I was in the delivery room for his final performance–the last time an obstetrician named Bill Masters, a doctor who would go on to become a world famous sex specialist, helped a child slide through a woman’s birth canal. I don’t remember the baby’s sex or weight or its mother’s glee. But I remember Masters presenting the newborn to its mom with the flourish of a circus maestro, and I recall my fellow med student fainting. His wife was pregnant.
As a junior in medical school I spent three weeks catching babies at Homer G. Phillips, the black public hospital in North St. Louis. I and my fellow student were the only white guys in the facility. Napping in a sleeping room on the second floor we were periodically awakened by a nurse yelling “don’t push—don’t push” as the creaky elevator carrying the almost-mother slowly whirred upwards.
Shortly after my grandmother was born her mother died. In her day death was common when childbirth was complicated by “post partum bleeding, or infections” or when the baby was unable to get through the pelvis.
The U.S. has the unenviable honor of having the “highest rate of maternal mortality in the industrialized world.” —17.8 per 100,000 in 2009. It’s especially high for African American women.6
The global maternal death rate has decreased by 44% in the last 25 years, but each year in the world’s 24 poorest countries, 400 women die for every 100,000 live births. In recent decades most western countries have cut their death rates in half; in the U.S. the number of women dying almost doubled. In California focused healthcare significantly helped reduce the mortality rate. 5
Throughout recorded history women “midwives” have assisted other members of their sex give birth. In the late 1800s and 1900s physicians, virtually all of whom were men, moved in and took over. In 1915 40% of all births were attended by midwives and by 1935, 20 years later, close to 90% of births were performed by male physicians.
In the U.S. Thirty three percent of children are delivered by C-section. (9% of the women who give birth this way had prior C-sections.) The nurse midwife who brought me up to date explained that in her practice about seven percent of women are delivered by C-sections and only one in 400 women require an episiotomy, and incision to widen the birth canal.
Giving birth vaginally is usually painful and half of the deliveries performed by the midwife I consulted had epidurals. A derivative of Novocaine is infused into the space outside the lower end of the spinal canal. The drug usually controls the pain of child birth. When a physician delivers the frequency of an epidural nears 95%.
C-sections carry the risk of bleeding, infection, and of nicking the bowel and bladder. 7 When the mother has active vaginal herpes or the infant would have to come out feet or bottom first, vaginal delivery brings with it an extra possibility of harm that usually more than justifies the approach. But that’s not the reason for the “worldwide explosion.” In Mexico City C -sections are performed for 45% of births.7 In China the C-section rate was 35% in 2014.
At $10-15,000 a try, in vitro fertilization (and other forms of assisted reproductive technology) led to the birth of a million babies between 1987 and 2015. The Center for Disease Control keeps track of successful births after 37 weeks of single, live, normal weight children. The number depends on factors such as: was the embryo fresh or frozen? Did it come from donor or non donor eggs? How many attempts were made? and how old was the woman?13 Under ideal conditions the process is successful, per attempt, 21% of the time.4
Before Obamacare became law, pregnancy was commonly classified as a pre existing condition. Medicaid picked up the bill if the woman was sufficiently “low income”. But some of the uninsured earned a bit too much. After 2010 expectant women could purchase insurance and they couldn’t be charged more because they were pregnant. If they wanted marketplace coverage they had to “enroll in a health plan during the open enrollment period, set by either the employer or the feds.”
During the first seven years after the ACA (Affordable Care Act) became law 13 million pregnant women “gained access to maternity services.” Medicaid expansion played a role. (Medicaid also covered “contraceptive supplies, sexually transmitted infections, and “screening” for sexual violence and breast and cervical cancer.”) 1,2
In 2006 the 4.3 million births in this country rang up a bill of $14.8 billion. A vaginal birth in 2010 was costing between $5000 and $7000; C sections went for about $10, 000.
The care of low and very low birth weight infants contributed another $18.1 billion to the birthing price tag. Modern doctors have the incredible ability to keep not-quite-ripe small infants alive, and premature newborns account for half a million of the live births in this country. Some of these kids spend weeks in neonatal intensive care units at a cost, nationwide, of $26 billion. That turns out to be “about half of all the money hospitals spend on newborns.” 1.7 percent of newborns weighed less than a thousand grams when born and one half of one percent were under 500 grams. Eighty five percent of the infants “survived to be discharged from the hospital.”3.
Prenatally doctors and nurse midwives check pregnant women for diseases that can be transmitted to their new born–infections like HIV and hepatitis B. Obstetricians checking for fetal abnormalities usually perform the first fetal ultrasound when a woman is 18 to 20 weeks pregnant. Screening tests are also performed for genetic and developmental problems. The second decade of the 21st century saw the emergence of blood tests that analyze fragments of placental DNA floating in the mother’s blood. Fetal DNA and placental DNA are identical. By pregnancy week 10 the level of fetal DNA in the blood of the pregnant woman is usually high enough to perform an accurate test. The studies look for chromosomal abnormalities and they aren’t perfect. The alternative, amniocentesis, is “invasive” and can induce a miscarriage one half to one percent of the time. Near birth ultrasound exams are performed to check the baby’s position and detect problems like placenta previa, a situation where the placenta covers the opening of the cervix and prevents a normal birth.
The fear of malpractice haunts the birthing profession. Childbirth mishaps, mistakes, and bad outcomes still account for close to 10% of all malpractice suits, and the amount awarded to injured children can easily be a million dollars or more. It takes an immense amount of money to care for a damaged child for 80 years. Not surprisingly the malpractice insurance rates for gynecologists are among the highest. (see malpractice.9)
For a period of time health insurers were overly aggressive in their attempt to get women out of the hospital shortly after they gave birth. Congress reacted. The Newborns’ Act was signed into law on September 26, 1996. It includes important protections for mothers and their newborn children with regard to the length of the hospital stay following childbirth. (HMOs) that are subject to the Newborns’ Act “may not restrict benefits for a hospital stay in connection with childbirth to less than 48 hours following a vaginal delivery or 96 hours following a delivery by cesarean section.”
There are about 40,000 Ob/Gyn physicians in the U.S. When I graduated medical school (1962) most were men. In their early years in practice they delivered babies. As they and their cliental aged the doctors spent an increasing portion of their time tending to the organs of conception. That’s changed. By 2001 seventy two percent of the residents in the subspecialty were women. During the last 35 years our local medical school, the University of California in San Francisco, trained and deployed hundreds of nurse midwives some of whom practice at local hospitals. The safety of home deliveries on low risk women by nurse midwives has been documented time after time, but this approach still accounts for less than 30,000 of the babies born in the U.S. each year.
In addition to caring for women during the birthing years, gynecologists have traditionally been the primary care physicians of many otherwise healthy women as they age. Among other things these physicians pay a lot of attention to the organs of conception.
Cancer of the cervix is “worldwide the third most common malignancy in women.” It’s much less common in this country (11,000 cases a year) because many women have regular “Pap smears.” It’s a test that was developed by a New York cytologist named Georgios Papanikolaou. A Greek who finished medical school in Athens in 1904 then served in the army, Papanikolaou decided early that he wanted to be a researcher. He was 30 when he and his wife Andromache came to the U.S. They didn’t speak English and “had little money.” She got a job as a button sewer for a department store and he tried to sell rugs. His job only “lasted a day.” He ended up earning money during his first year in the country playing a violin in restaurants. Then he got a job in the anatomy department of Cornell Medical College. His wife was hired as his assistant.12 Using Andromache as a subject he studied the appearance of cells from the lower part of the uterus, the cervix, and he noticed cancer cells looked different. When he brushed, stained, and evaluated tissue that the end of the uterus was about to shed, he sometimes found “bizarre” changes that indicated a cancer was present. It took years till his findings were accepted, but he eventually was able to teach doctors to recognize changes that indicated part of the cervix was almost, but not quite malignant.10
Responsible for over 33,000 cervical and vaginal cancers annually in the U.S., human papilloma virus is sexually transmitted and usually causes no symptoms. Most infections clear within two years, but 14 million Americans are infected annually and 80 million are, at least temporarily, sexually “contagious.” In 2014 the FDA approved two shot vaccine that effectively prevents the disease. It works best when it’s given to young women before they are likely to be sexually active, and it covers genotypes 16 and 18 (responsible worldwide for 70% of cervical cancers) and 4 additional genotypes that account for 20%.11
Some parents feel that by immunizing their daughters they are saying we assume you will become sexually active, and that’s a message they’d rather not send
Early on the tools of the GYN trade relied on feel and a speculum. The uterus and ovaries were felt by trained fingers in the vaginal canal pushing up towards and equally aware fingers on the abdomen pushing down. When the exam was painful or the woman was large or tense the exam had limited value.
Shadows of the uterus and ovaries are now sometimes visualized using an abdominal ultrasound, a CAT scan, or by placing an ultrasound probe into the vagina and watching a T.V. screen. The probe charge, in one location (chosen randomly on the Internet), is $200 per exam. I don’t know if insurance companies will pay for the test in the absence of a clear indication. It has not, best I can tell, become “routine”, though actress Fran Dresher and others thinks it should be. The $6.5 million dollar bill President Bush signed in 2007 “authorized the development of a national gynecologic cancer awareness campaign” but did not mandate screening vaginal ultrasounds.
Gynecologists have long evaluated the inside walls of the uterus with an operation known as a D and C. They dilate or stretch the cervical area. Then a sharp instrument is placed inside the uterus and the lining cells are scraped off, collected, and examined under a microscope. The main indication for the operation is unexplained uterine bleeding which could be caused by cancer of the inner lining wall of the uterus. Nowadays there’s a thin narrow scope that can slip into the uterine cavity and allow doctors to look for abnormalities. In this country hysteroscopy is usually performed in anesthetized patients. In Australia and elsewhere it’s sometimes performed with light sedation and numbing agents.
Finally the gynecologists were pioneers in the use of a tiny incision and a laparoscope (see surgery) to evaluate ovaries, treat cysts, or tie fallopian tubes so a woman could avoid pregnancy.
Gynecologic surgery is a relatively large ticket item. In this country 600,000 women have hysterectomies annually. 180,000 (30%) of the operations are done for “fibroids” benign growths that can cause symptoms.8Some hysterectomies are performed in an attempt to reduce or eliminate lower abdominal pain. The discomfort is sometimes caused by endometriosis, a condition where the kind of tissue that normally lines the inner wall of the uterus is growing elsewhere in the pelvis. Abnormal cells are sensitive to female hormones and can bleed when women are having a menstrual period. The condition is the alleged cause of the discomfort suffered by millions.
Close to ten million women “have trouble controlling their bladders.” Surgery in addition to medication and pessary (a flexible device that’s placed into the vaginal canal) sometimes helps. Operations also treat prolapse, a condition where a uterus, stretched by prior child birth, drops into the vagina or bulges into the bladder or rectum.
Finally the fear of ovarian cancer leads to a lot of testing. This is a real and worrisome condition, but it’s not on the rise. By age 30 it strikes one in 15,000 and by age 60 afflicts no more than one woman in 1500. It’s hard to detect at an early stage and benign ovarian cysts found on an ultrasound commonly lead to a number of additional exams and a modicum of anxiety. Given our current system and abilities, experts tend to discourage routine screening.
Jamila Taylor and Maura Calsyn, “5 Ways the Senate ACA Repeal Bill Hurts Women” (Washington: Center for American Progress, 2017),
N Engl J Med 2008; 358:1700-1711April 17, 2008 Management and outcomes of very low birth weight.
https://www.pennmedicine.org/updates/blogs/fertility-blog/2018/march/ivf-by-the-numbers
Ellison K, Martin N (December 22, 2017). “Severe Complications for Women During Childbirth Are Skyrocketing — and Could Often Be Prevented”. Lost mothers. ProPublica.
Li HT, et al. Geographic Variations and Temporal Trends in Cesarean Delivery Rates in China, 2008-2014. JAMA. 2017;317:69–76. doi: 10.1001/jama.2016.18663. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593338/
Heavy Menstrual Bleeding in Women with Uterine Fibroids. William D. Schlaff, M.D., et al NEJM January 23, 2020 https://www.nejm.org/doi/full/10.1056/NEJMoa1904351?query=featured_home “Half of women with Uterine fibroids (leiomyomas have symptoms: heavy menstrual bleeding, which can lead to anemia, pelvic pain and pressure, urinary and gastrointestinal symptoms, infertility, and complications of pregnancy.” They sometimes affect a woman’s physical, psychological, and social well-being.”
https://healthmatters.nyp.org/georgios-nikolaou-papanicolaou/
UpToDate
Papanikolaou https://www.newscientist.com/article/2202635-georgios-papanikolaou-inventor-of-the-pap-smear-cervical-cancer-test/
file:///C:/Users/User/Documents/ART-2013-Clinic-Report-Full.pdf assisted reproductive technology