One of my heroes in the childbirth movement is Prof Marjorie Tew of Glasgow, Scotland. I’d love to meet her and give her a hug. She came to be a supporter of homebirth even though she gave birth in hospital herself and even though she was highly sceptical when her evidence showed homebirth to be safer than hospital. This is the kind of science that I love—when the scientist holds the opposite belief but can still trust her/his method enough to change beliefs. This book review of her 3rd Ed. of “Safer Childbirth” will give you an idea of what she has done for women.
Safer childbirth: a critical history of maternity care. Third edition.
GP in rural Cumbria and member of the UK government’s Expert Maternity Group, which produced the report “Changing Childbirth”
Marjorie Tew. (442 pages, £15.95.) Free Association Books Ltd, 1998. ISBN 1-85343-426-4.
This book is exciting and makes humbling reading for doctors. Its relevance extends beyond maternity care. Marjorie Tew tells a tale of the abuse of professional power, the use of misinformation and the blindness and bigotry of those who should have known better. Even the very best, like Dugald Baird in Aberdeen, could lose their scientific footing in the headlong rush for doctors to take over and hospitalize childbirth: “if it is accepted that confinement in hospital is safer for certain types of patient, where the risks are high, it must also be safer for cases where the risks are less”.
The shift to hospital birth has been one of the great sociological changes in the industrialized world in the past 50 years. Yet this change took place with almost no evidence to support it. It ought to be a source of shame to those who promoted the shift through the 1950s, 60s and 70s that controlled trials were not considered necessary. Only a few brave voices cried in the wilderness, Archie Cochrane notably and Marjorie Tew.
Mrs Tew was teaching statistics to medical students and whilst using the results of the 1970 Birth Surveys found that the conclusions reached by government (through its specialist advisers) were not supported by the evidence. Despite her unbiased stance and clear presentation of the evidence, British medical journals disgracefully refused to publish her paper until the Journal of the Royal College of General Practitioners finally did so in 1985.1
Tew presents a sad litany of errors which doctors inflicted on childbearing women including: enforced recumbency in labour, induction rates at over 50% and X-rays. “It has been frequently asked if there is any danger to the life of the child by the passage of X-rays through it; it can be said at once that there is none if the examination is carried out by a competent radiologist” (Radiologist, 1937). I would personally add electronic fetal monitoring to this list. It is not Tew but a paediatrician who wrote in 1987 “the recent history of perinatal medicine abounds with instances in which belated controlled trials eventually revealed that the apparent benefits of some widely acclaimed treatment had merely disguised the real extent of its tragic consequences”. Most of this stemmed from a belief that biomedicine would solve all the problems of childbirth, ignoring social and psychological factors. Tew has a lovely example from the Rhondda of 1936, where Ovaltine not obstetricians may have reduced maternal mortality.
We should be grateful for Marjorie Tew for her courage and determination in the face of sometimes vicious opposition. She is in the end I believe too critical of the benefits of specialist care. There may be more balanced views, but Tew’s account is lively and impassioned. Readers ought to buy a copy and pass it on to an obstetric colleague, but don’t expect any thanks.
1 Tew M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985; 35: 390–394
Added October 2013
Tew, M. Place of birth and perinatal mortality. J R Coll Gen Pract 1985; 35(277): 390-94
Using the raw perinatal mortality rates (PMRs) from a 1970 British national survey, the hospital PMR was 27.8 per 1000 births versus 5.4 per 1000 for homebirths/general practitioner units (GPUs). This was not because hospitals handled more high-risk births. When PMRs were standardized based on age, parity, hypertension/toxemia, prenatal risk prediction score, method of delivery, and birth weight, adjusted hospital PMRs for each category ranged from 22.7 per 1000 to 27.8 per 1000 while homebirth/GPU rates ranged from 5.4 per 1000 to 10.5 per 1000.
The 1970 survey assigned a prenatal risk score to predict the likelihood of problems during labor. When PMRs for hospital versus home/GPU for the same level of risk (very low, low, moderate, high, very high) are compared, the hospital PMR was lower only at the very highest risk level. All differences, except in the “very high risk” category, were significant. The PMR for high-risk births in home/GPUs (15.5/1000) was slightly lower than that for low-risk births in the hospital (17.9/1000). Moreover, the PMRs in home/GPUs for very low, low, and moderate risk births were all similar, but hospital PMRs increased twofold between categories, which suggests that hospital labor management actually intensified risks.
The percentage of infants born with breathing difficulties (9.3% versus 3.3%), the death rate associated with breathing difficulties (0.94% versus 0.19%), and the transfer rate to neonatal intensive care units for infants with breathing problems who survived six hours (62.0% versus 26.2%) were all higher in the hospital (all p<0.001), further evidence that hospital interventions do not avert poor outcomes. Although no national study has been undertaken since, smaller studies confirm that increasing use of hospital confinement is not the reason for the overall drop in PMR since 1970. In fact, those years when the proportional increase in hospital births was greatest were the years when the PMR declined least and vice versa. (End of quote) Preterm labour study by M. Tew (link to abstract) http://www.midwiferyjournal.com/article/S0266-6138%2805%2980228-1/abstract
Quote from the book, Safer Childbirth by Marjorie Tew:
“The degree of pain in childbirth perceived by a woman depends not only on the physical stimulus, but also on her emotional state and her cultural expectations.
Her perceived pain is less when she feels relaxed, unafraid and reassured by the continuous, comforting support of her birth attendant.
Not all doctors or midwives can inspire peaceful confidence and this is rarely the atmosphere in a large obstetric hospital where the obstetric practices themselves have the effect of intensifying physical pain.”
“Safer Childbirth” by Marjorie Tew, p. 172