyton Rous and Karl Langsteiner who, among other achievements, brought blood transfusion to reality.

The so-called "Flexner Report," issued in 1910, was a game-changer in American medical education.

Previously, a man — or woman — could become a physician by sitting through a winter's worth of lectures at a "medical school," which might be some doctor's parlor. Only the more rigorous schools survived after 1910 — all the women's medical schools and most of those that accepted minority candidates closed.

Abraham Flexner

Candidates had to qualify for the schools that remained, and they spent years, not months, learning the craft, which began to include hands-on training with patients. All these innovations impacted the birth story.

Abraham Flexner, who wrote the report for the Carnegie Foundation, was primarily an educator. He got his start with a private laboratory school he founded in his native Louisville, Ky., after graduation from Johns Hopkins University, and wrote a book in 1908, The American College, that brought him national attention.

Flexner was deeply involved in re-structuring the nation's medical schools in the years leading up to World War I. Later, he was the first director of the Institute for Advanced Study, a colossally influential "think tank," founded in 1930 in Princeton, N.J., by Newark retailer Louis Bamberger and his sister Caroline Bamberger Fuld.

At the IAS, Flexner saw opportunity in the political clouds gathering over Europe, recruiting scientists like John von Newmann and Kurt Godel. And, Flexner personally wrote the letter that brought Albert Einstein to the United States in 1933.

The Bill & Melinda Gates Foundation this month committed $1.5 billion over the next five years to support programs that will work to improve maternal and child health, family planning and nutrition in developing countries.

Bill and Melinda Gates

Melinda Gates announced the  plan on Monday at Women Deliver 2010, a gathering of world experts, advocates and policy makers in Washington D.C.

“In poor countries, pregnancy and childbirth often end in tragedy. Our goal must be to build a world where every birth brings joy and hope for the future,” Gates said.

Gates said that the money will be used to support local efforts toward a comprehensive approach to health that will include family planning, prenatal care, nutrition and improving the conditions under which women give birth.

“Every year, millions of newborns die within a matter of days or weeks, and hundreds of thousands of women die in childbirth,” said Gates. “The death toll is so huge, and has persisted for so long, it’s easy to think we’re powerless to do much about it. The truth is, we can prevent most of these deaths – and at a stunningly low cost – if we take action now.”

Gates said, “Most maternal and newborn deaths can be prevented with existing, low-cost solutions – such as basic prenatal care, or educating mothers about the importance of keeping babies warm,” said Gates. “Countries that have made women’s and children’s health a priority – and have invested in proven solutions – are achieving amazing results.”

Researchers at the Institute for Health Metrics and Evaluation at the University of Washington say that maternal mortality has fallen more than 35 percent since 1980, from more than 500,000 maternal deaths to about 343,000 in 2008, according to a press release from the Gates foundation.

Deaths among children younger than 5 are also down dramatically. About 7.7 million children are expected to die this year, down from 11.9 million in 1990, and 16 million in 1970, the release stated.

The Bill & Melinda Gates Foundation, one of the world's largest philanthropic entities, is a "family foundation driven by the interests and passions of the Gates family," according to its stated principles. The foundation seeks to impact a number of major global issues, including health and education.

Bill Gates, founder of the Microsoft computer software giant, co-chairs the foundation with Melinda Gates and his father, William H. Gates Sr.

Photo by Kjetil Ree / www.commons.wikimedia.org

Here perhaps is one clue to the conundrum of why maternal mortality in the United States is relatively high for an industrialized nation, 12.7 deaths per 100,000 births in 2007: Two thirds of the women who died giving birth in New York State between 2003 to 2005 were obese, the New York Times reported on Sunday. The Safe Motherhood Initiative provided the figure.

Obese women are more likely to hemorrhage, have high blood pressure, diabetes, anesthesia complications, blood clots and strokes during pregnancy and childbirth.

Not only that, but very obese women, defined as having a body mass index (BMI) of 35 or higher, are three to four times more likely to experience a Caesarean section with their first baby than other as first-time mothers are, Anemona Hartocollis reports in the NYT story.

Obesity is not only hard on mothers, but it may also pose problems for their infants. Babies born to obese women are almost three times as likely to die within their first month of life than those born to women with BMIs within the normal range. Obese women are also nearly twice as likely to have a stillborn baby, Hartocollis reports.

About one in five women are obese when they become pregnant, according to data from the Centers for Disease Control in Atlanta, Ga. Obesity is gauged by a BMI of at least 30. A woman who stands five-foot-seven inches tall and weighs about 195 pounds has a BMI of 30.